Health and the city: why urban health systems need greater authority

Around four billion people, just over half the global population, live in urban areas. This proportion is projected to rise to two thirds by 2050, with most growth occurring in low and middle income countries (LMICs).1 Urbanisation affects health by changing the conditions in which people live, work, travel, and obtain care. Dense urban settings can improve access to services and economic opportunity, but rapid growth can also outpace housing, water, sanitation, transport, environmental regulation, and health service capacity, increasing exposure to air pollution, heat, injury, infectious disease, and conditions associated with non-communicable disease.2 These risks fall disproportionately on people living in informal settlements or facing insecure housing and employment, who may also have poorer access to care.34Urban governance shapes how urbanisation affects health: it influences the conditions that create risk, who is most exposed, and how effectively cities respond.5 It concerns how responsibilities, resources, and authority for decision making…