China, People's Republic of : Guangxi Wuzhou Healthy and Age-Friendly City Development Program

Health / Health sector development and reform - Health system development

Water and other urban infrastructure and services / Other urban services - Urban policy, institutional and capacity development

Urbanization is a key determinant of health and welfare. The urban population of the PRC has increased at an extraordinary pace, from 18% in 1978 to 65% by 2021. This urbanization has coincided with aging and demographic transition: one out of every five people will be more than 60 years old by 2030, increasing to more than one in three by 2050. Many older people will grow to very advanced ages, becoming part of an urban society spanning four generations. As the PRC and the world continue to age and urbanize, sustainable development will depend on making cities more livable. Improvements in urban residents' health, well-being, and quality of life will contribute to high-quality development as the overarching goal of the PRC's Fourteenth Five-Year Plan, 20212025.

The PRC launched its comprehensive Healthy China 2030 program in October 2016, calling for adherence to a "health in all policies" approach to the prevention and treatment of disease and the promotion of health, healthy lifestyles, and physical fitness. Healthy China 2030 emphasizes the importance of healthy cities and promotes the integration of health issues into urban planning, design, and management. It defines healthy cities as focusing on (i) constructing healthy environments, (ii) building a healthy society, (iii) optimizing health services, (iv) fostering healthy people, and (v) developing a health culture. As the first medium- to long-term national strategic plan for health since the PRC's founding in 1949, Healthy China 2030 reflects a high political commitment to participation in global health governance and to achieving the Sustainable Development Goals. Subnational governments in the PRC are developing their own healthy city plans and programs to contextualize and translate this national policy into local practice. In the Guangxi Zhuang Autonomous Region, the Wuzhou Municipal Government (WMG) issued Healthy Wuzhou 2030 in 2019.

Intersectoral collaboration and action play a key role in both Healthy China 2030 and Healthy Wuzhou 2030. Making cities healthier requires coordinated multisector urban governance and planning to provide clean, walkable, and barrier-free environments; accessible health, child welfare, and elderly care services; and infrastructure that improves the urban environment and encourages healthy lifestyles. All of these will ease public health management in an era when infectious diseases, noncommunicable diseases, and the challenges of aging population are converging, as in the PRC. Improved urban planning and design such as the development of mixed-use pedestrian-friendly areas, served by safe and convenient public transport and bike lanes, with attractive public spaces and green park networks, exercise facilities, playgrounds, and public toilets can help improve air and water quality, community fitness, and social connections that promote physical and mental health. Well-planned and conveniently located urban health care, childcare, and elderly care services help reduce disease, promote well-being and social inclusion, and reduce the care burden that disproportionately falls to women.

Wuzhou, a medium-sized city of 3.53 million people in the eastern Guangxi Zhuang Autonomous Region, is grappling with an urban environment and services that do not meet the health, safety, and social inclusion needs of its growing four-generation society (problem analysis diagram). This is particularly the case in the urban core comprising the three central urban districts of Changzhou, Longxu, and Wanxiu, where 17.6% of the population is over the age of 60. Four key constraints hamper urban health, well-being, and livability for all ages. The first is that urban spaces and infrastructure are not adapted to the population's evolving needs. Reasons include unmet demand for public green space and fitness facilities; non-barrier-free movement for people with mobility challenges; and unhygienic environments due to outdated infrastructure for solid waste, drainage, and sanitation. The second key constraint is that the supply and quality of age-friendly services and facilities do not meet demand. Wuzhou's large and growing number of older persons is straining existing capacity. There is a shortage of well-trained medical and care staff (primarily women) to provide elderly care, childcare, and social work services for vulnerable children. There is also an imbalance between the delivery modalities of home-based, community-based, and residential elderly care. A third constraint is less effective public service delivery and management, which stems from underdeveloped smart health systems and information platforms and sub-optimal use of new technologies. Health information and medical records are poorly integrated, and an emerging digital divide puts older persons at a significant disadvantage in accessing digital platforms. The fourth key constraint is low capacity and weak institutions to plan and implement healthy and age-friendly spaces and services. Wuzhou lacks integrated approaches to multisector program planning and capacity for multisector program implementation, as well as ensuring sustainable management and governance. Knowledge and coordination gaps underpin the issues of institutional capacity and underdeveloped service delivery standards and regulations.

To holistically address these challenges in a targeted, integrated manner, the proposed program is a time- and geographic slice of the Healthy Wuzhou 2030 program, prioritizing the most critical needs and considering achievable initiatives. It integrates concepts from the World Health Organization's healthy and age-friendly city guidelines, and directly responds to the National Health Commission's 2020 national plan to create 5,000 age-friendly communities around the country from 2021 to 2025, mobilizing resources to ensure healthy aging and build a shared age-friendly society. The Wuzhou program aligns closely with the National Health Commission's emphasis on the need to improve the quality of life and environment of older people, encourage their participation in public activities, and enrich their spiritual lives. The ambitious goal is for all urban and rural communities nationwide to be age-friendly by 2035.

The concept of healthy and age-friendly cities integrates previously isolated concepts and cuts across multiple sectors. It aligns with global initiatives including the New Urban Agenda as adopted by the United Nations Habitat III conference, and the new United Nations Decade of Healthy Aging (20212030), which aims at catalytic effort and collaborative action to support this major global demographic transition. The proposed program is also aligned with the Asian Development Bank (ADB) Strategy 2030 operational priorities 1 (addressing remaining poverty and reducing inequalities), 2 (accelerating progress in gender equality), 4 (making cities more livable), and 6 (strengthening governance and institutional capacity). The proposed program is closely aligned with the third pillar of the new country partnership strategy for the PRC, 2021-2025, aiming at both health security and responding to an aging society. The program is included in the indicative country operations business plan for the PRC, 2021-2023.

Results-based lending is the most suitable modality for several reasons. The complex, multisector, and multi-stakeholder nature of the development challenges related to healthy and age-friendly cities requires a results- and system-based approach. With many smaller and dispersed activities planned, a transaction and input-based approach as under an investment lending would not be as efficient, nor would it be as effective in terms of sustainable program results and system-wide improvements. Since healthy and age-friendly urban development is not a clear-cut sector, a sector development program approach is also not advised. The selection of RBL also considered the strong government ownership of the program, anchored on national and provincial plans that provide the mechanism to push initiatives forward (especially for elderly care) and enhance the potential for replicability and scaling-up. The program will be able to build on earlier ADB assistance to Wuzhou for urban and community development. There is clear institutional capacity but also scope for further institutional development. As the first RBL program to support healthy and age-friendly urban development, the program will have clear learning opportunities and demonstration and replication impacts within and beyond the PRC, to be achieved through a strong focus on knowledge generation as a main objective of the program.

Better health, well-being, and people-oriented socioeconomic development achieved

Livability, age-friendliness, and social inclusion in Wuzhou's urban center improved

Healthy and safe four-generation urban environments established

Integrated age-friendly services and facilities improved

Institutional development and capacity building promoted