Urban Health Issues, Challenges and Solutions

Outline of Presentation
1. Take home messages 2. Urbanization-Trends and Patterns 3. Health problems related to growing urbanization 4. Challenges to health system 5. The solutions 6. Take home messages
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Significance of Urban Health The World Health Day theme for 2010 Urbanization and Health

Take Home Messages

Urbanization due to migration
Is a reality Has reached to considerable proportions Leading to increased growth of slums Will increase further to greater proportions in the foreseeable future

Slums lack infrastructure in basic amenities like safe drinking water, sanitation, housing etc At increased risk of both communicable and non communicable diseases

Take Home Messages-2

Urban health is
Traditionally neglected in policy making Need of the hour considering the facts and figure available regarding the population at risk

Failure of NRHM to take urban health into account and pending launch of NUHM Policy influence needs to be done to sensitize the policy makers towards urban health issues
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Take Home Messages-3

Challenges exist in terms of
Administrative issues Policy issues Operational issues Involvement of non governmental service providers Large size of the population

Take Home Messages-4

The possible solutions can be
Ensuring adequate and reliable health related data Inter-sectoral co-ordination Sharing of successful experiences and best practice models Reducing the financial burden of health care through improved financing techniques Strengthening public private partnerships Strengthening public health care facilities
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Urbanization: Trends and Patterns

Movement of people from rural to urban areas with population growth equating to urban migration A double edged sword
On one hand- Provides people with varied opportunities and scope for economic development On the other- Exposes community to new threats

Unplanned urban growth is associated with

Environmental degradation Population demands that go beyond the environmental service capacity, such as drinking water, sanitation, and waste disposal and treatment
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Urbanization trends in India

Year 1800 1950 2000 2008 2030 Urban Total Population population
In million

2% 30% 47% ~50% ~ 60%

140

360 1027 1160

2050
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Source: UN, Urbanization prospects, the 1999 revision

Urbanization: Trends and Patterns-2

286 million people in India live in urban areas (around 28% of the population)* The proportion of urban population in India is increasing consistently over the years
From 11% in 1901 to 26% in 1991 and 28% in 2001

Estimated to increase to 357 million in 2011 and to 432 million in 2021* After independence 3 times growth - Total population 5 times growth - Urban population*

* Census of India 2001

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Urbanization: Trends and Patterns-3

4.26 crore people live in slums A large number of slums are not notified*- around 50%

Urban growth has led to rapid increase in the number of urban poor In-migration and a floating population has worsened the situation
* NSSO Report No. 486
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Migration-causes
Increased family size-limited agricultural property -Land use Pattern -Irrigation facilities Better income prospects Better educational facilities Better Life style Basic amenities health, transport,water, electricity. Victims of natural/manmade calamities-Refugees
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Migration-consequences
Overcrowding Mushrooming of slums Unemployment Poverty Physical & mental stress Family structure-Nuclear families -Single males
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Migration-cobweb
Slums Migration Illiteracy

Unhygienic conditions

Overcrowding

Unemployment

Communicable diseases

Stretching of overburdened systems Injuries Stress Life style modification Mental illness

Poverty

Crimes Non-Communicable diseases

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Health Problems due to Urbanization

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Urban Vs Rural health

Is urban health better than rural health?

Almost all health indicators are better for urban when compared to rural

When the urban slums are taken many are worser than rural !!!
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Factors Affecting Health in Slums*

Economic conditions Social conditions Living environment Access and use of public health care services

Hidden/Unlisted slums
Rapid mobility
* Agarwal S, Satyavada A, Kaushik S, Kumar R. Urbanization, Urban Poverty and Health of the Urban Poor: Status, Challenges and the Way Forward. Demography India. 2007; 36(1): 121-134
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MAIN DETERMINANTS OF
HEALTH & DISEASE LIE OUTSIDE THE REALM OF DIRECT MEDICAL COMPTETENCY
- SIR DOUGLAS BLACK
Past President of the Royal College of Physicians of London

Urban poor- key elements of health

Marriage & Fertility Maternal health Child survival Family planning Environmental Conditions, Infectious Diseases and Access to Health Care

