How to achieve great health for all? Start in your city.

At a glance

• The global population living in cities is projected to grow to about 70 percent by 2050. Large disparities in health outcomes within urban populations suggest that a city-level focus has significant potential to improve health.
• The McKinsey Health Institute (MHI) estimates that a focus on improving health at the city level can unlock 20 billion to 25 billion additional years of higher-quality life across cities globally (approximately five years per person living in urban areas). All organizations across sectors have a role to play to capture this opportunity.
• Immediately influenceable interventions, grounded in a rich existing evidence base, are a starting point to improve health at a city level. For example, interventions could add to residents’ healthy longevity and brain health, lessen the impacts of climate exposure, and improve health-worker capacity.

In the past 60 years, global longevity rates have risen substantially, increasing life spans for individuals by 20 years on average.¹“Life expectancy at birth, total (years),” World Bank, 2022; “Global burden of disease study 2019: Population estimates 1950-2019,” Institute for Health Metrics and Evaluation, 2023. Yet that accomplishment has not resulted in an equivalent gain in time spent in good health: at a global level, every additional year of life means an average of six months in ill health (Exhibit 1).

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Why has time spent in ill health increased so much? As the global population ages, the burden has shifted to three fields of age-related noncommunicable diseases (NCDs) broadly associated with the wear and tear of body and mind: cardiometabolic diseases, cancers, and mental, substance use, and neurological conditions. Today, all NCDs account for 69 percent of the global disease burden (Exhibit 2). The three big fields of age-related illness²Angela Chang et al., “Measuring population ageing: An analysis of the Global Burden of Disease Study 2017,” The Lancet Public Health, March 2019, Volume 4. account for 65 percent of the NCD burden, a trend that is expected to accelerate: one in six people worldwide will be over 60 (one in three in some countries) by 2030.³“Ageing and health fact sheet,” World Health Organization, October 1, 2022; “World Population Prospects 2022,” United Nations Department of Economic and Social Affairs, Population Division. By 2040, 11 of 14 of the disease categories predicted to increase will be NCDs, with age-related diseases such as diabetes or kidney diseases increasing the most—possibly by more than 60 percent by 2040.⁴Kyle J. Foreman et al., “Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: Reference and alternative scenarios for 2016–40 for 195 countries and territories,” The Lancet, October 2018, Volume 392, Issue 10,159.

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External threats to global health, including climate change and antimicrobial resistance (AMR), will further increase the disease burden. The impacts of climate change on human health will be varied and far-reaching—ranging from the direct effects of climate hazards on physical and mental health to effects on water and vector-borne disease transmission, food security, and air pollution. Even under a midrange emissions-reduction scenario, specific climate-change-related mortality is expected to increase to 250,000 excess deaths per year in 2050.⁵“Fact sheet–health,” International Panel on Climate Change, February 2023; impacts on malaria but not other diseases included in the estimate. Any climate-sensitive increase of the disease burden, including mental health, will be on top of that. Deaths from AMR are expected to increase to 10 million or more, up from less than 1.2 million, in the same period.⁶Bracing for superbugs: Strengthening environmental action in the One Health response to antimicrobial resistance, UN Environment Programme, February 7, 2023; Tackling drug-resistant infections globally: Final report and recommendations, Review on Antimicrobial Resistance, May 2016.

Addressing the shifting disease burden requires looking at factors beyond healthcare, including prevention and health promotion across all fields. MHI estimates that, by embracing a more comprehensive definition of health and actively working to address the drivers of health throughout life, each person on the planet could have up to six years of higher-quality life over the next decade.⁷Reflects global average. Lars Hartenstein and Tom Latkovic, “The secret to great health? Escaping the healthcare matrix,” McKinsey Health Institute, December 20, 2022. Every institution and every individual has a role to play (see sidebar “Cities are where the drivers of health play out in practice”).

Cities are a hub of opportunity to realize this potential. They are where many of the long-term drivers of health that can help address this shifting disease burden are playing out. Cities have a unique ability to mobilize cross-sectoral stakeholders quickly to create an enabling environment and focus on near-term, influenceable interventions. In the next section, we lay out three reasons why cities have a vital role to play in enabling better health for their citizens.

