Bulletin 22ISSN 2010-1198

URBANPOVERTY

HEALTH

ASIA

and

in

C

M

Y

CM

MY

CY

CMY

K

ATM #22 cover.pdf 1 6/11/13 3:31 pm

Nursing students in training, Yogyakarta, Indonesia

The Asian Trends Monitoring Bulletin is a project

sponsored by the Rockefeller Foundation, New

York and the Lee Kuan Yew School of Public Policy,

National University of Singapore. The Lee Kuan Yew

School of Public Policy gratefully acknowledges the

financial assistance of the Rockefeller Foundation.

The Asian Trends Monitoring Bulletin focuses on

the analysis of pro-poor projects and innovative

approaches that will contribute to alleviate poverty.

The emphasis is put on identifying major trends

for the poor in rural and urban areas, highlighting

sustainable and scalable concepts, and analysing

how these could impact the future of Asia’s well-

being and future development.

The Asian Trends Monitoring Bulletin are designed

to encourage dialogue and debate about critical

issues that affect Asia’s ability to reduce poverty and

increase awareness of the implications for pro-poor

policy and policy development.

Disclaimer

The opinions expressed in the Asian Trends Monitoring

Bulletin are those of the analysts and do not necessarily

reflect those of the sponsor organisations.

Frequency

The Asian Trends Monitoring Bulletin will be produced

eight times a year and can be downloaded for free at

http://www.asiantrendsmonitoring.com/downloads

Principal Investigators

Phua Kai Hong

T S Gopi Rethinaraj

Research Associates

Johannes Loh

Marie Nodzenski

Guest Writers

Nicola Pocock

Taufik Indrakesuma

Bianca Ayasha

Production

Johannes Loh, Production & Research Dissemination

Michael Agung Pradhana, Layout & Design

Image credits, with thanks

- Asian Development Bank on Flickr (Vaccination p.4)

- Flickr user #Pacom (Health check p.17)

- Flickr user dma-hawaii

- Boy with mask (p.2)

- Health worker (p.15)

- Global Environment Facility (GEF) on Flickr

- Thermometer (p.19)

- U.S. Embassy Jakarta on Flickr (Doctor p.8)

- World Bank Photo Collection on Flickr

- Nursing students (inside Cover)

- Children eating (p.5)

- Children washing hands (p.21)

- World Bank East Asia and Pacific on Flickr

- Nurses in Indonesia (p.18)

Permission is granted to use portions of this work

copyrighted by the Lee Kuan Yew School of Public

Policy. Please follow the suggested citation:

When citing individual articles

Phua, K. H. & Nodzenski, M. (2013). Prospects for

the Future: Towards Better Regional Governance in

Health. In Asian Trends Monitoring (2013), Bulletin 22:

Urban Poverty & Health in Asia (pp.17-19). Lee Kuan

Yew School of Public Policy, Singapore.

When citing the entire bulletin

Asian Trends Monitoring (2013), Bulletin 22: Urban

Poverty & Health in Asia. Lee Kuan Yew School of Public

Policy, Singapore.

When citing our survey data

Asian Trends Monitoring (2012). A dataset on urban

poverty and service provision. Lee Kuan Yew School

of Public Policy, National University of Singapore.

Please acknowledge the source and email a copy of

the book, periodical or electronic document in which

the material appears to chris.k@nus.edu.sg or send to

Chris Koh

Lee Kuan Yew School of Public Policy

469C Bukit Timah Toad

Singapore 259772

Contents4 s Urban Poverty and Health in Asia by Phua Kai Hong

6 s Protecting the Health of Asia’s Urban Poor by Nicola Pocock

9 s Healthcare-seeking Behaviour in Slums by Nicola Pocock

12 s The Unhealthy Impacts of Poor Water and Sanitation by Nicola Pocock and Taufik Indrakesuma

14 s Unregistered and Excluded: the Government Healthcare Problem by Taufik Indrakesuma and Johannes Loh

17 s Prospects for the Future: Towards Better Regional Governance in Health by Phua Kai Hong and Marie Nodzenski

3

Public health in urban areas has been and will continue to be affected

by global population trends. More than 50% of Southeast Asia’s total pop-

ulation is projected to be living in urban areas by 2025, which will exert

additional pressure on urban health systems. Traditionally, cities offered a

health premium over rural areas, especially as they advanced their infra-

structure. At the onset of the 20th century, improvements in water, san-

itation and sewage systems, roads, and green spaces meant that cities

became healthier places to live. In addition, the growth of cities provided

a range of indirect benefits to health, including the expansion of food mar-

kets with a steady and diverse supply, public services, transportation sys-

tems and a critical mass of educated people necessary to drive innovation

and commerce (Dye 2008). Public resources can be concentrated at lower

cost in cities, which is effective in public health interventions through basic

primary health care like immunization, clean water and waste disposal.

However, as this bulletin will demonstrate, these improvements in pub-

lic health are not equitably accessible to all parts of society. Even major

cities in the region such as Jakarta and Manila have large slums that are

deprived of healthy living conditions. Not only are health centres difficult

to access, the most basic amenities such as sanitation and piped water are

also scarce. As such, major interventions are necessary to close these gaps

and improve the health of poor communities in Southeast Asia.

In this bulletin, we focus on the trends in urban health in Asia, highlight-

ing the deficiencies in health and healthcare for the urban poor. We then

discuss the specific types of public services that need to be improved in

order to maximize impact. Throughout the bulletin, we will also include

case studies of micro-interventions that we found throughout Southeast

Asia, and point out opportunities to replicate their successes in cities. The

data and case studies that are used in this bulletin are the result of primary

data collection and field research. The team’s research on urban poverty

entailed travelling to four of Southeast Asia’s major cities: Jakarta, Manila,

Hanoi, and Vientiane. The team conducted an extensive Urban Poverty

Survey of 1,400 respondents as well as in-depth interviews with stakehold-

ers in all four cities. In this issue, we also compare the major challenges

faced by officials in these four cities in the field of public health. We pres-

ent the findings of the Urban Poverty Survey as supporting evidence of

the realities in the field. Finally, we will discuss the future of regional health

governance and the potential impact of further integration in ASEAN on

health systems and cities.

We invite you to share the ATM Bulletin with colleagues interested in

pro-poor issues in Southeast Asia. The Bulletin is also available for down-

load at www.asiantrendsmonitoring.com/download, where you can sub-

scribe to future issues. We encourage you to regularly visit our website

for more updates and recent video uploads in our blog. Thank you again

for supporting the ATM Bulletin, and as always, we gladly welcome your

feedback.

Phua Kai Hong

Johannes Loh

Marie Nodzenski

Guest Writers

Nicola Pocock

Taufik Indrakesuma

Bianca Ayasha

Urban Poverty and Health in Asia

Suggested citation

When citing individual articles

• Phua, K. H. & Nodzenski, M. (2013). Prospects for the

Future: Towards Better Regional Governance in Health. In

Asian Trends Monitoring (2013), Bulletin 22: Urban Poverty

& Health in Asia (pp.17-19). Lee Kuan Yew School of Public

Policy, Singapore.

When citing the entire bulletin

• Asian Trends Monitoring Bulletin (2013), Bulletin 22: Urban

Poverty and Health in Asia. Lee Kuan Yew School of Public

Policy, Singapore.

When citing our survey data

• Asian Trends Monitoring (2012). A dataset on urban poverty

and service provision. Lee Kuan Yew School of Public Policy,

National University of Singapore.

4

Urban Poverty and Health in Asia

Urbanization has been directly correlated

with economic growth in developed as well

as rapidly developing countries. The level of

urbanization defined simply as the proportion

of a country’s population living in cities has

been higher, the higher the country’s per capita

GDP. Yet burgeoning growth of cities through-

out the developing world appears to be posing

the most critical challenge to the future of these

cities and their societies to date. In facing such

a challenge, the cities that have linked urban

growth to economic development and housing

appear to have been most successful in address-

ing the issues posed by slums and the provision

of homes for the urban poor.

The effort to relate urban growth to hous-

ing development has been crucial in pre-empt-

ing many of the environmental and health

problems that have arisen because of poverty

and inadequate housing among urban popu-

lations. Adequate housing provision to meet

the needs of the urban poor and low-income

is crucial because it enables households to link

homes to infrastructure for potable water sup-

ply, solid waste removal and modern sanita-

tion. City governments in developing countries

around Asia are struggling with the prolifera-

tion of slums that include squatter settlements.

