World Mayors Conference. Cochin, Kerala - India: 2 nd - 4 th April, 2005

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1 Maternal and Child Health Conditions of Rapidly Growing Urban Poor Populations: The Way Forward for City Governments What can cities do to achieve MDGs? World Mayors Conference Cochin, Kerala - India: 2 nd - 4 th April, 2005 Organized by: All India Institute of Local Self Gove rnment, Mumbai, Govt. of Kerala & Kerala Institute of Local Administration Who are the urban poor? Urbanization and urban poverty What are the present Maternal and Child Health Conditions (MDG: 4&5) among the urban poor? Child, infant and neonatal survival far lower than urban averages Poor Neonatal health and care High incidence of Under nutrition among urban poor children Poor reach and usage of public sector services Compromised Water and Sanitation Services Less developed States considerably worse than National figures What challenges accost cities in responding to the poor MCH conditions of urban poor? How can city planners and key players enable progress of urban poor on the MDG path? Paper presented by Dr Siddharth Agarwal, Country Representative, USAID-EHP Urban Health Program With assistance from Arti Bhanot, Karishma Srivastava, Pravin Jha, Jack Eapen

2 Urbanization and Urban Poverty Who are the urban poor? Urbanization and growth of urban population: Rapid and unplanned urbanization is a marked feature of Indian demography. The urban population of India accounts for 27.8% of the total population equating to million. This represents a hundredfold increase in the past century, and a 40% increase during the last decade. If urban India was considered a separate country, it would be the fourth largest in the world after China, India and the United States. Urban Population projections: Population projections by several agencies indicate that by 2025, India s urban population will grow to 660 million with more than half of the total population living in urban areas. In 2001, there were 35 million plus cities and 393 cities above 100,000 population. It is estimated that the number of million plus cities in India will grow to 51 by 2011 and 75 by 2021 AD. In addition there would be, by 2021, 500 large cities with population above 100,000 (Sivaramakrishnan and Singh, 2001)2. In the last decade, as India grew at an average growth rate of 2%, Urban Indian grew at 3%, mega cities at 4% and slum populations increased by 5% representing the syndrome3. Magnitude of urban poverty: 23.6% of the urban population is poor ie their expenditure on consumption goods is less than Rs 454 per month 4. However, these estimates do not reflect the true magnitude of urban poverty because of the unaccounted for and unrecognized squatter-settlements, floating population and other invisible populations residing in pavements, constructions sites, urban fringes, etc. Other studies (Haddad et al, 99) 5 ; estimate that there are more than 90 million urban poor in the country. The benefits of urbanization have eluded this burgeoning urban poor population, most of who live in slums Census, Registrar General of India 2 Sivaramakrishnan K,C. and Singh B.N, 2001, Urbanization, planningcommission.nic.in/ reports/ sereport/ ser/vision202 5/urban.doc, accessed on 21 Sep Chatterjee, G Consensus versus confrontation: Local authorities and state agencies form partnerships with urban poor communities in Mumbai. Urban Secretariat, United Nations Human Settlements Programme. UNHABITAT 4 National Sample Survey Organization, 55 th round survey ( ) 5 Lawrence Haddad, Marie T. Ruel, and James L. Garrett, 1999, Are Urban Poverty And Undernutrition Growing? Some Newly Assembled Evidence