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Marriage & Fertility Indicators of Urban Poor in India: NFHS 3

Indicators Urban Poor Urban Overall Overall Non Urban Rural poor All India Urban Poor NFHS 2

Women age 20-24 married by age 18 years (%)

Women age 20-24 who became mothers before age 18 (%) Total fertility rate (children per woman) Higher order births (3+ births) (%) Birth Interval (median number of months between current and previous birth)

51.5

21.2

28.1

52.5

44.5

63.9

25.9

8.3

12.3

26.3

21.7

39.0

2.8

1.8

2.1

3.0

2.7

3.8

28.6

11.4

16.3

28.1

25.1

29.5

29.0

33.0

32.0

30.8

31.1

31.0
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Maternal Health Indicators of Urban Poor in India: NFHS 3

Indicators Urban Poor Urban Overall Overall Non Urban Rural Poor 83.1 41.8 74.7 34.8 43.7 18.8 All India Urban Poor NFHS 2 49.6 47.0 70.0 19.7 43.5 53.3 54.7
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Mothers who had at least 3 antenatal care visits (%) Mothers who consumed IFA for 90 days or more (%) Mothers who received tetanus toxoid vaccines (minimum of 2) (%) Mothers who received complete ANC (%) Births in health facilities (%) Births assisted by a doctor/nurse /LHV/ANM/other health personnel (%) Women age 15-49 with anaemia (%)

54.3 18.5

52.0 23.1 76.3 15.0 38.6 46.6 55.3

The statistics for urban poor 75.8 much 90.7 lesser 86.4 72.6 than urban non-poor and comparable to 11.0 29.5 23.7 10.2 rural population
44.0 50.7 58.8 78.5 84.2 48.5 67.4 73.4 50.9 28.9 37.4 57.4

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Maternal Health Indicators by place of residence

NFHS-3

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Child Survival Indicators of Urban Poor in India: NFHS 3

Indicators Urban Poor 39.9 27.3 44.7 56.2 54.2 47.1 71.4 34.9 54.6 72.7 Urban Non Poor 65.4 31.5 38.6 66.1 33.2 26.2 59.0 25.5 35.5 41.8 Overall Urban 57.6 30.3 40.7 63.1 39.6 32.7 63.0 28.7 41.7 51.9 Overall Rural 38.6 22.4 48.6 54.7 50.7 45.6 71.5 42.5 62.1 81.9 All India 43.5 24.5 46.4 56.7 48.0 42.5 69.5 39.0 57.0 74.3 Urban Poor NFHS 2 40.3 17.7 44.3 52.7 52.5 48.0 79.0 45.5 69.8
24 102.0

Children completely immunized (% Children under 5 years breastfed within one hour of birth (%) Children age 0-5 months exclusively breastfed (%) Children age 6-9 months receiving solid or semi-solid food and breast milk (%) Children who are stunted (%) Children who are underweight (%) Children with anaemia (%) Neonatal Mortality Infant Mortality Under-5 Mortality

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Completely Immunized Children in 1223 months age by place of residence

NFHS-3

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Child Survival by Residence

NFHS-3

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Family Planning Indicators of Urban Poor in India: NFHS 3

Indicators Urban Poor Urban Overall Overall Non Urban Rural Poor All India Urban poor NFHS 2

Any modern method (%) Spacing method (%) Permanent sterilization method rate (%)

48.7 7.6 41.1

58.0 19.8 38.2

55.8 16.9 38.9

45.3 7.2 38.1

48.5 10.1 38.3

43.0 4.6 38.4

Total unmet need (%)

Unmet need for spacing (%) Unmet need for limiting (%)

14.1
5.7 8.4

8.3
4.1 4.2

10.0
4.5 5.2

14.6
6.9 7.2

13.2
6.2 6.6

16.7
8.5 8.2
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Environmental Conditions, Infectious Diseases and access to Health Care in Urban Poor : NFHS 3
Indicators Urban Poor Urban Non Poor 62.2 30.7 95.9 258 89.1 0.31 49.1 5.8 Overall Urban Overall Rural All India Urban poor NFHS 2 13.2 72.4 40.5 535 42.1 na na 16.7
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Households with access to piped water supply at home (%) Households accessing public tap / hand pump for drinking water (%) Household using a sanitary facility for the disposal of excreta (flush / pit toilet) (%) Prevalence of medically treated TB (per 100,000 persons) Women (age 15-49) who have heard of AIDS Prevalence of HIV among adult population (age 15-49) Children under age six living in enumeration areas covered by an AWC (%) Women who had at least one contact with a health worker in the last three months (%)

