Global South cities hold key to unlocking health care solutions, studies show

Most people living in cities in low- and middle-income countries can reach primary care clinics within 30 minutes—yet average quality of care remains poor with clinicians failing to make correct diagnoses or implement appropriate treatments, new studies reveal.

The costs of providing services vary significantly and while most people report low out-of-pocket expenses, a minority face catastrophic health costs. Patients often bypass closer, cheaper clinics to access higher-quality care, even if it means traveling further and paying more.

A series of research papers published in Lancet Global Health reveal that the average quality of services is subpar, with frequent medicine shortages and inadequate management of long-term conditions.

The international team of researchers, led by the University of Birmingham, proposes a range of strategies to reshape the primary health care market in cities in low- and middle-income countries (LMICs). These include:

• Investing strategically in public health facilities—stimulating improvements across the sector, crowding out low-quality providers and encouraging higher standards;
• Strengthening regulation to enhance quality across public and private sectors;
• Integrating facility-based care with community health workers to provide comprehensive, equitable care, as demonstrated by successful models in Brazil;
• Providing ongoing education and training for health care providers are crucial for maintaining high standards of care;
• Empowering patients through health literacy initiatives and community engagement—driving demand for better services; and
• Removing user fees and providing vouchers to improve access to essential health services, particularly for the most vulnerable populations.

Lead author, Professor Richard J. Lilford, from the University of Birmingham, commented, “Our research underscores the importance of understanding the unique dynamics of urban health care markets in LMICs. Facilities are plentiful and easy to reach, but highly diverse in terms of cost, quality, and crowding, resulting in a market of competing public and private providers.

“Much policy discussion of health services in LMICs still relies on knowledge and models derived from rural contexts. It simply doesn’t account for the dense network of competing providers in the urban health service landscape.

“This means that improvement strategies which work in rural contexts are unlikely to be successful in a city setting. We must find ways of creating innovative policy approaches that give patients choice and competition—this will help to re-shape markets and improve the quality of health care.”

The researchers note that policymakers must balance public service expansion with subsidies for private care to improve access and equity. Research gaps persist, especially regarding marginalized populations and areas on the edge of cities.