Global South cities hold key to unlocking healthcare solutions - studies

A minority of patients face catastrophic health costs - often bypassing closer, cheaper clinics to access higher-quality care.

29 April 2025

Two doctors talking — Global South cities hold key to unlocking healthcare solutions

Most people living in cities across the Global South can reach primary care clinics within 30 minutes – yet average quality of care remains poor with clinicians failing to make correct diagnoses or implement appropriate treatments, new studies reveal.

The costs of providing services vary significantly and while most people report low out-of-pocket expenses, a minority face catastrophic health costs. Patients often bypass closer, cheaper clinics to access higher-quality care, even if it means traveling further and paying more.

A series of research papers published in Lancet Global Health reveal that the average quality of services is subpar, with frequent medicine shortages and inadequate management of long-term conditions.

Our research underscores the importance of understanding the unique dynamics of urban health care markets in LMICs. Facilities are plentiful and easy to reach, but highly diverse in terms of cost, quality, and crowding, resulting in a market of competing public and private providers.
Professor Richard J. Lilford - University �鶹��ѡ

The international team of researchers, led by the University �鶹��ѡ and funding from the National Institute for Health and Care Research (NIHR) proposes a range of strategies to reshape the primary health care market in cities in Low- and Middle-Income Countries (LMICs). These include:

Investing strategically in public health facilities - stimulating improvements across the sector, crowding out low-quality providers and encouraging higher standards;
Strengthening regulation to enhance quality across public and private sectors;
Integrating facility-based care with community health workers to provide comprehensive, equitable care, as demonstrated by successful models in Brazil;
Providing ongoing education and training for health care providers are crucial for maintaining high standards of care;
Empowering patients through health literacy initiatives and community engagement - driving demand for better services; and
Removing user fees and providing vouchers to improve access to essential health services, particularly for the most vulnerable populations.

Lead author Professor Richard J. Lilford, from the University �鶹��ѡ, commented: "Our research underscores the importance of understanding the unique dynamics of urban health care markets in LMICs. Facilities are plentiful and easy to reach, but highly diverse in terms of cost, quality, and crowding, resulting in a market of competing public and private providers.

"Much policy discussion of health services in LMICs still relies on knowledge and models derived from rural contexts. It simply doesn’t account for the dense network of competing providers in the urban health service landscape.

“This means that improvement strategies which work in rural contexts are unlikely to be successful in a city setting. We must find ways of creating innovative policy approaches that give patients choice and competition – this will help to re-shape markets and improve the quality of healthcare.”

The researchers note that policymakers must balance public service expansion with subsidies for private care to improve access and equity. Research gaps persist, especially regarding marginalised populations and areas on the edge of cities.

Notes for editors

For more information, please contact the Press Office at University �鶹��ѡ or +44 (0) 121 414 2772.

The University �鶹��ѡ is ranked amongst the world’s top 100 institutions. Its work brings people from across the world to Birmingham, including researchers, teachers and more than 8,000 international students from over 150 countries.

‘Supply-side and demand-side factors affecting allopathic primary care service delivery in low-income and middle-income country cities’ and ‘Policy and service delivery proposals to improve primary care services in low-income and middle-income country cities’ - Richard J Lilford et al are published in Lancet Global Health.

The research series includes data and analysis from the following countries: Algeria, Brazil, Bangladesh, China, India, Kenya, Malawi, Mozambique, Madagascar, Niger, Nigeria, Pakistan, Tanzania, Sierra Leone, Togo, and Uganda.

Participating institutions: University �鶹��ѡ, UK; Harvard T H Chan School of Public Health, Boston, USA; The University of Melbourne, Australia; The Aga Khan University, Karachi, Pakistan; The Hospital for Sick Children, Toronto, Canada; University of Stellenbosch, Cape Town, South Africa; University of Warwick, UK; University of the Witwatersrand, Johannesburg, South Africa; University of Ibadan, Nigeria; Oswaldo Cruz Foundation–Brazil, Salvador; University College London; African Population and Health Research Center, Nairobi, Kenya; University Hospitals Birmingham NHS Foundation Trust, UK; Makerere University, Kampala, Uganda; Drexel University, Philadelphia, USA; The University of Hong Kong; Oswaldo Cruz Foundation, Rio de Janeiro, Brazil; Georgetown University, Washington, USA.

Featured staff

Professor Richard Lilford, CBE
Director of National Institute for Health Research (NIHR) Applied Research Centre West Midlands (ARC WM)
Staff profile for Professor Richard Lilford CBE, who is Director of National Institute for Health Research (NIHR) Applied Research Centre West Midlands (ARC WM).
Phone: +44 (0)121 414 6772
Email: r.j.lilford@bham.ac.uk

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