18.5 72.4 47.2 461 63.4 0.47 53.3 10.1

50.7 41.6 83.2 307 83.2 0.35 50.4 6.8

11.8 69.3 26.0 469 50.0 0.25 91.6 14.2

24.5 42.0 44.7 418 60.9 0.28 81.1 11.8

Double Burden of Diseases

Overcrowding and related health issues Rapid growth of urban centers has led to substandard housing on marginal land and overcrowding Outbreaks of diseases transmitted through respiratory and faeco-oral route due to increased population density It exacerbates health risks related to insufficient and poor water supply and poor sanitation systems Lack of privacy leading to depression, anxiety, stress etc
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Double Burden of Diseases

Air pollution and its consequences Due to increase in the numbers of motorized vehicles and industries in the cities of the developing world Problems of noise and air pollution Air pollution can affect our health in many ways with both short-term and long-term effects Short-term air pollution can aggravate medical conditions like asthma and emphysema Long-term health effects can include chronic respiratory disease, lung cancer, heart disease, and even damage to other vital organs
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Double Burden of Diseases

Water and sanitation problems Due to increasing urbanization coupled with existing un-sustainability factors and conventional urban water management Nealy 1.1 billion people worldwide who do not have access to clean drinking water and 2.6 billion people i.e. over 400 million people, lack even a simple improved latrine Can lead to increased episodes of diarrhea and economic burden
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Double Burden of Diseases

Upsurge of Non-communicable diseases The rising trends of non-communicable diseases are a consequence of the demographic and dietary transition Decreases in activity combined with access to processed food high in calories and low in nutrition have played a key role Urbanization is an example of social change that has a remarkable effect on diet in the developing world
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Double Burden of Diseases

Traditional staples are often more expensive in urban areas than in rural areas, whereas processed foods are less expensive This favors the consumption of new processed foods This places the urban population at increased risk of NCDs In India, chronic diseases are estimated to account for 53% of all deaths and 44% of disability-adjusted lifeyears (DALYs) lost in 2005
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Challenges to Health System

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 Large segment of urban poor In migration and floating populations Diverse social and cultural backgrounds Greater vulnerability of the migrating populations

Inequitable distribution of health facilities Multiple agencies/bodies providing health care Lack of Standardization and standard treatment protocols Lack of integrated HMIS and databases

Socio Demographic

Operational

KEY CHALLENGES TO URBAN HEALTH SERVICES

Administrative
Various administrative units with little coordination. Districts and zones not clear Lack of grass root level structures like PRIs

Dual burden of diseases

Increased burden of diseases associated with overcrowding, poor sanitation and hygiene Diseases associated with air and water pollution Lifestyle and stress related diseases, accidents/violence, substance abuse 36 Diseases of nutrition

A scene which makes every Indian feel shameful

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Operational Challenges
Inequitable distribution of health facilities To connect every household to health facilities is a big challenge Distance of first point of contact for any health need Lack of a fully functional and well defined public outreach system
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Operational Challenges
Lack of standards for Provision of safe water and sanitation facilities Housing and waste disposal systems

No public health bill for setting up and regulating

these standards Lack of understanding of recent demands of urban health care delivery and poor planning/implementation
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Operational Challenges
Lack of infrastructure for setting up of primary health care facilities Many slums are not having even a single primary health care facility in their vicinity Multiple health care facilities/bodies but without coordination Lack of community level organizations/slum level organizations and lack of adequate support to them

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Operational Challenges
Lack of convergence among various determinants/domains of public health Failure of Urban Health Post scheme (Krishnan Committee) Bringing local practitioners into mainstream with provision of proper training and supervising their work

Lack of need based referrals/weak referral system

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Challenges in Involving NGOs & Private Practitioners

Accountability Sustainability Supervision and monitoring systems False reporting/over reporting Co-operation and coordination among large number of service providers is challenging 44

Which is better?