3 Urban scenario in the less developed states of India The eight EAG (Empowered Action Group, 2001 ) states [Uttar Pradesh, Madhya Pradesh, Rajasthan, Bihar, Orissa, Jharkhand, Chhatisgarh, Uttaranchal] constitute 32% of the total urban population. Based on NSSO estimates ( ), these eight states are home to 28 million or 43 % of India s urban poor. Urban Population in EAG States Urban Poverty in EAG States Rest of India, 68% EAG states, 32% Rest of India, 57% EAG states, 43% Population and poverty figures based on National figures (285m and 67m respectively) It is no surprise that these less developed states perform much below all-india indices for various maternal and child health parameters as detailed in later sections, bellowing the need to prioritize them in urban health programs as well. None the less the problems of urban health are not confined to the less developed states. What are the present Maternal and Child Health Conditions (MDG: 4&5) among the urban poor? The urban advantage evades the poor. When infrastructure and services are lacking, urban settlements are amongst the world s most life threatening environments6.inevitably, challenging living conditions undermine the capacity of care takers to provide optimal care for the estimated 2 million children born each year among the urban poor population (based on fertility rate of 3 for a population of 67 million). Goal 4 in the MDGs is to reduce child mortality ie reducing by two thirds the mortality rate among children under five, while, Goal 5 aims to improve maternal health aiming EAG (Empowered Action Group): In order to facilitate the preparation of area-specific programmes, with special emphasis on five states (MP, UP, Orissa, Bihar and Rajasthan which later split and totaled to eight states) that have been lagging behind in containing population growth (contributes 45% of the population of the country) to manageable limits, the Government of India constituted an Empowered Action Group in the Ministry of Health and Family Welfare w.e.f. 20th March, Members of the group consist of Minister for Health and Family Welfare, Chairman, Minister of State for H&FW, Vice Chairman, Secretaries of these 8 states, Secretaries of different Central Govt. Departments, Advisor (Health) Planning Commission, other Central Govt. officials and Joint Secretary (P) D/O Family Welfare as its convener. 6 WHO (1999). Creating healthy cities in 21st century, chapter 6 in David Satterthwaite (ed.). The Earthscan reader on Sustainable cities, Earthscan publications London.

4 at reduction of Maternal Mortality Ratio by three quarters. The present scenario of the urban poor women and children and their growing numbers indicates the stiff task ahead of us in meeting these goals Child, infant and neonatal survival far lower than urban averages Under-5, infant and neonatal mortality rates are considerably higher among urban poor as compared to National and State averages 7 and very distant from MDG targets. Infant and child mortality rates reflect the level of socio economic development and quality of life. They are useful indicators for monitoring and evaluating health programs and policies. Survival patterns among the urban poor, clearly point at the need for extra focus on this large segment of India s population. All urban poor child health indicators presented in this document are based on reanalysis (EHP, 2003) of NFHS 2, data, by standard of living index. Under-5 mortality among urban poor One out of 10 children born during the year is not destined to see their fifth birthday among the urban poor in India. In less developed states (like Madhya Pradesh) under-5 mortality among the 20 0 India MP urban poor may be 1.3 times higher than the corresponding National figure Low SLI Average Rural average Infant mortality among urban poor One out of 15 children born during the year is not likely to see their first birthday among the urban poor in India. Amongst urban poor in less developed states IMR is 1.6 times higher than the corresponding National figure India MP Low SLI Average Rural average 7 EHP, 2003: Re-analysis of NFHS 2, , by Standard of living Index

5 Poor Maternal and Neonatal Health and Care Maternal Health: More than half the pregnant urban poor women do not receive 3 antenatal check-ups. A similar number of women in reproductive age group are anemic. Qualitative research in Indore slums indicates insufficient preparedness for delivery. The high number of home deliveries varying from 50-80% amongst urban poor exposes mothers to risks and complications and delay in referral to facilities. Neonatal Care: The urban poor neonate comes into the world with destined disadvantages: a) almost 6 out of 10 are delivered at home in the slum environment; b) about 50 % are likely to be Low Birth Weight; c) only 18% are breast fed immediately after being born. Despite physical proximity to private, charitable and public sector health facilities in urban areas, the urban poor neonate is born and grows in uninspiring surroundings. This calls for enhancing skilled attendance at the time of delivery, through promotion of institutional deliveries and also through training of birth attendants in the community since home deliveries may continue to take place in sizable numbers for a long time. It also points to the needed emphasis of improving household newborn care India MP 13.5 Urbal Low SLI Urban Average Rural average Institutional deliveries 1.1 million births take place in the debilitating environment of urban poor settlements. Amongst urban poor in less developed states home deliveries are 1.3 times higher than the National figure. High Incidence of under-nutrition among urban poor children More than half of India s urban poor children are underweight and/or stunted. In most States, under-nutrition among urban poor is worse than in rural areas.

