• Cities in developing countries have a particular set of challenges in the battle against COVID-19.
  • Investment in primary healthcare is one of the best ways to overcome these barriers.
  • Scaling-up local health capacities can save precious resources as well as lives during a critical period.

The first wave of the COVID-19 pandemic may be receding in some parts of Western Europe, East Asia and North America, but it's rapidly taking-off in Latin America, Africa and South Asia. Countries in these lower- and middle-income regions are experiencing spiraling infections, hospitalizations and deaths. Owing to a lack of testing, it is likely that the true numbers are significantly higher. The impact of COVID-19 depends not just on national preparedness, but also on the readiness of states and municipalities. What cities in Brazil, Nigeria or India do next will not only determine the health of their residents, but the fate of their national economies.

Whether rich or poor, all cities face similar challenges as COVID-19 spreads, especially the way it decimates under-serviced neighbourhoods. Many cities have shortfalls in testing kits, protective gear and medical equipment. Hospitals, clinics and ICUs are limited and unevenly distributed. Cities in developing countries have a triple burden, however, including low health capacities, jarring socio-economic inequalities and high levels of informality that make physical distancing, shelter-in-place and curfews virtually impossible to adhere to, much less enforce.

Faced with surging case fatality rates and a monumental economic crisis, national, state and city governments in lower- and middle-income settings urgently need to make the right health policy moves. Investments need to be surgically precise, rigorously implemented and cost-effective, especially given that cities are facing falling revenues and rising deficits. Primary healthcare ticks all of these boxes and is likely the most effective and efficient tool to contain the COVID-19 pandemic, as well as future infectious disease outbreaks.

Cities offer the potential to scale primary health interventions. For one, over 80% of Latin Americans are already urbanites, among the highest concentrations of city dwellers in the world. Latin American cities are also among the most unequal, with roughly 25% of the region’s urban population – more than 160 million people - living in densely populated slums. What is more, primary healthcare is the responsibility of municipalities across the region and many other parts of the developing world. This means that cities are often equipped with sizable health assets, especially community health workers. They can help compensate for the limited quantity and poorer quality of healthcare facilities.

Take the case of community health agents operating on behalf of Brazil’s national Saúde da Família programme. These workers are typically more trusted than other public officials in the communities where they operate, and trust is critical to spreading health-related campaigns and in convincing locals to adhere to public health directives. Community health workers are frequently best-placed to visit hard-to-reach patients, including in informal settlements. Health agents are also in a good position to fight misinformation that is spreading rapidly on social media and in the news. Precisely because of their personal relationships with the people they serve, their words are more convincing than a message delivered by radio or WhatsApp.

COVID-19 cases in Latin America and the Caribbean as of 6 May
COVID-19 cases in Latin America and the Caribbean as of 6 May
Image: Statista

Whether in Brazil or elsewhere, community health agents have specialized knowledge about the neighborhoods they serve. This means they are ideally suited to tailor health campaigns to local realities. They usually serve as the eyes and ears of the municipal health system, collecting information on symptoms, screening residents for testing, and organizing contact-tracing where required. Not only do they help narrow testing and isolation measures, they help reduce the load on over-stretched healthcare providers.

Cities can also convert under-used and distressed assets into serviceable “low-intensity” medical facilities. The rapid set-up of testing centres, together with pre-screening and contact-tracing, can rapidly lower the number of testing kits required. Newly erected health facilities can also serve as local beacons for tele-health, further reducing the patient caseload. Hospitals and clinics that are supplying non-COVID-19-specific care can also distribute protective equipment and positive health messages while also testing where possible to avoid asymptomatic contagion.

Cities can and regularly do make use of their vast reservoirs of health, demographic and socio-economic data to drive health responses. This includes mapping vulnerable “hot spots”, especially neighbourhoods with higher concentrations of older, migrant, homeless and informal workers. Many at-risk people are simply unable to self-isolate and are more vulnerable to infection and severe illness. Targeting and intensifying resource allocation to affected areas and vulnerable populations is essential to reduce case fatalities. In this way, urban authorities can avoid blanket quarantines that generate mistrust and social unrest.

Ultimately, cities are the front- and last-line when it comes to fighting this pandemic and the next one. In many cases, they can access and mobilize data and have access to physical and human resources - especially primary healthcare providers – that make the difference between life and death. Enlightened national and state decision-makers must take note and leverage the power of their municipalities. In this way they can reduce the burden on hospitals and first responders. Not only will this save precious resources - it will save lives.