Urbanisationanditseffectsonpeopleshealth

Dr.RizwanSA,M.D.,
Anycityhoweversmall,isinfactdividedintotwo,onethecityofthepoor,the
otheroftherich.Theseareatwarwithoneanother.Plato

Outline

Definitions
Urbanization trends
Impacts of Urbanization on Health
WHO Initiatives on Urban Health
Urban Health Care Delivery System in
India
Policies & Schemes relevant to India
National Urban Health Mission
Role of Various Sectors

Definitions - 1
What is an urban area?

According to Census of India

A. All statutory places with a municipality, corporation, cantonment
board or notified town area committee, etc.
B. A place satisfying the following three criteria simultaneously:
i. a minimum population of 5,000;
ii. at least 75 per cent of male working population engaged in nonagricultural pursuits; and
iii. a density of population of at least 400 per sq. km. (1,000 per sq.
mile).

Definitions - 2
What is an urban slum?
i.

All specified areas in a town or city notified as Slum by State/Local

Government and UT Administration under any Act including a Slum
Act
ii. All areas recognized as Slum by State/Local Government and UT
Administration, Housing and Slum Boards, which may have not
been formally notified as slum under any act
iii. A compact area of at least 300 population or about 60-70 households
of poorly built congested tenements, in unhygienic environment
usually with inadequate infrastructure and lacking in proper sanitary
and drinking water facilities

Definition - 3
What is urbanization?
Urbanization refers to the change in size, density and
heterogeneity of cities

What is urban health?

The health of a population that lives and works closely together,
usually in an incorporated area, such as a city or town, with a common
water supply and with similar environmental conditions
The status of health in urban populations
Urban Health means putting the needs of people and communities at
the heart of the urban planning process to ensure better access to urban
services which improve human health for all

Urbanisation trends - 1
Indian Scenario 2011
Total Population
1028.6 Million
Urban Population
286 Million (27.8%)
Growth rate
Rural 17.9 %
Urban 31.2 %
Estimated Slum
Population
60 Million

World Scenario 2010

Total Population
6906.5 million
Urban Population
349.4 million (50.6%)
Growth rate
Rural 0.22 %
Urban 1.91 %

Urbanization trends - 2
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
7

Urbanization trends - 3
Slums

Migration

Illiteracy

Unhygienic
conditions

Overcrowding

Unemployment

Communicable
diseases

Non-Communicable
diseases

Stretching of
overburdened
systems

Poverty

Crimes
Injuries
Stress
Life style
modification

Mental
illness
Migration-cobweb

IMPACT OF URBANISATION
ON HEALTH

Impact of urbanisation on health

Environmental concerns
Housing and shelter quality: strong health determinants
Health hazards of poor water supply and sanitation
Violence and crime
Mental health, loneliness and depression
Substance abuse
Road traffic accidents
Climate change
Fuel
Health inequity

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 (%)

51.5

21.2

28.1

52.5

44.5

63.9

Women age 20-24 who became

mothers before age 18 (%)

25.9

8.3

12.3

26.3

21.7

39.0

2.8

1.8

2.1

3.0

2.7

3.8

Higher order births (3+ births) (%)

28.6

11.4

16.3

28.1

25.1

29.5

Birth Interval (median number of

months between current and previous
birth)

29.0

33.0

32.0

30.8

31.1

31.0

Total fertility rate (children per

woman)

11

Maternal Health Indicators of Urban Poor in India: NFHS 3

Indicators

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 (%)

Urban
Poor

Urban Overall Overall

Non Urban
Rural
Poor

All
India

Urban
Poor
NFHS 2

54.3

83.1

74.7

43.7

52.0

49.6

18.5

41.8

34.8

18.8

23.1

47.0

Urban poor are worse

75.8 than90.7
72.6
urban 86.4
non-poor
and 76.3
comparable to rural
11.0
29.5population
23.7
10.2
15.0

70.0
19.7

Births in health facilities (%)

44.0

78.5

67.4

28.9

38.6

43.5

Births assisted by a doctor/nurse

/LHV/ANM/other health personnel (%)

50.7

84.2

73.4

37.4

46.6

53.3

Women age 15-49 with anaemia (%)

58.8

48.5

50.9

57.4

55.3

54.7

12

Child Survival Indicators of Urban Poor in India: NFHS 3

Indicators

Urban
Poor

Urban
Non
Poor

Overall
Urban

Overall
Rural

All
India

Urban
Poor
NFHS 2

39.9

65.4

57.6

38.6

43.5

40.3

27.3

31.5

30.3

22.4

24.5

17.7

44.7

38.6

40.7

48.6

46.4

44.3

56.2

66.1

63.1

54.7

56.7

52.7

Children who are stunted (%)