6 There is a need for augmenting nutrition programs such as ICDS and PDS with targeted strategies to reach the vulnerable sections of urban populations. Efforts to better address household level care of young children are also required. Underweight and/ or stunted children India MP 58.4 Urbal Low SLI Urban Average Rural average Poor reach and usage of public sector services The reach and utilization of essential preventive health services to the urban poor is abysmal: a) about 60% of children are not completely immunized by 1 year of age; b) use of birth spacing methods is abjectly low at 4%; c) as few as 3 of the 10 children affected with diarrhea receive ORS. This scenario is reflective of a) the family s compromised ability to recover from the existing limiting environment, b) paucity of time to seek health care as parents/ caretakers are daily wagers, c) having to contend with pressing issues such the risk of eviction and struggle to access basic services such as water and sanitation, d) all these being compounded by low health awareness. Reach and effectiveness of maternal and child health services in urban slums are strained by several challenges. There are multitude of healthcare service providers such as the Municipality, Health Dept., Private Sector, NGOs etc with ill defined roles and weak coordination. Poor environment and sanitation conditions, high population density all increase disease transmission. Heterogeneity of slum dwellers, lack of common meeting area, fewer extended family connections and more women

7 engaged in work away from home compromise caring of children and information about health services and facilities India MP 17 Children age months who received all vaccinations 3 out of every 5 children less than 24 months among urban poor do not receive complete immunization. Urbal Low SLI Urban Average Rural average Use of birth spacing methods Use of birth spacing methods is abjectly low at 4%; India MP 2.1 Urbal Low SLI Urban Average Rural average Compromised Water and Sanitation Services Access to water supply and sanitation facilities among the urban poor is very poor. About half of urban poor households do not receive water supply and about twothirds do not have a toilet. Less developed States considerably worse than National averages Maternal and Child Health conditions among urban poor in less developed States are far worse than National urban poor data as shown above. Being home to 43% of India s urban poor, having relatively higher birth rates as compared to other States, and having weaker urban health program, these EAG States find their urban poor having far worse maternal and child survival rates than many other Indian States. 8 Atkinson S, Cheyne J. Immunization in urban areas: issues and strategies. Bulletin of World Health Organization, 1994, 72 (2):

8 What challenges accost cities in responding to the poor MCH conditions of urban poor? People - Searching for Citizenship Large proportions of slums are invisible Slums are considered illegal and remain invisible despite the economic contribution of this large informal work force. Hidden and missing pockets of urban poverty such as limestone and brick-kiln workers, construction site workers, workers of local industry (leather, jute, glass) are clusters where services usually do not reach, as they are not part of official slum lists. Bound to a specific industry, they are usually on some private land, unseen by most. Owing to long delays in updating of official slums list in most cities, slums may remain unrecognized for years. Evidence from detailed assessment of slums in four cities indicates that 328 slums with a population of about 510,397 were unrecognized. S.No. City Recognized slums Non recognized slums 1 Agra Dehradun Jamshedpur Bally slums (total) 328 unrecognized slums (population 510,397) 452 recognized slums (population 820,139) 1 Slum dwellers have few rights as urban citizens and consequently little power to influence their circumstances. Their capacities and environment vary across slums as discussed below. Differential vulnerability across Slums- Need to prioritize the vulnerable All slums are not equal and most vulnerable pockets are often not included in official slum lists; it is hence vital to identify and plot on city map all slums and prioritize the un-reached, vulnerable urban settlements to efficiently target resources.

