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Urban%20Health%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20Issues,%20Challenges%20and%20Solutions

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Title: Urban%20Health%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20Issues,%20Challenges%20and%20Solutions


1
Urban Health Issues,
Challenges and Solutions
2
Outline of Presentation
  1. Take home messages
  2. Urbanization-Trends and Patterns
  3. Health problems related to growing urbanization
  4. Challenges to health system
  5. The solutions
  6. Take home messages

3
Significance of Urban Health
The World Health Day theme for 2010 Urbanization
and Health
4
Take Home Messages
  • Urbanization due to migration
  • Is a reality
  • Has reached to considerable proportions
  • Leading to increased growth of slums
  • Will increase further to greater proportions in
    the foreseeable future
  • Slums lack infrastructure in basic amenities like
    safe drinking water, sanitation, housing etc
  • At increased risk of both communicable and non
    communicable diseases

5
Take Home Messages-2
  • Urban health is
  • Traditionally neglected in policy making
  • Need of the hour considering the facts and figure
    available regarding the population at risk
  • Failure of NRHM to take urban health into account
    and pending launch of NUHM
  • Policy influence needs to be done to sensitize
    the policy makers towards urban health issues

6
Take Home Messages-3
  • Challenges exist in terms of
  • Administrative issues
  • Policy issues
  • Operational issues
  • Involvement of non governmental service providers
  • Large size of the population

7
Take Home Messages-4
  • The possible solutions can be
  • Ensuring adequate and reliable health related
    data
  • Inter-sectoral co-ordination
  • Sharing of successful experiences and best
    practice models
  • Reducing the financial burden of health care
    through improved financing techniques
  • Strengthening public private partnerships
  • Strengthening public health care facilities

8
Urbanization Trends and Patterns
  • Movement of people from rural to urban areas with
    population growth equating to urban migration
  • A double edged sword
  • On one hand- Provides people with varied
    opportunities and scope for economic development
  • On the other- Exposes community to new threats
  • Unplanned urban growth is associated with
  • Environmental degradation
  • Population demands that go beyond the
    environmental service capacity, such as drinking
    water, sanitation, and waste disposal and
    treatment

9
Urbanization trends in India
Total population
Urban Population
  • Year
  • 1800
  • 1950
  • 2000
  • 2008
  • 2030
  • 2
  • 30
  • 47
  • 50
  • 60

In million
140
360
1027
1160
2050
Source UN, Urbanization prospects, the 1999
revision
10
Urbanization Trends and Patterns-2
  • 286 million people in India live in urban areas
    (around 28 of the population)
  • The proportion of urban population in India is
    increasing consistently over the years
  • From 11 in 1901 to 26 in 1991 and 28 in 2001
  • Estimated to increase to 357 million in 2011 and
    to 432 million in 2021
  • After independence
  • 3 times growth - Total population
  • 5 times growth - Urban population
  • Census of India 2001

11
Urbanization Trends and Patterns-3
  • 4.26 crore people live in slums
  • A large number of slums are not notified- around
    50
  • Urban growth has led to rapid increase in the
    number of urban poor
  • In-migration and a floating population has
    worsened the situation

NSSO Report No. 486
12
Migration-causes
  • Increased family size-limited agricultural
    property
  • -Land use Pattern
  • -Irrigation facilities
  • Better income prospects
  • Better educational facilities
  • Better Life style
  • Basic amenities health, transport,water,
    electricity.
  • Victims of natural/manmade calamities-Refugees

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

14
Migration-cobweb
Illiteracy
Slums
Migration
Unemployment
Overcrowding
Unhygienic conditions
Poverty
Stretching of overburdened systems
Communicable diseases
Crimes
Non-Communicable diseases
Injuries
Mental illness
Stress
Life style modification
15
Health Problems due to Urbanization
16
Urban Vs Rural health
  • Is urban health better than
    rural health?
  • Almost all health indicators are better for
    urban when compared to rural
  • When the urban slums are taken many are
    worser than rural !!!