54.2

33.2

39.6

50.7

48.0

52.5

Children who are underweight (%)

47.1

26.2

32.7

45.6

42.5

48.0

Children with anaemia (%)

71.4

59.0

63.0

71.5

69.5

79.0

Neonatal Mortality

34.9

25.5

28.7

42.5

39.0

45.5

Infant Mortality

54.6

35.5

41.7

62.1

57.0

69.8

Under-5 Mortality

72.7

41.8

51.9

1381.9

74.3

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 (%)

Family Planning Indicators of Urban Poor in India: NFHS 3

Indicators

Any modern method (%)

Urban
Poor

Urban Overall Overall

Non Urban
Rural
Poor

All
India

Urban
poor
NFHS 2

48.7

58.0

55.8

45.3

48.5

43.0

7.6

19.8

16.9

7.2

10.1

4.6

Permanent sterilization method rate

(%)

41.1

38.2

38.9

38.1

38.3

38.4

Total unmet need (%)

14.1

8.3

10.0

14.6

13.2

16.7

Unmet need for spacing (%)

5.7

4.1

4.5

6.9

6.2

8.5

Unmet need for limiting (%)

8.4

4.2

5.2

7.2

6.6

8.2

Spacing method (%)

14

Environmental Conditions, Infectious

Diseases and access to Health Care in
Urban Poor : NFHS 3
Indicators

Urban
Poor

Urban
Non
Poor

Overall
Urban

Overall
Rural

All
India

Urban
poor
NFHS 2

Households with access to piped water supply

at home (%)

18.5

62.2

50.7

11.8

24.5

13.2

Households accessing public tap / hand pump

for drinking water (%)

72.4

30.7

41.6

69.3

42.0

72.4

Household using a sanitary facility for the

disposal of excreta (flush / pit toilet) (%)

47.2

95.9

83.2

26.0

44.7

40.5

Prevalence of medically treated TB (per

100,000 persons)

461

258

307

469

418

535

Women (age 15-49) who have heard of AIDS

63.4

89.1

83.2

50.0

60.9

42.1

Prevalence of HIV among adult population

(age 15-49)

0.47

0.31

0.35

0.25

0.28

na

Children under age six living in enumeration

areas covered by an AWC (%)

53.3

49.1

50.4

91.6

81.1

na

Women who had at least one contact with a

health worker in the last three months (%)

10.1

5.8

6.8

14.2

11.8

16.7

15

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
16

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
17

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

18

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

19

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
life-years (DALYs) lost in 2005

20

CHALLENGES TO HEALTH
SYSTEM

Inequitable distribution of health facilities

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

Large segment of urban poor

In migration and floating populations
Diverse social and cultural backgrounds
Greater vulnerability of the migrating
populations

Socio
Demographic

Operational

KEY CHALLENGES TO
URBAN HEALTH
SERVICES

Administrat
ive
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
Diseases of 22
nutrition

SOLUTIONS FOR URBAN

HEALTH DEVELOPMENT

Framework for improving health outcomes in

urban areas

WHO initiatives on urban

health
Theme of World Health Day 2010
Thousand cities, thousand lives

WHO recommends the five calls to action to

build a healthy and safe urban environment:
1. Promote urban planning for healthy behaviours and
safety
2. Improve urban living conditions
3. Ensure participatory urban governance
4. Build inclusive cities that are accessible and agefriendly
5. Make urban areas resilient to emergencies and
disasters

Health system in Urban

India - 1
No well organised services in urban areas
Urban family welfare centers (UFWC)
Provide outreach services - primary health care, maternal
& child health, and distribution of contraceptives

Urban health posts (UHPs)

Postpartum centres (PPCs)
Provide outreach family welfare services to various slum
populations

Medical colleges
Provide tertiary health care services as well as primary
health care services to urban areas

Health system in Urban

India - 2
Urban ICDS projects
Set up to promote health & development of
women & children through integrated packages
of services for urban poor
Urban
basic
services
scheme
&
urban
development projects
Provide basic maternal &child health services
Urban malaria schemes (UMS)
Under UMS, surveillance staff & vector control
teams have been provided to control vector
borne disease
Urban RCH projects
Each project covered about 100,000 urban

Health system in Urban

India - 3
Other facilities run by
Central/ state govt
Municipalties/ Municipal corporation
NGOs
Private sectors
ESI dispensaries

Health system in Urban

India - 4
National Urban Health Mission
In order to effectively address the health concerns of
the poor population, the Health Ministry proposes to
launch National Urban Health Mission (NUHM).
The NUHM would have high focus on
Urban Poor Population living in listed and unlisted slums
All other vulnerable population such as homeless, ragpickers, street children, rickshaw pullers, construction and
brick and lime kiln workers, sex workers, any other
temporary migrants
Public health thrust on sanitation, clean drinking water,
vector control etc.
Strengthening public health capacity of urban local bodies