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Focusing on healthy cities: Cities are a critical nexus to advance health

For decades, groups such as the World Health Organization (WHO) have heralded cities for the health-related opportunities they present.⁸“WHO European Healthy Cities Network,” World Health Organization, accessed January 2024. Cross-city and local initiatives to improve health in cities, whether led by governments, nonprofit organizations, or the private sector, have been successful. For example, C40 Cities, a network of mayors from the world’s leading cities, is collaborating on climate-focused initiatives, including health-focused ones like air pollution reduction.⁹“Our cities,” C4 Cities, accessed January 2024. Global efforts such as the Partnership for Healthy Cities, the WHO European Healthy Cities Network, the International Society for Urban Health, and Fast-Track Cities, as well as private sector foundations such as the Novo Nordisk Foundation and Novartis Foundation, are other examples of city-focused health collaborations.

At the same time, the opportunity to do better and achieve improved and more equitable health outcomes in cities is still large. Attention on health at a city level could still be much higher. For example, while 100 percent of countries have a top official responsible for health at a national level,¹⁰These officials oversee programs that include health and well-being, public health, disease prevention, and health promotion. only 37 percent of the largest cities in the world¹¹Top five most populous cities per continent, as well as Dubai, Mumbai, Nairobi, Singapore, and Santiago de Chile. have a top official who is similarly focusing on health (Exhibit 3). Having a dedicated senior city leader for health can signal the city’s prioritization of health and facilitates the mobilization of city leaders to focus on health-related issues.¹²The role of national health departments in cities can vary significantly by country.

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Opportunities abound at any level of economic development: at all levels of average GDP per capita, the life expectancy in microregions across the world differs by decades (Exhibit 4). While 53 percent of the variation in life expectancy can be explained by a person’s income, the remaining 47 percent can be explained by other factors such as health-related interventions and innovations.¹³“A dividend paid in years: Getting more health from each dollar of income,” McKinsey Global Institute, December 7, 2022. These facts indicate that opportunities to improve health outcomes exist beyond growing income or stimulating economic growth.

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Based on updates to its foundational analysis, MHI has found that approximately five more years of higher-quality life per person living in urban areas is possible—an additional 20 billion to 25 billion years at a global level.¹⁴This means a large share of the additional years of higher-quality life in MHI’s foundational analysis can be captured in cities. The potential for adding higher-quality life years is calculated based on sizing three effects on a country’s urban population: increase of life expectancy (“extending”), decrease of lifetime spent in poor health, and decrease of lifetime in moderate rather than good health (“lifting” and “squaring the curve”). For more, see “Adding years to life and life to years,” McKinsey Health Institute, March 29, 2022. For major global cities, this could amount to 10 million to 190 million higher-quality life years for their residents (Exhibit 5).¹⁵The potential is calculated by multiplying each city’s metropolitan population by the number of “good and moderate health years” gained per person (based on previous MHI research outlined in “Adding years to life and life to years,” March 29, 2022), which varies depending on the country’s income band. There are three major reasons why cities have this potential (Exhibit 6).

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More than half of the global population today lives in cities. City population is projected to grow to about 70 percent by 2050 (high-income economies may see up to 87 percent of their population living in urban areas by that time).¹⁶World cities report 2022: Envisaging the future of cities, UN-Habitat. Older adults are increasingly living in urban areas and stand to benefit most from improvements in broader population health.¹⁷“Ageing in Cities: Policy highlights,” OECD, 2015. Between 2000 and 2015, the number of people 60 years or older in urban areas worldwide increased by 68 percent, with many in less-than-great health or socially isolated.¹⁸World population ageing report, United Nations, 2017; “Aging with purpose: Why meaningful engagement with society matters,” McKinsey Health Institute, October 23, 2023.

