1. Definition of Urbanization
In order to get a clearer understanding, it is important to explore the definitions of urbanisation. There are several definitions of urbanisation based on various insights and perspectives. Urbanisation can be defined as:
“The process of concentration of population to big cities due to social evolution. From the viewpoint of economy, it is characterized by extension of urban economy to rural areas and recombination of urban industry. From the viewpoint of sociology, it is an expanding process of urban factors in local regions which indicates the improvement of the integrate power of a country” (Huapu, 2002 p.1).
Hamdi and Majale (2005) in their book on Partnerships in urban planning: a guide for municipalities explains simply “urbanization is the process of growth in the proportion of people living in urban areas” (Hamdi & Majale, 2005 p.7). Therefore, urbanisation is defined as an increase in the number of cities and urban population. Urbanisation is not only about demographic movement but it is also the process of urbanisation, and its social, economic and psychological impacts which influence urban population. Urbanisation is a process that leads to the growth of cities due to industrialization and economic development, urban-specific changes in specialization, labor division and human behavior (Turan & Besirli, 2008). Huapu (2002) further commented that in general urbanisation reflects an increase in the proportion of urban population in the total population; conversion of agricultural population into nonagricultural population; expansion of city size; appearance of new towns in rural areas and prevalence of urban economic and living style (Huapu, 2002) .
2. Urbanisation around the World
Urbanisation is growing rapidly in both developed and developing countries. The existence of city as a consequence of urbanisation is very complex. Urbanisation brings and causes a variety of health problems within an environment. There are two general reasons to explain why people move from a rural to an urban: push factors and pull factors (Lankester, Booth, Martin, Tear, & Foundation for Teaching Aids at Low, 2001). The push factors centre around issues are such as not enough land to earn a livelihood for family members, not enough food to feed their family due to flood, drought, and war. However, people also can move from a rural to an urban area to access better health care, education, entertainment, and employment.
As a consequence of urbanisation, the number of people living in urban environment is increasing. The World Health Organization reported that population increase has occurred globally from 2000 to 2025, more than half of world’s population lives in urban areas and it will be estimated 60% by 2030 and 70% by 2050 (Kumaresan, 2008) where occurred generally in Asia and Africa (Lankester, et al., 2001). Total population of Africa and Asia in 2000 was 309,651,000 and 1,386,721,000 respectively. However, it is estimated that this will increase by 2025 to 752,082,000 and 2,507,732,000 respectively. Four out of every 10 people were living in cities or towns in the thirty years ago but this number will grow up to six out of ten by 2030 (WHO, 2010b) and 7 out of ten by 2050 (WHO, 2010a).
However, if referring to the WHO region, percentage of the people living in urban areas in 2009 is mostly in the region of Americas (80%) and European region (70%) while Africa regions and South-East Asia region are only 38% and 33% respectively. Unfortunately, according to World Health Organization (WHO)’s report that 50 % of the people living in cities of developing countries live in urban poverty with poor housing, environmental pollution hazards, inadequate water and sanitation, lack of security, decline of the traditional social infrastructure, and dual risk from infectious illness and the diseases of city life (Kumaresan, 2008).
The transfer of population not only lead to population agglomeration in the urban but urbanisation also brings a variety of implications: environmental, social, culture, economic, political implications and they impact on human health either population from the city itself or population from the rural areas. Therefore, it is important to review the process of urbanisation and its impact on population health.
3. A variety of Urban Health Problems
The problems created by this rapid urbanisation concern not only population density but also other factors. Baum in his paper summarized into six aspects of urban problems resulted from urbanisation. They are:
· Increased population density, overcrowding and congestion
· Increased transport, mobility and pollution
· Increased pollution caused by industrialization, transportation, energy production and commercial domestic waste
· Often large population occupying urban land area subject to landslides, floods, and other hazards
· Increased numbers of people living in poor conditions
Because of the complexity of various health problems in urban areas, in 2010 the WHO set of urban health matters as world health day theme (WHO, 2010b). It means that WHO recognizes the complexity of urban health problems faced nowadays. There are three important parts on urban health emphasized on the momentum namely, the impact of urbanisation to population health; urban setting as a determinant of health and health condition of urban population. Housing, land and security; water; sanitation; outdoor and indoor pollution; food; transport; noise exposure; climate change; social environment and health and social services are still crucial in the urban environment in various parts of the world.
