The Health of the Poor in Urban India
directions for strategy
April 26, 2004 Human Development Unit South Asia
List of Abbreviations and Acronyms AAA AIDS ANM ASCI AWW BPL CBO CEHAT CHV CINI DALY DFID Analytical and Advisory Activities Acquired immune deficiency syndrome Auxiliary nurse midwife Administrative Staff College of India Anganwadi worker Below poverty line Community-based organization Center for Enquiry into Health and Allied Themes Community health volunteer Child in Need Institute Disability-adjusted life year Department for International Development (United Kingdom) Directly observed treatment short-course Gross domestic product Geographical information system Health and Family Welfare Health, Nutrition, and Population (The World Bank) Housing and Urban Development Corporation Limited Integrated Child Development Services Implementation Completion Report Information, education and communication Infant Mortality Rate India Population Project Integrated Sanitation Program Intra-uterine device Local Initiatives Program LV MAS MCH MMH NFHS NGO NIUA NSS PHC PQR RCH RHP RTI SASEI SASES SASHD SEWA STD SRS TB TNUDP UHC ULB UNICEF USAID WB WHO Link Volunteer Mahila Aarogya Sangam Maternal and child health Marwari Maternity Hospital National Family Health Survey Non-governmental organization National Institute of Urban Affairs National Sample Survey Primary Health Center Probe Qualitative Research Reproductive and child health Rural health practitioner Reproductive tract infection South Asia Energy and Infrastructure Unit South Asia Environment and Social Unit South Asia Human Development Sector Self Employed Women’s Association Sexually transmitted disease Sample Registration Survey Tuberculosis Tamil Nadu Urban Development Project Urban health center Urban local body United Nations Children’s Fund U.S. Agency for International Development World Bank World Health Organization
DOTS GDP GIS H&FW HNP HUDCO ICDS ICR IEC IMR IPP ISP IUD LIP
Disclaimer: The findings, interpretations, and conclusions expressed here are those of the authors, and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank cannot guarantee the accuracy of the data included in this work. Great care has been taken to ensure accuracy of data and correctness of information. Errors that may have inadvertently been made are regretted.
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Contents Abbreviations and Acronyms Contents List of Tables, Boxes and Figures Preface Executive Summary Section 1 Urban poverty The context and the people The urbanization of independent India Poverty in the urban context Section 2 The health of the urban poor The current situation The link between poverty and health Comparative trends in health status: the Indian scenario The urban poor: major health challenges Section 3 The existing systemic framework Institutional and financial arrangements The public health system in India Institutional arrangements Health communication Financial arrangements Section 4 Coping with illness Care seeking behavior and health service utilization Perceptions of health and illness Care seeking behavior Health seeking by vulnerable sub-groups Utilization of health services Financing health care Section 5 In review Experiences and innovations in health care provision An overview of innovations Targeting the poor Ensuring that services reach the poor Co-opting new partners for better service and delivery Section 6 Directions for strategy Health care for the urban poor Identifying and targeting The required package of services Service delivery Urban health financing Bibliography ii iii iv v vii 1
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Appendices 53 Appendix 1: Figure A1 Comparison of total and urban population trends, India, 1880-2020 Table A1 Population, urban population, rural population and degree of urbanization, India, 1901-2001
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Table A2 Degree of urbanization: world, regions, continents and selected countries Table A3 Classification of towns and cities Figure A2 Rural and urban death rate trends, SRS, 1971-2000 Figure A3 Functional linkages and fund flow in the health sector Figure A4 Action taken for treatment of TB at different stages, Delhi Table A5 The private provision of health care services, select countries Appendix 2: Health care for the urban poor: background/case studies 58 Appendix 3: Constitutional provisions 61
List of tables, boxes and figures Tables Table 1.1 Age-wise distribution of the urban population by asset quintile, NSS 52, 1995-96 Table 2.1 Percentage distribution by sex of numbers of children below the age of 14 reporting minor illness among the urban and rural poor, NSS 52, 1995-96 Table 2.2 Incidence of infant and under-three mortality by asset quintile, NFHS-1 and 2 Table 2.3 Share of eight most commonly reported ailments during a two-week reference period by asset quintile, NSS 52, 1995-96 Table 2.4 Proportion of women suffering from anemia by asset quintile, NFHS-2, 1998-99 Table 2.5 Adoption of family planning methods by asset quintile, NFHS-1 and 2 Table 2.6 Morbidity – percentage ailing in a fifteen-day span by asset quintile, age and sex, NSS 52, 1995-96 Table 2.7 Immunization status and weight for age by asset quintile, NFHS-1 and 2 Table 3.1 State health expenditure for 2000-01, select states, Census of India 2001 Table 3.2 Overall position of state finances for 2000-01, select states, Census of India 2001 Table 4.1 Comparison of rural-urban percentage share of persons reporting illness who seek treatment, by sex and asset quintile, NSS 52, 1995-96 Table 4.2 Percentage share of outpatient treatment by source in the last 15 days by asset quintile, NSS 52, 1995-96 Table 4.3 Percentage distribution of hospitalized treatment by source in the last 365 days, NSS 42 and 52 Table 4.4 Expense per illness episode related to ambulatory treatment by major sources and asset quintile in constant Rs., NSS 42 and 52 Table 4.5 Percentage distribution of financing of health care by source among the rural and urban poor, NSS 52, 1995-96 Boxes Box 1.1 Classifying towns Box 1.2 The growth of city slums Box 3.1 What should a health system do? Box 3.2 Essential public health functions of urban local bodies in Tamil Nadu Box 4.1 Costs: the bottom line Box 4.2 Support to overcome barriers Box 5.1 Contractual agreements to reach underserved slum communities Figures Figure 1.1 Trends in rural and urban poverty levels, 1973-74 to 1999-2000 Figure 1.2 Distribution of Below Poverty Line (BPL) and urban slum population in select states, Census of India 2001 Figure 1.3 Share of informal sector employment by sex in total workforce, select cities, 1993-98 Figure 2.1 Health and poverty linkages Figure 2.2 Trends in rural and urban infant mortality rates, 1971-2000, SRS Figure 4.1 The process of care seeking