17
Factors Affecting Health in Slums
  • Economic conditions
  • Social conditions
  • Living environment
  • Access and use of public health care services
  • Hidden/Unlisted slums
  • Rapid mobility

Agarwal S, Satyavada A, Kaushik S, Kumar R.
Urbanization, Urban Poverty and Health of the
Urban Poor Status, Challenges and the Way
Forward. Demography India. 2007 36(1) 121-134
18
  • MAIN DETERMINANTS OF
  • HEALTH DISEASE LIE
  • OUTSIDE THE REALM OF DIRECT
  • MEDICAL COMPTETENCY
  • SIR DOUGLAS BLACK
  • Past President of the Royal College of Physicians
    of London

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

20
Marriage Fertility Indicators of Urban Poor in
India NFHS 3
Indicators Urban Poor Urban Non poor Overall Urban Overall Rural All India Urban Poor NFHS 2
Women age 20-24 married by age 18 years () 51.5 21.2 28.1 52.5 44.5 63.9
Women age 20-24 who became mothers before age 18 () 25.9 8.3 12.3 26.3 21.7 39.0
Total fertility rate (children per woman) 2.8 1.8 2.1 3.0 2.7 3.8
Higher order births (3 births) () 28.6 11.4 16.3 28.1 25.1 29.5
Birth Interval (median number of months between current and previous birth) 29.0 33.0 32.0 30.8 31.1 31.0
21
Maternal Health Indicators of Urban Poor in
India NFHS 3
Indicators Urban Poor Urban Non Poor Overall Urban Overall Rural All India Urban Poor NFHS 2
Mothers who had at least 3 antenatal care visits () 54.3 83.1 74.7 43.7 52.0 49.6
Mothers who consumed IFA for 90 days or more () 18.5 41.8 34.8 18.8 23.1 47.0
Mothers who received tetanus toxoid vaccines (minimum of 2) () 75.8 90.7 86.4 72.6 76.3 70.0
Mothers who received complete ANC () 11.0 29.5 23.7 10.2 15.0 19.7
Births in health facilities () 44.0 78.5 67.4 28.9 38.6 43.5
Births assisted by a doctor/nurse /LHV/ANM/other health personnel () 50.7 84.2 73.4 37.4 46.6 53.3
Women age 15-49 with anaemia () 58.8 48.5 50.9 57.4 55.3 54.7
The statistics for urban poor much lesser than
urban non-poor and comparable to rural
population
22
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23
Maternal Health Indicators by
place of residence
NFHS-3
24
Child Survival Indicators of Urban Poor in India
NFHS 3
Indicators Urban Poor Urban Non Poor Overall Urban Overall Rural All India Urban Poor NFHS 2
Children completely immunized ( 39.9 65.4 57.6 38.6 43.5 40.3
Children under 5 years breastfed within one hour of birth () 27.3 31.5 30.3 22.4 24.5 17.7
Children age 0-5 months exclusively breastfed () 44.7 38.6 40.7 48.6 46.4 44.3
Children age 6-9 months receiving solid or semi-solid food and breast milk () 56.2 66.1 63.1 54.7 56.7 52.7
Children who are stunted () 54.2 33.2 39.6 50.7 48.0 52.5
Children who are underweight () 47.1 26.2 32.7 45.6 42.5 48.0
Children with anaemia () 71.4 59.0 63.0 71.5 69.5 79.0
Neonatal Mortality 34.9 25.5 28.7 42.5 39.0 45.5
Infant Mortality 54.6 35.5 41.7 62.1 57.0 69.8
Under-5 Mortality 72.7 41.8 51.9 81.9 74.3 102.0
25
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26
Completely Immunized Children in 12-23 months age
by place of residence
NFHS-3
27
Child Survival by Residence
NFHS-3
28
Family Planning Indicators of Urban Poor in
India NFHS 3
Indicators Urban Poor Urban Non Poor Overall Urban Overall Rural All India Urban poor NFHS 2
Any modern method () 48.7 58.0 55.8 45.3 48.5 43.0
Spacing method () 7.6 19.8 16.9 7.2 10.1 4.6
Permanent sterilization method rate () 41.1 38.2 38.9 38.1 38.3 38.4
Total unmet need () 14.1 8.3 10.0 14.6 13.2 16.7
Unmet need for spacing () 5.7 4.1 4.5 6.9 6.2 8.5
Unmet need for limiting () 8.4 4.2 5.2 7.2 6.6 8.2
29
Environmental Conditions, Infectious Diseases and
access to Health Care in Urban Poor
NFHS 3
Indicators Urban Poor Urban Non Poor Overall Urban Overall Rural All India Urban poor NFHS 2
Households with access to piped water supply at home () 18.5 62.2 50.7 11.8 24.5 13.2
Households accessing public tap / hand pump for drinking water () 72.4 30.7 41.6 69.3 42.0 72.4
Household using a sanitary facility for the disposal of excreta (flush / pit toilet) () 47.2 95.9 83.2 26.0 44.7 40.5
Prevalence of medically treated TB (per 100,000 persons) 461 258 307 469 418 535
Women (age 15-49) who have heard of AIDS 63.4 89.1 83.2 50.0 60.9 42.1
Prevalence of HIV among adult population (age 15-49) 0.47 0.31 0.35 0.25 0.28 na
Children under age six living in enumeration areas covered by an AWC () 53.3 49.1 50.4 91.6 81.1 na
Women who had at least one contact with a health worker in the last three months () 10.1 5.8 6.8 14.2 11.8 16.7
30
Double Burden of Diseases
  • Overcrowding and related health issues
  • Rapid growth of urban centers has led to
    substandard housing on marginal land and
    overcrowding
  • Outbreaks of diseases transmitted through
    respiratory and faeco-oral route due to increased
    population density
  • It exacerbates health risks related to
    insufficient and poor water supply and poor
    sanitation systems
  • Lack of privacy leading to depression, anxiety,
    stress etc

