URBAN HEALTH - THE EMERGING SOCIAL IMPERATIVE FOR INDIA IN THE NEW MILLENNIUM

Transcription

1 REVIEW ARTICLE URBAN HEALTH - THE EMERGING SOCIAL IMPERATIVE FOR INDIA IN THE NEW MILLENNIUM S. AGARWAL*, K. SRIVASTAVA** A. Introduction : The population landscape has been changing very fast the world over in last century. The industrial revolution, characterized with establishment of large industrial settlements triggered large scale urbanization in Europe and America in early 20 th century. In the later decades lesser developed countries of Asia, Latin America, and the Caribbean have witnessed large growth in urban population. In 2008, the world entered the "urban millennium" as the proportion of the world's population living in urban areas crossed the 50% mark (United Nations Population Fund, 2007). Most observers believe that a very large proportion of all population growth from now on will be in cities: the urban population is projected to grow to 4.9 billion by 2030, increasing by 1.6 billion 1. Usually rural residents look towards cities as dream destinations with better quality of life, this surrealistic 'urban tide' does not bring dream shores/resources to all sailors., A large proportion of a city's poor, whether migrants or local residents squeezed into smaller spaces in a growing city, or shelterless residents and many other poor people find themselves residing in older or newer slums, or squatters or peri-urban spaces which accompany the sprawl of almost all cities. Urbanization, has resulted in sharper inequalities, specifically in terms of access to elementary healthcare which is universally essential for all of mother nature's mortal beings. Based on current rates of urbanization, population projections by the United Nations indicate that by 2030, India's urban population will grow to 538 million with more than half of the total population living in urban areas (United Nations 2005). For instance, 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 In addition there would be, by 2021, 500 large cities with population above 100, If urban India were a separate country, it would be the world's fourth largest country after China, India and United States of America.

2 Majority of urban dwellers (52%) in India lives in small and medium sized towns and cities (population less than 0.5 million).three largest agglomerations- Greater Mumbai, Kolkata and Delhi are home to 15% of Indian urban population. During , the annual population growth rates in India were: India - 2%, Urban India- 3%, Mega cities - 4% and Slums - 5% 3. B. Urban poverty in India : An estimated 336 million of 1.1 billion population of India resides in urban areas 4, and of this 336 million, as many as 100 million urban population lives in poverty conditions 5. These 100 million constitute the 'urban poor'. The urban poor reside in slums, squatters, pavements, constructions sites, urban fringes amidst problems such as poverty, lack of awareness, poor living conditions, poor family support system, low access to basic water, sanitation, health and nutrition services as many of them have evolved as encroachments and are not notified in official records. C. Health challenges in urban India : 1. Poor access to healthcare despite physical proximity : Although slum residents often live close to many health care providers, they generally have little access to high-quality care. Care-seeking patterns show that although less expensive, higher-quality government clinics may be available, slum residents who do seek care tend to choose more expensive private providers - for a multitude of reasons, from perceived quality to ease of access Research and knowledge/information gaps : Urban populations are heterogeneous and the diverse scenarios among different segments of the urban population are not evident from the aggregate data which is the most common form in which information is collected and published data is available. Aggregate data, usually not disaggregated by wealth index masks the real health conditions of the urban poor. With a large proportion of low income urban clusters being informal or "illegal", they are not part of official slum lists and hence are often not part of the mandate of public authorities to collect data on these urban poor

3 population. Consequently health planning is not being based on the full needs of the community. Lack of optimal systems for collecting data in slums results in inability to properly plan for infrastructure construction, programs, and resource allocation. Data usually available is not comprehensive and delineated enough to distinguish among types of residence, locations, and socioeconomic strata which would reveal the varied effects of urbanization on health indicators. 3. Large proportion of urban poor not enumerated : Cities grow owing to a variety of factors largely driven by their being centres of one or more forms of economic activities, most of which engage the poor as the workforce. Consequently a large proportion of the migration to into urban centers, is in search of employment. When they arrive, most migrants find only one affordable housing option: illegal and unplanned settlements lacking basic public infrastructure, where they must live in lodgings made from tenuous materials, such as used plastic sheets, discarded scrap metal, and mud. The United Nations Human Settlements Program (UN-Habitat) reports that 43% of urban residents in developing countries such as Kenya, Brazil, and India live in such slums7. Such slums, which are making up an increasing proportion of growing cities, lack not only most basic government services but also political recognition; as a result, so do their inhabitants. a. According to NSSO 58 th Round (2002) 49.4% slums are non-notified in India 8. b. Evidence from detailed assessment of slums in Dehradun, Indore and Bally, shows that the proportion of unlisted slums to listed slums is significantly high (35-99%); a) in Dehradun, 28 unlisted slums were identified beyond the official 78 (36%); b) 159 unlisted slums exist in Indore beyond official list of 438 (36%) and c) in Bally 47 unlisted slums against 75 listed ones (62%) 9. c. Due to long delays in updating official slum lists many slums remain unlisted for years and continue to be deprived to these services due to their illegal status. 4. Poor community awareness and weak community capacity to demand and access health care: Another contributing factor to poor health among the slum dwellers is the low awareness and practice of recommended behaviors as well as of the