Many of these are considered illegal because of

a lack of land tenure rights. Spiraling land costs

in fast growing cities mean that the most conve-

nient locations in and around the city centre to

stay for low-income earners are often unafford-

able. Slums and squatter settlements are the

housing solutions of the poor. In many cities in

developing countries, the population living in

such slum and squatter settlements makes up

a third or so of the urban population.

The pace of population migration, urbaniza-

tion and globalization represents current and

projected challenges for the health of urban

populations. As a broad array of influences

impacts on the health of populations in cities,

public policy and organization are necessary to

promote effective planning and evaluation of

policies and programs. While the historic role

of public health emphasized addressing the

rudiments of physical environment such as san-

itation, much of health care has come to focus

on individual level of health and addressing

individual risk factors. However, the influence

of living conditions on health in cities should

include the physical and social environment as

well as health services. At the broadest level, the

by Phua Kai Hong

Local health staff provides vaccination in Laos

5

physical environment involves quality of water,

food, air and noise levels but more recently, the

perspective of how the built environment can

affect health is gaining momentum.

Similarly, a livable environment brings up

concerns of size, density, diversity and complex-

ity that are hallmarks of global cities, but the role

of social networks and support as well as social

capital, is currently emphasized. Such physical

and social environment issues have implications

for public policy and public health practice in

terms of planning, implementation and impact

evaluation. Increasingly, consideration of other

influences including interfaces of municipal,

regional and national government, business

and civic organizations is critical and likewise,

the broader trends of migration, urbanization

and globalization will impact living conditions

that affect the health of urban populations.

Underlying these are the fundamental political,

economic and social/cultural factors serving as

the foundation for any perspective on human

development and well-being in Asia. Rapid and

unplanned urbanization in Asia has profound

implications for population health. With glo-

balization, governance failures at the domestic

and international levels have resulted in inequi-

ties that translate into severe health impacts for

the urban poor. Urban poverty and growth of

slums, informal settlements and squatter areas

thus pose obvious hazards and risks to health.

Asia is home to more than half of the world’s

population and in the near future, estimates are

that more than 60% of the increase in the global

urban population will also be in Asia. In a rap-

idly urbanizing environment, different groups

of people may be exposed to a wide range of

risks from communicable and non-communi-

cable diseases as well as violence and injuries.

Different groups exhibit varying degrees of vul-

nerability or exposure despite the fact that they

live in the same city. These varying vulnerabili-

ties are translated into unequal physical and

mental health outcomes. The most extreme end

of the health inequity gradient in cities includes

people in low-income informal settlements or

slums. Currently, it is estimated that 60% of the

world’s informal settlers and slum dwellers are

in Asian cities. In South Asia, slums and squatter

settlements constitute 58% of the total urban

population, compared to 36.4% in East Asia and

28% in Southeast Asia. In absolute figures this

translates to more than 550 million people.

A platform for the notion of healthy urban

governance seeking to improve the social,

political, physical and economic environment

in cities is crucial to improving the health of the

urban poor and may be considered as a strate-

gic pathway for healthy urbanization.“Healthy

urbanization”, as defined by the WHO Centre

for Health Development, refers to the process

of enabling cities to achieve health and equity

through eight key principles, the “8 Es”:- envi-

ronmental sustainability, empowerment of

communities, engagement of all sectors, energy

efficiency, elimination of extreme urban pov-

erty, enforcement of security and safety, equity-

based health systems and expression of cultural

diversity. ATM

"Towards healthy urban governance,

principles of good governance need to

be continuously applied to the fullest

promotion and protection of health.

There is no single solution, and actors

will need to continuously navigate a

fast-changing environment in order

to achieve results. Change is best

facilitated through nodes of power

and influence among the urban poor,

local governments and the public

health sector that are establishing

cross-linkages beyond geopolitical

regions. National decision-makers can

create more supportive and enabling

environments for achieving fairer

opportunities for all by rendering

visibility to the health vulnerabilities

of the urban poor through the skilful

framing of public policy. "

(WHO, 2008. Our cities, our health, our

future: Acting on social determinants for health

equity in urban settings. WHO Centre for Health

Development, Kobe, Japan.)

6

Protecting the Health of Asia's Urban Poor

Unhealthy environments

In many Asian cities, planning for healthy cit-

ies has not kept pace with city expansion and

inflows of urban migrants. Rapid rates of migra-

tion have caused demand for public services

to outgrow capacity in several cities. For exam-

ple, sewerage system infrastructure is poor in

developing Southeast Asian cities. Only 1% of

Jakarta’s population is connected to a sewerage

system, followed by 7% in Manila, 12% in Ho Chi

Minh City and 41% in Phnom Penh (BAPPENAS

2007).

The most apparent outcome of this failed

urban planning is the prevalence of slums.

Southeast Asia has seen the growth in slums in

Cambodia, Laos PDR, Myanmar and Thailand

(see Figure 1). In aggregate, the slum population

as a percentage of urban population has seen

a minor decrease in Southeast Asia, from 50.7%

in 1990 to 48.7% in 2005 (UNSD), but absolute

numbers of people remain high. In 2005, 67.8

million were living in slum areas in all coun-

tries except Brunei, Singapore and Malaysia,

constituting around 12% of the population in

ASEAN.

As Dye (2008) notes, health in urban areas is

typically better than in rural areas, when mea-

sured by lower fertility and infant mortality

rates as well as higher access to sanitation and

nutrition. However, the growth of slums could

offset these health gains. This is confirmed by

responses to the Urban Poverty Survey that

indicate the urban poor’s difficulty in accessing

health services (see Figure 2).

As shown in the data, a large number of

respondents still feel that health services are

expensive and a large strain on their house-

hold budgets. When asked about the prices of

medicine in particular, responses were more

positive, but only slightly. In following sections,

the repercussions of unaffordable formal health

care services are discussed.

Health outcomes are worse in slums com-

pared to rural and other urban areas (Unger

and Riley 2007). Slum residents face a greater

number of health risks related to their physi-

cal environment, such as overcrowding and

poor sanitation. Detrimental effects on health

include increased prevalence of communicable

diseases, elevated risk of dying from prevent-

able conditions such as diarrhea and leptospiro-

sis, as well as less obvious health risks. For exam-

ple, poor structural quality of housing can mag-

nify the adverse effects of disasters (Unger and

Riley 2007), typified by a survey respondent in

Manila who described the need to place old car

tires on the roof of her house during typhoons

(Loh et al 2012).

Overall, the impact of slum environments on

the health of their residents is overwhelmingly

negative. In figure 3, Unger and Riley (2007)

outline the adverse health outcomes that arise

from the physical condition and legal circum-

stances of tenure. This is also supported by

data collected in the Urban Poverty Survey on

the self-assessed health of respondents. Figure

4 shows, for example, that only 21% of respon-

dents believe their health to be in “very good”

or “excellent” condition. Given the multitude of

health risks faced on a daily basis, this is hardly

surprising.

by Nicola Pocock

7

8

In order to improve health outcomes in

slums in the short term, Riley and Unger (2007)

stress the need to gather data on slum disease

burdens and intra-urban health disparities. The

disease burden in slums may be very different

from national and even other urban disease pri-

orities. The Urban Poverty Survey was able to

gather information on the types of illnesses that

respondents suffered within the past month

before the survey (see Figure 5).

Riley and Unger (2007) also emphasize the

need to identify and target modifiable con-

ditions of slum life. Immediate interventions

could include reducing sewage run off, educat-

ing residents on hand-washing and hygiene,

and installing proper waste disposal systems

and toilets (ibid). In a slum built atop a trash

heap in Bekasi, Jakarta’s eastern suburb, the

building of new toilets in the vicinity of a school

as well as extensive hygiene education has

decreased open defecation in the community

(Indrakesuma et al 2012b). As an environmen-

tal determinant of health, housing quality has a

huge impact. A study in Thailand showed that

improvements in housing design and materials,

including in sanitation, equipment, ventilation

and fuel for indoor cooking and heating, has

played a role in health gains. Mosquito-proofing

houses (e.g. installing windows) and reducing

pools of open water has also been beneficial in

reducing mosquito-borne diseases (Friel et al

2004).

