The role urbanisation in determining people's health.

1. Urbanisation and its effects on people’s health
Dr. Rizwan S A, M.D.,
Any city however small, is in fact divided into two, one the city of the poor, the
other of the rich. These are at war with one another. - Plato

2. 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

3. 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 non-
agricultural pursuits; and
iii. a density of population of at least 400 per sq. km. (1,000 per sq.
mile).

4. 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

5. 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

6. 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 %

7. 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

8. Urbanization trends - 3
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
Migration-cobweb

9. IMPACT OF URBANISATION ON
HEALTH

10. 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

11. 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
11

12. 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
Urban poor are worse than
urban non-poor and
comparable to rural
population
12

13. 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 74.3 102.013

14. 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
14

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. CHALLENGES TO HEALTH SYSTEM

22. • 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
22

23. SOLUTIONS FOR URBAN HEALTH
DEVELOPMENT

24. Framework for improving health
outcomes in urban areas

25. 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 age-friendly
5. Make urban areas resilient to emergencies and disasters

26. 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

27. 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 slum
population

28. Health system in Urban India - 3
• Other facilities run by
– Central/ state govt
– Municipalties/ Municipal corporation
– NGOs
– Private sectors
– ESI dispensaries

29. 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, rag-pickers,
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

30. NUHM framework - 1

31. PUHC
(For every 50,000
Population)
SWASTHYA CHOWKI
(For every 10,000
population)
Mahila Arogya Samiti
(20 -100 Households)
• MOs – 2 (1 LMO)
• AYUSH Doctor – 1
• PHN – 1
• Pharmacist – 1
• ANM – 1(HQ) + 5
(field)
• Dresser – 1
• Nursing orderly - 1
• Soc. Mob. Officer – 1
• Counsellor - 1
• ANM – 1
• Male Community Worker - 1
• Community worker – 1 (USHA)
• SHGs
• Seed Money
5
Units
• 1st Level of Community Organization
• Untied funds
BASTI VIKAS MANCH
(upto 500 households or
2500 population)
5
Units
4
Units
NUHM framework - 2

32. 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

33. 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 Region Urban Development Programme
– Projects undertaken: Water Supply, Solid Waste Management,
Capacity building, institutional development and investment
programme management, Sewerage and sanitation projects

34. 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

35. 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 Housing & Slum Development Programme

36. 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.

37. 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

38. 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

39. 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.

40. 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

41. • 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
41

42. • 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
42

43. • 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
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44. THANK YOU