THE INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT
Int J Health Plann Mgmt 2015; 30: 192–203 Published online 12 January 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/hpm.2236
Urban health in India: who is responsible? Indrani Gupta1 and Swadhin Mondal2* 1 2
Health Policy Research Unit, Institute of Economic Growth (IEG), Delhi, India Institute for studies in Industrial Development (ISID), New Delhi, India
SUMMARY Urban health has received relatively less focus compared with rural health in India, especially the health of the urban poor. Rapid urbanization in India has been accompanied by an increase in population in urban slums and shanty towns, which are also very inadequately covered by basic amenities, including health services. The paper presents existing and new evidence that shows that health inequities exist between the poor and the non-poor in urban areas, even in better-off states in India. The lack of evidence-based policies that cut across sectors continues to be a main feature of the urban health scenario. Although the problems of urban health are more complex than those of rural health, the paper argues that it is possible to make a beginning fairly quickly by (i) collecting more evidence of health status and inequities in urban areas and (ii) correcting major inadequacies in infrastructure–both health and non-health– without waiting for major policy overhauls. Copyright © 2014 John Wiley & Sons, Ltd. KEY WORDS:
urban health; health services; policy; India
INTRODUCTION The share of the urban population in global population has crossed the 50% threshold in the year 2009 (Keating and Natella, 2012). The United Nations (UNFPA 2006) has projected that by 2030, urban population will be more than 60% of the global population. Massive growth of urbanization is taking place in developing countries (McGee 2011). Among regions, South Asia will see the largest growth with an increase of urban population of more than five times (USAID, 2006). India, too, has seen massive urbanization; over 2001–2011 alone, the growth of urbanization was 31%, which—while somewhat lower compared with other south Asian countries (Dutta and Noble, 2004)—in absolute terms adds up to more than 377 million people living in urban areas. Out of the world’s 10 largest urban agglomerations, three are in India (Delhi, Mumbai and Kolkata) (Index Mundi 2013). Projections suggest that India will have more than 700 million urban population by the 2040s (GoI, 2011).
*Correspondence to: S. Mondal, Quarter # B2, Institute of Economic Growth (IEG), University of Delhi North Campus, Delhi-110007, India. E-mail: [email protected]
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The rapid pace of urbanization potentially creates enormous economic advancement and gives an open environment to the urban as well as rural communities to prosper in a modern way (Redman and Jones, 2004; Ding, 2009; FIG Commission 3, 2010). However, there are significant environmental, social and public health implications of a burgeoning urban population in cities and towns ill-equipped to deal with such rapid change. The first visible impact of this process is the formation of slums and shanty towns, which results from cities not being able to accommodate migrants in habitable areas well-served by basic amenities (WHO and UN-HABITAT [World Health Organization, and United Nations Human Settlements Programme], 2010). The impact of such rapid and unplanned urbanization is on basic services and infrastructure such as water supply, electricity, sanitation and housing (Kessides, 1997). In India, too, rapid urbanization has been accompanied by the rise of the urban poor who live in slums and shanties and are mostly migrants from rural areas engaged in informal and unorganized sector (Gupta and Mitra, 2002a, 2002b). On the basis of the National Sample Survey (NSS) data, it is estimated that between 1993–1994 and 2004–2005, the number of the urban poor in India has risen by 4.4 million persons (Government of India, 2007). Relatively much less systematic research and discussion has taken place on the impact of rapid urbanization on health outcomes because of living conditions and inadequate health infrastructure. Sporadic research shows that the urban poor might be more impacted by disease because of the unhygienic conditions in which such populations live, which is made worse by their limited access to adequate health services (Gupta and Mitra, 2002a, 2002b; Awasthi and Agarwal, 2003; Gupta and Guin, 2006). Although organizations such as the Urban Health Resource Center, Delhi (UHRC, 2012a, 2012b), have been working on the health issues of the urban poor, the lack of policy discourse at the national level is conspicuous by its absence.
EVIDENCE BASE FOR POLICYMAKING ON URBAN HEALTH The most common way of including residence in research in India has been to use the rural–urban categories to analyze differential outcomes and access to services. At the same time, recognition of the changing nature of urbanization has also increasingly brought into focus the almost parallel sub-economies of original and earlier settlers and later migrants (WHO, 2010; ICSU Planning Group, 2011). Recognizing the infrastructural and basic needs deficit, the Indian government launched the Jawaharlal Nehru National Urban Renewal Mission (JNNURM) under the Ministry of Urban Development in 2005. The focus of JNNURM has been on sectors such as water supply, sewerage, drainage, solid waste management and urban transport under the sub-mission named Urban Infrastructure and Governance. Additionally, the Ministry of Housing and Urban Poverty Alleviation also launched the Basic Services for the Urban Poor and the Integrated Housing and Slum Development Programme, with a major emphasis on housing. However, there remained an unarticulated need for closing the loop by bringing in health outcomes and services in this discourse. Copyright © 2014 John Wiley & Sons, Ltd.
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The lack of policy recognition of health issues can be gleaned from the fact that the only comprehensive source of statistics on disease patterns in India—the Central Bureau of Health Intelligence (CBHI) under the Ministry of Health and Family Welfare (MoHFW)—does not separate disease data by residence for communicable diseases—a serious omission that prevents analysis of even rural–urban trends (MoHFW, 2010), not to mention differences between the urban poor and the nonpoor. The census office’s Sample Registration System (SRS, 2011a, 2011b) collects population statistics by residence (rural–urban) on vital statistics including fertility and childhood mortality rates but does not publish statistics on the poor and the non-poor. There are a few other sources of national data such as the National Family Health Survey and the District Level Household Survey that do some disease reporting by residence, and these can be cross-tabulated by economic status to obtain some insights into how the urban poor are faring. However, these are not comprehensive enough to enable a proper analysis of urban health issues. Even the NSS rounds on health, while allowing rural–urban analysis, do not have a sampling frame that would allow analysis of health issues of the urban poor (Government of India, 2011). The lack of national data has been partially responsible for sparse research in this area, which has in turn led to the lack of evidence-based research on urban health issues, putting research and policymaking in a cyclic vacuum. Because health is the primary responsibility of the MoHFW, it is probably appropriate that the MoHFW should, either itself or in collaboration with other relevant bodies and departments, collect information on urban health. This has yet to happen, leading to the continuation of the lack of evidence-based policymaking on the subject.