4 services that may be available. This coupled with low confidence contributes to the weak demand for services. Recent migrants are far less aware about location of health facilities, how services can be availed, they doubt whether they can approach the facilities and consequently service utilization by such groups is very low. Social heterogeneity in slums contributed to by migration from different areas, instability of slums, diversity of cultures, fewer extended family connections, and more women engaged in work, leads to lesser eagerness and fewer occasions to build urban slum community as a strong collective unit, which is seen as a major demand side public health challenge in improving access. Further, migratory trends among this segment of the population presents a problem in delivery of services. Similar concerns have also been raised in the IPP VIII completion report which states lack of homogeneity among slum residents, coming from neighboring states / countries to the large metropolitan cities, made planning and implementation of social mobilization activities very challenging. 5. Poor family support system The urban social environment usually lacks the health support often provided in rural settings by extended families and stronger kinship bonding and stronger social cohesion. This adds to the vulnerability of urban poor families vis-à-vis availing healthcare. For example, for women and children, the rural environment provides a socially well-knit community that often ensures physical safety, a fair level of food security, and the availability of social support for child care. Without these safeguards, many women's mobility is limited in urban areas, which compromises their ability to promptly avail healthcare for themselves and children when required. 6. Poor Environmental Conditions Access to safe water and to sanitary means of excreta disposal are basic human rights and form an indispensable component of primary health care. Provision of adequate sanitation services and safe water supply represents an effective health intervention which has shown to reduce the mortality caused by diarrhoeal disease by an average of 65 per cent and related morbidity by 26 %. Inadequate sanitation, hygiene and water result not only in more sickness and death but also in higher health costs, lower worker productivity and lower school enrollment and retention rates. Access to water supply and sanitation facilities among the urban poor is very poor:

5 about half of urban poor households do not receive piped water supply and about two-thirds do not have a toilet. 7. High Prevalence of Under-nutrition among urban poor children Under-nutrition is an important factor contributing to high morbidity and mortality among children 10. Malnutrition among children is often caused by the synergistic effects of inadequate or improper food intake, repeated episodes of parasitic or other childhood diseases such as diarrhoea, and improper care during illness 11,12. More than half of India's urban poor children are underweight and/or stunted. Under- nutrition among the urban poor is worse than among rural areas with 47.1% of the urban poor children being underweight as compared to 45.6 % of the children living in rural areas Sharp health disparities in urban India : U5MR far higher among urban poor Common factors contributing to childhood mortality in slums are water borne infections such as diarrhea, respiratory infections such as pneumonia and fevers which are the most prevalent diseases identified among slum children (Awasthi and Agarwal, 2003). These coupled with less than ideal handwashing practices, over-burdened mothers who are not able to provide adequate care to infants and children and over-crowding which leads to easy spread of respiratory diseases. In addition, under-nutrition contributed by sub-optimal feeding practices and a higher incidence of infections deplete the child's body of calories and essential nutrients and contributes to undernutrition. As per the re-analysis of the NFHS III data, Under 5 Mortality Rate (U5MR) among the urban poor is at 72.7, significantly higher than the urban average of 51.9.

6 9. Inadequate public health infrastructure in urban slums : One primary health care facility in an urban area caters to a much higher population compared to the norm of 1 center for every 50,000 population 14. From the providers' perspective service delivery in slums is an enormous challenge given the large and sometimes mobile population and large population covered by a single health worker. This leaves them with little scope for persuasion for appropriate behaviors with target families. Also there is an imbalanced focus on curative care, and a consequent near total neglect of preventive and promotive care. There is an over-emphasis in cities, particularly in the large ones, on super- specialty care centres in the private sectors which are clearly out of reach of the urban poor. High staff turnover, absenteeism, inadequately skilled staff and lack of their supportive supervision are hindering effective implementation of services. A large number of positions of medical officers and para-medical staff are vacant at the primary care facilities 14, which are supposed to cater to the slum clusters. Records maintained are not adequately used as tools for enhancing service quality. Lack of regular and optimal quality training on newborn care, absence of modalities for recognition for dedicated and frequent transfers also contribute to weakness of the services. 10. Weak coordination among different stakeholders : State health department, municipal bodies, ICDS, NGOs, charitable organizations are responsible for providing services in urban areas. Owing to weak coordination among these agencies often service areas of different agencies overlap while they are large areas where there are no services. Absence of a well plotted updated city map indicating slums and facilities leads to crowding of several primary care facilities in a small area of the city, usually its centre. Slums located in city fringes are often served neither by rural nor by urban health staff. D. How can we better design and operationalize urban healthcare system: 1. Understanding the How : A more complete understanding of determinants of health- related behavior and the logistics of the health care environment of urban areas would aid in the design of appropriate interventions. All three factors necessary to the effective utilization of health care - illness identification, care seeking, and care delivery - vary within urban settings, and hence need to be given due

