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Cover Story

Human Health in Urbanized India

India is rapidly urbanizing. As per estimates, the urban population in India is slated to go up to 50 per cent by 2050, and is at 33 per cent currently. While this urban population contributes immensely to India’s growth story, a disparity between the concerns for the health of the urban and rural residents still divides this story. Read on to know more…

WORDS BY: RINKU B

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India is fast emerging as a global superpower, thanks to several factors that support this phenomenal growth story that includes demographic trends, a rapidly expanding economy, and steady GDP growth at 8.4%. Of course, in a country like India, this tag comes with its own set of disadvantages.

Factors that work against us is a burgeoning population, increasing migration and dependence on cities, rising pollution levels, huge disparity between rich and poor – educated and illiterate and so on.

For a country like India, its cities are the nerve centres of its economy and people. Cities and towns are the centres or base of investments, technology, economic growth, and for the creation of jobs.

They provide the base and contribution for the growth of India’s GDP. They are the base of the educated middle-class who work hard, toil each day and pay taxes that helps build infrastructure and public facilities and so on.

India’s urban population has grown from 18 per cent in 1955 to 33 per cent in 2015, clearly indicating that urbanization is mainly concentrated in cities and urban industrial towns. Ninety million new urban residents were added between 2001 and 2011, and McKinsey Global Institute’s projection predicts that India’s urban population will soar from 377 million in 2011 to 590 million by 2030.

Reports suggest that by the year 2040, 40 per cent of India’s population would live in urban cities while by 2050, 50 per cent would reside in urban cities. This urban population will account for 70 per cent of nation’s GDP by 2030 and, with more than 68 cities with populations of more than a million each, these urbanites will contribute to nearly four-fold increase in per capita income.

This is a huge number considering the population and the restricted number of cities where this migration is concentrated.

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Migration from the rural areas in search of better jobs and facilities, education and health, standard of life etc. are the reason for this widespread, increasing rural-urban movement. Moreover, besides agriculture which is predominantly traditional and seasonal, the villages of India have nothing more to offer the youth in terms of real world opportunities.

Thus, the negative consequences of urbanization such as the high population density, slums and un-notified settlements, pollution, health problems, unemployment etc. impacts the overall health of India’s cities and towns. Health, nutrition, and population conditions are an important part of the urbanization equation.

Urban health has received relatively less focus compared with rural health in India, especially the health of the urban poor. Diseases are rapidly urbanizing. Ageing infrastructures, high levels of inequality, poor urban governance, rapidly growing economies and highly dense and mobile populations all create environments rife for many diseases that directly impact them.

According to G. Chatterjee, a researcher with UN-HABITAT, India’s urban growth follows a 2-3-4-5 pattern, that is, it has an annual population growth of 2 per cent, urban population growth of 3 per cent, mega-city growth of 4 per cent, and slum population growth of 5 per cent.

About a third of the major slums are not recognised in official records and a considerable proportion of the urban poor live in squatter settlements, on pavements, at construction sites and other fringe locations, and thus remain a floating population. The urban poor are key contributors to the national GDP growth, and ill health amongst them results in a cascading effect on the economy.

As per the last census of 2011, improvement in education levels in rural areas is two times than that in urban areas. As per to the data from various sources, the health condition of urban India is better than those of rural India, but the migration from rural to urban areas has resulted rapid growth in urban population and slums; the slum population faces greater health hazards due to over-crowding, environmental pollution. The existing health infrastructure in urban areas is insufficient to meet the basic needs of growing urban population. The municipalities, state government, and the central government have tried to build up urban health care infrastructure.

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Majority of hospitals, doctors and para-professionals are in urban areas but unlike to the rural health services there have been no efforts to provide the health care services to the areas that are geographically delineated. Thus, in many urban areas the primary health care facilities are not available; some of them are underutilized while there are overcrowding in secondary and tertiary care services. With no referral and screening system, most of the equipment’s and machinery in secondary and tertiary care centres are underutilized.

Disaggregated data from the 2015-16 National Family Health Survey revealed vast intra-urban disparities between urban poor and urban rich. For instance, the data showed that 28 per cent of urban poor women, that is, women from the poorest 40 per cent of the population, currently aged 20-24 years old, became mothers before they turned 18, compared to 16 per cent urban non-poor women, or 19 per cent rural women. During pregnancy, just 12 per cent of urban poor mothers received the full package of antenatal care, compared to 29 per cent urban non-poor mothers. And when it came to delivery, one in three urban poor women gave birth at home, compared to just 8 per cent amongst the non-poor.

Compared to their better-off peers, urban poor children fare poorly across health parameters. 54 out of every thousand children from urban poor households die before their fifth birthday, and 29 babies die within 28 days of being born, far more than among non-poor children (31 before 5 and 19 in the first month). Poor urban children are even worse off than poor rural children in some aspects – more poor rural children received complete immunisation (43 per cent vs 39 per cent) and fewer rural children under 5 were underweight (38 per cent vs 44 per cent).