URBANIZATION, SLUMS AND BASIC AMENITIES IN INDIA In India, the census in 2011 indicates that Tamil Nadu and Kerala have the maximum share of urban population to total population (48.4% and 47.7%, respectively). In fact, other major states such as Maharashtra, Gujarat, Karnataka, Punjab, Haryana, Andhra Pradesh (AP) and West Bengal (WB) all have shares of urban population above the national average of 31.1%. States such as Jharkhand, Chhattisgarh and Orissa have fairly low shares of urban population (Table 1); on the basis of the 65th report of the NSS on the characteristics of urban slums in 2008–09, it shows that among the major states, Maharashtra has the maximum share of slum population in India (34.7%), followed by AP (10.7%) and WB (10.3%), respectively. The other states listed are also high in slum population compared with the rest of the states not listed in this table. Three empowered action group1 states—Madhya Pradesh (MP), Orissa and Uttar Pradesh (UP)—are also in this group. Although many of the states with high urban share also have a high share of slum population, this need not always be the case. 1 In India, the eight socioeconomically backward states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh, referred to as the Empowered Action Group states, lag behind in the demographic transition and have the highest infant mortality rates in the country.
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Table 1. Percentage of notified and non-notified slums in different states and India States Andhra Pradesh Delhi Gujarat Karnataka Madhya Pradesh Maharashtra Orissa Tamil Nadu Uttar Pradesh West Bengal All India
Notified slum (%)
Non-notified slums (%)
Share of slums in India (%)
75.5 33.8 40.0 49.7 34.3 54.5 32.3 50.7 55.7 49.1 50.6
24.5 66.2 60.0 50.3 65.7 45.5 67.7 49.3 44.3 50.9 49.4
10.7 6.4 6.9 4.6 4.5 34.7 4.0 6.9 4.9 10.3 100
Source: National Sample Survey 65th round on “Some Characteristics of Urban Slums 2008-2009,” (2010).
To understand the slum situation a bit more, it must be stated that in India, there are two types of slums—notified and non-notified slums.2 The notified slums are those that are recognized by municipalities, corporations or any other local authority, and are, therefore, under policy ambit, at least on paper. By comparison, non-notified slums have almost no legal standing, making these vulnerable to policy omissions. Greater the share of non-notified slums in total slums, greater will be the possibility of inadequate policy targeting and greater will be the vulnerabilities to a variety of shocks, including health shocks. As Table 1 shows, almost all the states except AP have 50% or more slums that are non-notified. Orissa has as many as 68% of its slums in the non-notified category. Slums generally, and non-notified slums in particular, are also lagging behind in basic amenities. Looking at water-logging during monsoon months, presence of latrine, garbage disposal arrangement and presence of hospitals, we indicate in Table 2 that Orissa, Tamil Nadu, Gujarat and UP are doing quite poorly in terms of basic amenities for both types of slums. Some of the other states such as WB and AP are also not doing that much better. In absolute terms, all the four indicators are much worse for non-notified slums compared with those for notified slums, in all the states. If these amenities were the only determinants of health outcomes, then high proportion of slum population listed should always show unfavorable outcomes. Clearly, there are other parameters such as overall economic development and governance that matter as well and help in bringing under control quickly an epidemic or other public health concerns. However, the presence of slums that probably cannot be reached by usual policies would remain a serious challenge for achieving effective health outcomes.
2
Non-notified slums are defined as a compact settlement with a collection of poorly built tenements, mostly of temporary nature, crowded together usually with inadequate sanitary and drinking water facilities in unhygienic conditions.
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1 49 27 1
13
10
52
41
0 39 0 18
14 59 45 24
37 99 57 60
8
No latrine
18
Waterlogged during monsoon
10
11
3 33 12 16
0 62 0 48
3
No garbage disposal arrangement
Notified slums
46
55
45 67 34 47
10 52 19 85
41
No hospitals within 1 km
54
40
58 38 56 66
77 53 28 81
43
Waterlogged during monsoon
20
10
6 36 40 16
11 48 17 24
27
23
22
6 48 39 54
20 33 15 24
40
No garbage disposal arrangement
Non-notified slums No latrine
Source: National Sample Survey 65th round on “Some Characteristics of Urban Slums 2008-2009,” (2010).
Andhra Pradesh Delhi Gujarat Karnataka Madhya Pradesh Maharashtra Orissa Tamil Nadu Uttar Pradesh West Bengal India
States
Table 2. Basic amenities in slums, by type of slums
58
71
47 75 83 86
46 60 56 20
69
No hospitals within 1 km
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DISEASE BURDEN AND URBANIZATION Concerns have been raised about India’s ability to meet the Millennium Development Goals (MDGs) and the unresponsiveness of the infant mortality rate (IMR) to further prevention efforts (Deolalikar, 2005; Paul et al., 2011). Relatively much less focus has been on the extent to which urban India contributes to the lagging IMR and maternal mortality ratio in the country. A joint report of the WHO and UN-Habitat (2010) on health inequities in urban settings indicates that urban averages often mask hidden pockets of ill-health and overlooked populations, and although the MDGs targets are for countries as a whole, cities play—and will continue to play—an important role in their progress. Results presented in this UN report indicate that many health-related MDG targets will not be achieved in urban populations and the urban poor are most at risk of not achieving national MDG targets. The recent Global Burden Of Diseases, Injuries and Risk Factors Study 2010 (Lim et al., 2012) indicates that overall, the three risk factors that account for the most disease burden in India are dietary risks, household air pollution from solid fuels and tobacco smoking. Although morbidity and mortality from non-communicable diseases are rising quite rapidly, communicable diseases still remain a very important part of India’s disease profile; preventable diseases such as lower respiratory infections, diarrheal diseases, childhood-cluster diseases, tuberculosis (TB) and HIV/AIDS still remain important reasons for morbidity and mortality in India (WHO, 2009). In India, the National Health Profile 2010 of the CBHI indicates that among the various communicable diseases, acute respiratory infections and acute diarrheal diseases reported the highest cases during 2010. In addition, pulmonary TB, malaria, enteric fever, pneumonia and gonococci infection are the other diseases that saw more than 100 000 cases. Among these, pulmonary TB reported the maximum number of deaths. Although the data are not presented by residence, the high cases of these infectious diseases in the country do raise the very real possibility of slums contribution to the total case load. Also, vector-borne diseases are on the rise in many Indian cities and often threaten to take on epidemic proportion. Research indicates that diseases such as malaria, lymphatic filariasis and dengue are becoming major public health problems associated with rapid urbanization in many tropical countries (Knudsen and Slooff, 1992). An analysis of the top five states contributing to water-borne and vector-borne communicable diseases in the last 10 years indicates that Orissa has been in the top position in vector-borne diseases. Jharkhand, WB, Chhattisgarh and MP have also been frequently in this group, and even bigger states such as Maharashtra have shown up more than once in the top five list. For water-borne diseases, AP, Karnataka, Maharashtra and WB showed up frequently in the top five for the last 10 years. Many of these states have significant slum populations. Clearly, even economically better-off states need to watch out for infectious diseases; because of the very nature of congested areas such as slums, states such as Maharashtra, AP and WB—that are dealing with such large settlements—need to be alert to relatively adverse health outcomes from such areas, in both maternal/ child health and infectious diseases. Evidence exists to indicate that overcrowding makes outbreaks of respiratory diseases such as TB much more likely (Shetty, 2011). Copyright © 2014 John Wiley & Sons, Ltd.