Effective health interventions in slums will

require engagement with community groups

and, notably, private pharmacies that are often

the first point of contact for health services in

slum areas, as has been found in Indonesia

(Simanjuntak et al 2004) and Bangladesh (Khan

et al 2012). The reasons for this, as well as other

behavioral aspects of providing healthcare

for the poor, are discussed in the next section.

ATM

Life for Jakarta's Elderly

In Depok, Jakarta’s southern suburb, the team interviewed an old

man named Agus who could only approximate his age to be over 80.

Agus lives in a small house with his son’s family, numbering a total of

nine people, including several small children, in the house.

Agus used to work as a construction worker, but was forced to

retire when his body could no longer handle the work. Now he relies

on the support of his children to sustain himself, and has no savings

or pensions that he can draw from. When asked about whether he

smokes (an all too common affliction amongst Indonesia’s poor), he

could only smirk as he answered that he “used to smoke a bit too

much, but now has the discipline to restrict himself to one cigarette

per day”.

Given his limited financial resources, it was unsurprising to hear

that Agus does not make a habit of going for routine health check-

ups to the nearby health clinic. He reports that clinic visits are usu-

ally reserved for serious ailments that he or his family could not self-

medicate, and that the occasional cough, flu, or fever does not war-

rant any special medical attention. Though this is a common stance

towards medicine amongst the poor, it is especially risky for the

elderly, as deteriorating immune systems make self-medication and

bed-rest much less effective.

The recent health care reforms in Jakarta (discussed in detail in a

following section) have the potential to dramatically improve access

to health care for people in Agus’ position. However, the reforms

unfortunately do not reach poor families that have been forced out-

side of the city limits. Agus and his family had to move to their cur-

rent residence in Depok because slum crackdowns and rising costs of

living in the 1980s became unbearable. Depok, however, is not part

of the Jakarta Capital Region, and thus does not enjoy the benefits

of its health care reforms. Therefore, regular check-ups and proper

medical attention remain out of reach for Agus and his neighbors.

9

Healthcare-seeking Behaviour in Slums

In face of numerous health risks, slum resi-

dents face significant barriers to access health-

care. Private (and often unlicensed) pharmacies

and traditional healers may be located within

slums, but it is uncommon for formal health care

providers to be based nearby. The monetary

and opportunity costs of traveling to a health

centre may further deter slum residents from

accessing services. Even in cases where cheap

or free government health services are available,

slum dwellers are usually ineligible for such ser-

vices, as they are typically not formally regis-

tered as residents. Consequently, slum dwellers

often encounter the formal health sector in late

stages of often preventable chronic diseases

(Riley et al 2007). Respondents in the ATM’s

Urban Poverty Survey reported high levels of

difficulty in accessing formal health services, as

shown in Figure 6.

When facing illness, the urban poor tend

to self-treat with cheap medicine from private

pharmacies, or access the nearest available and

affordable alternative. A study on healthcare-

seeking behaviour of 160,261 residents in a

North Jakarta slum found that when faced with

diarrhea in the past month, 25% treated them-

selves, 23% visited a public health centre, 18%

visited a private provider, 16% went to hospital,

9% bought drugs from a drug vendor and 9%

used other healthcare providers, i.e. traditional

healers (Simanjuntak et al 2004). Children were

often brought to a public health centre, private

clinic or hospital, whereas adults tended to self-

treat. The poorest individuals were more likely

to use a public health centre compared to those

with higher income, corroborating earlier find-

ings on use of Posyandus (Indonesia’s public

health centres) by income (ibid, Kaye and Novell

1994a). The visualization of the ATM team’s sur-

vey results in Figure 7 shows that the current dis-

tribution of treatment preferences in Southeast

Asian cities is mostly skewed towards govern-

ment hospitals and health centres, though self-

medication and traditional medicine are still the

first choice for many poor families.

One worrying sign, however, is that there is

still a propensity to ignore their illnesses and let

them go untreated. One in four respondents in

by Nicola Pocock

10

the Urban Poverty Survey claimed that if they

fell sick, they would rather continue working

than seek treatment. Although the logic behind

it is clear – the cost of treatment and opportu-

nity cost of lost income are large in the short run

– the long-term consequences of deteriorating

health are often much greater.

Indonesia’s Posyandu system of publicly

funded primary health care centres is a model

of excellence among the countries visited by the

team. In several poor areas of Jakarta, Posyandus

were easily identifiable and found in different

corners of the slum, allowing local residents

easy access close to their homes. In Jakarta, 56%

of slum dwellers primarily used the Posyandu,

while public health centres in Manila, Hanoi, and

Vientiane were the first choice for 37%, 3% and

14% respectively. Past research corroborates the

positive effect of having access to free primary

healthcare in urban slums; one study found that

regular Posyandu users were more likely to be

immunized than non-users (Kaye and Novell

1994a). Crucially, this demonstrates that publicly

funded and accessible health centres can posi-

tively influence health behaviours.

However, the urban poor may use private

health services for other reasons. In a slum

settlement in Delhi, India, nearly 90% of study

respondents used private providers for basic

primary care, often unlicensed and unregis-

tered. Reasons given for not using public health

centres included long distance from home, lon-

ger time to get treated, rude behaviour and in

some cases, bribes that had to be paid to hospi-

tal staff to receive treatment (Barua and Pandav

2011). Anecdotal evidence from interviewees

in Manila and Hanoi support this claim: one

NGO in Manila reported that their beneficiaries

were reluctant to visit the local free health clinic

because they were afraid of being “scolded for

being poor, dirty, and unhealthy”. However,

survey responses seem to indicate that a slight

majority of respondents in all four cities (nearly

65%) are satisfied with the quality of services

provided by their local health centre.

The poorest in slums often face multiple

deprivations and may not be reached by offi-

cial health programs. In one urban slum in

Indonesia, evaluation of a national vitamin A

supplementation program found that 63% of

children in slums had not received the supple-

ment. They were more likely to be malnour-

ished, shorter, anemic, or to have had diarrhea

in the past week compared to children who had

received the supplement. They were also more

likely to come from families with a history of

infant or child death. The authors highlight that

children who were not reached by the vitamin

A program were also unlikely to be reached by

other programs, such as immunization (Berger

11

et al 2008).

Often, it is not a physical barrier of reaching

the poorest of the poor: infrastructure even in

the poorest areas of these cities is usually good

enough for assistance to reach them. The main

barrier then is usually informational or psycho-

social, where lack of awareness, shame, and

prejudice increase the poor’s inhibitions to seek

help. This is a barrier that is often forgotten or

unaccounted for when health providers design

their programs and interventions. ATM

MERCYCORP's KEBAL Program

Not all problems of health among poor urban communities are mat-

ters of finance. Some problems are matters of behavior, while oth-

ers are caused simply by lack of information. A perfect example can

be found in Jakarta’s pushcart vendors. For most poor households

in Jakarta, both parents need to work full time in order to make

enough money, meaning that they do not have enough time to pre-

pare meals for the family. Also, proper kitchen equipment is a rarity

in slums, with several households barely able to afford a small stove.

Thus, most households rely on pushcart vendors for their meals.

Pushcart vendors are a viable alternative due to how cheap the

prices are. However, this cheap food comes at a cost. In order to keep

prices low, vendors are often forced to cut corners in food prepara-

tion. Cheap ingredients, high use of MSG and generally prioritizing

flavor over nutrition are common traits, which is perhaps why several

popular street snacks are variations of deep fried flour. The end result

is that although these families appear to be well fed, they remain

malnourished.

At a glance, this does seems like a problem of finances. However,

one set of interventions from Mercy Corp, an international NGO,

proved otherwise. Mercy Corp sought to improve nutrition in

Jakarta’s slums by improving the food products sold by street ven-

dors. Thus, they launched a program called KEBAL, short for Kedai

Balitaku or “My Child’s Café” in 2009. The logic behind the program

was that if some food vendors started to sell healthier food while

keeping prices low, people would choose to buy the healthier,

slightly more expensive food rather than the cheaper, unhealthy

food.

