Demographic change and urban health: Towards a novel agenda for delivering sustainable and healthy cities for all

Demographic changes exert strong effects on urban health in all cities and regions

Demographic change does not refer only to changes in total population size. Rather, it encompasses a range of complex transformations including total population growth and decline, shifts in spatial distribution (across geographies and between urban and rural settings within countries), age-structural shifts (including ageing and youth ‘bulging’) and the evolution of family sizes and structures. These transformations have complex implications for formal healthcare provision and caregiving more generally, as well as for economic development, urban spatial transformation, and other factors, all of which will exert strong forces on urban health and wellbeing in future years.

Some demographic trends can be understood as global in scope. For example, nearly every country across the world is currently experiencing growth in both the size and proportion of its population of older people. Other trends are more specific to context. For instance, rates of population growth differ markedly across countries, regions, cities, income groups, and even by city neighbourhoods. Given this, how do (and will) demographic factors affect urban health and wellbeing? Here we briefly discuss these effects in relation to three key domains: population change, age-compositional change, and migration.

Urban health advocates should develop and follow a transformed approach to understanding the relationship between demographic change and urban health

The spectre of population control

Until the last decade of the twentieth century, policy discussions of demographic change often were dominated by the question of whether population growth is a problem for economic development and/or environmental sustainability. The debate remains controversial, especially among non-demographic experts, and advocating a demographic agenda that draws attention to negative effects of high fertility rates in LMICs or pro-natalist policies in higher-income contexts risks attracting accusations of neo-Malthusianism, racism, and/or sexism. In population policy and research circles, these concerns took expression in the 1994 Cairo Programme of Action. This was a landmark event that decisively shifted emphasis from macro-level rationales to justifications based on individual rights, including the right to be free from coercion, bringing welcome attention to women’s reproductive health. Today, many political economists and environmentalists would add that a focus on ‘population control’ distracts from the systems of production, consumption, and inequality that underpin climatic and environmental problems. Nevertheless, there remains considerable resistance to demography-facing interventions such as family planning programmes as routes to sustainable and productive futures.

Demographic changes unfold over a complicated political terrain, but some of the reluctance to engage seen outside the population field could be addressed by:

Demographic change, economic development, and health

There is little debate that population growth, decline, and age-structure changes exert strong effects on economic development from the local to the global scales, with potentially significant implications for health and wellbeing. But less consensus exists on the direction and strength of any one specific effect. Much depends on the trade-offs and potential complementarities among fertility, investments in human capital per child and per student, and investments in physical capital, all of which influence the course of economic growth.

Countries with growing populations of children and/or older persons living in towns and cities are likely to see additional demands placed on state and family budgets. This will likely strain the public finances and services that can be directed to education, systems of healthcare and social security, critical urban infrastructures, and other wealth-generating interventions. High levels of state spending on young-age and older-age dependants have the potential to ‘squeeze’ the living standards of working-age populations (Mason and Lee, 2022).

However, demographic changes can also generate policy opportunities to improve healthcare and the health of urban populations. To some, ‘population age structure and health status [are] key demographic determinants of economic progress’ (Bloom and Canning, 2007). The concept of ‘demographic dividends’ and ‘windows of opportunity’ has proven influential in policy circles, often inspired by the astonishing growth (linked to rapid demographic transitions) achieved in East Asian economies such as South Korea and Thailand since the 1970s. Currently, these discussions concentrate on the potential for economic growth in contexts of Latin America, South and South-East Asia, and sub-Saharan Africa.

The windows of opportunity can take several forms (following Fried, 2016; World Bank, 2016):

Meanwhile, the economic implications of ageing populations and population decrease have also attracted public and policy attention in diverse contexts including Singapore, Lebanon, South Korea, Australia, Vietnam, Italy, Russia, and some countries in Eastern European (for example, Bulgaria) and Latin America (for example, Chile and Costa Rica). Population ageing is often portrayed as being detrimental for economies owing to the reduced size of productive workforces, limited tax revenues, and increased (health)care and pension costs. Yet those relationships are not immutable recent research shows that declines in economic growth associated with population ageing can be moderated if older populations are in relatively good health (Cylus and al Tayara, 2021).

Whether low fertility rates and population ageing are a problem for countries depends on a complex interplay of factors including age-related patterns of income from labour, consumption levels, and the nature and extent of intergenerational transfers of wealth and care (Lee, Mason and members of the NTA Network, 2014). We can understand these relationships with the aid of two variables. A high fiscal support ratio (where a society enjoys a greater ratio of taxpayers to beneficiaries) tends to be favourable for public finances, allowing provision of more benefits at each age, lower taxes, a smaller budget deficit, or a combination of those three factors. A society with a higher support ratio (having more earners relative to consumers) means that each of its members enjoys proportionally greater availability of resources. That availability allows for more consumption, boosted savings and investments, or some combination of the two (ibid.). If either or both ratios are relatively low in a society, the sustainability of health and welfare systems are potentially threatened.

