The potential of city-level financing for NCDs

Cities play an integral role in population health and have access to different financial tools to fund noncommunicable disease prevention programs, according to experts attending last month’s Partnership for Healthy Cities Summit in Paris. “Cities have this incredibly important role in creating an enabling environment for health — that might be a physical environment like the air that we breathe, or the streets that we walk along, but it might also be the behavioral environment, in terms of what choices people make and what choices they can make,” explained Susannah Robinson, technical officer on urban health and NCD prevention at the World Health Organization. NCDs, including cancers, diabetes, and heart disease, are responsible for 82% of premature deaths globally. Meanwhile, over half the world’s population, 4.2 billion people, live in urban areas, with that number expected to rise to 68% by 2050. Cities often amplify major NCD risk factors, such as air pollution, access to unhealthy foods, and limited space for physical activity. “Both the physical design of the city and in the policies they choose, cities have a really important role and potential to change and create a world where health is equal,” said Robinson. In its 2019 report, The Power of Cities, WHO identified 10 interventions that cities could implement to reduce the number of NCD-related deaths. These include banning tobacco advertising, creating more walkable and bikeable streets, and improving air quality. Fines and city budgets Funding for these interventions can come from various sources outside the national budget, said summit attendees. “Everybody can use the ability that they have at their level of jurisdiction to make a difference,” said Dr. Mary-Ann Etiebet, president and CEO of global public health organization Vital Strategies. “What is in the purview of cities would be more along the lines of either specific levies, if they have the power or the authority to do it on specific products, or access penalties or fines from some of the interventions that they have,” Etiebet added. “If a population is well taken care of, works in a better environment, has good medical care, then the population is healthier and therefore the economy is healthier.” --— Anne Hidalgo, mayor of Paris For example, authorities in Bengaluru, India, are looking into using fines collected from violations of its smoke-free policy to fund its enforcement. It aims to be a smoke-free city by 2025 to help reduce the number of tobacco-related deaths. Over 1 million people die each year in India from diseases related to smoke, such as lung disease or cancer. Cities can also tap into budgets beyond that of health, looking at funding from the transport budget and education budgets, given the cross-cutting nature of NCDs, said Etiebet. “[It’s] really thinking about a bigger pie when it comes to funding sources,” she told Devex. Specific city NCD funds There are also specific funds cities can access. The City Cancer Challenge Foundation, launched by the Union for International Cancer Control in 2017, provides seed grants for research in cities in low- and middle-income countries. The Global Alliance for Chronic Diseases funds projects targeting NCD risk factors within city environments. Meanwhile, the Partnership for Healthy Cities created by Bloomberg Philanthropies in 2017, gives qualifying cities an initial $100,000, followed by $50,000 annually. This funding must be used for NCD prevention efforts, with cities expected to source private financing to build on that initial investment. Networks such as these, Paris Mayor Anne Hidalgo told Devex, help showcase city-led initiatives to private and philanthropic sectors, who may in turn invest. “We need to be very creative and find all the resources possible,” she said. Since becoming a member of the Partnership for Healthy Cities, Paris has transformed a city center expressway into a pedestrian and cycling path, installed air quality monitors, and planted more green vegetation to reduce pollution and promote physical activity. Additionally, Paris was able to tap into national and private funding allocated when the city was selected as the 2024 Olympics host, accelerating investments in bike lanes, mobility, and cleaning the Seine River. “It was so important for us to adapt the city to climate change and I [brought] this obsession to the Games [to] build that,” said Hidalgo. “I think, thanks to the Games, we had change.” Adapting a city to climate change goes hand in hand with reducing NCDs, according to the NCD Alliance. Promoting walking and cycling reduces emissions and enhances physical activity, while pivoting to more sustainable food systems can also benefit both the environment and public health. Shared resources Through various networks, cities are also able to tap into each other’s resources — such as blueprints for NCD regulations, policy language, and communications materials — saving money by not having to produce their own. In India, for example, Bengaluru scaled its ban on hookah pipes, aimed at reducing tobacco-related deaths, statewide by replicating the policies and enforcement mechanisms already in place. “[It] shows that even if you're missing a certain type of regulation at the national level, it doesn't mean there's nothing you can do about it. Somebody else could maybe innovate and push that work and then see it spread sort of the other way,” said WHO’s Robinson. Looking ahead While approaching NCDs from a city perspective can allow for access to different types of financing mechanisms, cities too face challenges amid the global slump in overseas development funding, said Ariella Rojhani, senior advocacy manager at the NCD Alliance, explaining that cities are not immune to the devastation of recent cuts to the U.S. Agency for International Development and other organizations. Administrator of the Dhaka North City Corporation in Bangladesh, Mohammad Azaz, told Devex it had been home to many USAID projects that supplied the likes of clean drinking water. “It's disappointing because many of the services, not only in Dhaka, even in other cities in Bangladesh, were dependent on these projects, and right now, all these projects are stuck,” he said. Yet an investment in NCD programming at the city level can save cities money in the long run and lead to economic gains, said the experts. “When you look at something like alcohol, the cost of not implementing these policies [on restricting the availability and advertising of alcohol] can be up to 2%-3% of GDP, which is significant,” said Etiebet. “For all of public health, trying to reframe cost as an investment is something we need to speak more about.” Vital Strategies, she said, is working to provide city-specific data on the return on investment to city governments. “At the end of the day, they are responsible for actually meeting the health care costs of their residents in many cases,” she said. Hidalgo called for the broader implementation of economic indicators that show the money saved from NCD interventions at the city level in order to convince other leaders to implement similar measures. “If a population is well taken care of, works in a better environment, has good medical care, then the population is healthier and therefore the economy is healthier,” she added. “When you talk money, people listen.” Visit Accelerating Action — a series highlighting pathways for funding NCD prevention and control, spotlighting innovative financing models and cross-sector collaborations. This is an editorially independent piece produced as part of our Accelerating Action series. To learn more about this series, click here.