The method used was to engage a number of street vendors in

eight neighborhoods in West Jakarta and partner them with nutri-

tionists. The nutritionists then created a menu of healthy meals and

snacks that would replace the unhealthy products that the vendors

used to sell. Food would be partially prepared in a central cooking

center so that ingredients remain fresh and clean, and exposure to

the unsanitary outdoor environments (one of the main hazards of

selling food from pushcarts) is kept to a minimum.

The program was designed to be self-sustaining, as the food

vendors were given ample training not only in cooking the healthy

menu and general hygiene, but also in financial literacy and man-

agement. The organization plans to expand the program through

micro-franchising, as it hopes the model is appealing enough for

more food vendors, as well as other aspiring micro-entrepreneurs,

to participate.

12

The Unhealthy Impacts of Poor Water and Sanitation

Many health problems, particularly commu-

nicable diseases, originate from poor quality

or lack of clean water and sanitation systems

for drinking, bathing, cooking and cleaning. A

study in 2004 showed that besides low house-

hold income and illiteracy, factors positively

associated with diarrhea episodes within the

last month in a North Jakarta slum were:

• use of water from a communal tap,

• poor rubbish disposal, daily consumption

of food from street vendors,

• living in a house that flooded within the

year prior,

• living in a wood structure and sharing a

toilet with other households.

Another household member having diarrhea

in the past month and being less than five years

old were also significant factors (Simanjuntak et

al 2004).

The lack of public service capacity has led

to the expansion of the private sector in water

provision and sewage systems. For example, the

Urban Poverty Survey found that 46% of slum

dwellers in Jakarta use private water vendors,

followed by 31% in Manila and 2.5% in Hanoi.

Relying on private water sources comes at sig-

nificant cost to the poor, who pay up to fifteen

times the amount of piped water. In Manila, the

price of five drums of water (1m3) costs around

US$3, whereas the same amount of piped water

costs only US$0.20 from a piped connection

(Padawangi in Indrakesuma et al 2012a).

Purchasing drinking water from vendors has

been associated with higher diarrhea preva-

lence and other negative health outcomes,

compared to those who don’t purchase drink-

ing water. In two Jakarta slums in 1994, 28% of

mothers reported that at least one child under

three years old had experienced diarrhea in the

last month, with frequency of reporting high-

est among poor mothers and those using water

from vendors (Kaye and Novell 1994b). Purchase

by Nicola Pocock & Taufik Indrakesuma

Open defecation – a common issue in Southeast Asia’s slums

13

of cheap drinking water has also been associated

with malnutrition, diarrhea and greater infant

and child mortality. A 2009 study showed that

families that purchased cheap drinking water

tended to have less educated parents, more

crowded households, fathers who smoked, and

lower socioeconomic levels (Semba et al 2009).

It is clear that structural conditions, i.e. having a

piped water connection, and access to a toilet,

can affect health.

However, the Urban Poverty Survey does

not show these connections conclusively. In

the results shown in Figure 9 below, responses

showed no strong link between sources of water

and frequency of illness as a whole. There does

appear to be a link between primary source of

drinking water and frequency of contracting

diarrhea, as 15% of those who shared a commu-

nal tap also reported contracting the disease in

the past month, compared to 4% of those with

a household connection and 6% of those who

used other sources.

Both household and community level struc-

tural improvements are needed. One quasi-

experimental study in Ahmedabad, India

reported that upgrading in slum water and

sanitation systems at the household level led

to significant decreases in the incidence of

water-borne diseases (Butala et al 2010). The

intervention involved communal infrastruc-

tural improvements, such as paving of internal

roads, street lighting, storm water drainage and

solid waste management. Individual house-

holds benefitted from water connections, toi-

let construction and underground sewage sys-

tems (ibid). The authors draw attention to slum

upgrading at the household level, as opposed

to the neighbourhood level (via shared facili-

ties). The latter has been shown to not reduce

the transmission of communicable diseases

(Zwane and Kremer 2007, in Butala et al 2010).

It is often overlooked by authorities that slum

upgrading can have wide-ranging multiplier

effects that will lower the burden of public bud-

gets. A healthier and cleaner environment helps

to improve educational outcomes, strengthen

families’ economic situation and lowers health

expenditure e.g. for water-borne diseases. While

it is difficult to precisely measure the cumulative

impact of upgrading in slums, studies as above

have illustrated the positive outcomes. ATM

14

Unregistered and Excluded: the Government Healthcare Problem

In order to curb expenditures and prevent mis-

use, most government healthcare subsidies are

limited by a number of criteria. Eligibility criteria

differed between the cities visited, but foremost

depended on being a registered “poor resident”

of the city. This requires having both residency

status and household income information in

the local government database. This way, local

governments ensure that the free healthcare

services are not being exploited by those who

can afford it.

Unfortunately, these requirements are often

a severe impediment for the poor. As one dis-

trict head in Jakarta noted, a large number of

slum residents are migrants who do not register

their residency and are thus ineligible for care. In

some cases, the residents are seasonal migrants

who return to their villages during harvesting

season. Of the Urban Poverty Survey respon-

dents in Jakarta, 12% have only lived in the city

for 5 years or less, which partially explains their

difficulties in accessing government healthcare.

In Manila, a similar story emerged – 29% of

respondents reported a great degree of diffi-

culty in accessing health services. PHILHEALTH,

the national insurance scheme, is estimated

to have only 50% coverage (REF). This is also

likely due to gaps in official resident databases,

causing a great number of households to be

excluded from insurance coverage.

In Hanoi, being registered on the “poor list”

guarantees access to all government services,

including healthcare, but getting onto the list

is cumbersome (Indrakesuma and Loh, 2012).

Only the poorest registered residents in each

district are put on the “poor list”, so being a reg-

istered resident does not automatically guaran-

tee access to healthcare.

As shown in Figure 10 on the left, health

insurance cover varied significantly between

the cities. Jakarta’s health insurance cover-

age was the lowest of four cities, with 10% of

respondents reporting some form of insurance.

Vientiane followed with 11%, while Manila and

Hanoi had much higher coverage rates (31% and

54% respectively). This is further evidence that

government healthcare programs still have very

limited coverage.

Fortunately, there are efforts in place to

improve data collection and coverage of gov-

ernment health insurance programs. The two

case studies below, one from Jakarta and one

from Manila, demonstrate innovations that

directly address the main weaknesses of gov-

ernment healthcare plans, and are good exam-

ples for other cities to follow. ATM

by Taufik Indrakesuma & Johannes Loh

15

Health worker conducts a basic health assessment in Indonesia

16

Free Healthcare for Jakarta – What Problems Remain?

--- by guest contributor Bianca Ayasha ---

The Jakarta Health Card program was recently launched by Joko

Widodo, the new Governor of Jakarta, on November 10th, 2012. The

program is part of his goal to provide free health care for all residents

of Jakarta, especially the low and middle income groups. The Jakarta

Provincial Government aims to disburse four million Jakarta Health

Cards in total. Cardholders will be eligible for free medical treatment

in 340 public health centres (Puskesmas), 88 regional general hos-

pitals, as well as some private hospitals that are participating in the

program.

The program is funded by the Provincial Health Insurance bud-

get, so only residents of Jakarta are eligible to receive the program.

Proof of residency in Jakarta is the one requirement to obtain the

Jakarta Health Card. This is done by showing their Identification

Card (Kartu Tanda Penduduk) or Household Information Card (Kartu

Keluarga).

Prior to this program, it was neither easy nor cheap for residents

of Jakarta to access healthcare services. Some poor people were eli-

gible to receive free healthcare by obtaining Declaration of Poverty

letters from their neighborhood authorities. Without this letter,

people either had to pay full price for medical services or be denied

treatment altogether. In this sense, the Jakarta Health Care program

does simplify the process for a large number of Jakarta’s residents to

seek medical treatment.

After five months of implementation, there has been on aver-

age a 70% increase of patients across all regional general hospitals.

At a glance, the significant rise of patients shows that the public is

responding positively to the Jakarta Health Card. However, some

cases have shed light on the shortcomings of the Jakarta Health

Card program.