The extension of years of good-quality life is in itself a profoundly beneficial advance. There is a risk of being too narrow in framing economic development in conventionally economic, ‘monetized’ terms. That being said, the conditions under which old-age groups are adequately supported and enjoying good-quality lives is due to prior investments made in the human capital of all population groups, increases in the physical capital with which the labour force works, and rates of innovation and technological progress.

A key ongoing debate centres on the fundamental drivers of declining fertility rates, and hence on the best mechanisms to reduce fertility rates and deliver associated benefits. Recently researchers have argued that investments in human capital such as education are more significant in delivering the demographic dividend than changing age structures (Lutz et al., 2019). There is also some debate concerning the causes of stalls in the fertility declines of African countries and urban areas (Schoumaker, 2019). At minimum, these debates imply that an advocacy agenda centred on the urban health/demographic nexus should be careful to encompass and demonstrate the links between demographic shifts, wider political and economic transformations, and necessary investments in human capital to ensure that the positive effects of these shifts are enhanced, or their negative effects are alleviated.

Much of the work assessing the economic dynamics and impacts of population change focuses on the national or regional level and has yet to be downscaled to urban and intra-urban areas. How such factors could or will affect urban health and wellbeing in different contexts has not yet emerged as a specific topic of research interest. We could reasonably hypothesize that investments in urban health and wellbeing could play an important role in promoting the positive effects and alleviating the negative effects of demographic changes in towns and cities. No studies have assessed the specific extent to which urban health investments might do so, or how such investments should be optimally targeted in space and time.

Demographic change and shifting policy/practice landscapes

Changing age profiles in societies will shift the political influence of various demographic groups; some groups will be better positioned than others to make claims on public and private institutions for the provision of social security, healthcare, and other health-promoting services or infrastructures. Alternatively, this political influence may be used to resist changes that would promote the health of other urban groups or urban populations more generally.

Demographic processes will ultimately shift the terms of electoral and patronage politics, and by implication the politics of urban health, in all settings. For example, the political implications of large (often unemployed and deprived) youthful urban populations in African settings is well documented. In India, the politics of the youth attracts public attention, while the significance of youth-led political mobilization has been noted further afield in relation to the Occupy movements of North America, the ‘Arab Spring’ uprisings, the 15-M Spanish anti-austerity movement, and the 2019–20 Hong Kong protests, among other events. As political attention shifts towards the demands and aspirations of urban groups in many contexts, particularly less-urbanized LMICs, we can expect renewed accusations of ‘urban bias’ to emerge and strengthen alongside reactionary political coalitions.

The growing political influence of older populations in North American and European contexts is also much discussed (Greer et al., 2021). Countries like Singapore, South Korea, Japan, and Russia have adopted pro-natalist policies to compensate for low fertility rates and population ageing. The implications of pro-natalist policies for future consumption, emissions, and climatic/environmental change have not attracted much critical debate. Many countries resorting to pro-immigration policies have experienced ‘nativist’ political backlashes.

Moreover, demographic changes will colour the nature, extent and characteristics of social movements related to urban health. How this happens should be considered both in terms of the participants of social movements – how they shape the goals, ideologies, and tactics of their movements – and in terms of how the demographic characteristics of society more broadly influence such factors (Goldstone, 2015). A paper by Thomas et al. in this collection (forthcoming) examines social justice and equity movements in the context of urban health.

What insights for urban health does a demographic perspective offer?

The emergence of an influential and widespread ‘age-friendly cities and communities’ movement over the past several decades has served as a helpful extension of earlier ‘healthy city’ concerns and programmes (De Leeuw, 2017). In particular, the age-friendly movement has:

More generally, a demographic perspective is useful in highlighting issues of temporality and the necessity of having available and accurate data. That is, a demographic perspective reveals the medium- and long-term structural transformations that will influence how cities and urban health change (including age-structural shifts and related disease burdens), how much money is available to states and societies to invest, how local and national governments plan, and when and where money should be invested. Consequently, promoting urban health and wellbeing should involve anticipating both short-term and multi-decadal demographic changes and their geographic distributions, while planning and investing in health-promoting initiatives through spatial and temporal targeting, including through investments and practices that are not necessarily directly related to the health sector (e.g. urban planning or urban infrastructure finance and management). A demographic perspective therefore highlights the importance of having data that are accurate, recent, and representative of the population, and of collecting longitudinal data that enable the separation of correlation from causality, which is important when attempting to influence policymakers and decision-makers.

The Global Monitoring Report 2015/2016 (World Bank, 2016) produced a new global typology of countries that ties demographic change to development potential. The typology recognized the various pathways through which demographic change affects the prosperity of nations, enabling the disaggregation of policy priorities and recommendations according to the position occupied by countries within this typology. Countries were grouped into pre-demographic-dividend, early dividend, late dividend, and post-dividend categories.

