State of Urban Health in Madhya Pradesh

Abstract

India’s Urbanization and Poverty Scenario
Urban migration and simultaneous natural growth of urban population has resulted in rapid proliferation of urban
agglomerations. The urban population of India constitutes 285 million and is estimated to reach 660 million by
2025. Population growth is significantly faster in urban areas - decadal growth during 1991-2001 was 31.2% in
urban areas vis-à-vis 17.9% in rural areas . Over one-fourth of the urban population of India today lives in slums, under inhumane conditions resulting in increased susceptibility to disease and ill health. Trends in urban poverty suggest that the number of urban poor will increase considerably in future unless a well-planned, long-term intervention strategy, is in place.
Importance of Focusing on the Health of Urban Poor
The urban poor suffer from adverse health outcomes which do not get reflected in commonly available health
statistics. Most sources of health information which are available as rural and urban aggregates mask the inequalities which exist within the various economic groups in rural and urban areas. For instance, the under five mortality rates (U5MR) among the urban poor (112.2) are nearly three times higher than the rates for the urban high income groups (39.4). As per the second round of the National Family Health Survey (NFHS 2) conducted in 1998-99, only 43% urban poor children are fully immunized by completion of one year of age. The percentage of severely underweight children among the urban poor is 23 which is approximately twice the urban average (11.6%) and five times (4.5%) that of urban high income group.
Why are the Urban Poor Vulnerable ?
The poor in urban areas are vulnerable to health risks as a consequence of living in a degraded environment,
inaccessibility to health care, irregular employment, widespread illiteracy and lack of negotiating capacity to
demand better services. A significant proportion of slums are not listed in official records and therefore remain
outside the purview of public services including health which accentuate their vulnerability. As the vulnerability of the urban poor is influenced by a variety of factors, the variation in these factors result in some slums being more vulnerable than others. It is essential that development programmes recognize the differential vulnerability of slums so that context specific approaches and effective targetting of resources to the most vulnerable is made possible.
Government of India’s Focus on Health of the Urban Poor
The Government has recognized the non-availability of primary health care services to urban poor in important
policy statements such as National Population Policy (NPP) 2000, second phase of the Reproductive and Child
Health program (RCH II) and Tenth Five Year Plan. The National Rural Health Mission (NRHM) (2005-2012),
launched by the Government of India throughout the country to provide comprehensive integrated healthcare, has constituted a Task Group on Urban Health to recommend strategies for delivery of health services to the urban poor. It envisages a specific focus on Empowered Action Group (EAG) states like Madhya Pradesh (MP). The Ministry of Health and Family Welfare, Government of India has formulated guidelines for development of city level urban slum health projects which provide a mechanism for urban health delivery and its overall management. The National Urban Renewal Mission (NURM) has a sub-mission on basic services to the urban poor which covers over sixty cities in India including four cities in Madhya Pradesh - Indore, Bhopal, Jabalpur and Ujjain.
Madhya Pradesh (MP) – Urban poverty, Policies and Reproductive and Child Health Services
MP is one of the least developed states of India with over 6 million urban poor.
MP is the second largest state in India with respect to surface area (308,252 sq. km.). It is home to 60 million
people or 6% of the country’s population. 16 million persons live in the towns and cities of Madhya Pradesh
which comprises 27 % of the population. The urban population of Madhya Pradesh is growing significantly faster than the rural population and is estimated to comprise 45 % of the population by 2051. 38.4% of the urban population lives below the ‘below poverty line’ which equates to about 6 million. Madhya Pradesh is also among the least developed states in India.
RCH related policies and provisions for urban poor
MP Government has formulated its own policy level mandate for improving living conditions of the urban poor.
The MP Population Policy recognizes the lack of dedicated primary health infrastructure and envisages the creation of a suitable service delivery system. The policy also reiterates the important role of the private sector in improving health conditions in urban slums. The Jawaharlal Nehru National Urban Renewal Mission (JNNURM) has a Sub-Mission on Basic Services to the Urban Poor. This mission covers 60 cities in India including four cities in MP. The mission proposes to cover projects for providing housing at affordable rates, improving water supply/sewerage/community toilets, construction and improvement of drains and sanitation facilities in slums. Inspite of the clear mandate at the policy level, this has not been translated into effective programmes which have significant impact on the health of the urban poor. In order to translate policies into effective programmes, it is essential that there is improved coordination between various departments that work in urban slum communities. The 74th Constitutional Amendment which envisages an enhanced role of urban local bodies (ULBs) calls for enhancing the capacity of ULBs to manage urban health programmes.
