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Urban Health Issues, Challenges and Solutions. Outline of Presentation 1.Take home messages 2.Urbanization-Trends and Patterns 3.Health problems related.

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Presentation on theme: "Urban Health Issues, Challenges and Solutions. Outline of Presentation 1.Take home messages 2.Urbanization-Trends and Patterns 3.Health problems related."— Presentation transcript:

1 Urban Health Issues, Challenges and Solutions

2 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

3 Significance of Urban Health 3 The World Health Day theme for 2010 “Urbanization and Health”

4 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

5 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

6 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

7 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

8 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

9 Urbanization trends in India Year 1800 1950 2000 2008 2030 2% 30% 47% ~50% ~ 60% Source: UN, Urbanization prospects, the 1999 revision Total population 360 1027 140 1160 In million Urban Population 2050 9

10 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

11 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

12 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

13 Migration-consequences Overcrowding Mushrooming of slums Unemployment Poverty Physical & mental stress Family structure-Nuclear families -Single males 13

14 Migration-cobweb Migration Stretching of overburdened systems Stretching of overburdened systems Overcrowding Unemployment Crimes Poverty Illiteracy Communicable diseases Communicable diseases Unhygienic conditions Unhygienic conditions Slums Injuries Mental illness Mental illness Stress Life style modification Life style modification Non-Communicable diseases Non-Communicable diseases 14

15 Health Problems due to Urbanization 15

16 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

17 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

18 “MAIN DETERMINANTS OF HEALTH & DISEASE LIE OUTSIDE THE REALM OF DIRECT MEDICAL COMPTETENCY” - S IR D OUGLAS B LACK Past President of the Royal College of Physicians of London

19 Urban poor- key elements of health Marriage & Fertility Maternal health Child survival Family planning Environmental Conditions, Infectious Diseases and Access to Health Care 19

20 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 (%) 51.521.228.152.544.563.9 Women age 20-24 who became mothers before age 18 (%) 25.98.312.326.321.739.0 Total fertility rate (children per woman) 2.81.82.13.02.73.8 Higher order births (3+ births) (%)28.611.416.328.125.129.5 Birth Interval (median number of months between current and previous birth) 29.033.032.030.831.131.0 20

21 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 (%) 54.383.174.743.752.049.6 Mothers who consumed IFA for 90 days or more (%) 18.541.834.818.823.147.0 Mothers who received tetanus toxoid vaccines (minimum of 2) (%) 75.890.786.472.676.370.0 Mothers who received complete ANC (%) 11.029.523.710.215.019.7 Births in health facilities (%)44.078.567.428.938.643.5 Births assisted by a doctor/nurse /LHV/ANM/other health personnel (%) 50.784.273.437.446.653.3 Women age 15-49 with anaemia (%)58.848.550.957.455.354.7 The statistics for urban poor much lesser than urban non-poor and comparable to rural population 21

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23 Maternal Health Indicators by place of residence NFHS-3 23

24 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 (%39.965.457.638.643.540.3 Children under 5 year’s breastfed within one hour of birth (%) 27.331.530.322.424.517.7 Children age 0-5 months exclusively breastfed (%) 44.738.640.748.646.444.3 Children age 6-9 months receiving solid or semi-solid food and breast milk (%) 56.266.163.154.756.752.7 Children who are stunted (%)54.233.239.650.748.052.5 Children who are underweight (%)47.126.232.745.642.548.0 Children with anaemia (%)71.459.063.071.569.579.0 Neonatal Mortality34.925.528.742.539.045.5 Infant Mortality54.635.541.762.157.069.8 Under-5 Mortality72.741.851.981.974.3102.0 24

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26 Completely Immunized Children in 12- 23 months age by place of residence NFHS-3 26

27 Child Survival by Residence NFHS-3 27

28 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 (%)48.758.055.845.348.543.0 Spacing method (%)7.619.816.97.210.14.6 Permanent sterilization method rate (%) 41.138.238.938.138.338.4 Total unmet need (%)14.18.310.014.613.216.7 Unmet need for spacing (%)5.74.14.56.96.28.5 Unmet need for limiting (%)8.44.25.27.26.68.2 28

29 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 (%) 18.562.250.711.824.513.2 Households accessing public tap / hand pump for drinking water (%) 72.430.741.669.342.072.4 Household using a sanitary facility for the disposal of excreta (flush / pit toilet) (%) 47.295.983.226.044.740.5 Prevalence of medically treated TB (per 100,000 persons) 461258307469418535 Women (age 15-49) who have heard of AIDS63.489.183.250.060.942.1 Prevalence of HIV among adult population (age 15-49) 0.470.310.350.250.28na Children under age six living in enumeration areas covered by an AWC (%) 53.349.150.491.681.1na Women who had at least one contact with a health worker in the last three months (%) 10.15.86.814.211.816.7 29

30 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

31 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

32 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

33 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

34 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

35 Challenges to Health System 35

36 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 Diseases of nutrition Various administrative units with little coordination. Districts and zones not clear Lack of grass root level structures like PRI’s Inequitable distribution of health facilities Multiple agencies/bodies providing health care Lack of Standardization and standard treatment protocols Lack of integrated HMIS and databases Large segment of urban poor In migration and floating populations Diverse social and cultural backgrounds Greater vulnerability of the migrating populations Socio Demographic Operational Dual burden of diseases Administrative KEY CHALLENGES TO URBAN HEALTH SERVICES 36

37 A scene which makes every Indian feel shameful… 37

38 38

39 39

40 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

41 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

42 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

43 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

44 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

45 Vs Which is better? 45

46 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

47 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

48 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

49 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

50 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

51 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

52 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

53 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

54 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

55 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

56 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 The Solutions 56

57 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

58 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

59 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

60 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

61 Thank You 61


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