Health of the Urban Poor in India:Concerns, Opportunities and Way Forward

INTERNATIONAL CONFERENCEURBAN HEALTH INITIATIVES

February 9, 2006

Community Medicine Department, Government Medical College, Surat, Surat Municipal Corporation & Health & Family Welfare Department, Government of Gujarat, India.

Karishma Srivastav, Dr. Siddharth AgarwalUrban Health Resource Centre [formerly EHP India]

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Presentation Outline

• Urban Growth and Urban Poverty

• Health Concerns of the Urban Poor

• Challenges and Opportunities

• Suggestions

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Especially in Their Smaller and Medium Sized Cities

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

2-3-4-5 phenomenon of population growthUrban population - 285 million1

Urban poor estimated at 702 -903 million

Unabated Growth of the Urban Poor

1 2001 Census of India.2 1999-2000 NSSO (55th round) using 30 day recall of consumer expenditure. 3 Lawrence Haddad, Marie T. Ruel, and James L. Garrett, 1999. Are Urban Poverty And Under-nutrition Growing? Some Newly Assembled Evidence.

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Health Concerns ofUrban Poor

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

0

20

40

60

80

100

020406080

100120140160

Under 5 Mortality * Infant Mortality * Neonatal Mortality *

Poor Child Health and Survival

Health conditions of urban poor are similar to or worse than rural population and far worse than urban averages

[Re-analysis of NFHS 2 (1998-99) by Standard of Living Index, EHP: 2003]

103.7

46.7

Rural Average

103.7

63.147

73.3

31.7

49.638.4

Urban Average Urban Poor

101.3

66

39.1

56.0

Nutritional Status

* Mortality per 1000 live births

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Poor Access to Health Services

0

10

20

30

40

50

60

70

80

Complete ANC (3ANC+IFA+TT)

Home deliveries

24.8

52.7

74.3

Re-analysis of NFHS 2 (1998-99) by Standard of Living Index, EHP: 2003

33.9

Rural Average

Urban Average

30.4

54.1

Urban Poor> 1million babies are born every year in slum homes

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Poor Access to Health Services

[Re-analysis of NFHS 2 (1998-99) by Standard of Living Index, EHP: 2003]

0

10

20

30

40

50

60

70

36.6

60.5

Complete Immunization by age 12-23 months

Rural Average

Urban Average

42.9

Urban Poor

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Sub-optimal Health Behaviors

0

10

20

30

40

50

60

70

80

BreastfeedingInitiation within 1hr

Initiation of Complementary Feeds by 7mths

Rural Average

Urban Average

14.819.2

60.5

73

Urban Poor

17.9

56.5

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Poor Environmental Conditions

About two thirds urban poor households do not have access to piped water supply and toilet

facility

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

High Prevalence of HIV/AIDS in Urban Areas

51.34 Total

21.27 Urban

HIV estimates 2004(in lakhs)

30.07

Rural

http://www.nacoonline.org/facts_hivestimates.htm

Estimated Prevalence of HIV+ cases in urban areas is substantially higher as compared to rural areas

High risk categories include sex workers, migrant laborers, truck drivers

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Challenges and Opportunities

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Challenge 1

Urban poor searching for citizenship

Considered ‘Illegal’ and unwanted despite the vital contribution of this large informal work force

Few rights as urban citizens and consequently little power to influence their circumstances

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Challenge 2:Large proportion of slums are invisible

328 unlisted slums( population, , )5 10 397

452 listed slums( , , ) population 8 20 139

( )780 slums total

Findings (listed vs un-listed slums) from Agra (215 vs 178), Dehradun (78 vs 28), Bally (75 vs 45), Jamshedpur (438 vs 101)Besides unrlisted slum settlements, urban poor also include pavement dwellers, population residing

in construction sites, fringes of the city, floating population etc

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Challenge 3: Inadequate Urban Primary Health Infrastructure

There is one UFWC/HP for about 1.5 lakh urban population

Others1.0%

Chemists4.6%

Government doctors12.3%

Private doctors82.1%

Low utilization of public health services in urbanslums(Gujarat State-wide Multi-Indicator Cluster Surveys (MICSs), 1996)

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Challenge 4: Weak Demand Among Urban Poor

• Low awareness about services, behaviours and provisions

• Weak community organization and social cohesion

• Weak negotiation capacity

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Challenge 5: Greater focus on rural areas

79%

21%

ICDS coverage

ICDS not covered

Rural areas

16%

84%

ICDS coverage

ICDS not covered

Urban areas

ICDS Coverage Differentials

Source: Department of Women and Child Development, Ministry of Human Resource Development. Integrated Child Development Services (ICDS), New Delhi.2000.