First, there is Dera Nur Anggraini's case. In February 2013, Dera

Nur Anggraini and Dara Nur Anggraini, twin daughters of Eliyas

Setya Nugroho and Lisa, were born prematurely. As premature

babies, they required treatment inside the neonatal intensive care

unit (NICU). In addition, Dera's pharynx was also imperfectly devel-

oped. The estimated cost of NICU treatment was between one and

two million IDR per day. Under the Jakarta Health Card scheme, all

of Dera and Dara's hospital expenses would be covered. However,

Dera died because she was rejected by eight hospitals before her

parents found one that would treat her. Four of the hospitals were

full, while the other four hospitals reasoned that their equipment

was not advanced enough to treat Dera.

The second case is Ana Mudrika, who died of intestinal block-

age after being rejected treatment by four hospitals. One hospital

claimed to not have a specialist who was able to treat her and also

that it was not part of the Jakarta Health Card program. Three other

hospitals rejected Ana because all of their ICUs were full.

Both Dera and Ana's deaths stirred public uproar in the media

and social media, such as Twitter and Facebook. These cases have

also shown that there are still issues that the Jakarta Provincial

Government needs to address to further improve health care

provision.

First, the local clinics and the hospitals have experienced short-

ages, both in manpower and capacity. Several clinics and hospi-

tals are suffering from a shortage of doctors, in particular special-

ists. Doctors in some local clinics could attend up to fifty patients

a day. Sometimes, patients are only attended by nurses. There is

also a shortage of beds in most of the regional general hospitals.

The increases in the number of hospital beds have not been able

to accommodate the rising number of hospitalized patients. The

Jakarta Health Card program is likely to worsen the discrepancy

between the number of patients and available beds as well as the

number of doctors. Thus, the Jakarta Health Card might be coun-

terproductive in terms of the efficiency and quality of the medical

services that each patient receives. Involving more private hospitals

inside the Jakarta Health Card program might be one solution.

Secondly, there is the issue of moral hazard. As medical services

are now free, there is now a greater risk of service overuse. This

would exacerbate the service capacity problems. Thus, campaigns of

how to live healthy lives should be implemented hand in hand with

the Jakarta Health Card program, to build awareness that despite the

now affordable health care, prevention is still better than treatment.

Finally, the Jakarta Provincial Government must resolve the long-

running residency issues of migrants. There are residents of Jakarta

that have been staying and working “illegally” in the city for years.

These people include street sweepers, security guards, bus driver,

etc. Despite their “de facto” resident status, they still do not have

official documentation which clearly states that their domicile is, in

fact, in Jakarta. The Jakarta Provincial Government needs to set eas-

ier requirements for people to apply for Jakarta residency. By being

legally acknowledged as a resident of Jakarta, they will receive iden-

tification cards and household information cards, which enable

them to apply for Jakarta Medical Cards.

17

Promoting the National Health Insurance Scheme for the Poor--- by Nicola Pocock ---

The Micro-insurance Innovations Program for Social Security (MIPSS)

has been supporting the expansion of the Philippines’ national

insurance scheme for the poor, Philhealth, since its launch in 1995.

According to the social health insurance provider, 82% of the popula-

tion had enrolled in the scheme in 2011. Of them, the poorest mem-

bers (34%) are fully sponsored by the government and the LGU.

Specifically, MIPSS has been involved in promoting the group reg-

istration scheme, KaSAPI, in collaboration with a network of MFIs, to

increase horizontal coverage since 2005.

The MFIs receive a commission according to the number of

people enrolled. However, due to insufficient marketing, poor data

exchange between MFIs and Philhealth, and a lack of participation

from MFIs in the design process, enrollment has not been as high

as anticipated. According to Dr. Antonis Malagardis, MIPSS’ program

director, the scheme has not reached the 150,000 enrollment target

yet.

The benefits package may be too shallow to incentivize people to

enroll - “ 90% of claims are hospital bills, and the scheme only reim-

burses 30% of the bill. So out-of-pocket payments are 70% for the

patient”. The low proportion of claims by the poor (fully sponsored

group), in relation to membership proportion, may indicate that the

poor are less likely to make claims, compared to private and gov-

ernment employees. To increase the depth of coverage, MIPSS has

supported the shift from fee-for-service towards a capitation pay-

ment model, whereby the hospital can be reimbursed for treatment

up to a capped amount per person. According to Dr. Malagardis,

MIPSS has not yet developed a health microinsurance product, as

the Department of Health has prioritized increasing enrollment in

Philhealth. Private insurers haven’t been all that interested either –

“among those who can provide MI products, they have not yet come

up with one that is affordable, accessible and simple to understand”.

Health Maintenance Organizations (HMOs), private entities that pro-

vide both insurance and treatment, charge premiums that are five

to six times higher than Philhealth. In slums, informal health insur-

ance providers offer some insurance schemes, but the payout is a

maximum of just PHP 10,000 per annum for hospital visits. In order

to market micro health insurance to the poor, messages need to be

targeted. Dr Malagardis already has some ideas to market products

to slum dwellers: “microinsurance premiums are as low as the cost of

one cigarette or one SMS per day”.

Two key lessons can be taken away from this case study. First, the

lack of participatory inclusion of MFIs in the design of benefits pack-

age means they have not been as engaged in rolling out the group

membership scheme. This shows the importance of engaging all rel-

evant stakeholders, as MFIs are likely to have the greatest reach in

marketing financial products to the poor compared to other formal

insurance providers and financial institutions.

Secondly, Philhealth and MIPSS are already working to increase

the depth of coverage by shifting from fee for service to capitation

based payment model for hospital reimbursement. However, infor-

mal health insurance providers remain an untapped potential part-

ner in these efforts. Could formalization of already existing informal

schemes in slum areas help increase coverage for slum dwellers?

For more information, please see: http://www.microinsurance.ph/

index.php

18

Prospects for the Future: Towards Better Regional Governance in Health

Which regional trends are most likely to have

an impact on health in ASEAN countries?

It is expected that Southeast Asia’s political

influence and economic growth will continue

to expand over the next decades. At the same

time, population trends in fertility decline and

ageing will continue to be key challenges for

growing economies. Rural-urban migration

flows will intensify both within and between

Southeast Asian countries. The need to reduce

unemployment in some countries and to fill

labour shortages in others will continue to be a

key driver of migration in Asia. Migration flows

in the region will be further intensified as the

ASEAN integration process moves forward to

become “a single market and production base”

by 2015. Enhanced integration will most likely

cause sustained movement of people. Health

being a key outcome in the migration experi-

ence and in light of migrants’ contribution to

economic development, health and labour

productivity are likely to be some of the great-

est socio-economic and political challenges in

ASEAN’s social integration.

As recent history has shown, infectious dis-

eases continue to be a leading health challenge

in ASEAN. The 2003 SARS episode has been a

crucial determinant in shaping regional gover-

nance for health. Yet, in light of demographic

and epidemiological changes, new health

issues require intense cooperation between

Southeast Asian countries. Economic growth

and rapid urbanization, demographic changes

and migration flows will put added pressure on

urban centers too. How are Southeast Asian cit-

ies likely to look like in the near future? Although

regional demographic and epidemiological

trends can be identified in Southeast Asia, pre-

dicting their impact on different countries is

difficult, given the great diversity and dispari-

ties between them. Southeast Asia can be con-

sidered a microcosm. The region is constituted

of countries at various stages of development

(from first world to third world), of various eth-

nicities and religions, of various political systems

and ideologies - it is thus difficult to generalize

about the future of Southeast Asian cities in the

light of health trends and challenges.

Nevertheless, lessons should be drawn from

comparing the leading cities as challenges and

by Phua Kai Hong & Marie Nodzenski

19

solutions will be different in megacities such as

Jakarta and Manila (with population densities

reaching 10,000 people per km2) or in Lao and

Cambodian cities which are less densely popu-

lated but which may have to deal with larger

flows of rural‐urban migration. Political systems

and political history are also crucial in determin-

ing a city’s pace of development and approach

to urbanization. Past socialist models of strong

top‐down control have liberalized towards a

greater growth of markets and a number of bot-

tom‐up movements have been contributing to

change in these countries. Generally, compe-

tition and opposition movements will be the

leading force in demanding urban changes in

the development process.

