Urbanisation and its effect on people's health

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 All statutory places with a municipality, corporation, cantonment board or notified town area committee, etc. A place satisfying the following three criteria simultaneously: a minimum population of 5,000; at least 75 per cent of male working population engaged in non-agricultural pursuits; and a density of population of at least 400 per sq. km. (1,000 per sq. mile) .

4. Definitions - 2 What is an urban slum? 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’ 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 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 U rban 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 74.3 102.0 13

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. 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: Promote urban planning for healthy behaviours and safety Improve urban living conditions Ensure participatory urban governance Build inclusive cities that are accessible and age-friendly 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 1 st 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 s chemes 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 43

44. Thank you