7 attention while understanding the operational aspects of urban health interventions. 2. Quality issues to be addressed : Studies show that the care received by the urban poor is often of low quality. One study examining the care provided by 100 private practitioners in an urban slum in Mumbai, India, found 80 different treatment regimens being used for tuberculosis, only 4 of which met the guidelines of the World Health Organization Consolidate learning from urban slum health projects/programs : There have been some initiatives in the country for improving the health care delivery in the urban areas such as the World Bank supported India Population Projects (IPP) V (Mumbai and Chennai) and VIII ( implemented in Bengaluru, Kolkata, Hyderabad, Delhi and ) and urban health programs implemented in the cities of Agra, Uttar Pradesh and Indore, Madhya Pradesh. Lessons from these initiatives have informed the Ministry of Health and Family Welfare's Urban RCH Program, as well as the recommendations of the Task Force to Advise the National Rural Health Mission on "Strategies for Urban Health Care" (MOHFW-2006). 4. Urban situation responsive adaptation of interventions : Fundamental public health services, such as vaccination, safe water supply and sanitation, and oral rehydration therapy, timely ante-natal care, safe delivery, newborn and infant care, and childhood immunization remain important. Operational research in urban slum contexts is required in order to adapt the operational aspects to implement them effectively such that all urban poor/slum population is reached. Adapting interventions for implementation by trained slum-based community health workers) or trained midwives has shown benefit. Experience has demonstrated that a cadre of health care workers practicing in slums must be trained in order to reach this population Urban Slum based operational health re search: Our knowledge base also needs to be supplemented through dedicated research. Epidemiologists must develop methods for collecting precise and accurate data and surveillance on the health of urban populations. Research must be conducted on the design of interventions and approaches to using proven public health tools that exploit the advantages conferred by urban settings, such as the concentration of target populations and better communication and transportation infrastructures for delivery of care and health education.

8 Also data collection at the local/city level is necessary to correctly comprehend the status of urban health and to assess the urban community needs for health care services. Improved systems for collecting data in slums are urgently needed for the planning of infrastructure construction, programs, and resource allocation. Precise data that distinguish among types of residence, locations, and socioeconomic strata would reveal the varied effects of urbanization on health indicators, allowing for focused interventions. 6. Improved coordination among different stakeholders : "Urban" as an agent determining health is complex combination of the effects of many sectors operating in the city. Coordination among different agencies is one of the most pressing challenges common to cities worldwide. The State of World's Cities has cited examples from cities across the developing world where lack of coordination across functional and territorial units have resulted in suboptimal impact on services to population especially to the low income segments of the cities. The success of urban health programs depend on different sectors and technical disciplines working together. Key sectors whose collaborative efforts are crucial include water and sanitation, education, housing and urban development, democracy and governance. It is worth acknowledging that the urban development, or housing, water, sanitation, drainage and related infrastructure service sector has longer experience of efforts at addressing the problems of the urban poor in developing countries than the health sector. In recent years, policies and programs that aim at 'slum improvement', which involves both sectors, have attracted the support of international donors. What we need is sensitive and accurate planning which is responsive to the true needs and aims at mainstreaming of the urban poor in the economic growth story of our urban areas. Such planning and execution would include relocation; land tenure; restoration or improvement of housing structures; debt burdens and the impact on women. It will be beneficial for our cities if health programs develop a system to pool the efforts of government, non-government and other stakeholders in servicing the urban poor population Governments, Municipal bodies, nongovernmental organizations, and private providers must come together for implementing new policies and programs towards promoting good governance, increasing capacity, and ensuring universal access to care.