Southeast Asia is a fast‐growing and fast‐

changing region. A mix of rapid demographic

changes, a rise in epidemics and bad gover-

nance constitutes a possible worst case sce-

nario for the region. Yet, in light of efforts at the

regional level to tackle emerging health issues,

the probable scenario would be one riddled

with episodes such as SARS which can also spark

innovative responses, contributing therefore to

a more optimistic vision of the future. But it is

crucial to reflect on how to create more equi-

table, inclusive and healthy cities which do not

leave vulnerable population groups to the vaga-

ries of development. This rests on the condition

that Southeast Asian countries, both individu-

ally and as a regional grouping, strive towards

better governance for health.

What needs to get done to improve health

among ASEAN populations?

Social capital or solidarity is a firm base for urban

health equity interventions, and programmes

that build stronger communities at local level

should be a part of any intervention package. It

is clear that for the people in slums and informal

settlements, improving the living environment

is essential in the cities. Many experts highlight

the creation of healthy housing and neighbour-

hoods as a priority. This includes provision of

clean water and sanitation, energy supply and

environmental pollution control. Other inter-

ventions need to promote and facilitate good

nutrition and physical activity, as well as create

safe and healthy places in which to work and

play. In addition, many communities require

effective action to prevent urban violence and

substance abuse. In order to ensure access to

essential health care services, the health system

needs to be designed on an equitable basis.

While communicable disease control is still a

priority, new interventions concerning injuries,

non-communicable diseases (NCD) and mental

health are of growing importance. For the poor

to acquire access to the necessary services, as

well as improved food, education and transport,

evidence suggests that effective intervention to

invest in health and social programs are indeed

necessary for sustained economic growth.

It is recognized that these interventions

involve implementing different levels of health-

related improvements and that extending the

numbers to the entire population is not a sim-

ple exercise. Nevertheless, in order to scale

up action that will help the people who live

in slums or informal settlements today, and to

avoid more people living in such conditions

in the next 25 years, bold steps are needed to

improve urban governance in ways that achieve

better housing, water and sanitation, transpor-

tation, education, employment, healthier work-

ing conditions and access to health-promoting

interventions as well as health services (WHO,

2008).

Temperature check with a mercury free infrared thermometer

20

How can good governance for health in

Southeast Asia be achieved?

The role of ASEAN in health governance has

been stimulated by health crises which have

affected Southeast Asian countries across bor-

ders and which have required concerted action.

SARS in 2003 is considered a turning point in

regional health governance. The economic

and health costs of the epidemic have fostered

cooperation in ASEAN and have led to the cre-

ation of regional mechanisms.

“Rapid urbanization, popula-

tion movement, and high-density

living raise concerns about newly

emerging infectious diseases, but

these outbreaks have stimulated

regional cooperation in information

exchange and improvement in dis-

ease surveillance systems”

(Chongsuvivatwong V, Phua KH, Yap MT et al,

Lancet 2011)

ASEAN’s potential as a global health actor

expanded with the adoption of the ASEAN

Charter in November 2007 and with the birth

of an ASEAN Health Division. While institu-

tional development in ASEAN has been clearly

visible in economic and security fields, the

post‐SARS period witnesses the emergence of

public health as an important area for regional

governance. Effective regional cooperation can

increase the capabilities of national health sys-

tems which have been heavily taxed by health

crises but yet, are under‐resourced. Under the

Charter were also established three pillars for

cooperation in politics and security, economics

and the socio-cultural fields. The Socio-Cultural

Community Pillar paves the way for further

social integration and is central to the creation

of an ASEAN Community by 2020.

Enhanced cooperation in health has, in part,

been supported by the growing awareness that

health and development are closely linked. For

example, the estimated cost of SARS to East

and Southeast Asia has been estimated to be

US$18 billion (Coker et al. 2011). Environmental

health issues such as the haze are also increas-

ingly thought to impact on political stability

and economic development in the region. In

1997, the total social costs incurred by the haze

amounted to US$9 billion. Similarly the long‐

term cost of unhealthy population segments

such as migrants are likely to impact Southeast

Asia’s development.

It is therefore necessary to address, both

at national and regional level, issues pertain-

ing to the health of vulnerable population

groups. Indeed, rapid growth in Southeast Asia

has led to important health disparities, pos-

ing great public health challenges. Inequity in

health has been a central theme of this Asian

Trends Monitoring issue. Closing inequity

gaps both within and between ASEAN coun-

tries is an imperative. The concept of equity is

further central to a reflection on good gover-

nance. Achieving good governance in ASEAN

will require addressing disparities between its

member states.

Regional health governance will also have

to be more inclusive of various stakeholders (in

particular of civil society organizations) and will

be most effective through the use of flexible

arrangements between those stakeholders,

such as in public‐private partnerships. Health

governance will further have to be inter‐sec-

toral in order to better address the social deter-

minants of health. These are preconditions to

the design of a holistic and effective approach

to health in Southeast Asia.

While health issues, such as urban health,

which require taking measures to reduce pov-

erty or improve infrastructure and sanita-

tion, seem to belong to the domestic sphere,

regional health governance can have a positive

impact on national developments and health

improvements. Although it may seem difficult

to design legislation or to create enforcement

mechanisms on such issues at regional level,

ASEAN has a crucial role to play as a platform for

knowledge and information exchange, as a plat-

form for more developed countries to share best

practices with less developed countries as well

as to improve data tracking. As a regional orga-

nization, ASEAN will increasingly have to push

for the harmonization of health standards, and

especially between the urban cities throughout

the region. ATM

“Further growth and integration

of the ASEAN region should include

as a priority, enhanced regional

cooperation in the health sector to

share knowledge and rationalize

health systems operations, leading

to further public health gains for the

region’s diverse populations”

(Chongsuvivatwong V, Phua KH, Yap MT et al,

Lancet 2011)

21

School children in Laos wash their hands during a break

22

ReferencesAsian Trends Monitoring (2012). A dataset on urban

poverty and service provision. Lee Kuan Yew

School of Public Policy, National University of

Singapore.

Baird S, de Hoop J & Ozler B (2011). Income shocks

and adolescent mental health. World Bank Policy

Research Working Paper Series, 5644.

Baird S, McIntosh C & Ozler B (2011). Cash or condi-

tion? Evidence from a cash transfer experiment.

Bureau for Research and Economic Analysis of

Development (BREAD) Working Paper, February

23, 2011.

BAPPENAS. (2007). Urban sanitation: portraits, expe-

riences and opportunities – its not a private

matter anymore, Indonesia Sanitation Sector

Development Program (ISSDP).

Barua N, and Pandav CS (2011). The allure of the pri-

vate practitioner: is this the only alternative for

the urban poor in India? Indian Journal of Public

Health, 55, (2), pp. 107 – 14.

Berger SG, de Pee S, Bloem MW, Halati S, and Semba

RD (2008). Malnutrition and morbidity among chil-

dren not reached by the national vitamin A cap-

sule programme in urban slum areas of Indonesia,

Public Health, 122, (4), pp. 371-8.

Bernard T, Dercon S, and Taffesse AS(2011). Beyond

fatalism – an empirical explanation of self-efficacy

and aspirations failure in Ethiopia. Centre for the

Study of African Economies (CSAE) Working Paper

2011 - 03, Dept. of Economics, Oxford University.

Butala NM, Van Rooyen MJ and Patel RB (2010).

Improved health outcomes in urban slums

through infrastructure upgrading. Social Science

and Medicine, 71, pp. 935 – 940.

Capewell S and O’Flaherty M (2011). Rapid mortality

falls after risk-factor changes in populations. The

Lancet, 378, (9793), pp. 752-753.

Chan JCN, Malik V, Jia W, Kadowaki T, Yajnik CS, Yoon

KH, and Hu FB (2009). Diabetes in Asia: epidemiol-

ogy, risk factors and pathophysiology, Journal of

the American Medical Association, 301, (20), pp.

2130 – 2140.

Chongsuvivatwong V, Phua KH, Yap MT, Pocock NS,

Hashim JH, Chhem R, Wilopo S.A, Lopez, AD:

Health and health‐care systems in southeast Asia:

diversity and transitions. Lancet 2011, 377 (9763):

429‐37

Coker RJ, Hunter BM, Rudge JW, Liverani M,

Hanvoravongchai P: Emerging infectious diseases

in Southeast Asia: regional challenges to control.

Lancet 2011, 377 (9765): 599‐609

Community Interventions for Health (CIH), website.