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Preface From March 2002, the South Asia Human Development Unit (SASHD) of the World Bank undertook an analysis of the status of health of the urban poor in India, and of the nature of health care delivery mechanisms available to them. The task was to be accomplished in a year through a variety of activities under the rubric of “Health of the Poor in Urban India.” A cross-sectoral team was formed at the Bank with representation from the health, urban and social development sectors, with access to several other units of the Bank – notably poverty reduction and economic management, and water and sanitation. The team built upon work that SASHD and others had earlier done on the health of the poor. In particular, the work took, as a point of departure, the World Development Report 1993 (WB), A Fine Balance: Some Options for Private and Public Health Care in Urban India 1999 (WB), World Health Report 2000 (WHO), World Development Report 2000 (WB), Socio-economic Differences in Health, Nutrition and Population 2000 (WB), Better Health Systems for India’s Poor 2002 (WB) and Implementation Completion Report of the India Welfare (Urban Slums) Project 2003 (WB). A consultation of important stakeholders was held in India in July 2002 to discuss a range of issues critical to the health of the urban poor. These issues included several broad concerns such as current health status, identification and targeting, service package and delivery, and financial sustainability. The discussion was subsequently summarized in a report. Guided by the discussions and conclusions of this consultation, five studies were commissioned to examine issues relevant to the health of the urban poor in India. This policy note is based on the data generated by these five case studies, on advice received by the team, and also on more widely available data. In addition, eight cases studies of recent health interventions in urban settings by various donors/stakeholders were carried out. The studies involved field visits and discussions with the urban poor groups reached by these interventions as well as stakeholder focus groups. The studies have been shared with the people whose work they describe to ensure that no inaccuracies had crept into the rendition. A consultation was again held in March 2003, this time to discuss the opportunities and challenges of communication for urban health. The participants included stakeholder groups such as the media, the government at central, state and corporation levels, NGOs, the private sector, and donors. The report of this consultation has also been published. There was clear buy-in from the government on the work. In his foreword to the Report of the July consultation, J.V.R. Prasada Rao, Secretary, Government of India, says “ ….In fact the Consultation and studies are very timely, as they come at a time when the Government of India is planning a second Reproductive and Child Health project (with its strong urban accent) and has committed to developing an urban primary health care system in the Tenth Plan period. … The studies planned by the team working on this AAA activity, will provide useful background to the Government of India’s plans of urban health.” Chairing the panel discussion at the same meeting, S.S. Chattopadhyay, Secretary, Urban Development and Poverty Alleviation, Government of India, remarked “We generally look at slum improvement as an
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infrastructure issue. I think it’s time we included social services as part of this package.” Thus this policy note aims at a better understanding of the health situation of the urban poor, and possible directions for working towards a more responsive health care system. The sections that follow analyze primary and secondary data in detail.
The core team: Suneeta Singh, Senior Public Health Specialist and Task Leader; Nupur Barua, consultant medical anthropologist; K. Mukundan, Senior Urban Specialist; Varalakshmi Vemuru, Senior Social Development Specialist; Anil Deolalikar, Lead Human Development Economist; V. Selvaraju, Health Economist; Rashmi Sharma, Operations Officer; and Agnelo Gomes, Team Assistant. The team acknowledges the guidance and support of Charles C. Griffin, Sector Director, SASHD; Anabela Abreu, Sector Manager, SASHD; Vincent Guoarne, Sector Director, SASEI; Sonia Hammam, Sector Manager, SASEI; Richard Ackerman, Sector Director, SASES; Hugo DiazEtchevehere, Lead Operations Officer, SASHD; Richard Skolnik, former Sector Director; S. Jayaraman, Supriya Musherjee, Dave Gwatkin, Paul Garner, Professor Yesudian and Naira Kalra, consultants. Government counterparts have also shown great interest. The team acknowledges J.V.R. Prasada Rao, Meenakshi Datta-Ghosh, Prema Ramchandran, P.S.S. Thomas, P. Krishnamurthy, Nandita Chatterjee, S. Agarwal, and Renu Khosla. The team also acknowledges the contributions of Gopi Gopalakrishnan from Janani, Indrajit Pal from the European Commission, Arvind Lal from Lal’s Pathlabs, Abu Sayeed from Technical Assistance Inc., Dhaka, Mirai Chatterjee and Rajshree Swaminarayan from SEWA, Massee Bateman and Siddharth Agarwal from USAID-EHP, Neelam Sawhney and Pattabhi Ramaiah from IPP VIII, Kishore K. Singh from Care-PLUS, and M. Sakrapani from ISP.