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Other studies have documented that urban areas contribute about 15% of the total malaria cases in India and are primarily associated with construction activities and migrant population (Dash et al., 2008). Continuous construction activities and increasing slum populations with poor sanitation have been contributing to increasing cases of malaria in urban areas. Although the CBHI shows a sharp increase in dengue cases in the last 4 years, there is a global evidence that dengue is more prevalent in urban and semi-urban areas, particularly in Asia, with mosquitoes breeding in water storage containers in households (Sommerfeld, 2011).
HEALTH INEQUITY AND URBANIZATION Evidence from the District Level Household Survey-II, DLHS II (2004) on TB and malaria for rural and urban areas as well as by economic categories (Figures 1 and 2) indicates that the top contributors for both diseases are the Empowered Action Group states. To compare with more developed states, two major states that contribute significantly to the total disease load have been taken as well. In terms of estimated prevalence, the North-Eastern states top the list for both malaria and TB but do not necessarily add significantly to the total disease burden in the country because of their smaller populations. However, Orissa has a high prevalence as well as it contributes a high share to the total malaria cases in India. Apart from North-Eastern states and Orissa, MP, Chhattisgarh and Maharashtra also have high prevalence compared with the remaining states. For TB, the major states with high prevalence are Bihar, AP, WB and UP in that order. Figure 1 shows that the all-India estimated TB prevalence per 100 000 population was 366 for rural areas compared with 225 for urban areas, respectively, in 2002–2004, indicating fairly high burden of TB in urban areas. By looking further at prevalence among economic categories, it is seen that the prevalence of TB among low income groups is highest relative to the middle and high income groups for both rural and urban areas. Among the high burden states, the low economic categories had a higher prevalence in almost all the states including economically better-off states such as
Figure 1. Persons suffering from tuberculosis (per 100 000 population) by economic class in selected states Copyright © 2014 John Wiley & Sons, Ltd.
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Figure 2. Persons suffering from malaria (per 100 000 population) by economic class in selected states
AP and to a lesser extent for Maharashtra for both rural and urban areas. For example, in urban areas of UP, Bihar and MP, the prevalence is significantly high among the low economic categories. Similarly, Figure 2 for malaria shows higher prevalence for rural areas, but within both urban and rural areas, the prevalence is higher for low economic categories. Again, this is true in most cases except for urban UP (where the middle economic category has slightly higher prevalence compared with the low category). Clearly, the urban poor in each state would be one key determinant of inter-state health inequity as well as socioeconomic gradients in health outcomes. Even more forceful is the evidence from smaller surveys on health outcomes for the urban poor and the non-poor. Evidence from an eight-city study indicates that IMR for slums and poorest quintile is always worse than that for the city as a whole as well as non-slum population (Gupta et al., 2009). The study included cities from the betteroff states such as AP (Hyderabad), Maharashtra (Mumbai) and Tamil Nadu (Chennai). Similarly, stunting was seen to occur at a much higher rate among the city poor and slum dwellers compared with others. Similar evidence of inequality between urban poor and non-poor women in terms of their health status also now exists from a variety of sources (Agarwal, 2011). Other studies show that the IMR among the urban poor is 54.6 whereas for the non-poor, it is 35.5 (UHRC, 2012a, 2012b). As for service delivery, a variety of evidence exists. For example, only 40% of children from poor household received all recommended vaccination (NFHS-3, 2006). Antenatal visits were much lower at 54.2% for the urban poor compared with those at 83.1% for the urban non-poor (UHRC, 2007). A four-city recent survey conducted among 2000 households covering 10 929 individuals in slums of Ludhiana, Jaipur, Mathura and Ujjain on access to health services indicated lack of government facilities and services, a very high preference for private health facilities, high expenses in both private and public facilities and a perception that private facilities were offering high quality services (Gupta and Guin, 2006). It is logical that major states such as AP, Gujarat, Karnataka and Maharashtra will do much better on all the economic development fronts compared with states such as Copyright © 2014 John Wiley & Sons, Ltd.
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MP, Orissa and UP; these also have a much higher per capita expenditure on health, unlike the three other states. Clearly, the health outcomes in these states are expected to be better despite large slum populations because of their development that enables superior coping mechanisms. The relative welfare of the worse off in these states will be better than the welfare of similar individuals in poorer states. This is supported by an evidence that indicates, for example, that neonatal mortality among urban poor in Maharashtra was 21 compared with that in MP, which was at 54.8 (Agarwal, 2011).
DISCUSSION AND POLICY IMPLICATIONS To overlook the health of the urban poor is to overlook health equity concerns. In the current changing landscapes of cities in developing countries, much of the health inequity in outcomes and access to services have to do with how the poor are faring, rural or urban. To help move the agenda on health equity and the urban poor, it is first and foremost important to recognize the problem. It is important to collect sound and quantifiable evidence that can feed into policy formulation. The need of the hour is to map health outcomes as well as health services separately for urban and rural areas and within urban areas for the poor and the non-poor. The need for a more nuanced health policy that is more consistent with the regional and local realities is not new (Gupta and Mitra, 2002a, 2002b, Peters et al., 2003). The fact that increases in income in urban areas do not necessarily ensure improvements in living condition of all is now increasingly being recognized (Madhiwalla, 2007). The Planning Commission’s report of the Steering Committee on Urban Development for Eleventh Five Year Plan states that due to burgeoning urban population growth, the big cities viz., metropolitan (million plus) and mega cities are under severe strain particularly in terms of making access to infrastructure services to the inhabitants. Overall the urban dwellers in the country have low access to infrastructure services such as water supply, sanitation, power supply and solid waste disposal. (Eleventh Five Year Plan, 2007–2012). The progress of JNNURM has been uneven, although some cities did benefit greatly from the focused attention. The reasons for slow progress have to do mainly with inadequate financing, governance and capacity, especially at state levels (Ahluwalia, 2011; Grant Thornton India, 2011). The main concern, however, is that JNNURM has not linked up with similar initiatives in the health sector. Urban health is truly multi-sectoral, and the JNNURM gave an opportunity to the health ministry to work in tandem with these other departments to confront the health needs of the poor. So while JNNURM addresses basic amenities, it continues to be the case that there remains more or less a vacuum vis a vis urban health. In fact, urban health itself remains a neglected policy area in India. The earlier plan of launching the National Urban Health Mission (NUHM), which was to cost Rs 20 000 crore and was cleared by the finance ministry’s expenditure finance committee, was aimed at providing a dedicated public health delivery system to address treatment challenges in towns and cities, with a particular focus on the 90 million poor living in slums. The NUHM was expected to cover 779 cities. Copyright © 2014 John Wiley & Sons, Ltd.