NUHM framework - 1

PUHC
(For every 50,000
Population)

SWASTHYA
CHOWKI
(For every 10,000
population)

BASTI VIKAS
MANCH
(upto 500
households or
2500 population)

Mahila Arogya
Samiti
(20 -100
Households)

5
Unit
s

4
Unit
s

ANM 1
Male Community Worker - 1

Community worker 1 (USHA)

5
Unit
s

AYUSH Doctor 1
PHN 1
Pharmacist 1
ANM 1(HQ) + 5
(field)
Dresser 1
Nursing orderly - 1
Soc. Mob. Officer 1
Counsellor - 1

1st Level of Community

Organization
Untied funds

SHGs
Seed
Money

NUHM framework - 2

Urban development schemes in

India - 1
Jawaharlal Nehru National Urban Renewal Mission
To encourage reforms and fast track planned
development of identified cities

Provision of Urban Amenities in Rural Areas

(PURA)
To simulate urban amenities in rural areas to
discourage migration to urban area

National Urban Sanitation Policy

Ministry of Housing and Poverty Alleviation is
administering a Centrally Sponsored Scheme for
Integrated Low Cost Sanitation

Urban development schemes in

India - 2
National Urban Housing & Habitat Policy
To promote sustainable development of habitat to ensure
equitable supply of land shelter and services at affordable
prices to all sections of the society, through strong partnerships
between public private and cooperative sectors

Interest Subsidy Scheme for Housing the Urban Poor

To provide interest subsidy on housing urban poor to make the
housing affordable and within the repaying capacity of EWS/LIG

North
Eastern
Programme

Region

Urban

Development

Projects undertaken: Water Supply, Solid Waste Management,

Capacity building, institutional development and investment
programme management, Sewerage and sanitation projects

Urban development schemes in

India - 3
National Capital Region Plan
Provides suggestions and strategies to develop the
surrounding 108 urban and 7,528 rural settlements
situated in the adjoining states of Haryana, Rajasthan
and
Uttar
Pradesh
by
creating
employment
opportunities and strengthening infrastructure

Tax Free Municipal Bonds

Funds raised from Tax Free Municipal Bonds are to be used
only for capital investments in urban infrastructure for
providing one or more of the following:- Potable Water
Supply, Sewerage or Sanitation, Drainage, Solid Waste
Management, Roads, Bridges and Flyovers, Urban Transport

Urban development schemes in

India - 4
Swarna Jayanti Shahari Rozgar Yojana (SJSRY):

3,76,855 micro enterprises have been set up and

3,93,913 urban poor have been imparted skill
upgradation training

Valmiki Ambedkar Awas Yojana (VAMBAY):

3,69,499 slum families have been covered for providing

them shelter/dwelling units and 59,885 sanitation units
have been sanctioned.

Integrated
Programme

Housing

&

Slum

Development

Role of other sectors - 1

Urban planners
Use zoning and land use regulations to prevent exposure of
city dwellers to pollution emissions hazards from industrial
activities, waste and chemicals, and well as transport
Develop/adopt building practices that protect health among
building users regarding indoor air environment, safety,
noise, water, sanitation and waste management, among
several other health determinants in urban settings
Build compact cities, where dwellers have easy access to
green areas, public transport, cycle paths and health,
education and other fundamental social services.
Incorporate Health Impact Assessment (HIA) into the
consideration of alternative planning choices and policies.

Role of other sectors - 2

Local governments
Show leadership by providing role models and by
setting an example
Champion walking, cycling, active lifestyles and
community designs that support these activities.
Foster collaboration within local government
through forums for city departments (such as
transport, health, public safety, parks and recreation
and education) to discuss the development of an
integrated urban health strategy
Encourage public health and urban planners to work
closely together

Role of other sectors - 3

Civil society
Ensure that people are fully engaged in shaping
the policies and programmes that affect their lives
Include residents of informal settlements in formal
processes by setting up groups, associations and
federations

Organizations of the urban poor should come together

to

Identify social & economic conditions they are facing

Find practical solutions to these problems
Struggle against marginalization &
Ensure access to goods and services

Role of other sectors - 4

Researchers
Generate and systematize knowledge to
address
many existing information gaps,
including:
potential advantages of urbanization and urban
growth
Inequities of health disaggregated by intra-urban
area
Effectiveness of proactive approaches to deal with
health inequity in cities &
Importance of involving all citizens in the decisions
that affect their habitat and their health.

Take Home Messages - 1

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

40

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
41

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

42

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
43

THANK YOU