Urban problems are getting more complex because urban areas have already had own problems while people moving from the countryside to the city will also bring own problems with different culture, social structure, values, belief, habits and behavior impact influence city life. As, a result, urban problems are more and more and difficult to be addressed. Therefore, urbanisation is a problem not only for immigrants but also for domestic people in the cities themselves (Turan & Besirli, 2008). The World Bank categorizes urban health into 11 themes. These are environmental health; water, sanitation and hygiene; urban transport; urban solid waste management; housing; impact of climate change and global warming; urban crime and violence; HIV/AIDS in urban areas; health service provision in urban areas; vulnerable urban populations; and planning and monitoring for health outcomes (UNDP, 2010).
Moore, Gould and Keary (2003) mentioned that the problems of cities will increase due to urbanisation which is related to jobs, education, health and culture. A consequence of this urbanisation process it leads to imbalance in urban development economically and socially; degraded environment, poverty and poor public services; inadequate housing (slum area), lack of sanitation facilities, pollution, crime, civil conflict, injury and disaster; and increase in environmental based diseases, vector diseases and vulnerability (Darmawan, Thabrany, & Kamso, 2007).
Apart from physical health impacts, urbanisation impacts on mental health (Turan & Besirli, 2008). The rapid growth of urban population leads to overcrowding and an increase in sub-standard life, unemployment, poverty, crime, pollution, cultural change, conflict, isolation, child employment, and disintegration of families, shanty houses and living in poor home environment, traffic problems, uncertainty of future and a variety of urbanisation impacts in the urban. All of the above factors can cause some mental disorders, suicide and homicide, drug abuse, violence, coronary heart diseases and traffic accidents.
Still related to urban problems, Turan and Besirli (2008) explain that one of the main problems as a consequence of urbanisation is slum areas, violence and unemployment. Slums form inadequate environment for children and this might affect and influence their personalities that tend to commit crime. Houses and buildings of poor sanitation and inadequate housing environment, and unemployment, may result in disharmony (Turan & Besirli, 2008).
4. Determinants of Urban Health
Urban health particularly in developing countries is determined by many factors across multi- levels. Harpham (2009) mentioned multi-sectoral and multi-level determinants of urban health. There is recognition that the determinants of urban health have to be viewed from a variety of aspects. It can be influenced by such as poverty, social, physical environment and health services.
Urban poverty leads to poorer nutritional status, overcrowded living conditions, environmental hazards, social fragmentation due to lack of community and inter-household mechanism for social security, crime and violence such as homicide, injuries, mental ill health, traffic accidents and natural disasters. Most of the urban poverty aspects are harmful for health and they can be categorized as negative health. The social problems that affect urban health are both domestic violence and street violence, and feelings of low self esteem insecurity. Another determinant of urban health is the physical environment and health services. Inadequate physical environment factors are recognised and accepted as one important factor to urban health. Environmental factors such as water, sanitation and hygiene cause nine-tenths of child diarrhea and cause 4-8% of the overall burden of disease (World Health Report in (T. Harpham, 2009). Also it is about health services. Even though it is recognized that availability, appropriateness, affordability of quality health service are better in urban areas than rural areas, many urban dwellers are unsure of how to utilize the health service facilities due to habits and culture.
As mentioned above that urban health outcomes are not only determined by multi-sectors but also multi-level factors. The multi-level factors referred to in research generally focus on individual characteristics such as biological, demographic, psychological/personality and behavioral. However, there is increasing evidence that place and community level factors influence on health. Geographic aspects and places such as recreation, facilities, location of food outlets also directly and indirectly impact on health. Therefore, individual, household and community dimensions including multi-level determinants impact on health in the urban environment (Trudy Harpham, 2007). However, the existence of multi-level factors as complementary parts of multi-sectoral determinants is currently not well analyzed by urban planners (T. Harpham, 2009).
How does the urban living influence health? Galea and Vlahov (2005) in their paper on Urban Health argued that there are three broad theories and mechanisms that explain how a city context can influence and affect health (Galea & Vlahov, 2005). Galea, Frendenberg and Vlahov (2006) proposed a conceptual framework for urban health (VLAHOV & BOUFFORD, 2010) and it was adopted by WHO
The framework notes that the health outcomes are result of various interactions. They are influenced by urban living condition such as physical environment, social environment and social and health services. To create such living conditions these rely on municipal level determinants and key global and national policies. The framework also recognizes the importance of urban governance to achieve the health outcome. It recognizes that to achieve better living and working conditions the role of city population, civil society, private sector, local and national government work together are crucial. Urban governance and health specifically will be discussed in the separate section. Further the framework also explains that better health outcomes can only be achieved if supported by intermediary factors such as community health knowledge, health seeking behavior and community empowerment and social support networks as well. In general the difference of the original framework for urban health suggested by Galea, Frendenberg and Vlahov (2006) and the adopted framework proposed by WHO is outcome and intermediary factors. The original framework considers health outcome and non health outcome while WHO only focuses on the health outcome. Another difference is WHO adds intermediary factors as important ingredients that affect health outcome.