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The NUHM did not materialize, and now, there is a move to merge the urban and National Rural Health Mission under one National Health Mission (Gaur, 2012), which may not help the cause of urban health. There have been cuts in health allocations in the recent budget even to National Rural Health Mission, and under this scenario, it does not seem likely that urban health will obtain priority or funding in the near future. There are some bright spots, however, in the form of non-government organizations taking the lead together with government bodies to improve basic amenities in urban poor areas as well as making sure that accessibility to health services improves in such areas. The use of public–private partnerships in improving availability and accessibility of health services is now quite visible and usual (Ghanashyam, 2008). That such models are also coming into urban areas is relatively less well documented and known; the Urban Health Resource Centre has also teamed up with government bodies in urban areas such as Agra to propose models that can work to increase accessibility and availability of health services (UHRC, 2012a, 2012b). The most recent example of such public–private partnership is the Government of National Capita Territory of Delhi’s Mission Convergence Programme, locally called Samajik Suvidha Sangam. This United States Agency for International Development funded program is an innovative public–private partnership that teams up with local community organizations to improve the health and well-being of the urban poor of Delhi (USAID, 2012). However, it is not clear whether such instances are scalable and replicable to address the humongous problem of urban health, which must remain the primary responsibility of the government. It is probably easier to address the supply side issues of health care in urban areas than to stem the flow of migrants or curb urbanization. If urbanization is going to continue in the pace it has, the government authorities cutting across multiple sector must wake up to the fact that the health issues go beyond the responsibility of the health departments. The health departments need to be pro-active and link up with other departments that deal with issues such as water, sanitation, housing and slums—to name a few—to really make an impact on urban health. This is especially true in the context of infectious, communicable and vaccinepreventable diseases, which still are an important part of the total disease burden in India, especially among the lower socioeconomic categories. Having said that, the departments of health in states and the MoHFW must realize how severely inadequate the supply of health facilities and services are in the urban areas. Most recent reports indicate that there are 1083 Urban Family Welfare Center3 (UFWC) and 871 health posts4 catering to 377 105 760 (Census India, 2011) urban population of the country, which translates to one urban family welfare center/health post per 192 992 urban population, compared with the norm of one center for every 50 000 population, indicating severe accessibility issues (Agarwal et al., 2007; MoHFW, 2009). 3
It provides family welfare services in urban areas since the early 1950s and is equipped to provide contraceptive supplies. On the basis of the population covered by each UFWC, it is classified in three types and has different staffing patterns. Type I covers a population of 10 000–25 000, type II between 25 000 and 50 000, and type III above 50 000. 4 It was introduced in 1983 with a view to provide service delivery outreach, primary health care, family welfare and maternal and child health services in urban areas. Unlike UFWC, it is also classified into four types, A, B, C and D, but with lesser population base. Copyright © 2014 John Wiley & Sons, Ltd.
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Other estimates indicate the need for an additional requirement of 500 urban health and family welfare centers to meet the current needs of the urban poor (ASSOCHAM, 2006). Rectifying this does not require big missions or 5-year plans. The lack of vision and planning around urban health on the one hand and the lack of accountability from those who are in-charge of all the civic amenities on the other hand will probably ensure that urban health would continue to contribute a disproportionate share to the total disease burden of the country.
CONFLICT OF INTEREST The authors have no competing interests.
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Dutt AK, Noble AG. 2004. Urban Development in South Asia. in Dutt AK, Challenges to Asian Urbanization in the 21st Century. p. 256; Kluwar Academic Publishers: Netherlands. Eleventh Five Year Plan. 2007–2012. Report of the steering committee on urban development for eleventh five year plan (2007–2012). FIG Commission 3. 2010. Rapid urbanization and mega cities: the need for spatial information management. FIG Report no. 48, 2010. Gaur A. 2012. National Urban Health Mission to enhance access to urban poor. Times of India. March 20 Available at: http://articles.timesofindia.indiatimes.com/keyword/nuhm Ghanashyam B. 2008. Can public–private partnerships improve health in India? Lancet 372(9642): 878–879. GoI [Government of India]. 2011. Urban infrastructure, housing, basic services and poverty alleviation. Eleventh Five Year Plan 2011. Government of India. 2007. Housing and urban policy in India. Ministry of Housing and Urban Poverty Alleviation. Available at: http://mhupa.gov.in/policies/index2.htm Government of India. 2011. Ministry of Statistics and Programme Implementation. Available at: http://mospi. nic.in/Mospi_New/site/inner.aspx?status=3&menu_id=31 Grant Thornton India. 2011. Appraisal of Jawaharlal Nehru National Urban Renewal Mission (JnNURM). Available at: http://jnnurm.nic.in/wp-content/uploads/2012/06/ Appraisal-of-JnNURM-Final-Report-Volume-I-.pdf Gupta I, Guin P. 2006. Health status and access to health services: a study of four slums. In “Well-being of the Urban Poor: Assessment and Policy Issues. A Study of Slum-Clusters in Jaipur, Ludhiana, Mathura and Ujjain.” Report submitted to the Ministry of Urban Development, Government of India.
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URBAN HEALTH IN INDIA Gupta I, Mitra A. 2002a. Basic amenities and health in urban India. Natl Med J India 15(1) (Supplement): 26–31. Gupta I, Mitra A. 2002b. Rural migrants and labour segmentation: micro level evidence from Delhi slums. Econ Polit Wkly XXXVII(2): 163–168. Gupta K, Arnold F, Lhungdim H. 2009. Health and living conditions in eight Indian cities. National Family Health Survey (NFHS-3), India, 2005–06. Mumbai: International Institute for Population Sciences; Calverton, Maryland, USA: ICF Macro. Available at: http://www.measuredhs.com/pubs/pdf/OD58/OD58.pdf `ICSU Planning Group. 2011. Report of the ICSU planning group on health and wellbeing in the changing urban environment: a systems analysis approach. International Council for Science, Paris Index Mundi. 2013. World demographic Profile 2013. Available at: http://www.indexmundi.com/world/ demographics_profile.html Keating G, Natella S. 2012. Opportunities in an urbanizing world. Credit Suisse 2012. Available at: http:// static.pulso.cl/20121018/1637131.pdf Kessides C. 1997. World bank experience with the provision of infrastructure services for the urban poor: preliminary identification and review of best practices. The World Bank. Knudsen and Slooff. 1992. Vector-borne disease problems in rapid urbanization: new approaches to vector control. Bull World Health Organ 70(1): 1–6. Lim SS, Vos T, Flaxman AD, et al. 2012. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet 380(9859): 2224–2260. Madhiwalla N. 2007. Health care in urban slum in India. Natl Med J India 20(3): 13–14. McGee T. 2011. Urbanization takes on New dimensions in Asia’s population giants. Available at: http://www.prb. org/Publications/Articles/2001/UrbanizationTakesonNew DimensionsinAsiasPopulationGiants.aspx MoHFW [Ministry of Health & Family Welfare]. 2009. Draft final report of the task force to advise the National Rural Health Mission on “Strategies for Urban Health Care”. New Delhi: Ministry of Health & Family Welfare; 2006. Available at: http://mohfw. nic.in/NRHM/Task_grp/Tg_index.htm.