The large disparities in health outcomes within urban populations suggest that a city-level focus could have substantial potential to improve health. For example, despite being eight miles apart in London, there is a 14-year difference in life expectancy among people who live near Prince Regent station and those who live near Charing Cross.¹⁹“Lives on the line: A map of life expectancy at birth,” Tube Creature, accessed August 2023. In Chicago, there is a 30-year life expectancy gap between residents in Streeterville, a neighborhood where residents have an average life expectancy of 90, and Englewood, a neighborhood nine miles away where the average is 60 years.²⁰“Large life expectancy gaps in U.S. cities linked to racial & ethnic segregation by neighborhood,” NYU Langone Health, June 5, 2019; Sarah Holder and David Montgomery, “Life expectancy is associated with segregation in U.S. cities,” Bloomberg, June 6, 2019. Around the world, rapid urbanization has often meant urban poverty, where growth in population outpaces infrastructure and support. In 2020, one in four urban dwellers lived in informal settlements or slums,²¹Informal settlements and slums are characterized by UN-Habitat as lack of access to improved water, improved sanitation, sufficient living area, and quality/durability of structure. Security of tenure is also an indicator but not included in the estimate due to data limitations. See The sustainable development goals report, United Nations. which translates to more than a billion people worldwide living with barriers such as limited access to a healthy diet²²Mireya Vilar-Compte et al., “Urban poverty and nutrition challenges associated with accessibility to a healthy diet: A global systematic literature review,” International Journal for Equity in Health, January 2021. and basic services.²³Aurelio Menendez, “Access to basic infrastructure by the urban poor,” Economic Development Institute of the World Bank, 1991. City-specific interventions show potential to improve population health within cities.

Many of the stakeholders that have a large influence on population health are located in cities. In addition to conventional healthcare players, stakeholders include private sector companies, the government, philanthropists, employers, as well as civil society. Cities are an ideal place to convene all of these players to further health. Usually, a relatively small set of players within a city has an outsize influence on the drivers of health. For example, in Paris, more than 20 percent of employees work in the public sector, and ten hospitals cover 65 percent of hospital capacity.²⁴Characteristics of establishments at the end of 2020, Department of Paris (75), Insee, December 13, 2022; MHI analysis based on APMI Partners data, 2023. In London, 86 percent of the supermarkets are run by just four major chains.²⁵“Top supermarket chains in the UK: Location analysis,” ScrapeHero, accessed December 2023. In Nairobi and Singapore the situation is similar, with 90 percent of supermarkets operated by five chains in Nairobi,²⁶MHI analysis based on Trendtype data, 2023. and 70 percent operated by five players in Singapore.²⁷MHI analysis based on Euromonitor data, 2022. In addition, only the five largest employers in each of the 12 cities referenced in Exhibit 5 have a total annual revenue of $600 billion.²⁸S&P Capital IQ, 2023; examples of the total revenues of top five companies from individual cities include London (USD $85 billion to $90 billion), Singapore (USD $65 billion), and Tokyo (USD $55 billion to $60 billion). This illustrates that powerful stakeholders are indeed a presence in large cities and that harnessing this power is a great opportunity for human health.

Taking action: Focus on neglected areas and start with immediately influenceable interventions

Where possible, doubling down on what cities are currently doing to improve health with their current resources can be helpful. When investing more to drive initial change, immediately influenceable interventions are an effective way to start, especially for stakeholders that are stepping up their involvement in health. In contrast to large-scale infrastructure investments, for instance, immediately influenceable interventions take a relatively short time to implement, have a relatively short payback period, and can typically be advanced by a number of different stakeholders. In principle, any meaningful company, public agency, or civil-society organization can contribute.

Four categories of interventions can harness cities’ unique potential to tackle the growth in noncommunicable diseases: healthy longevity interventions (including those that address cancers, cardiovascular diseases, and diabetes), brain health interventions (including initiatives that address mental, substance use, and neurological conditions), climate-related health interventions, and interventions that improve health-worker capacity. All of these intervention groups are highly relevant across the globe, addressable, and underresourced. Immediately influenceable interventions for each of these areas can take a variety of forms (see sidebar “Examples of immediately influenceable interventions to scale in cities worldwide”).

Healthy aging and longevity. Many interventions can materially contribute to healthy longevity, including effective screening and treatment for cardiometabolic conditions or cancer, as well as interventions enabling better diets or societal participation of older people. For instance, high blood pressure is a critical early marker of compromised cardiometabolic health, and early action can materially improve health outcomes. Even smaller-scale low-cost interventions can make a big difference: providing blood pressure testing kits with appropriate cuff sizes to health workers can increase the share of people with accurate blood pressure measurements.

