Comparing Performance in Health, Education and Wealth

Hong Kong

Amongst the 129 city regions analysed in this survey, Hong Kong’s scores best in health (0.88 out of 1), followed by wealth (0.77 out of 1) and education (0.66 out of 1). It shares this overall pattern with Singapore, which scores higher than Hong Kong only in wealth, but also with Paris and London, which it surpasses on health. While its special status as a city-state with a highly specialised economy and development history may render comparisons with the other regions difficult, no other metropolitan area achieves its combination of high life expectancy at birth (82.5 years) and a very low infant mortality rate (two per 1,000 live births). Hong Kong’s comparatively low performance in education reflects lower average years of schooling and enrolment rate compared to European and North American averages.

New York City

The wider metropolitan area of New York scores equally well on all three dimensions – education (0.80), wealth (0.79) and health (0.78). It is outperformed nationally by San Francisco in all dimensions and by Boston on education and (very marginally) on wealth. This may reflect its higher poverty rate (12 per cent) and income inequality measured by the Gini coefficient (50.2), than both San Francisco (10 per cent and 46.5) and Boston (9.8 per cent and 46.1). Internationally, New York achieves high scores in education and wealth, surpassing high-income Asian and European regions. The latter outscore New York only in health, reflecting higher life expectancies and lower infant mortality rates in these regions. Within its North American context, New York’s strong health performance may reflect significant investment and local autonomy in health care and its increasing targeting of health policies towards vulnerable neighbourhoods and at-risk groups, in an effort to reduce health inequalities and gaps in health care access.


London’s metropolitan region scores significantly better for health (0.79) and wealth (0.77) than it does for education (0.71). While London does better than all North American city regions in health, it scores lower than most other West European capitals in health and in education. In fact, the UK capital suffers from a significantly higher infant mortality rate than many other European capitals – with wide discrepancies between wealthier West London and the more deprived East London, which has for generations been home to immigrant communities. Within the UK, London performs strongly, particularly in relation to wealth, reflecting its role as an international financial centre and a key location for specialist service firms. This is translated at the European level by a high wealth score, with only Stockholm and Paris edging past it. By European standards, London is at the same time an attractive location for educated migrants and a site of low educational achievement with an unequal educational profile.


Istanbul’s metropolitan region scores strongly in wealth (0.68) placing it among the top regions in emerging economies, but it achieves low scores in health (0.57) and education (0.52). Within Turkey, Istanbul also performs more strongly in wealth than in health or education, with literacy and infant mortality rates that mirror national averages. Ankara, the nation’s capital, performs more strongly on education and health, with almost 9 per cent more of its population of more than six years of age having at least high school education. Its overall pattern is very similar to that observed for Brazilian regions, where improvements in wealth do not seem to have translated into better social conditions so far. Istanbul’s low scores in health and education may be explained in part by national school attendance patterns (adults achieve only 6.5 years of schooling on average, for example) and the high levels of rural in-migration from areas that suffer from significant regional inequalities.


Mumbai’s extended urban region scores lower in education (0.44) than in health (0.54) or wealth (0.56), a pattern similar to the Chinese city regions. It is India’s second-highest scoring city in education behind Kochi, and its third-highest scoring city in health, following closely behind Kochi and Chennai. With more than half its population living in slums, Mumbai’s low international performance across all indicators reflects its lack of basic infrastructure, insufficient formal housing and lack of access to education, health and formal employment on international standards. Yet Mumbai significantly outperforms the national average across all measures. In relation to health, for example, 88.1 per cent of children are completely immunised, compared to 53.3 per cent nationally, and in terms of material welfare, 86.1 per cent of households have access to a toilet, compared to 49.3 per cent nationally.


Shanghai is weaker in education (0.53) than in either health (0.62) or wealth (0.67), a pattern that is common to most urban areas in the region. Shanghai outperforms the Chinese national average in all measures, but only marginally in relation to education. Its strong economic performance at a global level – similar to Mexico City, São Paulo and St Petersburg – and within China reflects its role as the country’s financial capital, with the relative autonomy to implement pro-growth policies. Its comparatively weak performance in relation to health and especially education may reflect Shanghai’s rising inequalities (it has a Gini coefficient of 45), as well as the impact of China’s hukou policy which, despite recent modifications, restricts access to basic services for rural-urban migrants.

Mexico City

Mexico City’s extended metropolitan region scores equally on all three dimensions, with 0.64 on both health and wealth and 0.62 in education. Internationally, it performs less well than North American cities on all dimensions, and is also surpassed by Buenos Aires and Monterrey in Latin America, but remains within the top tier of metropolitan regions for all three indicators reflecting a sustained effort to improve housing, education and health over recent years. The Distrito Federal, Mexcio City’s central district with nine million residents, has put a strong focus on inclusiveness, especially of the elderly and informal workers; with important measures such as free access to medication for informal workers, large-scale health promotion campaigns and screening tests for non-transmitted diseases in the public space. However, the wider metropolitan area performs only marginally better than the national average across all measures used to calculate these indices. This unexpectedly low performance reflects the extremely extensive nature of its geographical boundary which embraces very diverse communities spread thinly across a wide area. In fact, within the vast urban conurbation of 35.4 million people, it is only the central Distrito Federal which has been able to concentrate health, education and economic resources effectively, while far less developed and low-performing surrounding regions may suffer from access to core services.

São Paulo

Reflecting its status as the economic powerhouse of the Brazilian economy, São Paulo’s wider metropolitan region scores well internationally on wealth (0.67), but underperforms on education and health (0.58), a pattern that is replicated at the national level. São Paulo outperforms Brazil significantly in economic terms but aligns itself to national averages in both health and education. This makes São Paulo one of the lowest scoring regions in South America on health, and places it in the same category as Turkish, Indonesian and Chinese urban regions. An explanation for this relatively low health score might be found in the fact that there is significantly more variation in health performance amongst the municipalities that make up the Brazilian city regions than there is in either education or wealth performance, suggesting that the high rates of income inequality in Brazilian cities (São Paulo’s Gini coefficient is 61) find their most extreme manifestation in health outcomes. Nonetheless, the city authorities have made a concerted effort to improve health conditions for its residents, and in 2000 integrated the national health insurance system, which guarantees free health assistance to all its citizens.


With 0.62 in both education and wealth, Johannesburg is the highest-scoring metropolitan region in Africa, surpassing all Northern African cities and reaching levels similar to those observed in South America and China. However, in terms of health, Johannesburg’s score of 0.30 puts it at the very bottom, close to Sub-Saharan African regions, reflecting the high incidence of HIV in South African cities, especially in areas with high levels of informal development and poor access to services. Despite Johannesburg’s poor health performance internationally, it does better than the national average in this regard, while the picture is more mixed in education and wealth. Johannesburg’s difficulties may stem from its high social and spatial inequalities (its Gini coefficient is 75, one of the highest in the world) and insufficient infrastructure, despite efforts towards universal education and health, housing and neighbourhood improvements.

This research has been led by Antoine Paccoud, Researcher, LSE Cities, London School of Economics and Political Science.