In 2017-18 budget, Finance Minister Arun Jaitley said that an Action Plan has been prepared to reduce infant mortality rate (IMR) from 39 per 1,000 in 2014 to 28 by 2019, and maternal mortality rate (MMR) from 167 per 100,00 live births in 2011-13 to 100 by 2018-2020.

Children’s health in urban India:
The increasing number of urban residents and migrants into the urban areas creates environmental problems that are directly affects children’s health. Children remain the most vulnerable portion of urban population, especially urban poor children living in urban slums. A child living in household greater than 5 persons per sleeping room is 1.4 times higher than the household with less than 4 persons per sleeping room. Poor environmental conditions, sanitation and hygiene, and inadequate diet, results in high malnutrition in urban areas especially in slums. Out of a billion of child population living in urban India, about 300 million face exclusion from essential health services and other services like safe drinking water, sanitation, education etc. Their existence is not recognized, as neither their births nor their deaths are registered. They vulnerability makes them a victim for many diseases, physical trauma and disasters. Childhood to them is only a fantasy or nightmare. The urban-rural health disparity has long been studied, but the disparity that exists among the urban children has been neglected.
Over 60 per cent urban poor children do not receive complete immunization as compared to 58 per cent in rural children; 47.1 per cent urban poor children under 3 years of age are underweight as compared to 45 per cent rural children. More than half of the India’s urban poor children are underweight or stunted. In most parts of the country, undernutrition among the urban poor children is more than the rural children.

According to NFHS-3, only 39.9 per cent of urban poor children get full immunization against the 65.4 per cent of urban non-poor children. About 49.8 per cent of urban poor children under 3 years of age was reported as underweight as compared to 26.2 per cent of urban non-poor children.

The above figure shows that the urban poor population is on a par with that of the rural population. We can see from the bar of the figure for urban poor children and for rural children that the health condition of urban poor children is not good as much as to the rural children.

Annual health survey 2010-11 shows that the neo-natal mortality rate (NNMR) among the empowered action group (EAG) and Assam is very high.

Estimated Infant Mortality Rate, India

Uttar Pradesh has the highest neo-natal mortality 54 and lowest in Jharkhand (26). From Figure 4, during the period of 2009-10, most of the states showed a sharp decline in infant mortality rate but still there is a long way to go. The IMR is very high in urban areas of the country together with the national level.

In Uttarakhand, total IMR is 43 against the 33/1000 in urban areas. As from the data above mentioned we can say that the IMR for urban poor for the states of Rajasthan, Uttar Pradesh, Bihar, Chhattisgarh, and Madhya Pradesh is relatively very high or even above the national average of infant mortality rate (47).

Maternal health in urban India:
Among the urban population, the maternity services also show the disparity between urban poor and urban population. The proportion of urban poor women received full antenatal care is very low as compared to the urban non-poor women.

In 2017-18 budget, Finance Minister Arun Jaitley said that an Action Plan has been prepared to reduce infant mortality rate (IMR) from 39 per 1,000 in 2014 to 28 by 2019, and maternal mortality rate (MMR) from 167 per 100,00 live births in 2011-13 to 100 by 2018-2020.

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Although urban India has a relatively very sound and strong healthcare infrastructure with public as well as private management, but there is marked a huge disparity of distribution of service availability, and utilization of resources within the regions between rich and poor,

About 56,000 women die each year in childbirth, which accounts almost 19 per cent of the world. While on the one side India shows economic progress but on the other side, the country still faces the heavy burden of maternal deaths.

It is estimated that 44.4 per cent of urban poor women have access to institutional deliveries against the 67.5 per cent of urban non-poor women. Utilization of healthcare services is poor among urban poor women as compared to urban non-poor women. The primary health facilities have not increase in proportion to the growth of the urban poor population.

Only 54.3 per cent of urban poor mothers have at least 3 antenatal care check-ups during pregnancy, while it is 83.1 per cent for urban non-poor women and 43.7 per cent for rural mothers.

STATE OF URBAN HEALTH:
In study undertaken by Sundeep Salvi and colleagues in a report called The Lancet Global Health, India’s urban health situation is cited on the medical symptoms and diagnoses and the characteristics of patients who sought treatment from qualified primary health-care practitioners across 880 cities and towns on one day in 2011. This study provides a national perspective on the state of both population health and health systems in the context of an increasingly urban India.

The distribution of illness and diagnosed conditions reported in the study furthers understanding of the urban disease burden.
Hypertension, an important risk factor for cardiovascular disease, was the most commonly diagnosed medical condition at urban primary care practices. Alarmingly, the researchers noted that one in five patients diagnosed with hypertension was younger than 40 years.

These data accord with 2013 Global Burden of Disease findings that high blood pressure is the leading risk factor in attributable disability-adjusted life-years (DALYs) in India. That there are such high rates of hypertension in younger people has important implications for premature death and disability in the most productive years of life, with economic effects that would extend to the families supported by these people. Furthermore, there are national economic losses to consider with the premature death of people in the middle of their working lives.