Effective screening interventions paired with appropriate follow-up interventions, such as enabling healthier nutritional choices in collaboration with local stores, can unlock years of higher-quality life per person. For starters, employers and businesses could raise awareness, provide spaces, or offer incentives for employees to increase testing. There is opportunity to work with city stakeholders to proactively improve health and quality of life of its older residents through enabling their more meaningful participation and contribution. Examples include the following:

• Childhood obesity. In New York City, a public–private partnership for food security among a nongovernmental organization, a philanthropic foundation, and the New York City government to deliver produce prescription programs²⁹Wholesome Wave’s fruit and vegetable prescription program, New York City: 2013 outcomes, Wholesome Wave, 2014. and home delivery of fresh produce³⁰“NYC Health + Hospitals launches produce prescription program study to improve the health of children with overweight and obesity,” NYC Health + Hospitals press release, June 2, 2022. led to 40 percent of children lowering their BMI after four months.³¹“Doctors at HHC Elmhurst and Bellevue Hospitals write fruit & vegetable ‘prescriptions’ for vulnerable children and their families,” NYC Health + Hospitals press release, October 16, 2014. In Amsterdam, a program targeting childhood obesity led to a 12 percent decrease in obesity over a three-year period.³²The Amsterdam healthy weight approach: Investing in healthy urban childhoods: A case study on healthy diets for children, UNICEF, City of Amsterdam, EAT, November 2020. The program involves citywide government-led initiatives and policies, including screening infants at risk of obesity, implementing healthy corner stores, curtailing junk food marketing, and subsidizing sports clubs. For those living with obesity or are overweight, the city provides tailored nutrition and exercise plans from child-health nurses, alongside regular check-ins from a volunteer buddy network.
• Societal participation of older people. Age Friendly Seoul’s 2012 Comprehensive Plan for Senior Citizens included the creation of and support for senior-community organizations, senior clubs, and cultural programs and a skills-matching volunteer program. Building on its 2012 plan, Seoul published its Aging Society Master Plan in 2020, which set “the realization of an age-friendly city” as its main policy goal.³³“Progress of Seoul’s Join,” Age Friendly Seoul, accessed January 2024. Seoul became the first Korean city to join the WHO’s Global Network of Age-Friendly Cities & Communities in 2013.³⁴“Age-friendly world: Seoul,” World Health Organization, accessed January 2024.

Brain health. Increasing access to effective mental health supports by training clinical and nonclinical workers³⁵Clinical workers could include doctors, nurses, and clinical social workers. Nonclinical workers could include school counselors, caregivers, and community health workers. to provide brief, basic versions of existing evidence-based psychological treatments (for example, cognitive behavioral therapy, interpersonal therapy, problem-solving therapy) is an approach that can help address a range of common mental disorders, including low to moderate symptoms of anxiety and depression, and substance use. Data shows that this “task sharing” of psychosocial interventions can have a positive impact on patient outcomes, particularly for those with anxiety and mood conditions.³⁶Nadja Ginneken et al., “Primary‐level worker interventions for the care of people living with mental disorders and distress in low‐ and middle‐income countries,” Cochrane Database of Systematic Reviews, 2021.

Task sharing can also be utilized to strengthen the community-based crisis care continuum and prevent overreliance on first responders (such as emergency medical services), emergency departments, and psychiatric hospitals. For example, clinical and/or nonclinical workers trained as part of a task-sharing approach can be deployed in community mental health settings to support individuals who have experienced or are experiencing a mental health crisis. In order to expand access to mental health supports in a wide range of contexts, there is an opportunity to move toward long-term sustainability of task-sharing models by leveraging technology, health system innovation, and community support.

