Transcript Urban Health Issues, Challenges and Solutions Outline of Presentation 1. Take home messages 2.

Urban Health
Issues, Challenges and Solutions
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
2
Significance of Urban Health
The World Health Day theme for 2010
“Urbanization and Health”
3
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
4
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
5
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
6
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
7
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
8
Urbanization trends in India
Year
Urban
Total
Population population
In million
1800
1950
2000
2008
2030
2%
30%
47%
~50%
~ 60%
140
360
1027
1160
2050
Source: UN, Urbanization prospects, the 1999 revision
9
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
10
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
11
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
12
Migration-consequences
•
•
•
•
•
•
Overcrowding
Mushrooming of slums
Unemployment
Poverty
Physical & mental stress
Family structure-Nuclear families
-Single males
13
Migration-cobweb
Slums
Migration
Illiteracy
Unhygienic
conditions
Overcrowding
Unemployment
Communicable
diseases
Poverty
Stretching of
overburdened
systems
Crimes
Non-Communicable
diseases
Injuries
Stress
Life style
modification
Mental
illness
14
Health Problems due to Urbanization
15
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 !!!
16
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
17
“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
Urban poor- key elements of health
• Marriage & Fertility
• Maternal health
• Child survival
• Family planning
• Environmental Conditions, Infectious Diseases and
Access to Health Care
19
Marriage & Fertility Indicators of Urban
Poor in India: NFHS 3
Indicators
Urban
Poor
Urban Overall Overall
Non Urban
Rural
poor
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
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
Total fertility rate (children per
woman)
20
Maternal Health Indicators of Urban
Poor in India: NFHS 3
Indicators
Mothers who had at least 3 antenatal
care visits (%)
Mothers who consumed IFA for 90
days or more (%)
Mothers who received tetanus toxoid
vaccines (minimum of 2) (%)
Mothers who received complete
ANC (%)
Urban
Poor
Urban Overall Overall
Non Urban
Rural
Poor
All
India
Urban
Poor
NFHS 2
54.3
83.1
74.7
43.7
52.0
49.6
18.5
41.8
34.8
18.8
23.1
47.0
76.3
70.0
15.0
19.7
The statistics for urban poor
75.8 much
90.7 lesser
86.4
72.6
than urban
non-poor and comparable to
11.0
29.5
23.7
10.2
rural population
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
21
22
Maternal Health Indicators by
place of residence
NFHS-3
23
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
39.9
65.4
57.6
38.6
43.5
40.3
27.3
31.5
30.3
22.4
24.5
17.7
44.7
38.6
40.7
48.6
46.4
44.3
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
24
102.0
Children completely immunized (%
Children under 5 year’s breastfed within
one hour of birth (%)
Children age 0-5 months exclusively
breastfed (%)
Children age 6-9 months receiving solid or
semi-solid food and breast milk (%)
25
Completely Immunized Children in 1223 months age by place of residence
NFHS-3
26
Child Survival by Residence
NFHS-3
27
Family Planning Indicators of Urban
Poor in India: NFHS 3
Indicators
Any modern method (%)
Urban
Poor
Urban Overall Overall
Non Urban
Rural
Poor
All
India
Urban
poor
NFHS 2
48.7
58.0
55.8
45.3
48.5
43.0
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
Spacing method (%)
28
Environmental Conditions, Infectious
Diseases and access to Health Care in
Urban Poor : NFHS 3
Indicators
Households with access to piped water supply
at home (%)
Households accessing public tap / hand pump
for drinking water (%)
Household using a sanitary facility for the
disposal of excreta (flush / pit toilet) (%)
Prevalence of medically treated TB (per
100,000 persons)
Women (age 15-49) who have heard of AIDS
Prevalence of HIV among adult population
(age 15-49)
Children under age six living in enumeration
areas covered by an AWC (%)
Women who had at least one contact with a
health worker in the last three months (%)
Urban
Poor
Urban
Non
Poor
Overall
Urban
Overall
Rural
All
India
Urban
poor
NFHS 2
18.5
62.2
50.7
11.8
24.5
13.2
72.4
30.7
41.6
69.3
42.0
72.4
47.2
95.9
83.2
26.0
44.7
40.5
461
258
307
469
418
535
63.4
89.1
83.2
50.0
60.9
42.1
0.47
0.31
0.35
0.25
0.28
na
53.3
49.1
50.4
91.6
81.1
na
10.1
5.8
6.8
14.2
11.8
16.7
29
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
30
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
31
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
32
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
33
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 lifeyears (DALYs) lost in 2005
34
Challenges to Health System
35
• Large segment of urban
poor
• In migration and floating
populations
• Diverse social and cultural
backgrounds
• Greater vulnerability of the
migrating populations
• Inequitable distribution of
health facilities
• Multiple agencies/bodies
providing health care
• Lack of Standardization and
standard treatment protocols
• Lack of integrated HMIS and
databases
Socio
Demographic
Operational
KEY CHALLENGES TO URBAN
HEALTH SERVICES
Administrative
• Various administrative units
with little coordination.
• Districts and zones not clear
• Lack of grass root level
structures like PRI’s
Dual burden
of diseases
• Increased burden of diseases
associated with overcrowding,
poor sanitation and hygiene
• Diseases associated with air
and water pollution
• Lifestyle and stress related
diseases, accidents/violence,
substance abuse
36
• Diseases of nutrition
A scene which makes every Indian feel shameful…
37
38
39
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
40
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/implementation
41
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
42
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
43
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
44
Which is better?
Vs
45
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
46
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
47
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
48
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
49
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 50
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
51
Administrative Challenges
Policy Advocacy
•
Policy advocacy is the key to achieve the objective
•
Policy advocacy alone wouldn’t help in achieving the target
•
Stakeholders should facilitate and support the
implementation and conversion of
Policy
Programme
Action
Success
52
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
53
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
54
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
55
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
56
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
57
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
58
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
59
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
60
Thank You
61