PHM-Exch> Health care for urban poor falls through the gap in India

[Claudio Schuftan]

From: Kamayani <kamayni at gmail.com>

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2960215-8/fulltext

Health care for urban poor falls through the gap
Original Text
Priya Shetty<http://www.thelancet.com/search/results?fieldName=Authors&searchTerm=Priya+Shetty>
While governments and donors focus on health care for those living in rural
poverty in developing countries, the residents of the world's slums are
being neglected, writes Priya Shetty.
The slums of Mumbai and the favelas of Rio de Janeiro are images of urban
poverty so extreme that they are indelibly stamped on the identity of those
cities. But urban poverty now goes far beyond these notorious icons.
The world is becoming more urbanised overall . 2008 was a demographic
turning point—for the first time, according to the UN Population Fund
(UNFPA), more people lived in urban areas than in rural ones. Yet these new
urbanites, especially in developing countries, are overwhelming cities that
were never designed to have so many inhabitants, and therefore simply do not
have the infrastructure to cope.


These people struggle on a daily basis with poor housing, a lack of basic
services such as electricity and water, and extreme overcrowding that often
leads to infectious disease epidemics. They do not have the capacity to
afford health care that wealthy city dwellers access but neither do they
benefit from health programmes run by non-governmental organisations (NGOs)
or governments in the way that rural areas do. In short, they fall through
the cracks, living in the hinterlands of health care.
Developing nations and foreign donors have ignored the problem to an
extraordinary degree. Governments such as China and Vietnam have responded
to growing urbanisation by instituting draconian measures to stop migration
from villages to cities. Donors, meanwhile, have continued to focus on the
rural poor, in part because these populations are easier to target through
vertical health programmes.
But the problem of extreme urban poverty is becoming harder to wish away.
The UN says that most of the world's future population growth will be in
cities in low-income and middle-income countries. Asia and Africa are
projected to double their urban populations from 1·7 billion in 2000 to 3·4
billion in 2030, according to the 2007 UNFPA report: *State of the world's
population: unleashing the potential of urban growth*.
The urban poor rarely fare better than their rural counterparts when it
comes to health. Infant mortality and childhood vaccination rates are about
the same in both populations. If anything, the health of the urban poor can
be even worse than that of rural populations. According to the Urban Health
Resource Centre in India, slum children are even more likely than rural
children to be malnourished. Overcrowding makes outbreaks of respiratory
diseases such as tuberculosis much more likely. For instance, in
impoverished parts of the city of Karachi in Pakistan, tuberculosis
prevalence is twice the national average. Running water and sewage systems
are non-existent in most slums. WHO says that in urban areas, almost 137
million people have no access to safe drinking water, and more than 600
million do not have adequate sanitation.
Even though the health needs of the urban poor are high, they have virtually
no access to health care. This is partly because of the “ineffective
outreach and weak referral system of the urban public health system”, says
Indrajit Hazarika, senior lecturer at the Indian Institute of Public Health,
Delhi. “Social exclusion and lack of information and assistance restricts
the use of private facilities by poor people. More importantly, lack of
economic resources inhibits the use of private facilities. These make the
urban poor more vulnerable and worse off than their rural counterparts.”
One main reason for the lack of access to health care is that slum
populations are not considered to be a part of urban society. Since slums
are usually illegal structures, local governments tend not to acknowledge
their existence except when they are demolishing them, and no money is
invested in counting or mapping. This situation means that the inhabitants
of slums are unable to get social benefits such as subsidised health care.
Women's health is especially neglected—1 billion Indian babies are born in
slums every year with little or no medical assistance.
Mapping the urban poor is also challenging because slums are still largely
undefined. After analysing USAID's Demographic Health Survey, Anthony Kolb,
urban health adviser at USAID, found that the definition of a slum is fairly
nebulous. Hazarika agrees. In hugely overcrowded cities such as Mumbai, for
instance, where housing is some of the most costly in the world, living in
decrepit, “slumlike” housing does not always connote extreme poverty or
disadvantage, he says.
The use of aggregate data on health indicators also complicates the issue
because the disparity between the health needs and access to care between
poor and rich people can be extreme. “To get beyond that simplistic analysis
one must use a combination of sample survey information that considers a
wealth measure, and use creative mapping techniques to describe the often
interesting geographic aspects of urban poverty, eg, slum mapping”, Kolb
tells *The Lancet*.