Urban India has a high concentration of health-care providers, yet, as the researchers explain, not everyone has easy access to health care. The data on patients’ characteristics highlight two urban health system issues that have received inadequate attention. First, more than half of patients visiting a doctor were male, despite the expectation that women would represent most of the patient load.

There are several possible explanations for why there were fewer female patients than male patients reported. That gynaecologists were not included in the study sample meant that visits by women to this kind of practitioner were not captured by researchers. Second, issues such as lack of empowerment and financial barriers to accessing health care will affect women more than men. And third, the difficulty in accessing care from a female doctor might limit the willingness of women to seek care: one study estimated that only 17 per cent of doctors in India are women.

Issues of access to health care also affect older people. Although national surveys show that reports of ailments increase with age, only 7–9 per cent of the visits recorded by Salvi and colleagues were made by patients older than 60 years.

Given the abundance of health-care providers in urban India, the reasons behind the low proportion of older patients reported might be because of physical impairments that make a visit to a health provider difficult, or the lack of financial resources to pay for health care.

With life expectancy increasing across India, the issues of access and affordability of health care for older people will only become more important.

Access to the health services in urban areas follow different patterns:
• Marginalisation of the urban poor: urban poor people lack access to healthcare services while majority of the urban non-poor have access to them
• Substantial urban exclusion: both urban poor and non- poor may lack access to services
• Universal healthcare: most of the population, irrespective of their socio-economic level, is able to access healthcare services

However, governance systems in urban areas, vary widely in structure – from municipal corporations to nagar panchayats – and in their capacity for autonomy, resources and interdepartmental coordination.

This dilutes responsibility for quality of public health services provided, which causes the majority of urbanites, including the urban poor, to turn to private providers for their healthcare needs – with all the financial burden that entails.

SOLUTIONS:
The National Urban Health Mission (NUHM) was launched in 2013 along the lines of the 2005 National Rural Health Mission (GoI 2012) to address this huge gap in health outcomes, by setting up primary health centres in urban slums and ensuring community processes for key health interventions.

The mission aimed to provide free access to basic healthcare facilities to the urban poor. These health reforms include the significant reorganization and expansion of the urban healthcare system, public–private partnerships in the delivery of services and enhanced health system governance.

This is supported by various initiatives to strengthen the monitoring of the people’s health status, which is considered a vital investment for the changing burden of diseases.

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Indian leadership at the recently concluded Global Conference on Primary Health Care at Astana, led by India’s Health Minister J.P. Nadda, expressed continued commitment to achieving health for all through the Ayushman Bharat Health and Wellness Centres.

There is, however, much to be done: data is still sparse, listed slums do not include the entire slum and urban poor communities, the size of the urban poor population is growing rapidly, and the NUHM involves complex collaborations with governments at many levels, particularly urban local bodies. Mukesh Sharma, who leads the Challenge Initiative for Healthy Cities, points out the potential impact of better collaboration, “A multi-stakeholder approach led by Urban Local Bodies can change the urban health status in India. Urban Health should not be the sole responsibility of the Department of Health.” The Challenge Initiative strengthens sectoral collaborations to address health systems gaps for the urban poor in Uttar Pradesh, Madhya Pradesh and Odisha.

Alongside governance, the environmental and social determinants will need to rapidly transform even as health systems ramp up. As Damodar Bachani, lead of ‘Building Healthy Cities’ project, puts it, “When decision making across these areas is harmonized, people will benefit from improved access to health services, decreased environmental and lifestyle risk factors for chronic diseases, a lower burden of infectious diseases, and an increased availability of useful data for decision-making.” The Building Healthy Cities Project is a global initiative funded by USAID to build smart cities that embody this holistic perspective.

Finally, urban communities need to be engaged in the process of making urban India a healthy place to live. As Shaonli Chakraborty, urban lead at the Invest For Wellness programme at Swasti Health Catalyst, puts it, “People living in urban areas can no longer afford to be mere recipients of services; their active participation in decision making about their own health will be critical for better health for all. The focus needs to be on what works for people and how to make it work.”

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Indian leadership at the recently concluded Global Conference on Primary Health Care at Astana, led by India’s Health Minister J.P. Nadda, expressed continued commitment to achieving health for all through the Ayushman Bharat Health and Wellness Centres. Ushering in a new generation of comprehensive primary health care for the poor, Mr. Nadda said that it is essential to leverage multi-sectoral collaborations that bring insights and leverage resources from different sectors to strengthen health outcomes.

The urban poor in India are the most vulnerable section of the urban population regarding the health indicators showed in this paper, and for many indicators the differentials is very high. Almost all of the urban poor population has less access to healthcare facilities as immunization, antenatal care, delivery by health professionals etc. Infant and child undernutrition is also very high among the urban poor population or rather more than the rural population.

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