(http://www.3four50.com/cih/)

Deb, P. and Seck, P. (2009). Internal migration, selec-

tion bias and human development: evidence

from Indonesia and Mexico, Human Development

Research Paper 2009 / 31, UNDP.

Dercon, S. & Krishnan, P. (2009). Poverty and the psy-

chosocial competencies of children: evidence

from the young lives sample in four developing

countries. Children, Youth & Environments, 19 (2),

138 – 163.

Dye C (2008). Health and urban living, Science, 319, pp.

766 – 769.

EnFaNCE Foundation. Annual Report, 2011.

Freudenberg N, Galea S and Vlahov D (2005) Beyond

urban penalty and urban sprawl: Back to liv-

ing conditions as the focus of urban health. J

Community Health 20; 30(1):1-11.

Freudenberg N, Galea S and Vlahov D, eds. (2006)

Cities and the health of the public. Vanderbilt

University Press.

Friel S, McMichael AJ, Kjellstrom T & Prapamontol T

(2004). Housing and health transition in Thailand,

Reviews in Environmental Health, 19 (3-4), pp.

311-27.

Galea S and Vlahov D, eds. (2005) Handbook of urban

health: Populations, methods, and practice

Springer Science and Business Media Publishers.

Gawad Kalinga. Annual report, 2010.

Habaradas R and Aquino ML (2010). Towards inno-

vative, liveable, and prosperous Asian megaci-

ties. Gawad Kalinga: innovation in the city (and

beyond). August 2010.Working paper 2010-01C,

Angelo King Institute, De La Salle University,

Manila.

Haddad L, Ruel MT and Garrett JL (1999). Are urban

poverty and under nutrition growing? Some

newly assembled evidence, World Development,

27, (1), pp. 1891 – 1904.

Health Promotion Board (HPB) Singapore, website.

(www.hpb.gov.sg)

Hu TW, Mao Z, Liu Y, de Beyer J and Ong M (2005).

Smoking, standard of living, and poverty in China,

Tobacco Control, 14, pp. 247–50.

Indrakesuma T, Pocock N and Loh J (2012a). Jakarta’s

poor: strategies for defusing violence and protect-

ing migrants, Asian Trends Monitoring Bulletin,

16, Lee Kuan Yew School of Public Policy, National

University of Singapore.

Indrakesuma T, Pocock N and Loh J (2012b). Good

water governance matters, Asian Trends

Monitoring Bulletin, 15, Lee Kuan Yew School of

Public Policy, National University of Singapore.

Isaacs BA, Dixon J and Banwell C (2010). Fresh market

to supermarket: nutrition transition insights from

Chiang Mai, Thailand, Public Health Nutrition, 13,

(6), pp. 893 – 897.

Jones-Smith JC, Gordon-Larsen P, Siddiqi A and Popkin

BM (2011a). Emerging disparities in overweight by

educational attainment in Chinese adults (1989–

2006), International Journal of Obesity, 36, pp.

866-875.

Jones-Smith JC, Gordon-Larsen P, Siddiqi A and

Popkin BM.(2011b). Cross- national comparisons of

time trends in overweight inequality by socioeco-

nomic status among women using repeated cross-

sectional surveys from 37 developing countries,

1989–2007, American Journal of Epidemiology,

173, pp. 667–675.

Katan MB (2009). Weight-loss diets for the prevention

and treatment of obesity, New England Journal of

Medicine, (360), pp. 935 – 5.

Kaye K, and Novell MK (1994a). Health practices and

indices of a poor urban population in Indonesia

part I: Patterns of health service utilization, Asia-

Pacific Journal of Public Health, 7, (3), pp. 178-182.

Kaye K, and Novell MK (1994b). Health practices and

indices of a poor urban population in Indonesia

part II: Immunization, nutrition, and incidence of

diarrhea, Asia-Pacific Journal of Public Health, 7,

(4), pp. 224-227.

Khan MM, Gruber O, and Kramer A (2012). Frequently

used healthcare services in urban slums of Dhaka

and adjacent rural areas and their determinants,

Journal of Public Health, 34, (2), pp. 261-71.

Kinra S, Andersen E, Ben-Shlomo Y, Bowen L, Lyngdoh

T, Prabhakaran D, Reddy KS, Ramakrishnan

L, Bharathi A, Vaz M, Kurpad A, Smith GD,

and Ebrahim S (2011). Association between

urban life-years and cardiometabolic risk: the

Indian Migration Study, American Journal of

Epidemiology, 174, (2), pp. 154 – 164.

Kinra S (2004). Commentary: beyond urban – rural

comparisons: towards a life course approach to

understanding health effects of urbanization,

International Journal of Epidemiology, 33, pp. 777

– 778.

Kleevens JWL (1972) Housing and health in a tropical

city. Van Gorcum &Comp.n.v. Assen, Netherlands.

Leon DA (2008). Cities, urbanization and health,

International Journal of Epidemiology, 37, pp. 4–8.

Lim MK, Eggleston K, Chen KY, Yunxian C, Sung I,

Griffiths S, Yeoh EK, Hisham Hashim J, Jimba M,

Anderson Johnson C, Palmer P, Le VA, Tran HB,

La NQ and Wispriyono B (2010). Prevention and

control of chronic non-communicable disease in

nine Pacific Rim cities, Stanford Asia Health Policy

Program, Working Paper No. 21.

23

Lo FC and Yeung YM, eds. (1996) Emerging World Cities

in Pacific Asia. Tokyo: United Nations University

Loh J, Pocock N and Indrakesuma T (2012). Manila’s

Poor: bridging service gaps and strengthen-

ing mental resilience, Asian Trends Monitoring

Bulletin, 17, Lee Kuan Yew School of Public Policy,

National University of Singapore.

Ma S, Cutter J, Tan CE, Chew SK and Shyong Tai E.

(2003). Associations of diabetes mellitus and eth-

nicity with mortality in a multiethnic Asian pop-

ulation: data from the 1992 Singapore National

Health Survey, American Journal of Epidemiology,

158, (6), pp. 543 – 552.

Manderson L and Naemiratch B (2010). From Jollibee to

BeeBee: “lifestyle” and chronic illness in Southeast

Asia, Asia Pacific Journal of Public Health, 22, (sup-

plement 3), pp. 117S – 124S.

Mercado S, Havemann K, Nakamura K, Kiyu A, Sami

M, Alampay R, Pedrasa I, Salvador D, Na Thalang

J and Le Truy T (2007). Responding to the health

vulnerabilities of the urban poor in the “new urban

settings” of Asia, Center for Sustainable Urban

Development, July 15 – 20, 2007.

Microinsurance Innovations Program for Social

Security (MIPSS). Demand study of microinsur-

ance in the Philippines, October 2009. Available

at: http://www.microinsurance.ph/data/

uploads/reports/Demand%20Study%20of%20

Microinsurance%20in%20the%20Philippines.pdf

Ooi GL and Phua KH (2007). Urbanization and slum

formation, Journal of Urban Health: Bulletin of

the New York Academy of Medicine, 84, (1), pp.

27 – 34..

Osteria, TS. (1991) The poor in ASEAN cities:

Perspectives in health care management.

Singapore: Institute of Southeast Asian Studies.

Padawangi R (unpublished). Building markets through

quenching thirst: clean water supply for the urban

poor in Jakarta and Manila, Working Paper No.8,

New Approaches to Building Markets in Asia.

Centre for Asia and Globalisation, Lee Kuan Yew

School of Public Policy, National University of

Singapore.

Popkin B, Adair LS and Ng SW (2012). Global nutrition

transition and the pandemic of obesity in develop-

ing countries, Nutrition Reviews, 70, (1), pp. 3–21.

Popkin BM and Drewnowski A (1997). Dietary fats and

the nutrition transition: new trends in the global

diet, Nutrition Reviews, 55, pp. 31–43.

Popkin BM (1994). The nutrition transition in low-

income countries: an emerging crisis, Nutrition

Reviews, 52, pp. 285–298.

Ramachandran A, Wan Ma RC and Snehalatha C (2010).