Coverage

Coverage

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Higher urban allocation for bigger citiesWhile medium-small cities have significant urban population

Percentage Distribution of urban population by size of Towns/UA (Census of India, 2001)

156

179

2131

01020304050

10 millionand above

5 millionto 10

million

1 millionto 5

million

500,000to 1

million

100,000to

499,999

Below100,000

Today’s 35 million plus urban agglomerations (37% total urban population) will double by 2026 *

Municipal Capacity weak in medium-small cities

Preparedness needed to meet the challenge of rapidly growing medium sized cities

*Dyson et al, 2004. Twenty First Century India. Population, Economy, Human Development and the Environment

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Diminishing MCH service delivery capacity of most Municipal Bodies

Weak health program management experience

Inadequate infrastructure (Health Dept+ Municipal): One Urban Primary Health Centre for about 1.5 lakh urban population,

often with 3-4 ANMs

Weak political consciousness about significance of urban health1083 UFWCs (1950) and 871 Health Posts (under Urban Revamping Sceme1983); many run from hospitals, not proximal to slums

IPP VIII (1993 to 2003) covered 7 million slum population (8% of India’s urban poor) in 4 mega cities and 94 smaller towns in 4 states

Challenge # 6

Municipal Health Infrastructure/Services Inadequate

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Most Vulnerable

Moderately Vulnerable

Less Vulnerable

Challenge 7:

All slums are not equal…

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

…Hence the Need to Prioritize Most Vulnerable

32.3 23.6

61.7 48.839

27.6 21.749.8 45.3

42.8

11.4 19.630.8 33.8

46.5

0102030405060

Water Supply Use of SpacingMethods

InstitutionalDeliveries

CompleteImmunization

Underwieght <--2SD

Most Vulnerable Moderately Vulnerable Less Vulnerable

Reference: EHP, 2004:Indore Slum Maternal and Child Health Survey

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Opportunities in Urban Areas

Growing recognition of the problem and burgeoning interestamong Government agencies, corporate sector, donors and NGOs

Resources and Potential Partners available for collaboration

NRHM has projected a separate financial outlay for Urban Health

74th Constitutional Amendment, a mandate-backed opportunity for Municipal Bodies

Urban Poor clusters geographically approachable

Easier to reach with communication activities

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

How can we work towards improved health of urban poor populations?

Suggestions

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Suggestion 1:

Strengthen Supply/Services

Identify and map all urban poor (e.g. Map of Agra)

Strengthen Urban Health services including outreach activities with focus on vulnerable urban settlements

Promote Public Private Partnership for expanding and improving health service delivery

Develop inter-sectoral mechanism at different levels

Motivational training to health providers (ANMs, Supervisors, MOs)

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Strengthen Municipal Health Program Capacity[Specially in medium-small cities]

Negotiate with Central and State Governments for complete implementation of 74th amendment

Facilitate linkage of ULBs with professional technical agencies

Leverage existing municipal buildings used for health services e.g. rent out portions to private doctors/enterprise

Initiate multi-stakeholder coordination at Ward level to improve reach and quality of health services

§ Train elected representatives and officials on 74th amendment, Govt. policies, programs including exposure visits/cross learning

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Increase awareness about optimal behaviors, services and provisions

Enhance capacity of slum communities to negotiate, improve behavior by strengthening CBOs (youth clubs, Mohalla Samitis, SHGs)

Identify and train Community Health Volunteers in slums to strengthen community-provider linkages through NGOs

Ensure that demand is met with increased availability

Suggestion 2:

Strengthen Demand and Community Behaviour

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Suggestion 3: Public Private Partnership

Private sector caters to most of the health needs even among the poor

• PPP can be an important strategy for meeting the critical public health challenge of quickly expanding services in urban areas.

• Utilizing existing private infrastructure (where available) rather than building new infrastructure saves time and costs eg. in Guwahati

• PPP can help in improving quality and broadening range of services

• Most vulnerable slums can be covered through Public Private Partnerships eg. Bangalore

• Private NGOs can help improve community demand and hence increase utilization of existing services

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

• Supplement Health Investments and services needed to address urban health challenge

• Sharing of expertise pertaining to demand generation, marketing and management

• Advocacy for enhanced attention to health of urban poor population

& . Potential Role of Corporate Non Govt Sector

Baroda Citizens Council Health Services Delivery in Slums

Federation of Gujarat Industries MS University of VadodaraVadodara Municipal Corporation

Corporate Partnership for Urban Health in Baroda since 1966

Example of Corporate supported Urban Health Efforts

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Suggestion 4: Better Policies and Policy Implementation

Increased attention and resources to the urban poor

Improve policies to make them more urban poor friendly, practical and measurable

Ensure energetic policy implementation by training of officers and increased information to urban poor

Real progress on inter-sectoral approaches is vital

Identify and address policy constraints to PPP

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Recall the face of the poorest and the weakest manwhom you may have seen and ask yourself,

if the step you contemplate is going to be of any use to him.Will he gain anything by it?

Will it restore him to a control over his own life and destiny?

In other words, will it lead to Swaraj for the hungry and spiritually starving

millions?-- Gandhi ji, 1947

Srivastav K and Agarwal S (2006). Health of the Urban Poor in India : Concerns Opportunities and the Way Forward. Presentation made at the International Conference on Urban Health Initiatives, Surat, February 9-11, 2006.

Let us build bridges of enablementfor a healthier tomorrow