Webinar: Achieving Universal Health Coverage in Urban Settings: Incentives, Challenges, and Opportunities

On February 7, Management Science for Health (MSH) and the Joint Learning Network for Universal Health Coverage (JLN) convened us—a group of public health experts—to discuss emerging issues in urban health in low- and middle-income countries with a focus on South and Southeast Asia.

Moderated by MSH’s Principal Technical Advisor for Health Economics and Financing, Anupama Sharma, the conversation provided valuable insights into the evolving landscape of urban health in India and Malaysia.

Here we share a summary of the key points each of us raised in the discussion and invite you to watch the event recording and send us your questions and feedback at asharma@msh.org.

Key Insights

Dr. Atul Kotwal highlighted the need for a unique approach to urban health to achieve Universal Health Coverage (UHC). As the Executive Director of India’s National Health System Resource Centre, he described the country’s progress toward UHC as based on pillars like accessibility, availability, affordability, equity, safety, and quality of care. He emphasized the importance of the National Quality Assurance Standards and the development of urban healthcare infrastructure guided by Finance Commission recommendations. Highlights include:

• Strengthening Urban Primary Healthcare: A new urban health structure is proposed, directing funding to sub-centers under primary healthcare facilities in disadvantaged areas. These centers will be managed by medical officers to ensure clinical expertise.
• Expanding Access to Essential Services: The availability of drugs and diagnostics are expanded in urban primary health care facilities
• Urban Polyclinics and Specialist Services: Selected primary health facilities restructured to polyclinics with contracted specialists from the private sector functions in the evening to serve the working class.
• Community Engagement and Intersectoral Coordination: Use of community structures, like women’s health committees (Mahila Arogya Samitis) and urban health workers, to create inclusive and tailored urban health care planning. Adapting rural models, such as Village Health, Sanitation, and Nutrition Days in urban areas is still under consideration.
• Addressing Metro-Specific Challenges: Mumbai’s model of strengthening maternal and child hospitals and linking them with private non-profit facilities was highlighted as a successful example of integrated urban healthcare delivery.

Dr. Somil Nagpal, Lead Health Specialist at the World Bank’s Global Practice on Health, Nutrition, and Population (East Asia & Pacific Region), highlighted the critical issues impacting service delivery, aging populations, health inequities, and the involvement of the private sector in the urban health landscape in the region. Key insights from Somil include:

• Non-Communicable Diseases (NCDs) and Service Coverage: The Pacific and East Asia regions face challenges in covering NCD services, which often remain undiagnosed or inadequately treated.
• Aging Populations and Socioeconomic Pressure: East Asia and the Pacific are facing elderly care challenges due to a demographic shift, with 300 million individuals aged 65 and older, especially in urban areas with limited family support.
• Health Inequities in Urban Areas: National averages may suggest healthier urban populations, but closer examination reveals significant disparities among income quintiles. The urban poor experience worse health outcomes, with catastrophic health expenditures worsening these inequalities.
• Private Sector Engagement and Health Financing Innovations: Urban populations often rely on private health care for initial care, but health systems struggle with integration, resulting in inefficient referrals. Despite some financial innovations and gatekeeping models, gaps remain.
• Urban Innovations and Cross-Sectoral Strategies: Innovative approaches to improve urban health, including:
  • Mental health support: Mobile-based interventions, chatbot assistance, and community awareness programs.
  • Obesity and NCD prevention: Public health campaigns, sugar taxes, improved food labelling, and urban planning that promotes walking and cycling.
  • Air pollution and traffic: Smart traffic management, congestion surcharges, and enhanced public transport infrastructure.
  • Climate resilience and health infrastructure: Telemedicine, workforce training, early warning systems, and eco-friendly urban development.
  • Vaccination and disease surveillance: Expanded adult vaccination programs, including for cervical cancer and emerging NCD-related health risks.

Dr. Dinash Aravind, Senior Assistant Principal Director, Health Transformation Office, Government of Malaysia, shared insights into Malaysia’s dual health care system, its urban health challenges, and opportunities for UHC expansion. Key insights from Malaysia’s experience include:

• Dual Healthcare System and Fiscal Pressures: Malaysia’s public-private health care model provides universal access through the government sector while the private sector serves those who can afford it. Rising medical costs (15%) and increased demand are pushing more patients to public care, straining government resources.
• Urbanization and Infrastructure Development: About 80% of the population lives in urban areas, resulting in concentrated health facilities. Public hospitals are more evenly distributed, but private hospitals cluster in cities, creating accessibility disparities for lower-income groups.
• Non-Communicable Disease Burden: The government launched a National Health Screening Initiative to improve early detection and management of non-communicable diseases (NCDs). The establishment of a strategic purchaser within the Ministry of Health, ProtectHealth Corporation Sdn. Bhd. (PHCorp) allows for purchasing from both the private and public sectors. It implements Skim Peduli Kesihatan programs, the (PeKa B40) scheme, aimed at increasing health screenings for NCDs for those aged 40 and above, focusing on the lower-income group.
• Digitalization and Public-Private Collaboration:
  • One patient, one record: A nationwide digital health system to streamline care and reduce redundancy.
  • Strategic purchasing mechanisms: Government-funded health service procurement from private providers to ease public sector burden.
  • Value-based health care and financing reforms: A shift toward outcome-based payment models to enhance efficiency.