RCH infrastructure and services focusing on urban poor
In urban areas of MP, RCH services are available through District or Municipal hospitals, Urban Family Welfare
Centers (97 in number in the year 2000), Health Posts and Post Partum (PP) Centers. Select RCH services are also supported through Anganwadi Centers (AWCs). Urban areas do not have dedicated primary health infrastructure unlike rural areas. Existing health facilities are also not in the vicinity of urban slum communities and therefore not accessible to them. Rapid urbanization has also rendered the already inadequate health infrastructure further inadequate. For instance, primary health facilities which were initially planned for a population of 50,000 cater to much higher populations. As a result, most slums are either outside the purview of health services or receive very poor quality care. In order to improve access of health service to the urban poor, it is essential to partner with the private sector who have a vast presence in urban slums. Link volunteers who are recruited from the community and provided training inputs can generate awareness on health issues and improving linkage with health providers. The situation analysis of Indore is presented in this document as a reference case study of the emerging health delivery system needs of a rapidly urbanizing city. This analysis revealed that approximately 40% of the residents live in slums. There are 539 slums in Indore, of which 438 are officially recognized. Based on the criteria of socioeconomic and health status of the community , access and availability of basic infrastructure, water supply, health facilities, AWC and existing capacity of community groups, 157 slums have been categorised as vulnerable.
Reproductive and Child Health Conditions among Urban Poor in M.P. – Reanalysis of National
Family Health Survey (NFHS 2,1998-99) Data
Most information on health conditions that is available for MP, provides for only rural – urban comparisons
including NFHS. This commonly leads to false conclusions about the relative conditions of the urban poor as the
averages mask the disparities that exist within urban areas. NFHS 2 (1998-99) data for MP was analysed according to Standard of Living Index (SLI), an asset-based indicator to analyze the disparities which exist within urban areas.
The analysis of the RCH conditions among urban poor in MP uses the low SLI segment of urban population as
representative of ‘urban poor’. The inadequacy of health infrastructure, coupled with poor economic and environmental conditions restrict the chances of child’s survival as is reflected by the high Neonatal Mortality Rates (NMR), Infant Mortality Rates and under 5 mortality rates among urban poor which are 69.7, 99.4 and 131.9, respectively. This is significantly higher than the urban average mortality rates of 44 for neonatal, 61.9 for infant and 82.9 for under-5 age groups. More than two thirds of the pregnant women (68%) among the urban poor do not receive the recommended 3 or more antenatal check ups which serve as important contact points to disseminate RCH related information including family planning. Domiciliary delivery is still the norm, with 3 out of 4 deliveries taking place at home. Only 38% of the total deliveries among urban poor are attended by trained personnel. The situation is further worsened by the fact that only one-fifth of the children aged 12-23 months are completely immunized. Dropout and left out rates are far higher among urban poor households (36.1 and 25.2 respectively), in comparison to the urban average (26.1 and 17.4 respectively).
Fertility levels are high among the urban poor. Total Fertility Rate (TFR) among this group is 3.6 compared to the urban average of 2.6. Mean number of children ever born to ever-married women aged 40-45 years was 5.5. Bringing the TFR to replacement levels appears to be a herculean task with only 3.4% spacing method usage. Usage of permanent methods (female sterilization) is also low at 32%. This too, is an ineffective means to bringing population growth to replacement level as, women usually adopt permanent methods only after bearing a minimum of 3-4 children.
Further evidence of the rich-poor disparity in health status in urban areas is evident as children from poor urban
families are thrice as likely to be undernourished as compared to children from rich families. Prevalence of anemia was found to be higher among urban poor children compared to other economic groups. Only 8% of the urban poor neonates are breastfed within one hour of birth. Nearly half (47%) of the children do not receive complementary foods by 7-9 months of age among the urban poor. The health conditions deteriorate further due to the compromised environmental conditions. About 50% of the urban poor do not have access to pipe water supply while only 13% have access to a private sanitary facility.
Conclusion
The current poverty scenario in MP indicates that four out of every ten urban dwellers in MP are poor. The health conditions and service coverage for this section of the population are poor. The urban public health infrastructure on which the poor are most dependent is woefully inadequate. The implementation of existing pro-poor policies needs to be vitalized to ensure that benefits reach the poor. Reanalysis of NFHS 2 highlights the disparities across economic groups in MP which necessitates rethinking on allocation of resources and targeting the urban underserved.
There is a need to augment infrastructure and services to ensure a primary health care delivery center for 50,000 urban population and an Auxiliary Nurse Midwife (ANM) for 12,000-15,000 population. In order to strengthen services and improve the health of the urban poor, the following measures are suggested :
1. Augmentation of urban health infrastructure and services. Partnerships with the private sector are an effective
way to improve access to health services in urban slums
2. Improving of functional convergence of all stakeholders (such as health, ICDS, water supply, sanitation, slum
development, public distribution system etc). A task force at the city level comprising officials of different
departments which reviews different programmes can bring in synergy and improve impact of the various
programmes.
3. Improve capacity of Urban Local Bodies to manage health services better. This can be achieved through training programs which expose the elected reprsentatives and officials to the various policy and program provisions meant for improving the health of the urban poor. Exposure visits to successfully managed urban health programs can also help urban local bodies to initiate similar programs in their cities.
4. Recognize that all slums are not alike and that there is a need to focus on the most vulnerable. It is essential
that all slums are listed and assessed for their health vulnerability. Slum lists should be periodically updated as
rapid urbanization results in the creation of new slum clusters regularly.
5. Migratory trends need to be considered while planning RCH services. Specific communications strategies
should be designed for such populations and health providers should be mandated to provide services to
temporary and new residents in addition to population in their service records.
6. Strengthen community networks such as Self Help Groups (SHGs) and their linkages with health providers.
Such groups can generate awareness, increase demand and negotiate for better services.