Diabetes in Asia, The Lancet, 375, pp. 408–18

Rampal L, Rampal S, Khor GL, Zain AM, Ooyub SB,

Rahmat RB, Ghani SN and Krishnan J (2007). A

national study on the prevalence of obesity

among 16,127 Malaysians, Asia-Pacific Journal of

Clinical Nutrition, 16, (3), pp. 561-566.

Reddy SK, Shah B, Varghese C and Ramadoss A. (2005).

Responding to the threat of chronic diseases in

India, The Lancet, 366, pp. 1744–49.

Riley LW, Ko AI, Unger A and Reis MG (2007). Slum

health: diseases of neglected populations, BMC

International Health and Human Rights, 7, (2).

Samb B, Desai N, Nishtar S, Mendis S, Bekedam H,

Wright A, Hsu J, Martiniuk A, Celleti F, Patel K,

Adshead F, McKee M, Evans T, Alwan A and Etienne

C (2010). Prevention and management of chronic

disease: a litmus test for health-systems strength-

ening in low-income and middle-income coun-

tries. The Lancet, 376, pp. 1785-97.

Semba RD, de Pee S, Kraemer K, Sun K, Thorne-Lyman

A, Moench-Pfanner R, Sari M, Akhter N and Bloem

MW (2009). Purchase of drinking water is associ-

ated with increased child morbidity and mor-

tality among urban slum-dwelling families in

Indonesia, International Journal of Hygiene and

Environmental Health, 212, (4), pp. 387-97.

Sha E and Smith GD (2001). Exporting failures?

Coronary heart disease and stroke in developing

countries. International Journal of Epidemiology,

(30), pp. 201 – 25.

Simanjuntak CH, Punjabi NH, Wangsasaputra F, Nurdin

D, Pulungsih SP, Rofiq A, Santoso H, Pujarwoto H,

Sjahrurachman A, Sudarmono, P., von Seidlein L,

Acosta C, Robertson SE, Ali M, Lee H, Park J, Deen

JL, Agtini MD and Clemens JD (2004). Diarrhoea

episodes and treatment-seeking behaviour in a

slum area of North Jakarta, Indonesia. Journal of

Health, Population and Nutrition, 22 (2), pp.119-29.

Singapore Sports Council (2012). Facilities, last

updated 07/09/2012.

http://www.ssc.gov.sg/publish/Corporate/en/partici-

pation/hotspot.html

Sinha R and Sinha UP (2007). Ecology and quality of

life in urban slums: an empirical study. Concept

Publishing Company.

Spears D (2010). Economic decision-making in poverty

depletes cognitive control. Princeton University

Working Paper, December 1, 2010.

Tagaytay City (undated). City development strategies.

http://www.tagaytay.gov.ph/other%20documents/

City%20Development%20Strategies.pdf

Trzesniewski, K.H., Donnellan, M.B. and Robins, R.W.

(2003). Stability of self-esteem across the life span.

Journal of Personality and Social Psychology, 84

(1): 205 – 220.

Unger A and Riley LW (2007). Slum health: from under-

standing to action, PLOS Medicine, 4, (10), pp. 1561

– 1566.

United Nations, Department of Economic and Social

Affairs, Population Division. World Urbanization

Prospects, 2011 revision. http://esa.un.org/unpd/

wup/CD-ROM/Urban-Agglomerations.htm

United Nations Human Settlements Programme

(2003). The challenge of slums: global report on

human settlements 2003. London and Sterling,

Earthscan Publications.

United Nations Population Fund (2007). State of world

population 2007: Unleashing the potential of

urban growth. New York.

United Nations Statistics Division. Millennium

Development Goals Database.

Vlahov D and Galea S (2002) Urbanization, urbanicity,

and health. J Urban Health 79(4), Suppl 1:S1-S12.

Vlahov D and Galea S (2003) Urban health: a new disci-

pline. Lancet 362:1091-1092.

Wang Y, Mi J, Shan XY, Wang QJ, Ge KY (2007). Is

China facing an obesity epidemic and the conse-

quences? The trends in obesity and chronic dis-

ease in China, International Journal of Obesity,

(31), pp. 177–88.

WHO (2008a). Health in Asia and the Pacific. Chapter

12, Public Health Functions, pp. 479 – 515.

World Health Organization. (2008b) Our cities, our

health, our future: Acting on social determinants

for health equity in urban settings. Report to the

WHO Commission on Social Determinants of

Health from the Knowledge Network on Urban

Settings, WHO Centre for Health Development,

Kobe, Japan. http://www.who.int/healthy_set-

tings/types/cities/en/index.html

Wong F, Stevens D, O’Connor-Duffany K, Siegel K and

Gao Y (2011). Community Health Environment

Scan Survey (CHESS): a novel tool that captures

the impact of the built environment on lifestyle

factors, Global Health Action, 4, (5276).

24

Johannes Loh is working as a Research Associate at

the Lee Kuan Yew School of Public Policy. He holds

a Master’s degree in Public Policy from the Hertie

School of Public Policy in Berlin, and a Bachelor of Arts

in Integrated Social Science from Jacobs University

Bremen. His previous research experience includes aid

governance, visual political communication and pub-

lic sector reform in developing countries. Prior to join-

ing the Lee Kuan Yew School of Public Policy he has also

worked for the United Nations Environment Programme in Geneva, Transparency

International Nepal, and the Centre on Asia and Globalisation in Singapore. His email

is johannes.loh@nus.edu.sg and you can follow his updates on trends in pro-poor

policies in the region on Twitter @AsianTrendsMon.

Taufik Indrakesuma is a research associate at the Lee

Kuan Yew School of Public Policy. He is a recent grad-

uate of the Master in Public Policy programme at the

Lee Kuan Yew School of Public Policy. He also holds a

Bachelor in Economics degree from the University of

Indonesia, specialising in environmental economics.

Taufik has previously worked as a Programme Manager

at the Association for Critical Thinking, an NGO dedi-

cated to proliferating critical thinking and human rights

awareness in the Indonesian education system. His research interests include behav-

ioural economics, energy policy, climate change mitigation and adaptation as well as

urban development policy.

Phua Kai Hong is a tenured professor at the LKY School

of Public Policy and formerly held a joint appointment as

Associate Professor and Head, Health Services Research

Unit in the Faculty of Medicine. He is frequently con-

sulted by governments within the region and interna-

tional organisations, including the Red Cross, UNESCAP,

WHO and World Bank. He has lectured and published

widely on policy issues of population aging, health-

care management and comparative health systems in

the emerging economies of Asia. He is the current Chair of the Asia-Pacific Health

Economics Network (APHEN), founder member of the Asian Health Systems Reform

Network (DRAGONET), Editorial Advisory Board Member of Research in Healthcare

Financial Management and an Associate Editor of the Singapore Economic Review.

His email address is spppkh@nus.edu.sg

T S Gopi Rethinaraj joined the Lee Kuan Yew School

of Public Policy as Assistant Professor in July 2005.

He received his PhD in nuclear engineering from the

University of Illinois at Urbana-Champaign. Before

coming to Singapore, he was involved in research and

teaching activities at the Programme in Arms Control,

Disarmament and International Security, a multi-disciplin-

ary teaching and research programme at Illinois devoted

to military and non-military security policy issues. His

doctoral dissertation, “Modeling Global and Regional Energy Futures,” explored the

intersection between energy econometrics, climate policy and nuclear energy futures.

He also worked as a science reporter for the Mumbai edition of The Indian Express

from 1995 to 1999, and has written on science, technology, and security issues for

various Indian and British publications. In 1999, he received a visiting fellowship from

the Bulletin of the Atomic Scientists, Chicago, for the investigative reporting on South

Asian nuclear security. His current teaching and research interests include energy secu-

rity, climate policy, energy technology assessment, nuclear fuel cycle policies and inter-

national security. He is completing a major research monograph "Historical Energy

Statistics: Global, Regional, and National Trends since Industrialisation" to be published

in Summer 2012. His email address is spptsgr@nus.edu.sg

Principal Investigators Research Associates

25

The Lee Kuan Yew School of Public Policy is an autonomous, professional graduate school of the National University of Singapore.

Its mission is to help educate and train the next generation of Asian policymakers and leaders, with the objective of raising the

standards of governance throughout the region, improving the lives of its people and, in so doing, contribute to the transformation

of Asia. For more details on the LKY School, please visit www.spp.nus.edu.sg