Dr. Madan Gopal, an advisor to India’s National Health System Resource Centre (NHSRC), discussed India’s significant initiatives to achieve UHC, including the National Health Policy (2017). A key focus has been reducing out-of-pocket expenditures (OOPE) and enhancing public health spending. As the Secretariat for National Health Accounts plays a crucial role in monitoring financial flows, and while government spending on health has increased, OOPE remain a challenge.

India, with 480 million urban residents and a 35% internal migration rate, faces significant healthcare access disparities. Recognizing this, the government has evolved from rural-focused programs like the National Rural Health Mission (NRHM) to a unified National Health Mission (NHM) that integrates both rural and urban health strategies. To address secondary and tertiary health care needs, financial protection schemes like the Rashtriya Swasthya Bima Yojana (RSBY), now expanded into the Pradhan Mantri Jan Arogya Yojana (PM-JAY), aim to prevent catastrophic health expenses for 750 million people. The urban healthcare landscape, with its mix of public and private providers, demands innovative service delivery models. Some of the key initiatives to address include:

• Urban health and wellness centers ensuring access to primary health care services.
• Polyclinics provide specialist consultations, diagnostics, and medicines free of cost.
• Public-private partnerships for addressing demand-supply local needs.
• Digital health integration in smart city initiatives, for instance use of disease surveillance dashboards.

Pollution, waste management, and infrastructure directly play a significant role in urban health. The Smart Cities Mission incorporates health into urban planning by adding cycling tracks, open gyms, and environmental monitoring while enhancing inter-sectoral governance between urban local bodies and health departments. India’s urban health framework, developed by NHSRC, aims to integrate social determinants into health planning, potentially transforming urban health governance if widely adopted by line ministries. The journey to UHC is ongoing, and challenges like referral pathways and healthcare standards continue to exist.

Dr. Atul Kotwal on the Way Forward for Urban Health

Dr. Kotwal emphasized the need for a distinct approach to urban health while striving for UHC. Unlike rural health systems, urban areas require solutions that address complex social determinants of health, including intersectoral coordination, environmental concerns, and the dual burden of non-communicable and communicable diseases, particularly in urban slums.

He highlighted the importance of incentivizing and retaining health care professionals in urban public health systems. While many join initially, they often move to private sector opportunities, leading to inefficiencies in human resource deployment. Strengthening governance and administrative structures is essential to ensure long-term retention and effective service delivery.

A critical takeaway from Dr. Kotwal’s reflections was the need to rethink urban health infrastructure planning. Often, health facilities for the urban poor end up being under-resourced and underutilized. Instead, a more sustainable approach would be to create facilities that also attract the urban middle class, thereby ensuring higher quality care and better financial sustainability. To make this vision a reality, increased investment, optimised resource use, and reducing unspent funds under the Finance Commission and National Health Mission (NHM) are required.

Dr. Kotwal also emphasized the importance of community participation in urban health, particularly in gated communities where engagement remains weak. While Resident Welfare Associations have been explored, their effectiveness is limited. There is a pressing need to develop new models that strengthen health awareness, preventive care, and participation across different socio-economic groups.

In closing, he invited all experts to share their insights and contribute to refining the draft guidelines for urban health care, which are in an advanced stage. He stressed the need for continued dialogue, collaboration, and evidence-based policy recommendations to shape resilient and inclusive urban health systems aligned with India’s UHC goals.

About the Authors

Anupama Sharma, Principal Technical Advisor, Health Economics and Financing, Management Sciences for Health

Dr. Atul Kotwal, Executive Director, National Health System Resource Centre, Ministry of Health and Family Welfare, India

Dr. Somil Nagpal, Lead Health Specialist, Global Practice on Health, Nutrition & Population, East Asia and Pacific Region, World Bank

Dr. Dinash Aravind, Pharmacist & Economist, Health Transformation Office, Government of Malaysia

Dr. Madan Gopal, Advisor, National Health System Resource Centre, Ministry of Health and Family Welfare, India

Dr. Rahul S Reddy Kadarpeta, Executive Director, Joint Learning Network for Universal Health Coverage, Amref Health Africa