9 Differential vulnerability can be understood with involvement of local representatives from various public sector, NGOs and community institutions can provide a rich information base regarding slums, which otherwise remain incompletely understood owing the dynamic nature of slums marked by frequent new growth, re-allocation, official eviction and resettlement etc. Context appropriate criteria of health vulnerability can be determined through group discussion with slum dwellers (primary stakeholders) and others directly working in slums (such as AWWs/ ANMs). Visits to slums of the city at different levels of development e.g. old vs new; city center vs periphery; recognized vs unrecognized etc. help understand these perspectives more clarely. Some key determinants of health vulnerability of slums are: Economic conditions regularity and constraints of livelihood/occupation, access to fair credit Social conditions alcoholism, gender equity, education Living environment water and drainage systems, sanitation facilities, housing and land tenancy Access and usage of public health services ICDS and DHFW Health status and morbidity prevalence of diarrhea, fever and cough among children, and service coverage Community confidence and negotiating capacity Presence of organized community collective effort Such a qualitative and participatory process of understanding slums enables programs better understand the urban poverty situation in a city, identify factors that enhance vulnerability in slums and prioritize slum areas requiring health interventions Strained Resources Municipal Health Infrastructure/Services is Inadequate In most of the 73 rapidly urbanizing 2 lac to 40 lac size cities, the Maternal and Child Health service delivery capacity of Municipal bodies is rapidly diminishing. Most

10 Municipal Bodies (their elected leaders as well as officials) have inadequate health program management experience Existing centrally funded Urban Health infrastructure is insufficient There is one Urban Primary Health Centre for about 1.5 lakh urban population, often with 2-4 ANMs. There are 1083 UFWCs (1950) and 871 Health Posts (Urban Revamping Sceme1983); many run from hospitals, not proximal to slums. Through India Population Project (IPP) VIII (1993 to 2002) 531 new facilities were constructed and 661 facilities were upgraded /renovated in Bangalore, Delhi, Hyderabad and Kolkatta. However, the program did not reach all urban poor even in these cities. Staffing has not increased in response to urban growth. Inequitable distribution of resources and Greater focus on rural poverty There is inequitable distribution of available resources for urban poor among different cities. Weak political consciousness to address concerns of urban poor and greater focus on rural poverty also contributes to weak MCH program efforts for the urban poor and low utilization of available resources. Higher urban allocation for bigger cities While, medium small cities have significant urban population most urban programs have focused on mega cities. Percentage Distribution of urban population by size of Towns/UA (Census of India, 2001) Below 100, ,000 to 499, ,000 to 1 million 17 1 million to 5 million 6 5 million to 10 million million and above Percentage Distribution

11 Today s 35 million plus urban agglomerations (37% total urban population) will double by Thus p reparedness is needed to meet this growing challenge. Alos, capacity of Municipal Bodies is weak in most medium-small cities. Greater focus on rural areas In India being a predominantly rural country, the focus of most maternal and child health initiatives has been on villages. An analysis of rural and urban ICDS coverage shows that one AWC to total population ratio in rural areas is 1:1260 (79%) and 1:6114 in urban areas (16%). Rural ICDS 589m Urban ICDS 47m Urban-Total 286m Rural-Total 742m Four Scenarios of Urban Health Program Capacity at City level Mega cities: Financially and Institutionally Medium sized Cities in States where Municipal Capable Municipal Corporations manage Capacity/Authority is weak: health services. These have been past 40-50% Urban Primary Health Centers run by recipients of major programs such as IPP V MCs and VIII and other bilateral assistance for 50-60% run by State Health Dept.. Inadequate urban health. linkages with health Dept Weak Health program Capacity among elected representatives and officials Diminishing capacity at Municipal level to secure resources Small Cities in States with Weak Municipal Capacity and Authority: Little or absent Urban Health Infrastructure for the Poor Very weak Municipal Capacity to manage programs Medium-Small Cities in States with Strong Municipal Capacity: Fair Health program Management and overall Governance capacity Often Generate local resources and sustain health services e.g. WB Stronger Political Consciousness for the health needs of the urban poor 9 Dyson et al, Twenty First Century India. Population, Economy, Human Development and the Environment