31
Double Burden of Diseases
  • Air pollution and its consequences
  • Due to increase in the numbers of motorized
    vehicles and industries in the cities of the
    developing world
  • Problems of noise and air pollution
  • Air pollution can affect our health in many ways
    with both short-term and long-term effects
  • Short-term air pollution can aggravate medical
    conditions like asthma and emphysema
  • Long-term health effects can include chronic
    respiratory disease, lung cancer, heart disease,
    and even damage to other vital organs

32
Double Burden of Diseases
  • Water and sanitation problems
  • Due to increasing urbanization coupled with
    existing un-sustainability factors and
    conventional urban water management
  • Nealy 1.1 billion people worldwide who do not
    have access to clean drinking water and 2.6
    billion people i.e. over 400 million people, lack
    even a simple improved latrine
  • Can lead to increased episodes of diarrhea and
    economic burden

33
Double Burden of Diseases
  • Upsurge of Non-communicable diseases
  • The rising trends of non-communicable diseases
    are a consequence of the demographic and dietary
    transition
  • Decreases in activity combined with access to
    processed food high in calories and low in
    nutrition have played a key role
  • Urbanization is an example of social change that
    has a remarkable effect on diet in the
    developing world

34
Double Burden of Diseases
  • Traditional staples are often more expensive in
    urban areas than in rural areas, whereas
    processed foods are less expensive
  • This favors the consumption of new processed
    foods
  • This places the urban population at increased
    risk of NCDs
  • In India, chronic diseases are estimated to
    account for 53 of all deaths and 44 of
    disability-adjusted life-years (DALYs) lost in
    2005

35
Challenges to Health System
36

KEY CHALLENGES TO URBAN HEALTH SERVICES
37
A scene which makes every Indian feel shameful
38
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39
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40
Operational Challenges
  • Inequitable distribution of
  • health facilities
  • To connect every household
  • to health facilities is a big
  • challenge
  • Distance of first point of contact
  • for any health need
  • Lack of a fully functional and well defined
    public outreach system

41
Operational Challenges
  • Lack of standards for
  • Provision of safe water and sanitation
    facilities
  • Housing and waste disposal systems
  • No public health bill for setting up and
    regulating these standards
  • Lack of understanding of recent demands of urban
    health care delivery and poor planning/implementa
    tion

42
Operational Challenges
  • Lack of infrastructure for setting up of primary
    health care facilities
  • Many slums are not having even a single primary
    health care facility in their vicinity
  • Multiple health care facilities/bodies but
    without coordination
  • Lack of community level organizations/slum level
    organizations and lack of adequate support to them

43
Operational Challenges
  • Lack of convergence among various
  • determinants/domains of public health
  • Failure of Urban Health Post scheme
    (Krishnan
    Committee)
  • Bringing local practitioners into
  • mainstream with provision of proper
  • training and supervising their work
  • Lack of need based referrals/weak referral system

44
Challenges in Involving NGOs Private
Practitioners
  • Accountability
  • Sustainability
  • Supervision and monitoring systems
  • False reporting/over reporting
  • Co-operation and coordination among large number
    of service providers is challenging

45
Which is better?
Vs
46
What makes private services inaccessible?
  • Paying more from patients to maintain competency
  • Vulnerable people cannot afford treatment in
    corporate hospitals - tend to seek treatment from
    quacks
  • Focused on curative services particularly on
    non-communicable diseases,
    Malignancies etc.
  • Preventive and promotive components are
    completely omitted