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MoHFW [Ministry of Health & Family Welfare]. 2010. National health profile 2010. Central Bureau of Health Intelligence. Nigam A. Health Ministry may submit its own draft chapter to Plan panel. Business Line, 12 August 2012. Paul VK, Sachdev HS, Mavalankar D, et al. 2011. Reproductive health, and child health and nutrition in India: meeting the challenge. Lancet 377(9762): 332–349. Peters D, Rao S, Robert F. 2003. Lumping and splitting: the health policy agenda in India. Health Policy Plan 18(3): 249–260. Redman CL, Jones NS. 2004. The environmental, social, and health dimensions of urban expansion. PopulationEnvironment Research Network cyber seminar. Shetty P. 2011. Health care for urban poor falls through the gap. Lancet 377(9766): 627–628. Sommerfeld J. 2011. Dengue vector control research completed in Asia: 5 year initiative focused on eco-bio-social strategies. World Health Organization 2011. Available at: http://www.who.int/tdr/news/2011/dengue-control/en/ SRS (Sample Registration System). 2011a. Available at http://censusindia.gov.in/Vital_Statistics/SRS/Sample_ Registration_System.aspx SRS (Sample Registration System). 2011b. Available at: SRS Bull 46(1): 1–6. UHRC. 2012. Agra urban health program. Available at: http:// www.uhrc.in/index.php?module=ContentExpress&func= display&ceid=3&meid= 1 UHRC (Urban Health Resource Center). 2012. Available at: http://www.uhrc.in/ USAID. 2006. Urban development: recent additions to the USAID library. USAID. 2012. Making the Indian health system work for the urban poor. Strategies for extending financial risk protection and a continuum of health care. USAID. August 2012. WHO [World Health Organization]. 2009. Global health risks: mortality and burden of disease attributable to selected major risks. WHO and UN-HABITAT (World Health Organization, and United Nations Human Settlements Programme). 2010. Hidden cities: unmasking and overcoming health inequities in urban settings. Available at: http://www.hiddencities.org/ report.html WHO [World Health Organization]. 2010. India: health profile. Available at: http://www.who.int/gho/countries/ ind.pdf
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Int J Health Plann Mgmt 2015; 30: 192–203 Published online 12 January 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/hpm.2236
Urban health in India: who is responsible? Indrani Gupta1 and Swadhin Mondal2* 1 2
Health Policy Research Unit, Institute of Economic Growth (IEG), Delhi, India Institute for studies in Industrial Development (ISID), New Delhi, India
SUMMARY Urban health has received relatively less focus compared with rural health in India, especially the health of the urban poor. Rapid urbanization in India has been accompanied by an increase in population in urban slums and shanty towns, which are also very inadequately covered by basic amenities, including health services. The paper presents existing and new evidence that shows that health inequities exist between the poor and the non-poor in urban areas, even in better-off states in India. The lack of evidence-based policies that cut across sectors continues to be a main feature of the urban health scenario. Although the problems of urban health are more complex than those of rural health, the paper argues that it is possible to make a beginning fairly quickly by (i) collecting more evidence of health status and inequities in urban areas and (ii) correcting major inadequacies in infrastructure–both health and non-health– without waiting for major policy overhauls. Copyright © 2014 John Wiley & Sons, Ltd. KEY WORDS:
urban health; health services; policy; India
INTRODUCTION The share of the urban population in global population has crossed the 50% threshold in the year 2009 (Keating and Natella, 2012). The United Nations (UNFPA 2006) has projected that by 2030, urban population will be more than 60% of the global population. Massive growth of urbanization is taking place in developing countries (McGee 2011). Among regions, South Asia will see the largest growth with an increase of urban population of more than five times (USAID, 2006). India, too, has seen massive urbanization; over 2001–2011 alone, the growth of urbanization was 31%, which—while somewhat lower compared with other south Asian countries (Dutta and Noble, 2004)—in absolute terms adds up to more than 377 million people living in urban areas. Out of the world’s 10 largest urban agglomerations, three are in India (Delhi, Mumbai and Kolkata) (Index Mundi 2013). Projections suggest that India will have more than 700 million urban population by the 2040s (GoI, 2011).
*Correspondence to: S. Mondal, Quarter # B2, Institute of Economic Growth (IEG), University of Delhi North Campus, Delhi-110007, India. E-mail: [email protected]
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The rapid pace of urbanization potentially creates enormous economic advancement and gives an open environment to the urban as well as rural communities to prosper in a modern way (Redman and Jones, 2004; Ding, 2009; FIG Commission 3, 2010). However, there are significant environmental, social and public health implications of a burgeoning urban population in cities and towns ill-equipped to deal with such rapid change. The first visible impact of this process is the formation of slums and shanty towns, which results from cities not being able to accommodate migrants in habitable areas well-served by basic amenities (WHO and UN-HABITAT [World Health Organization, and United Nations Human Settlements Programme], 2010). The impact of such rapid and unplanned urbanization is on basic services and infrastructure such as water supply, electricity, sanitation and housing (Kessides, 1997). In India, too, rapid urbanization has been accompanied by the rise of the urban poor who live in slums and shanties and are mostly migrants from rural areas engaged in informal and unorganized sector (Gupta and Mitra, 2002a, 2002b). On the basis of the National Sample Survey (NSS) data, it is estimated that between 1993–1994 and 2004–2005, the number of the urban poor in India has risen by 4.4 million persons (Government of India, 2007). Relatively much less systematic research and discussion has taken place on the impact of rapid urbanization on health outcomes because of living conditions and inadequate health infrastructure. Sporadic research shows that the urban poor might be more impacted by disease because of the unhygienic conditions in which such populations live, which is made worse by their limited access to adequate health services (Gupta and Mitra, 2002a, 2002b; Awasthi and Agarwal, 2003; Gupta and Guin, 2006). Although organizations such as the Urban Health Resource Center, Delhi (UHRC, 2012a, 2012b), have been working on the health issues of the urban poor, the lack of policy discourse at the national level is conspicuous by its absence.
