urban health issues, challenges and solutions
TRANSCRIPT
Urban Health Issues, Challenges and Solutions
Outline of Presentation
1. Take home messages2. Urbanization-Trends and Patterns3. Health problems related to growing
urbanization4. Challenges to health system5. The solutions6. Take home messages
2
Significance of Urban Health
3
The World Health Day theme for 2010“Urbanization and Health”
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
• 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
5
• 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
6
• 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
Take Home Messages-4
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
1800 1950 2000 2008 2030
2% 30% 47%~50%~ 60%
Source: UN, Urbanization prospects, the 1999 revision
Total population
3601027
140
1160
In million
Urban Population
2050
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
Migration
Stretching of overburdened
systems
Overcrowding Unemployment
Crimes
Poverty
Illiteracy
Communicable diseases
Unhygienic conditions
Slums
Injuries
Mentalillness
StressLife style
modification
Non-Communicable diseases
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 BLACKPast 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 UrbanPoor
UrbanNon poor
Overall Urban
OverallRural
AllIndia
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 31.020
Maternal Health Indicators of Urban Poor in India: NFHS 3
Indicators UrbanPoor
UrbanNon
Poor
Overall Urban
OverallRural
AllIndia
Urban Poor
NFHS 2Mothers 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
21
22
Maternal Health Indicators by place of residence
NFHS-3 23
Child Survival Indicators of Urban Poor in India: NFHS 3
Indicators UrbanPoor
UrbanNon
Poor
Overall Urban
OverallRural
AllIndia
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 74.3 102.024
25
Completely Immunized Children in 12-23 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 UrbanPoor
UrbanNon
Poor
Overall Urban
OverallRural
AllIndia
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
28
Environmental Conditions, Infectious Diseases and access to Health Care in
Urban Poor : NFHS 3Indicators Urban
PoorUrban
NonPoor
Overall Urban
OverallRural
AllIndia
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 16.729
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 life-years (DALYs) lost in 2005
34
Challenges to Health System
35
KEY CHALLENGES TO URBAN HEALTH SERVICES
36
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 system43
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
Vs
Which is better?
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 them48
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
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
Administrative Challenges
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 modelsSuccessful 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
• Reducing the financial burden of health care throughCommunity health fundsHealth insuranceSubsidized 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
The Solutions
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
• 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
58
• 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
59
• 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
60
Thank You
61