Vs

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What makes private services inaccessible?

Paying more from patients to maintain competency
Vulnerable people cannot afford treatment in corporate hospitals - tend to seek treatment from quacks Focused on curative services particularly on non-communicable diseases, Malignancies etc. Preventive and promotive components are completely omitted

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Operational Challenges
Need to identify the households actually needing PDS services Failure of TPDS Lack of transparency regarding costs and treatment protocols especially in the private sector No risk pooling or community insurance system Need for skilled manpower and technical support at all levels Lack of well defined urban component of many National Diseases Control programmes 47

Operational Challenges
Lack of any campaigns to counsel people to bring about changes in health related behavior/attitudes Absence of defined geographical / demographic population allocations. Lack of integrated HMIS and databases Limitations of NRHM in urban context - norms for urban primary health infrastructure are not part of the NRHM proposal Lack of efficient mobile health teams/problems faced by them
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Challenges faced by Mobile health teams

Security problems Worn-out vehicles Tired and stressed staff Poor roads Seasonal obstacles Uncertainty about population movements Erratic funding
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Operational Challenges
Prioritizing the most vulnerable among the poor (destitutes,beggars , street children, construction workers , coolies etc) Need to change the behavior and attitudes of the health care provider for e.g. to avoid unnecessary referrals Constraints of the health care users like time, lack of faith and mobility Considering occupational and environmental hazards 50

Administrative Challenges
A more complex planning system due to involvement of local urban bodies There is little coordination between State Government, local bodies, autonomous bodies and Central Government Lack of grass root level structures like Panchayati Raj Institutions Need for clarity of responsibilities among various administrative bodies

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Administrative Challenges
Policy Advocacy

Policy advocacy is the key to achieve the objective Policy advocacy alone wouldnt help in achieving the target Stakeholders should facilitate and support the implementation and conversion of Policy Programme Action Success
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Administrative Challenges
District level planning is the method GOI has been adopting for most health programs This results in patchy implementation of health services in cities Lack of an integrated District Health Action Plan which will cover not only rural but also the urban population
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Administrative Challenges
Duplication of services
Lack of clear and well defined norms for delivery of primary care Health service guarantee and concurrent audit at the levels of funds release and utilization Need for stronger laws for illegal and unauthorized settlements

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The Solutions
Ensure adequacy and reliability of health related data
For understanding the graveness of situation and for planning purposes

Need for inter-sectoral co-ordination Sharing of successful experiences and best practice models
Successful experiences from other countries can be adopted. These can be adopted with local adaptations to suit the need of the people and the current situation

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The Solutions
Reducing the financial burden of health care through
Community health funds Health insurance Subsidized out patient care provision by private providers

Application of PURA (Provision of Urban amenities to Rural Areas) model to slums

To improve the infrastructure To increase community participation through SHGs To enhance self reliability of the communities

Strengthening public private partnerships Strengthening public health care facilities

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Take Home Messages

Urbanization due to migration
Is a reality Has reached to considerable proportions Leading to increased growth of slums Will increase further to greater proportions in the foreseeable future

Slums lack infrastructure in basic amenities like safe drinking water, sanitation, housing etc At increased risk of both communicable and non communicable diseases

57

Take Home Messages-2

Urban health is
Traditionally neglected in policy making Need of the hour considering the facts and figure available regarding the population at risk

Failure of NRHM to take urban health into account and pending launch of NUHM Policy influence needs to be done to sensitize the policy makers towards urban health issues
58

Take Home Messages-3

Challenges exist in terms of
Administrative issues Policy issues Operational issues Involvement of non governmental service providers Large size of the population

59

Take Home Messages-4

The possible solutions can be
Ensuring adequate and reliable health related data Inter-sectoral co-ordination Sharing of successful experiences and best practice models Application of PURA models Reducing the financial burden of health care through improved financing techniques Strengthening public private partnerships Strengthening public health care facilities 60

Thank You

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