From the public governance perspective, the WHO defines health as a resource for everyday life and a necessary condition for socio-economic development and a fundamental human right. Governments are expected to intervene and maintain public health by providing medical infrastructure and services using public resources (such as tax budgets) as necessary supplementary means to health provision by the private sector. This is due to the defect of private-sector health provision. While it might be efficient in meeting some aspects of individual health needs, like the allocation of food, private-sector health provision creates nuisance effects, for example, inequalities in health access due to individuals having varied financial limits. Hence, health services cannot be simply or primarily treated as private good like they currently are in many developed states.
Urban health resources or services are determined by social, environmental and technological features which could be public, private, club goods or even common-pool resources (Table 1). For example, food and common vaccines are ideally public goods as they are basic conditions for health. No one should be excluded from these basic conditions, nor should anyone’s access to food and common vaccines be an obstacle for others to obtain the same. Products like toothbrushes and facial masks are necessarily exclusive and rivalry for health purpose, they, therefore, are private goods. Premium health maintenance and high-end wellbeing products are often club goods which allow non-rivalry and exclusive access depending on consumers’ willingness to pay. Urban green spaces are known to have multiple health benefits, they are not exclusive to any individuals, but some users entering a green space could result in less available space or facilities for other potential users. Therefore, urban green spaces, for example, are often considered common-pool resources.
Table 1
typology of urban health resources
| Excludable | Non-excludable |
Rivalry | Private goods e.g., toothbrushes, facial masks, retail and prescribed drugs | Common-pool goods e.g., urban green spaces, medicinal plants, health centers, public hospital beds and equipments |
Non-rivalry | Club goods e.g., Premium health maintenance and high-end wellbeing products, tailored personal care, private parks, swim clubs, | Public goods e.g., free healthcare, health norms, common health culture, food and common vaccines, healthy urban living environment |
Therefore, urban health governance requires dealing with the entire range of goods and services which a city provides. Urban health is an outcome of many interacting social, environmental and technological determinants in the city, such as transportation, housing, education, food and nutrition, the economy and income opportunities, green spaces and social cohesion. One single form of governance to address all types of urban health goods and services is insufficient for managing health; rather, it becomes malfunctioning when public health emergencies appear in the first instance. Accordingly, health governance needs to use the entire bandwidth of governance types: market or private sector, the government, and communities. A systems approach is a suitable approach for urban health governance, as it is about the management of the total urban system goods and services, which, by their interactions and functioning, constitute urban health.
Apart from applying different governance types to the appropriate type of good or service and at the right scale, a systems approach to urban health governance consists of (1) an improved understanding of the complex interactions and functioning of one or more determinants of urban health and possible causes for an infectious disease outbreak, (2) the active participation and collective action of stakeholders in the co-creation, management and knowledge of urban health. As such, the systems approach constitutes a multi-level collective learning cycle. With each cycle, the knowledge and management of certain urban health aspects can improve and contribute to advancing collective intelligence in society. Collective intelligence is an emergent property of (1) an improved data metabolism, which turns data into information and knowledge, (2) it consists of the transformation of knowledge into action, and (3) involves all stakeholders in a continuous learning process with multiple feedbacks. A systems approach is the precondition for collective intelligence to emerge.
In line with that understanding of urban health and its governance, the level of public health depends not only on the services which governments provide, but also on individual members of society to co-create and maintain it. The individual members of society need to recognize that it is within their responsibility to learn and participate in public health management. The Ottawa Charter for Health Promotion recognizes the need to enable people to have greater control over their health and well-being.[34] The Healthy China 2030 Agenda also emphasizes that people should be responsible for their health under the leading of governments.[35]
5. Recommendations for better public health governance in an increasingly urban future
Back to the experience of the countries mentioned above coping with COVID-19, effective centralized coordination and rapid response to a public health emergency of a large population and economic scale need to be recognized and widely learnt among the international health management community. Besides, the rapid global spread of COVID-19 has shown that world governments, public health sectors and individual citizens by and large lack a precautionary mindset in public health management. A precautionary approach is better than the best emergency response, especially when human health is at stake.
Drawing these lessons learned and the above-presented systems approach framework, we thereby provide recommendations for better public health governance for national and local governments worldwide in an increasingly urban future. First, we recommend governments adopt a more polycentric urban health governance approach with better regulation, information and multiple stakeholder participation. Governments not only need to take on the responsibility to act upon COVID-19 with the notion of health as a public good but also need to accept their limitations. Governments need to cultivate a sense of shared responsibility and transparency between themselves, social enterprises and citizens, for building better social capital and maximizing the utility of existing private, club and common-pool health resources. Health promotion is not merely the responsibility of the health sector nor the vested interest of divided private enterprises. In this globalized world, the COVID-19 pandemic has quickly come to affect everyone. Individual citizens and enterprises, therefore, need to take on the responsibility to speak and act upon their best knowledge and potential for the health of their community. Governments need to facilitate public participation and private sector support in maintaining health with transparent and updated information. Confronting an outbreak like COVID-19 requires trust and collaboration. "No single organization can deliver the wide range of services and systems needed for a truly global mechanism that prepares for and responds to outbreaks and emergencies," writes Margaret Chan, former director-general of the WHO, as she reflects on experiences from coping with Ebola.[36] Diversity in institutions and types of governance for health increases the effectiveness of preventive measures and societal resilience against a virus outbreak. Collective intelligence and societal resilience would reduce the high social and economic costs of drastic administrative decisions like the quarantine taken during an emergency.
Second, we recommend the public health system to move from responding to emergencies to long-term preparation with a precautionary mindset. This is due to the multiple attributes of urban health resources (Fig. 2). For example, common-pool resources such as public hospital bed facilities and medical equipment require good public funding planning and long-term investment to set in place. In addition, due to the unpredictability and increased likelihood of future pandemics, it is necessary to prepare emergency medical supplies and medical professionals for the long term. A pandemic monitoring and early warning system based on health information contributed from bottom-up without constraints would be critical to improving the preparedness of the public health system. Additionally, acoording recent studies, the aerosol transmission route, the source origin as well as the seasonality of 2019 novel coronavirus are all poorly understood.[37–42] Besides, Feng He stated that it is still too early to develop an accurate R 0 estimate or to assess the dynamics of transmission.[43]
A better scientific understanding of the emergence and transmission of the virus in the context of demographic, climate and environmental change is needed in the future, which can help governments make long-term preparation of public health system.
As we look to the future, pandemics are likely to become more frequent globally, unless we adopt a systems approach to urban health governance. In a globally interconnected world, health concerns us all and getting its governance right is urgently needed. As the rising numbers of confirmed cases of COVID-19 are showing, the world remains dangerously unprepared for a global pandemic. It is inappropriate to meet urban and public health challenges by relying on the government or private sector alone. As social justice and equity are core foundations for health, it is critical to involve the people to engage in long-term health prevention and maintenance. In addition to emergency response, public health governance needs to reform by adopting a more systemic approach that is long-term, multi-stakeholder, multi-sectoral, organized around community health services, particularly in the context of global climate change, rapid urbanization, demographic and epidemiological changes.