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Executive Summary ES1 Rapid urbanization Rapid urbanization in India, and the significant growth of the urban population in absolute numbers, has made new and greater demands on urban infrastructure and service delivery. In addition to natural increase, urbanization has been caused by rural-urban migration as well as emerging urban-urban migration. ES2 The urban poor The urban poor comprise a heterogeneous group. Although most of the urban poor live in slums, a significant number are also homeless, and often on the move from one temporary shelter to another. These high-risk groups, the hardest to locate and identify, are also the least visible in terms of existing statistics on urban poverty. ES3 Urban poverty Urban poverty is characterized by food insecurity, extremely poor living conditions and a lack of job security. Thus the urban poor are vulnerable in multiple ways. Their dependence on the informal sector makes their income highly insecure. Events such as serious illness typically lead to financial shock for the household. The environmental conditions in which they live, and the lack of access to water, sanitation and safe drinking water, increases their physical vulnerability. The significant number of marginal women workers and children below the age of 14 among the urban poor increases the number of those who are doubly vulnerable. Since a disproportionate number of the urban poor belong to the already socially marginalized – whether Scheduled Caste, Scheduled Tribe or Other Backward Caste – their poverty, and its social implications, hit them harder. The degree of ruralurban migration also implies that a sizeable number of the poor in urban areas are unfamiliar with the urban context and social mores. ES4 Their health situation Disaggregated figures reveal that the health situation of the urban poor is not very different from that of the rural poor and in some respects such as immunization rates is even worse. In fact, health outcomes such as death rate and infant mortality rate have shown a slower decline than for rural populations. The poorest urban residents demonstrate a high level of vulnerability similar to that of their rural counterparts, and this is particularly evident when their health indicators are compared with those of the better off among the urban population. The distribution of ailments across economic classes shows that the living conditions and the nutritional insecurity of the urban poor increase their vulnerability to communicable and water-borne diseases, anemia prevalence and reproductive health problems, low birth weight, undernutrition and inadequate immunization cover. ES5 Existing systems and provisions In contrast with rural areas where a clearly delineated primary health care system has been put in place there has been less success in creating primary health care networks in urban areas. Despite legal provisions for public responsibility, municipalities have not been able to provide the services that the poor can utilize in
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times of need. Problems include non-availability of primary health care facilities in many areas, underutilization of existing institutions, and overcrowding in most secondary and tertiary care centers. At the state level, predictability of funds flow is of concern when interventions are planned; and with competing demands for budgetary support, most local bodies are not able to allocate the requisite resources for health services. ES6 Health seeking behavior of the urban poor The poor are quick to shift to other sources of medical care when they perceive value received to be low. Such perceived value is related to cost, both direct and indirect; effectiveness; potential subsidy and responsiveness. For the poor who lack “urban literacy” or the ability to negotiate their treatment in an urban setting, the attitudes of the provider, and the support of intermediaries, are especially relevant. Consequently these factors assume importance in efficacious interventions by health services. ES7 Health care utilization The poor prefer private sources of ambulatory care; public facilities are more likely to be utilized in the event of fewer options, or lack of options. The difference in the cost of ambulatory health care in private and in public facilities is, however, not large. For the urban poor, the utilization of public hospitals for inpatient treatment is much higher than that for ambulatory care. ES8 Spending on health care The poor spend significant amounts on health care and undertake short term borrowings for health related expenditures, particularly in the case of catastrophic illness. Along with job insecurity, lack of credit and lack of support systems, illness pushes them into debt and further poverty. ES9 Strategic directions Urbanization poses challenges of monetization of transactions, environmental conditions, stress and anxiety, lack of social cohesion and unfamiliar social mores. The empirical basis provided in this policy note indicates that the most vulnerable of the urban poor, located within and beyond slums, need to be identified and targeted as a special group requiring additional attention. The state is constrained in responding fully to local needs, and in implementing legislated positive action for the marginalized. Significant efforts are required to orient health services and financing to the actual conditions, preferences and constraints of the poor in urban areas. The required package of services would need to include primary preventive care through community-based programs. It would also need to include basic curative care, diagnostic services and support for catastrophic illness. Creative strategies are needed to develop community insurance and other mechanisms to protect the urban poor from the impact of financial loss during illness. And finally, collaboration and cooperation with a more regulated private sector will help improve the quality of health care services available to the urban poor.
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