47
Operational Challenges
  • Need to identify the households actually needing
    PDS services
  • Failure of TPDS
  • Lack of transparency regarding costs and
    treatment protocols especially in the private
    sector
  • No risk pooling or community insurance system
  • Need for skilled manpower and technical support
    at all levels
  • Lack of well defined urban component of many
    National Diseases Control programmes

48
Operational Challenges
  • Lack of any campaigns to counsel people to bring
    about changes in health related
    behavior/attitudes
  • Absence of defined geographical / demographic
    population allocations.
  • Lack of integrated HMIS and databases
  • Limitations of NRHM in urban context - norms for
    urban primary health infrastructure are not part
    of the NRHM proposal
  • Lack of efficient mobile health teams/problems
    faced by them

49
Challenges faced by
Mobile health teams
  • Security problems
  • Worn-out vehicles
  • Tired and stressed staff
  • Poor roads
  • Seasonal obstacles
  • Uncertainty about population movements
  • Erratic funding

50
Operational Challenges
  • Prioritizing the most vulnerable among the poor
    (destitutes,beggars , street children,
    construction workers , coolies etc)
  • Need to change the behavior and attitudes of the
    health care provider for e.g. to avoid
    unnecessary referrals
  • Constraints of the health care users like time,
    lack of faith and mobility
  • Considering occupational and environmental
    hazards

51
Administrative Challenges
  • A more complex planning system due to involvement
    of local urban bodies
  • There is little coordination between State
    Government, local bodies, autonomous bodies and
    Central Government
  • Lack of grass root level structures like
    Panchayati Raj Institutions
  • Need for clarity of responsibilities among
    various administrative bodies

52

Administrative Challenges
  • Policy Advocacy
  • Policy advocacy is the key to achieve the
    objective
  • Policy advocacy alone wouldnt help in achieving
    the target
  • Stakeholders should facilitate and support the
    implementation and conversion of
  • Policy Programme
    Action Success

53
Administrative Challenges
  • District level planning is the method GOI has
    been adopting for most health programs
  • This results in patchy implementation of health
    services in cities
  • Lack of an integrated District Health Action Plan
    which will cover not only rural but also the
    urban population

54
Administrative Challenges
  • Duplication of services
  • Lack of clear and well defined norms for
    delivery of primary care
  • Health service guarantee and concurrent audit at
    the levels of funds release and utilization
  • Need for stronger laws for illegal and
    unauthorized settlements

55
The Solutions
  • Ensure adequacy and reliability of health related
    data
  • For understanding the graveness of situation and
    for planning purposes
  • Need for inter-sectoral co-ordination
  • Sharing of successful experiences and
    best practice models
  • Successful experiences from other countries can
    be adopted. These can be adopted with local
    adaptations to suit the need of the people and
    the current situation

56
The Solutions
  • Reducing the financial burden of health care
    through
  • Community health funds
  • Health insurance
  • Subsidized out patient care provision by private
    providers
  • Application of PURA (Provision of Urban amenities
    to Rural Areas) model to slums
  • To improve the infrastructure
  • To increase community participation through SHGs
  • To enhance self reliability of the communities
  • Strengthening public private partnerships
  • Strengthening public health care facilities

57
Take Home Messages
  • Urbanization due to migration
  • Is a reality
  • Has reached to considerable proportions
  • Leading to increased growth of slums
  • Will increase further to greater proportions in
    the foreseeable future
  • Slums lack infrastructure in basic amenities like
    safe drinking water, sanitation, housing etc
  • At increased risk of both communicable and non
    communicable diseases

58
Take Home Messages-2
  • Urban health is
  • Traditionally neglected in policy making
  • Need of the hour considering the facts and figure
    available regarding the population at risk
  • Failure of NRHM to take urban health into account
    and pending launch of NUHM
  • Policy influence needs to be done to sensitize
    the policy makers towards urban health issues

59
Take Home Messages-3
  • Challenges exist in terms of
  • Administrative issues
  • Policy issues
  • Operational issues
  • Involvement of non governmental service providers
  • Large size of the population

60
Take Home Messages-4
  • The possible solutions can be
  • Ensuring adequate and reliable health related
    data
  • Inter-sectoral co-ordination
  • Sharing of successful experiences and
    best practice models
  • Application of PURA models
  • Reducing the financial burden of health care
    through improved financing techniques
  • Strengthening public private partnerships
  • Strengthening public health care facilities

61
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