5. Challenges in improving Urban Health
Harpham (2009) noted that the challenges to improving health especially in the urban poor are financial factors. This is a major challenge for urban health development. It is also about political challenge. Political challenge is the main problem of municipal or city structures in developing countries to urban health development. The responsibility of health at governmental levels is crucial from both local government and state government. On the other side, health is not a political sexy subject for decision makers such as mayors and public representatives. Sometimes health programs cannot run well caused by a change new mayors or new leaders as experienced by Brazil in developing healthy city program. The healthy city program was unsustainable due to changing political context and main decision makers (mayors). Health issues are not sexy issues also for other sectors (Trudy Harpham, 2007). Still related to the political challenge of urban health, healthy city program as a strategy for urban health is the lack of a powerful body to coordinate health-related activities across sectors (WHO, 1995 in (T. Harpham, 2009). In many countries healthy city’s activities are usually delegated to health department or the health office of local government while health office has same level with other sector. In fact, it does not have enough strong power to coordinate and mobilise other sectors.
The same experience also occurred in Bangladesh in developing urban health system experiencing obstacles and challenges in building partnership as the impact of lack of political commitment (Datta, Kouletio, & Rahman, 2005 p.92) as following statement:
“Starting dialog with the Saidpur municipality was also challenging. Health had never been one of their main priorities. Public representatives preferred to gain votes by working on more tangible issues. As a result, the benefits of an intangible programme like the CSP (Child Survival Program) were difficult for them to grasp”
Another challenge is partnership. A variety of partnerships are needed for large-scale urban health promotion. Partnerships can include local, national or international partnerships. The mistrust of government at local level of Non Governmental Organisations (NGOs) and Community Based Organisations (CBOs) and may be among governmental agencies be able to also block for successful pilot projects. Partnerships need both ‘bottom up’ partnership and ‘top down’ partnership.
Partnerships can be broken if the cabinet or decision makers change because new cabinet has new policies and this also occurred in Bangladesh as following statement:
“The CSP partnership with Mymensingh municipality started in August 1998. But following elections in February 1999, the Mimengsingh municipality cabinet changed. The new cabinet argued that the proposed CSP program strategy could not benefit the municipality unless some logistical supports was provided which include seven ambulances, salaries for municipal health staff and 21 health centers. Providing this logistic support was out of CSP’s scope. The partnership was broken and Concern had to withdraw the CSP from Mimengsingh” (Datta, et al., 2005 p.91).
Further study on partnership will be discussed in chapter IV. Other problems are about leadership and innovation. Both of these are needed because leadership relates to the ability to mobilise urban sources from government, private sectors and community sectors. On the other hand, leadership itself is innovation. People who have strong leadership have strong innovation as well.
To address the urban health problems as stressed on the 2010 World Health Day there are 5 major actions: promote urban planning for healthy behaviours and safety; improve urban living conditions; ensure participatory urban governance; build inclusive cities that are accessible and age-friendly and make urban areas resilient to emergencies and disasters (WHO, 2010b).
With the complexity of various problems created by urbanization on urban health, this should be a special concern for urban planners and how they involve the relevant sectors to build a healthier lifestyle and environment. Therefore, the next section is to be important to review how the urban planning and urban governance affect health.
In summary, urbanisation process has brought positive impact to society in the field of health, education and economic growth. However, uncontrolled urbanisation leads to a variety of urban health challenges. Therefore, a comprehensive approach to address those impacts needs to be strengthened like healthy cities approach.
REFERENCES
Kumaresan, J. (2008). Urban health from a global perspective. Paper presented at the 7th International conference on urban health 29 October 2008, Canada. http://www.isuh.org/download/Jacob_Kumaresan.pdf
WHO. (2010a). Urban planning essential for public health Retrieved 8 May, 2011, from http://www.who.int/mediacentre/news/releases/2010/urban_health_20100407/en/
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