EVIDENCE BASE FOR POLICYMAKING ON URBAN HEALTH The most common way of including residence in research in India has been to use the rural–urban categories to analyze differential outcomes and access to services. At the same time, recognition of the changing nature of urbanization has also increasingly brought into focus the almost parallel sub-economies of original and earlier settlers and later migrants (WHO, 2010; ICSU Planning Group, 2011). Recognizing the infrastructural and basic needs deficit, the Indian government launched the Jawaharlal Nehru National Urban Renewal Mission (JNNURM) under the Ministry of Urban Development in 2005. The focus of JNNURM has been on sectors such as water supply, sewerage, drainage, solid waste management and urban transport under the sub-mission named Urban Infrastructure and Governance. Additionally, the Ministry of Housing and Urban Poverty Alleviation also launched the Basic Services for the Urban Poor and the Integrated Housing and Slum Development Programme, with a major emphasis on housing. However, there remained an unarticulated need for closing the loop by bringing in health outcomes and services in this discourse. Copyright © 2014 John Wiley & Sons, Ltd.
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The lack of policy recognition of health issues can be gleaned from the fact that the only comprehensive source of statistics on disease patterns in India—the Central Bureau of Health Intelligence (CBHI) under the Ministry of Health and Family Welfare (MoHFW)—does not separate disease data by residence for communicable diseases—a serious omission that prevents analysis of even rural–urban trends (MoHFW, 2010), not to mention differences between the urban poor and the nonpoor. The census office’s Sample Registration System (SRS, 2011a, 2011b) collects population statistics by residence (rural–urban) on vital statistics including fertility and childhood mortality rates but does not publish statistics on the poor and the non-poor. There are a few other sources of national data such as the National Family Health Survey and the District Level Household Survey that do some disease reporting by residence, and these can be cross-tabulated by economic status to obtain some insights into how the urban poor are faring. However, these are not comprehensive enough to enable a proper analysis of urban health issues. Even the NSS rounds on health, while allowing rural–urban analysis, do not have a sampling frame that would allow analysis of health issues of the urban poor (Government of India, 2011). The lack of national data has been partially responsible for sparse research in this area, which has in turn led to the lack of evidence-based research on urban health issues, putting research and policymaking in a cyclic vacuum. Because health is the primary responsibility of the MoHFW, it is probably appropriate that the MoHFW should, either itself or in collaboration with other relevant bodies and departments, collect information on urban health. This has yet to happen, leading to the continuation of the lack of evidence-based policymaking on the subject.
URBANIZATION, SLUMS AND BASIC AMENITIES IN INDIA In India, the census in 2011 indicates that Tamil Nadu and Kerala have the maximum share of urban population to total population (48.4% and 47.7%, respectively). In fact, other major states such as Maharashtra, Gujarat, Karnataka, Punjab, Haryana, Andhra Pradesh (AP) and West Bengal (WB) all have shares of urban population above the national average of 31.1%. States such as Jharkhand, Chhattisgarh and Orissa have fairly low shares of urban population (Table 1); on the basis of the 65th report of the NSS on the characteristics of urban slums in 2008–09, it shows that among the major states, Maharashtra has the maximum share of slum population in India (34.7%), followed by AP (10.7%) and WB (10.3%), respectively. The other states listed are also high in slum population compared with the rest of the states not listed in this table. Three empowered action group1 states—Madhya Pradesh (MP), Orissa and Uttar Pradesh (UP)—are also in this group. Although many of the states with high urban share also have a high share of slum population, this need not always be the case. 1 In India, the eight socioeconomically backward states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh, referred to as the Empowered Action Group states, lag behind in the demographic transition and have the highest infant mortality rates in the country.
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Table 1. Percentage of notified and non-notified slums in different states and India States Andhra Pradesh Delhi Gujarat Karnataka Madhya Pradesh Maharashtra Orissa Tamil Nadu Uttar Pradesh West Bengal All India
Notified slum (%)
Non-notified slums (%)
Share of slums in India (%)
75.5 33.8 40.0 49.7 34.3 54.5 32.3 50.7 55.7 49.1 50.6
24.5 66.2 60.0 50.3 65.7 45.5 67.7 49.3 44.3 50.9 49.4
10.7 6.4 6.9 4.6 4.5 34.7 4.0 6.9 4.9 10.3 100
Source: National Sample Survey 65th round on “Some Characteristics of Urban Slums 2008-2009,” (2010).
To understand the slum situation a bit more, it must be stated that in India, there are two types of slums—notified and non-notified slums.2 The notified slums are those that are recognized by municipalities, corporations or any other local authority, and are, therefore, under policy ambit, at least on paper. By comparison, non-notified slums have almost no legal standing, making these vulnerable to policy omissions. Greater the share of non-notified slums in total slums, greater will be the possibility of inadequate policy targeting and greater will be the vulnerabilities to a variety of shocks, including health shocks. As Table 1 shows, almost all the states except AP have 50% or more slums that are non-notified. Orissa has as many as 68% of its slums in the non-notified category. Slums generally, and non-notified slums in particular, are also lagging behind in basic amenities. Looking at water-logging during monsoon months, presence of latrine, garbage disposal arrangement and presence of hospitals, we indicate in Table 2 that Orissa, Tamil Nadu, Gujarat and UP are doing quite poorly in terms of basic amenities for both types of slums. Some of the other states such as WB and AP are also not doing that much better. In absolute terms, all the four indicators are much worse for non-notified slums compared with those for notified slums, in all the states. If these amenities were the only determinants of health outcomes, then high proportion of slum population listed should always show unfavorable outcomes. Clearly, there are other parameters such as overall economic development and governance that matter as well and help in bringing under control quickly an epidemic or other public health concerns. However, the presence of slums that probably cannot be reached by usual policies would remain a serious challenge for achieving effective health outcomes.
2
Non-notified slums are defined as a compact settlement with a collection of poorly built tenements, mostly of temporary nature, crowded together usually with inadequate sanitary and drinking water facilities in unhygienic conditions.
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1 49 27 1
13
10
52
41
0 39 0 18
14 59 45 24
37 99 57 60
8
No latrine
18
Waterlogged during monsoon
10
11
3 33 12 16
0 62 0 48
3
No garbage disposal arrangement
Notified slums
46
55
45 67 34 47
10 52 19 85
41
No hospitals within 1 km
54
40
58 38 56 66
77 53 28 81
43
Waterlogged during monsoon
20
10
6 36 40 16
11 48 17 24
27
23
22
6 48 39 54
20 33 15 24
40
No garbage disposal arrangement
Non-notified slums No latrine
Source: National Sample Survey 65th round on “Some Characteristics of Urban Slums 2008-2009,” (2010).
