India is urbanising at an unprecedented pace. 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. This burgeoning 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. In spite of these awesome figures, the plight of the urban poor doesn’t feature in any narrative.
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. Despite their importance, they have remained largely “invisible” to policymakers and programme managers. The rhetoric of urban growth and development masks the real condition of the urban poor, which is even worse than that of the rural population. 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% of urban poor women, that is, women from the poorest 40% of the population, currently aged 20-24 years old, became mothers before they turned 18, compared to 16% urban non-poor women, or 19% rural women. During pregnancy, just 12% of urban poor mothers received the full package of antenatal care, compared to 29% urban non-poor mothers. And when it came to delivery, one in three urban poor women gave birth at home, compared to just 8% 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% vs 39%) and fewer rural children under 5 were underweight (38% vs 44%).
Why does this still remain the case?
There is a distinct set of health concerns for those who live in cities, which is linked to the nature of the urban environment. According to urbanist Sumetee Gujjar, “There are health issues emerging from urban spaces and how society is functioning — issues of traffic congestion, pollution of air, water and solid waste, declining green cover, and depleting water resources immediately come to mind. While these affect everyone, the people who have limited access to resources, i.e., the urban poor, are the worst hit.”
Health infrastructure is concentrated in urban areas, with numerous public and private hospitals and diagnostic facilities based in cities and towns. This is also true of human resources in health, such as physicians, specialists and other clinicians, who prefer to live and work in urban areas. Given the higher availability of health resources, one may ask why is there such poor health among part of the urban population? The answer is that urban poor communities face barriers to access — inadequate infrastructure, overcrowded facilities, lack of information about available services, ineffective outreach, and a weak referral system, among others.
Access to the health services in urban areas may 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.
How do we address this?
The National Urban Health Mission (NUHM) was launched in 2013 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. There is, however, much to be done: data is still sparse, listed slums don’t 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.”
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, Nadda said that it is essential to leverage multi-sectoral collaborations that bring insights and leverage resources from different sectors to strengthen health outcomes.
Shama Karkal is a public health expert and currently chairs the Steering Committee of the Asia Pacific Alliance for Sexual and Reproductive Health, and is a Trustee of the Catalyst Foundation. She also serves as Chief Executive Officer of Swasti Health Catalyst.
Dipankar Bhattacharya leads the knowledge generation vertical in the Learning4impact knowledge collaborative for Reproductive, Maternal, Newborn, Child and Adolescent Health and TB, which is supported by USAID India Health Office.