A holistic approach to urban health and wellbeing could make use of a similar typology that is specifically tailored towards urban areas. Urban health programmes in different contexts could be framed as helping cities to progress positively through the stages of the demographic-developmental transition. Such programmes would take a long-term view and recognize that initial policy priorities (such as increasing access to family planning in pre-dividend cities) may need to give way to other priorities and interventions as cities ‘mature’ (for example, health policies that promote and protect female labour force participation in an early-dividend city). In the same way that a life-course approach draws attention to the ways in which different health risks and needs arise over the course of a lifespan, so a ‘city life-course approach’ would highlight that:

Priority data and research

Our discussion has indicated a range of research areas and topics that demand further attention if we are to better understand and harness the relationship between demographic change and urban health. These should be seen as a complement to the set of global research priorities for urban health recently identified by the World Health Organization, which do not encompass demographic issues or processes (WHO, 2022). Our priorities for data and research include investigation of:

Addressing these research priorities will require considerable advances in the availability and quality of suitably disaggregated data. It is now clear that simple national disaggregation by urban and rural categories will not be sufficient for an accurate understanding of the interface between demographic change and urban health (Duminy et al., 2021). At minimum, researchers and policymakers require data revealing how demographic factors are distributed among different settlements and types/categories of urban areas, including intra-urban differences. Disaggregation by ‘slum’ and ‘non-slum’ categories (as in the Bangladesh Urban Health Survey programme), or by wealth index (as with India’s National Family Health Survey), provides a useful starting perspective on inequality that ideally would be refined through a focus on neighbourhood-level differences. Moreover, urban demographic data could be linked to climate projections to enable a better understanding of how different demographic cohorts living in towns and cities will experience emergent climatic risks such as increased heat stress.

There are new developments in the domain of spatial data and measurement that present opportunities to make the need to address the demographic/health interface in towns and cities to policymakers and decision-makers more compelling than it may have been in the past. For instance, the ‘Degree of Urbanization’³ measure, which is derived from satellite data and scheduled to be updated every two years, offers a way of approximating, with high specificity, where urban spatial growth is taking place and at least provides a proxy of where urban population growth is concentrated.

In terms of reforming related programmes and datasets, we have identified the following priority actions:

Beyond the reform of international programmes, there are opportunities to make use of supplementary or alternative sources of data to enhance understanding of intra-urban dynamics and differentials. One cost-efficient approach is for national demographic and health surveys to include a ‘booster’ sample of selected cities (Gupta et al., 2009).

A second approach would be for researchers of the demographic/health nexus to engage with an urban-focused citizen science movement. Technology-aided social or community-based mapping and census-taking offer a set of approaches with the potential to generate accurate local datasets that take account of local definitions and social dynamics, encourage community engagement, while promoting local ownership and coproduction of data and project interventions. There may be opportunities to work with and learn from urban-focused networks like Slum/Shack Dwellers International (SDI), which promote community-based enumeration activities in poor urban areas of LMICs, but not necessarily with an explicit or detailed health lens (Patel et al., 2012). Nonetheless, these initiatives provide granulated insights that could be linked to existing demographic and health datasets, or communities undertaking self-enumerations could be encouraged to collect data on appropriate demographic and health factors. For their part, such organizations would benefit from the skills and techniques of demographic and health experts with their methodological rigour and the quality of their datasets.

We have argued that an effective response to the demographic-health agenda in urban areas demands data that are available for most contexts, accurate, recent, and sufficiently spatially and demographically disaggregated. However, discussions of data reform often assume that policymakers and decision-makers will somehow have the appropriate professional and technical capacity to use these data to analyse and act on complex urban relationships. There may be a need for a specific research agenda that considers, for example, the kinds of intellectual, professional, and technical capacities that are required to adequately document, understand, and act on the relationships between demographic change and urban health and wellbeing. This kind of research agenda, which is concerned more with the ‘means of implementation’ than the substantive nature of the demographic-health interface, is all the more pressing given that the agenda addressed by this article calls for the ‘joining up’ of two relatively discrete fields of inquiry and practice: demography and urban health (Harpham et al., 2021). In some cases, that process of ‘linking’ may require:

Consequently, there is a need to gather case studies of institutions or initiatives that have attempted to link the demographic and urban health (or perhaps other) fields through data practices, to build capacity to analyse complex urban problems, and to use the resulting information to shift the basis of policy- and decision-making. Examples include the work of the African Population and Health Research Centre, which has used longitudinal data on urban demographic and health change to influence policymaking in Nairobi and Kenya, or the Bloomberg Centre for Government Excellence at Johns Hopkins University, which supports and coaches local leaders to build data-driven approaches to urban governance.