Andhra Pradesh Delhi Gujarat Karnataka Madhya Pradesh Maharashtra Orissa Tamil Nadu Uttar Pradesh West Bengal India
States
Table 2. Basic amenities in slums, by type of slums
58
71
47 75 83 86
46 60 56 20
69
No hospitals within 1 km
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DISEASE BURDEN AND URBANIZATION Concerns have been raised about India’s ability to meet the Millennium Development Goals (MDGs) and the unresponsiveness of the infant mortality rate (IMR) to further prevention efforts (Deolalikar, 2005; Paul et al., 2011). Relatively much less focus has been on the extent to which urban India contributes to the lagging IMR and maternal mortality ratio in the country. A joint report of the WHO and UN-Habitat (2010) on health inequities in urban settings indicates that urban averages often mask hidden pockets of ill-health and overlooked populations, and although the MDGs targets are for countries as a whole, cities play—and will continue to play—an important role in their progress. Results presented in this UN report indicate that many health-related MDG targets will not be achieved in urban populations and the urban poor are most at risk of not achieving national MDG targets. The recent Global Burden Of Diseases, Injuries and Risk Factors Study 2010 (Lim et al., 2012) indicates that overall, the three risk factors that account for the most disease burden in India are dietary risks, household air pollution from solid fuels and tobacco smoking. Although morbidity and mortality from non-communicable diseases are rising quite rapidly, communicable diseases still remain a very important part of India’s disease profile; preventable diseases such as lower respiratory infections, diarrheal diseases, childhood-cluster diseases, tuberculosis (TB) and HIV/AIDS still remain important reasons for morbidity and mortality in India (WHO, 2009). In India, the National Health Profile 2010 of the CBHI indicates that among the various communicable diseases, acute respiratory infections and acute diarrheal diseases reported the highest cases during 2010. In addition, pulmonary TB, malaria, enteric fever, pneumonia and gonococci infection are the other diseases that saw more than 100 000 cases. Among these, pulmonary TB reported the maximum number of deaths. Although the data are not presented by residence, the high cases of these infectious diseases in the country do raise the very real possibility of slums contribution to the total case load. Also, vector-borne diseases are on the rise in many Indian cities and often threaten to take on epidemic proportion. Research indicates that diseases such as malaria, lymphatic filariasis and dengue are becoming major public health problems associated with rapid urbanization in many tropical countries (Knudsen and Slooff, 1992). An analysis of the top five states contributing to water-borne and vector-borne communicable diseases in the last 10 years indicates that Orissa has been in the top position in vector-borne diseases. Jharkhand, WB, Chhattisgarh and MP have also been frequently in this group, and even bigger states such as Maharashtra have shown up more than once in the top five list. For water-borne diseases, AP, Karnataka, Maharashtra and WB showed up frequently in the top five for the last 10 years. Many of these states have significant slum populations. Clearly, even economically better-off states need to watch out for infectious diseases; because of the very nature of congested areas such as slums, states such as Maharashtra, AP and WB—that are dealing with such large settlements—need to be alert to relatively adverse health outcomes from such areas, in both maternal/ child health and infectious diseases. Evidence exists to indicate that overcrowding makes outbreaks of respiratory diseases such as TB much more likely (Shetty, 2011). Copyright © 2014 John Wiley & Sons, Ltd.
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Other studies have documented that urban areas contribute about 15% of the total malaria cases in India and are primarily associated with construction activities and migrant population (Dash et al., 2008). Continuous construction activities and increasing slum populations with poor sanitation have been contributing to increasing cases of malaria in urban areas. Although the CBHI shows a sharp increase in dengue cases in the last 4 years, there is a global evidence that dengue is more prevalent in urban and semi-urban areas, particularly in Asia, with mosquitoes breeding in water storage containers in households (Sommerfeld, 2011).
HEALTH INEQUITY AND URBANIZATION Evidence from the District Level Household Survey-II, DLHS II (2004) on TB and malaria for rural and urban areas as well as by economic categories (Figures 1 and 2) indicates that the top contributors for both diseases are the Empowered Action Group states. To compare with more developed states, two major states that contribute significantly to the total disease load have been taken as well. In terms of estimated prevalence, the North-Eastern states top the list for both malaria and TB but do not necessarily add significantly to the total disease burden in the country because of their smaller populations. However, Orissa has a high prevalence as well as it contributes a high share to the total malaria cases in India. Apart from North-Eastern states and Orissa, MP, Chhattisgarh and Maharashtra also have high prevalence compared with the remaining states. For TB, the major states with high prevalence are Bihar, AP, WB and UP in that order. Figure 1 shows that the all-India estimated TB prevalence per 100 000 population was 366 for rural areas compared with 225 for urban areas, respectively, in 2002–2004, indicating fairly high burden of TB in urban areas. By looking further at prevalence among economic categories, it is seen that the prevalence of TB among low income groups is highest relative to the middle and high income groups for both rural and urban areas. Among the high burden states, the low economic categories had a higher prevalence in almost all the states including economically better-off states such as
Figure 1. Persons suffering from tuberculosis (per 100 000 population) by economic class in selected states Copyright © 2014 John Wiley & Sons, Ltd.
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Figure 2. Persons suffering from malaria (per 100 000 population) by economic class in selected states
AP and to a lesser extent for Maharashtra for both rural and urban areas. For example, in urban areas of UP, Bihar and MP, the prevalence is significantly high among the low economic categories. Similarly, Figure 2 for malaria shows higher prevalence for rural areas, but within both urban and rural areas, the prevalence is higher for low economic categories. Again, this is true in most cases except for urban UP (where the middle economic category has slightly higher prevalence compared with the low category). Clearly, the urban poor in each state would be one key determinant of inter-state health inequity as well as socioeconomic gradients in health outcomes. Even more forceful is the evidence from smaller surveys on health outcomes for the urban poor and the non-poor. Evidence from an eight-city study indicates that IMR for slums and poorest quintile is always worse than that for the city as a whole as well as non-slum population (Gupta et al., 2009). The study included cities from the betteroff states such as AP (Hyderabad), Maharashtra (Mumbai) and Tamil Nadu (Chennai). Similarly, stunting was seen to occur at a much higher rate among the city poor and slum dwellers compared with others. Similar evidence of inequality between urban poor and non-poor women in terms of their health status also now exists from a variety of sources (Agarwal, 2011). Other studies show that the IMR among the urban poor is 54.6 whereas for the non-poor, it is 35.5 (UHRC, 2012a, 2012b). As for service delivery, a variety of evidence exists. For example, only 40% of children from poor household received all recommended vaccination (NFHS-3, 2006). Antenatal visits were much lower at 54.2% for the urban poor compared with those at 83.1% for the urban non-poor (UHRC, 2007). A four-city recent survey conducted among 2000 households covering 10 929 individuals in slums of Ludhiana, Jaipur, Mathura and Ujjain on access to health services indicated lack of government facilities and services, a very high preference for private health facilities, high expenses in both private and public facilities and a perception that private facilities were offering high quality services (Gupta and Guin, 2006). It is logical that major states such as AP, Gujarat, Karnataka and Maharashtra will do much better on all the economic development fronts compared with states such as Copyright © 2014 John Wiley & Sons, Ltd.