9 7. Review and analyze policy opportunities and gaps : Focus has been largely rural since the past several decades ever sicne India gained independence in There have been urban policy initiatives in recent years - JNNURM, 74 th constitutional amendment, Urban RCH II, these and the recent policy documents such as the National Population Policy (2000), National Health Policy (2002), and Tenth and Eleventh Five Year Plans (2002 and 2009) have clearly recognized the shortcomings of the existing health delivery system to effectively address the health needs of the urban poor, particularly the vulnerable slum populations. Under the 12 th Schedule of the 74 th Amendment, health services are mandated as functions of 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 Conclusion : As India becomes increasingly urban, the health of the urban poor is likely to suffer. Decades of progress in public health through the various policies and programs, could be erased, and the stage could be set for large segments of populations with poor access to essential health care such as maternity care, childhood immunization, prevention of diarrhoea, air-borne infections, large proportions of children in urban poor families being undernourished and thus not growing into optimally productive adults. Multifarious factors contribute to the health outcomes of slum dewllig urban poor. These include access to and quality of water and sanitation, security of land tenure, food security, their nutritional status, the level of empowerment of women, social exclusion of certain disadvantaged groups, education and livelihood apart from availability of health services. Concerted efforts will be needed for improving the health status of urban poor women and children. Improvement in public health infrastructure, schemes for reaching out to the urban poor, facilitation of development of community's negotiation capacity for increasing demand for maternal and child health services and improved access to health care are necessary for making progress towards reaching the MDGs. Any intervention to improve health of the population will have limited impact in the absence of a well coordinated action from a variety of players offering these varied services. It is therefore imperative that urban health receives due attention and is accompanied by coordinated actions from all stakeholders and more importantly, a strong political commitment for addressing the growing problems of the urban poor.

10 In view of the fast urbanisaiton accompanied by rapid growth of urban under-served population, our country definitely needs a comprehensive and dedicated "mission" or similar system which would provide accessible, affordable, effective and reliable primary healthcare facilities to the millions of underprivileged city dwellers who despite being in the neighborhood of India's growing millionaires, continue to suffer social, nutritional, health and capability deprivation. Proactive thinking and action is urgently needed not only to address the inequities but also to ensure that our health governance and service delivery is inclusive and enables a large section of the urban workforce to be healthy, fully productive and contribute to the nation's economic growth and overall development. References : 1. State of the world population 2007: unleashing the potential of urban growth. New York : United Nations Population Fund, Sivaramakrishnan, K.C. and Singh B.N., 2001, Urbanization, n.doc. 3. Chatterjee G Consensus versus confrontation: Local authorities and state agencies form partnerships with urban poor communities in Mumbai. Urban Secretariat, United Nations Human Settlements Program (UNHABITAT). 4. Office of the Registrar General and Census Commissioner, India. Population Projections for India and the States New Delhi: Office of the Registrar General and Census Commissioner; Available from: censusindia.gov.in/. Accessed February 19, 2010, 5. Ministry of Health and Family Welfare. National Population Policy, New Delhi, India:Ministry of Health and Family Welfare, Government of India; Available from: URL: Accessed February 19, Kapil U, Bharel SM, Sood AK. Utilisation of health care services by mothers in an urban slum community of Delhi. Indian J Public Health 1989;33: [Medline] 7. United Nations Human Settlements Programme. The challenge of slums: global report on human settlements London: Earthscan, Ministry of Statistics and Programme Implementation, Conditions of Urban Slums : National Sample Survey (58th Round), Government of India, 2002

11 9. Agarwal S, Taneja S. All slums are not equal: child health conditions among the urban poor. Indian Pediatr 2005; 42: Briend, A., B. Wojtyniak, M. G. M. Rowland Breast feeding, nutritional status, and child survival in rural Bangladesh. British Medical Journal 296(6626): Pelletier DL, Frongillo EA Jr, Schroeder DB, Habicht J-P The effects of malnutrition on child mortality in developing countries. Bulletin of the WHO 73: Ruzicka, L. T, P. Kane Nutrition and child survival in south Asia. In K. Srinivasan and S. Mukerji, eds. Dynamics of population and family welfare, pp Bombay : Himalaya Publishing House. 13. Urban Health Resource Centre. Health of the Urban Poor in India. Key Results from the re-analysis of NFHS-3, data by wealth index quartiles (Wall chart). New Delhi, India: Urban Health Resource Centre; Available from: wall-chart.pdf. Accessed February Shekhar, C. and Ram, F., 2005 National Report on Evaluation of Functioning of Urban Health Posts/UrbanFamily Centres in India. Mumbai : International Institute for Population Sciences 15. Garner P, Thaver I. Urban slums and primary health care. BMJ 1993;306: Ministry of Health and Family Welfare. Draft Final Report of the Task Force to Advise the National Rural Health Mission on "Strategies for Urban Health Care". New Delhi: Ministry of Health and Family Welfare, Government of India; May, Agarwal S, Satyavada A, Patra P, Kumar R (2008) Strengthening functional community - Provider linkages: lessons from the Indore Urban health programme. Global Public Health 3: