This document discusses urban health issues, challenges, and solutions in India. It notes that urbanization is increasing rapidly due to migration, leading to overcrowded slums lacking basic infrastructure. This puts urban populations at risk of communicable and non-communicable diseases. Key challenges to the health system include the dual burden of diseases, large urban poor populations, administrative issues, and operational challenges in equitably providing health services and coordinating various agencies. Proposed solutions include improving health data, inter-sectoral coordination, strengthening public-private partnerships, financing techniques, and public health facilities.

1. Urban Health
Issues, Challenges and Solutions

2. 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
2

3. Significance of Urban Health
3
The World Health Day theme for 2010
“Urbanization and Health”

4. 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 4

5. • 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
Take Home Messages-2
5

6. • 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-3
6

7. • 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
Take Home Messages-4
7

8. 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
8

9. Urbanization trends in India
Year
1800
1950
2000
2008
2030
2%
30%
47%
~50%
~ 60%
Source: UN, Urbanization prospects, the 1999 revision
Total
population
360
1027
140
1160
In million
Urban
Population
2050
9

10. 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 10

11. 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 11

12. 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
12

13. Migration-consequences
• Overcrowding
• Mushrooming of slums
• Unemployment
• Poverty
• Physical & mental stress
• Family structure-Nuclear families
-Single males
13

14. Migration-cobweb
Migration
Stretching of
overburdened
systems
Overcrowding Unemployment
Crimes
Poverty
Illiteracy
Communicable
diseases
Unhygienic
conditions
Slums
Injuries
Mental
illness
Stress
Life style
modification
Non-Communicable
diseases
14

15. Health Problems due to Urbanization
15

16. 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 !!!
16

17. 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
17

18. “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

19. Urban poor- key elements of health
• Marriage & Fertility
• Maternal health
• Child survival
• Family planning
• Environmental Conditions, Infectious Diseases and
Access to Health Care 19

20. Marriage & Fertility Indicators of Urban
Poor in India: NFHS 3
Indicators Urban
Poor
Urban
Non
poor
Overall
Urban
Overall
Rural
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
Total fertility rate (children per
woman)
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
20

21. Maternal Health Indicators of Urban
Poor in India: NFHS 3
Indicators Urban
Poor
Urban
Non
Poor
Overall
Urban
Overall
Rural
All
India
Urban
Poor
NFHS 2
Mothers who had at least 3 antenatal
care visits (%)
54.3 83.1 74.7 43.7 52.0 49.6
Mothers who consumed IFA for 90
days or more (%)
18.5 41.8 34.8 18.8 23.1 47.0
Mothers who received tetanus toxoid
vaccines (minimum of 2) (%)
75.8 90.7 86.4 72.6 76.3 70.0
Mothers who received complete
ANC (%)
11.0 29.5 23.7 10.2 15.0 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
The statistics for urban poor
much lesser than urban
non-poor and comparable to
rural population
21

22. 22

23. Maternal Health Indicators by
place of residence
NFHS-3 23

24. 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
Children completely immunized (% 39.9 65.4 57.6 38.6 43.5 40.3
Children under 5 year’s breastfed within
one hour of birth (%)
27.3 31.5 30.3 22.4 24.5 17.7
Children age 0-5 months exclusively
breastfed (%)
44.7 38.6 40.7 48.6 46.4 44.3
Children age 6-9 months receiving solid or
semi-solid food and breast milk (%)
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 81.9 74.3 102.0
24

25. 25

26. Completely Immunized Children in 12-
23 months age by place of residence
NFHS-3 26

27. Child Survival by Residence
NFHS-3 27

28. Family Planning Indicators of Urban
Poor in India: NFHS 3
Indicators Urban
Poor
Urban
Non
Poor
Overall
Urban
Overall
Rural
All
India
Urban
poor
NFHS 2
Any modern method (%) 48.7 58.0 55.8 45.3 48.5 43.0
Spacing method (%) 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
28

29. 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
29

30. 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
30

31. 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
31

32. 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
32

33. 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
33

34. 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
34

35. Challenges to Health System
35

36. • 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 nutrition
• Various administrative units
with little coordination.
• Districts and zones not clear
• Lack of grass root level
structures like PRI’s
• 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
Dual burden
of diseases
Administrative
KEY CHALLENGES TO URBAN
HEALTH SERVICES
36

37. A scene which makes every Indian feel shameful…
37

38. 38

39. 39

40. 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
40

41. 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
41

42. 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 42

43. 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 43

44. 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

45. Vs
Which is better?
45

46. 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 46

47. 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

48. 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
48

49. 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 49

50. 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 hazards50

51. 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 51

52. Policy Advocacy
• Policy advocacy is the key to achieve the objective
• Policy advocacy alone wouldn’t help in achieving the target
• Stakeholders should facilitate and support the
implementation and conversion of
Policy Programme Action Success
Administrative Challenges
52

53. 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
53

54. 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 54

55. 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
55

56. • 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
The Solutions
56

57. 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

58. • 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
Take Home Messages-2
58

59. • 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-3
59

60. • 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
Take Home Messages-4
60

61. Thank You
61