12 How can city planners and key players enable progress of urban poor on the MDG path? The sub-optimal maternal and child health conditions, with a feeble health delivery system to cater to the burgeoning 90 million urban poor poses a stiff task for the City planners and other key players. The aim is not only to ensure reach and utilization of services by this vulnerable group but also to cause an impact which involves an integration of different services beyond health alone. Opportunities in urban areas Growing Recognition of the problem and burgeoning interest: There has been growing recognition of the problem of urban slum dwellers among Government agencies, donors and NGOs. The Government has acknowledged the non-availability as well as substantial under utilization of available primary health care facilities in urban areas along with an overcrowding at secondary and tertiary care centers. MCH services to the urban poor have been recognized as important thrust area by the government under the National Population Policy-2000, National Health Policy-2002, Draft RCH II and the Tenth Five Year Plan. Resources and Potential Partners Abound: City planners and programmers can collaborate with a range of public sector and private partners: Health Dept., NGOs, Private and Charitable hospitals, amongst others. Integrated Child Development Services (ICDS), where present has a greater impact on immunization coverage in urban slums than rural areas. Urban Poor Geographically Approachable: Seeing the glass half full or half empty; crowded living of slums makes larger number of people geographically accessible for outreach activities in lesser time unlike rural areas where population is more dispersed. 74 th Constitutional Amendment, an Opportunity for City Governments: Under the 12 th Schedule of the 74 th Amendment, Health services are mandated as functions of

13 Urban Local Bodies (ULBs). It is also in the political interest of elected representatives to utilize this opportunity and broaden the spectrum of their current interest and activities to include health services to the urban poor. This will help better serve and nurture their constituencies. The Way Forward This paper suggests four broad approaches to move forward on the agenda of progressing towards the MDGs by the urban poor. (I) Strengthen Municipal Health Program Capacity As noted above, barring the few mega-cities or cities in a few states urban governance and Municipal Capacity is not adequate in providing services to the urban poor masses. Certain measures are critical in enhancing municipal health delivery capacity as listed below. Train elected representatives and officials on 74th amendment, Govt. policies, programs including exposure visits/cross learning Negotiation with State Governments for complete implementation of 74th amendment Facilitate linkage of ULBs with professional technical agencies to broaden their information base and improve implementation capacity Better leverage existing municipal buildings being used for health services e.g. rent out in evenings to private doctors Initiate multi-stakeholder coordination at Ward level to improve reach and quality of health services (II) Strengthen Services in coordination with State Health System and Private Partners The Health and Family Welfare Department forms the mainstay for delivery of health service in many cities. Municipal Governments should proactively link with it to ULB refers to Municipal Corporation, Municipality, Nagar Panchayat

14 ensure reach to all pockets, avoiding duplication of efforts and better manage health services. This would entail: Identification and mapping of all urban poor (including unlisted/hidden pockets) Augmenting Urban Health services including outreach camps with focus on vulnerable urban settlements Establish Urban Health Program Management Unit at municipal level and proactively coordinate with RCH 2 to augment services. Strengthen Program Management capacity (including financial management) Public (Municipal) Private Partnership for health service delivery Motivational training to health providers (ANMs, MOs, Supervisors) to i) be more sensitive towards the disadvantaged and ii) recognize and coordinate with Community Health Volunteers and CBOs (III) Demand side measures Balancing quality supply and demand is essential such that each fuels the other. Just as the service delivery systems and processes need strengthening so does social mobilization and increased community health care seeking behavior. Peoples capacity to negotiate for availing health services may be non-existent or impaired owing to the challenging environment and livelihood issues that surmount. There is an opportunity to improve behavior by strengthening CBOs (youth clubs, Mohalla Samitis, NHGs) and training identified Community Health Volunteers to strengthen community-provider linkages (IV) Pro-urban Poor Policies and Energetic Implementation Advocate for implementation of 74th constitutional amendment and strengthen ULBs Increased attention and resources to the urban poor Improve policies to make them more urban poor friendly, practical and measurable

15 Ensure energetic policy implementation by training of officers and increased information to urban poor, including health, poverty alleviation and watersanitation schemes. Real progress on inter-sectoral approaches will be key Identify and address policy constraints to PPP Periodic uproar by Civil society and media to focus on health needs of the urban poor