A practical example of what task sharing may look like in practice is the Common Elements Treatment Approach (CETA). CETA teaches clinical and nonclinical mental health practitioners how to address a range of mental health issues (for example, trauma, depression, anxiety, and substance use) in a single treatment flow. CETA’s system of care includes a mental health assessment, triage, treatment, safety for suicide/violence/abuse, and monitoring and evaluation. Another task-sharing model, Friendship Bench, was developed in Zimbabwe to enhance mental well-being and improve quality of life through the use of problem-solving therapy delivered by lay health workers. Uniquely, the Friendship Bench engages “grandmothers”—trained community volunteers, without prior medical or mental health experience—to counsel patients on wooden benches in their communities. Other effective task-sharing models under consideration include mhGAP Intervention Guide, EMPOWER, the Shamiri Model, and Group Interpersonal Therapy.

Climate-related health. There are a wide range of climate-related health challenges in cities such as heat, air pollution, and flooding. Cities are developing climate and heat action plans to counter the health effects of climate change. Such plans set guidelines for managing acute emergencies, such as working with local government and outdoor-labor-intensive businesses to ensure that employees are protected from working during the most heat-exposed hours of the day and that vulnerable residents have a place to go. Other efforts enhance urban greening to mitigate the impact of extreme heat. There is potential to work with key stakeholders to further prioritize climate-related health issues on public health agendas and improve data and technology and healthcare systems to prepare for the upcoming challenges. The following are examples of existing heat action plans.

The government in Ahmedabad, India, developed South Asia’s first heat action plan in 2013.³⁷Ahmedabad heat action plan: Guide to extreme heat planning in Ahmedabad, India, Ahmedabad Municipal Corporation, 2019. The plan had three components: an emphasis on increased public awareness through billboards, digital marketing, and partnerships with local organizations; the development of an early-warning system with a seven-day heatwave forecast and plans to mobilize first responders, media agencies, and community groups; and improved health-worker training to recognize and treat heat-related illness. The heat action plan contributed to the prevention of deaths both during and outside of heatwaves, with an estimated 1,190 lives saved per year.³⁸Jeremy Hess et al., “Building resilience to climate change: Pilot evaluation of the impact of India’s first heat action plan on all-cause mortality,” Journal of Environmental and Public Health, 2018. In Miami, the world’s first chief heat officer launched the Climate and Heat Health Task Force in 2021, in partnership with academia, the private sector, and community groups, to shape the city’s extreme-heat action plan.³⁹“Extreme heat action plan,” Miami-Dade County Office of Resilience, November 2021.

A road map for driving health in cities

So how, in practice, can cities start on the journey to becoming a healthy city? A four-step approach could allow stakeholders to rapidly mobilize around a joint aspiration for their city and get going (Exhibit 7).

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To make this approach work in practice, it is important to learn from both past experiences as well as emerging successes. Early successes are critical, as they can help to set in motion a sustainable, virtuous cycle between institutional action and individual behaviors on city level. The following factors can help ensure that residents and stakeholders fully capture the potential of this approach:

• Understanding the “unlock”: identifying root causes for the problems with known solutions and tailoring the design to local needs
• Focusing on the “point” intervention: picking a few effective actions to speed up progress and deliver efficiency
• Enhancing the execution engine: concentrating on running a well-organized system that can help people quickly
• Mixing the old with the new: combining long-proven methods with innovation and new technologies (such as artificial intelligence)
• Making the investment attractive: identifying allies, as this is crucial for obtaining the resources needed to advance
• Identifying anchor stakeholders: starting with a small group of senior leaders, ideally of leading social, public, and private sector institutions, who are ready to own this effort

Everybody stands to gain, and the prize could be huge. Businesses could see healthier, happier, and more productive workforces and customers. For health innovators, cities can present an interesting lead market for the large and largely untapped healthcare-adjacent market of prevention and promotion. Residents—both older people and younger generations—stand to gain years of healthy additional life. Cities have the potential to add an extra five years of healthier life per person—up to 25 billion years in total. For all city stakeholders, it’s worth considering how best to get involved, and to do so now.

As part of its commitment to help people live longer and healthier lives, MHI is taking action to advance health in cities by partnering with city-level, national, and global stakeholders. As a non-profit-generating entity, MHI aspires to help advance health on the ground in selected cities across continents and to then share findings, innovation, resources, and data in the public domain. The aim is to enable others to replicate what proves effective.