Some developing countries are now starting to realise the urgency of this
problem. In Bangladesh, for instance, government agencies are using mapping
technologies to identify the distribution of slums across cities.
Progress is extremely slow and halting, however. For instance, the Indian
Government set up the National Rural Health Mission in 2005 to prevent and
treat disease in rural areas, and, some experts say, to make rural life
easier so that people would not migrate into cities. The country was due to
launch a National Urban Health Mission, but last year this plan was shelved
indeterminately. In theory, the two missions will now be combined, and a
joint National Health Mission launched, but this will not happen until after
2012.
When developing governments do finally engage with this issue, they will
face two major challenges: the best way to improve housing, and the most
effective way to increase access to health care. Upgrading existing slums
can be difficult. Often, they are tightly and haphazardly clustered
together, so putting in electricity lines or water pipes is almost
impossible. Yet relocating residents is not straightforward either because
some slum communities have existed for years which gives their inhabitants a
sense of “identity and belonging and community ties”, says Peter Williams,
founder of Archive, an NGO that works on the link between housing and
health. Archive tends to favour upgrading, but Williams says that often,
those in political and economic power push hard for relocation when
communities occupy land that has a high commercial value.
The challenge of providing health care is enormous, and the best way to go
about it is contentious. Given that slum communities are at constant risk of
eviction and relocation, providing a continuous health service can be
problematic. When slum populations are growing so fast, it is not
economically feasible to provide handouts, nor could any government ever
build enough hospitals to service these populations, says Williams. In any
case, he points out, there is an inherent futility to giving someone a
course of tuberculosis drugs then sending them right back to the terrible
housing conditions that puts them at constant risk of reinfection. Instead,
Williams advocates training up local community health workers who can travel
in the slums to provide basic health care and education.
Meanwhile, Hazarika says that “mere provision for home-based or
facility-based care is unlikely to solve the problem. An important
intermediate step would be to bring poor people under a social security net,
to provide financial assistance and facilitate their access to health
services.” USAID consultant Anthony Kolb agrees. Urban life is typically
much more cash dependent than rural life. “As a result”, he says,
“addressing the affordability of health care access in urban areas is
typically a much higher priority or more appropriate approach than focusing
on physical accessibility”.
Health policy makers clearly have major challenges ahead, and will need to
work extremely closely with departments of housing and education, for
example, if they are to make any headway. But there needs to be a major
shift in policy makers' attitudes to urbanisation, says George Martine,
author of the 2007 UNFPA report, and now an independent consultant on
urbanisation. A recent UN survey showed that policy makers are still
futilely trying to obstruct urbanisation, says Martine. Since urbanisation
is inevitable, he says, urban planners and policy makers must be prepared to
radically rethink the existing infrastructure.
One obvious reason is that advanced planning will be cheaper and easier than
dealing with the situation in a few decades time. Martine warns that the
failure to plan properly for urban expansion can be catastrophic. Extreme
poverty, scarce resources, and social exclusion are often the factors that
have fuelled the violence, gang warfare, and drug trafficking that have
characterised slums and ghettos in Latin America, says Martine, who is based
in Brazil. Although the high rates of urbanisation in Latin America, and
Brazil in particular, has led to rapid economic growth, it has left a
troubling legacy of social dystopia in many cities where the urban poor are
subject to inequity in all aspects of life. Martine warns that “unless
African and Asian countries, who are at the beginning of their urban
transition, take a more proactive stance [to urban development], this could
very easily become part of their future problems”.
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