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MP, Orissa and UP; these also have a much higher per capita expenditure on health, unlike the three other states. Clearly, the health outcomes in these states are expected to be better despite large slum populations because of their development that enables superior coping mechanisms. The relative welfare of the worse off in these states will be better than the welfare of similar individuals in poorer states. This is supported by an evidence that indicates, for example, that neonatal mortality among urban poor in Maharashtra was 21 compared with that in MP, which was at 54.8 (Agarwal, 2011).
DISCUSSION AND POLICY IMPLICATIONS To overlook the health of the urban poor is to overlook health equity concerns. In the current changing landscapes of cities in developing countries, much of the health inequity in outcomes and access to services have to do with how the poor are faring, rural or urban. To help move the agenda on health equity and the urban poor, it is first and foremost important to recognize the problem. It is important to collect sound and quantifiable evidence that can feed into policy formulation. The need of the hour is to map health outcomes as well as health services separately for urban and rural areas and within urban areas for the poor and the non-poor. The need for a more nuanced health policy that is more consistent with the regional and local realities is not new (Gupta and Mitra, 2002a, 2002b, Peters et al., 2003). The fact that increases in income in urban areas do not necessarily ensure improvements in living condition of all is now increasingly being recognized (Madhiwalla, 2007). The Planning Commission’s report of the Steering Committee on Urban Development for Eleventh Five Year Plan states that due to burgeoning urban population growth, the big cities viz., metropolitan (million plus) and mega cities are under severe strain particularly in terms of making access to infrastructure services to the inhabitants. Overall the urban dwellers in the country have low access to infrastructure services such as water supply, sanitation, power supply and solid waste disposal. (Eleventh Five Year Plan, 2007–2012). The progress of JNNURM has been uneven, although some cities did benefit greatly from the focused attention. The reasons for slow progress have to do mainly with inadequate financing, governance and capacity, especially at state levels (Ahluwalia, 2011; Grant Thornton India, 2011). The main concern, however, is that JNNURM has not linked up with similar initiatives in the health sector. Urban health is truly multi-sectoral, and the JNNURM gave an opportunity to the health ministry to work in tandem with these other departments to confront the health needs of the poor. So while JNNURM addresses basic amenities, it continues to be the case that there remains more or less a vacuum vis a vis urban health. In fact, urban health itself remains a neglected policy area in India. The earlier plan of launching the National Urban Health Mission (NUHM), which was to cost Rs 20 000 crore and was cleared by the finance ministry’s expenditure finance committee, was aimed at providing a dedicated public health delivery system to address treatment challenges in towns and cities, with a particular focus on the 90 million poor living in slums. The NUHM was expected to cover 779 cities. Copyright © 2014 John Wiley & Sons, Ltd.
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The NUHM did not materialize, and now, there is a move to merge the urban and National Rural Health Mission under one National Health Mission (Gaur, 2012), which may not help the cause of urban health. There have been cuts in health allocations in the recent budget even to National Rural Health Mission, and under this scenario, it does not seem likely that urban health will obtain priority or funding in the near future. There are some bright spots, however, in the form of non-government organizations taking the lead together with government bodies to improve basic amenities in urban poor areas as well as making sure that accessibility to health services improves in such areas. The use of public–private partnerships in improving availability and accessibility of health services is now quite visible and usual (Ghanashyam, 2008). That such models are also coming into urban areas is relatively less well documented and known; the Urban Health Resource Centre has also teamed up with government bodies in urban areas such as Agra to propose models that can work to increase accessibility and availability of health services (UHRC, 2012a, 2012b). The most recent example of such public–private partnership is the Government of National Capita Territory of Delhi’s Mission Convergence Programme, locally called Samajik Suvidha Sangam. This United States Agency for International Development funded program is an innovative public–private partnership that teams up with local community organizations to improve the health and well-being of the urban poor of Delhi (USAID, 2012). However, it is not clear whether such instances are scalable and replicable to address the humongous problem of urban health, which must remain the primary responsibility of the government. It is probably easier to address the supply side issues of health care in urban areas than to stem the flow of migrants or curb urbanization. If urbanization is going to continue in the pace it has, the government authorities cutting across multiple sector must wake up to the fact that the health issues go beyond the responsibility of the health departments. The health departments need to be pro-active and link up with other departments that deal with issues such as water, sanitation, housing and slums—to name a few—to really make an impact on urban health. This is especially true in the context of infectious, communicable and vaccinepreventable diseases, which still are an important part of the total disease burden in India, especially among the lower socioeconomic categories. Having said that, the departments of health in states and the MoHFW must realize how severely inadequate the supply of health facilities and services are in the urban areas. Most recent reports indicate that there are 1083 Urban Family Welfare Center3 (UFWC) and 871 health posts4 catering to 377 105 760 (Census India, 2011) urban population of the country, which translates to one urban family welfare center/health post per 192 992 urban population, compared with the norm of one center for every 50 000 population, indicating severe accessibility issues (Agarwal et al., 2007; MoHFW, 2009). 3
It provides family welfare services in urban areas since the early 1950s and is equipped to provide contraceptive supplies. On the basis of the population covered by each UFWC, it is classified in three types and has different staffing patterns. Type I covers a population of 10 000–25 000, type II between 25 000 and 50 000, and type III above 50 000. 4 It was introduced in 1983 with a view to provide service delivery outreach, primary health care, family welfare and maternal and child health services in urban areas. Unlike UFWC, it is also classified into four types, A, B, C and D, but with lesser population base. Copyright © 2014 John Wiley & Sons, Ltd.
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Other estimates indicate the need for an additional requirement of 500 urban health and family welfare centers to meet the current needs of the urban poor (ASSOCHAM, 2006). Rectifying this does not require big missions or 5-year plans. The lack of vision and planning around urban health on the one hand and the lack of accountability from those who are in-charge of all the civic amenities on the other hand will probably ensure that urban health would continue to contribute a disproportionate share to the total disease burden of the country.
CONFLICT OF INTEREST The authors have no competing interests.
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