A case for focussing on MNCH efforts for the urban Poor in India. Siddharth Agarwal Growing urbanization in India, as elsewhere, is rapidly increasing the urban poor population. As per the Census in 2001, 27.

8 percent of the country’s population, comprising 285. 4 million, people lived in urban areas. Projections estimate the number at about 335 million in 20081.It is expected that by the year 2030, more than half (55 percent) of the country’s population will live in cities (UNFPA, 2007 State of World Population, Unleashing the Potential of Urban Growth.

ww. unfpa. org/swp. ). Growing urbanization in India has led to an increase in the share of poverty in urban areas and the urban poor are the fastest growing segment of the Indian population, with migration, expansion of city limits and natural growth expected to increase from an estimated 802 - 1003 million in 2005 to 202 million in less than 15 years.

4 (UN-HABITAT, 20062007. State of the World’s Cities Report, London: EarthScan. ).Health of Urban Poor Far Worse than Urban Averages: The urban poor are vulnerable to many health risks as a consequence of living in conditions characterized by cramped, low-quality housing with limited sanitation, limited access to affordable quality health care, widespread illiteracy, social isolation, and a lack of negotiating capacity to demand improved public services. This is reflected in their health outcomes. Health indicators among urban poor are much worse than urban averages and generally similar to those of rural populations.

For example, The National Family Health Survey - 35 (2005-06) and other sources show: The urban poor have an infant mortality rate of 54. 6 in comparison to 35. 5 of urban nonpoor and 41. 7 of urban average. Despite proximity to specialty hospitals, 56% of slum children are born at home without skilled birth attendants, increasing the risk of neonatal and maternal mortality.

Only 40% of urban poor children received all recommended vaccinations, comparable to that in rural households (39%) and much lower than the urban average of 58%.Nearly fifty percent of urban poor children are underweight for age. This rate is worse than rural areas (46%) and significantly worse than the urban average (33%). Nearly 60% of urban poor women aged 15 – 49 years are anaemic, increasing the likelihood of maternal and infant death, premature birth and low weight babies. Less than half (49%) of the urban poor use any modern method of family planning as compared to the urban average of 58%.

The use of spacing methods among the urban poor is limited to 8%.Marginalized urban populations also suffer from greater levels of domestic violence and substance abuse, higher rates of accidents and injuries and higher incidence of mental illness and other disabilities compared to rural counterparts. Less than one fifth (18. 5%) of urban poor households in India have piped water in their home, less than half have access to any toilet and nearly all face exposure to high rates of air and water pollution, which contributes to a higher prevalence of morbidity in slums.Need for Increased Policy Focus and Capacity: Government efforts to address these vulnerabilities and improve the health of the urban poor have been limited in scope and inconsistent over time. This can be attributed to several factors: Registrar General of India, 2006: Population Projections for India and the States 2001-26.

New Delhi: Office of the Registrar General and Census Commissioner. 2 National Sample Survey Organization, 2007. Poverty Estimates based on 61st round, 2005-06. New Delhi : NSSO 3 Ministry of Health and Family Welfare. 000.

National Population Policy. New Delhi “ MoHFW. 4 Planning Commission, Poverty Estimates for 2004-05 and National Population Policy, 2000; State of World’s Cities, 2006/07 5 Re-analysis of 3rd National Family Health Survey (2005-06) was conducted to determine the health of the urban poor in India and its comparison with other population groups.The wealth index developed by NFHS based on 33 assets and household characteristics has been re-categoriesd. The bottom quartile in urban areas has been taken as representative of the urban poor.

 The bottom quartile in urban areas is taken as the representative of the urban poor. Since India has been predominantly a rural country until recently, there has been a lack of policy focus on urban health and development issues There is limited availability of dedicated healthcare infrastructure for the urban poor Municipal governments fail to make needed investments to improve living conditions in urban slums and do not recognize many slum communities that have evolved as encroachments and are not notified in official records.Planners, implementers and managers lack the experience and capacity to address the unique challenges of urban health Slum communities often have large migrant populations that create challenges in providing services. At the same time, urban areas, including slums, have some inherent advantages that can be leveraged to improve health status.

For example, many urban slums include a mix of income groups and some residents have the ability to pay for services.A large number of NGOs are active in slum areas on a variety of issues such as housing, microfinance, slum development and education and can become engaged in improving health care delivery. Scarcity of providers is less intense in urban areas as health facilities are generally available within the city (however there is also a plethora of unqualified practitioners serving slum areas and few of these offer important preventive services). Finally the concentration of populations in urban slums increases the efficiency of reaching them with programs and communication activities.Emerging Opportunities: The Government of India is increasingly recognizing the disproportionate burden of ill health on the urban poor and has drafted the NUHM that outlines their vision, strategies, approaches and available resources for improving the health condition of the urban poor, especially slum communities.

The NUHM offers a unique opportunity to bring the urban health agenda into the forefront of national efforts to ensure health for all.Other Indian government initiatives, including the Jawharlal Nehru National Urban Renewal Mission as well as efforts to universalize the Integrated Child Development Services (ICDS) program, present further opportunities to reinforce and consolidate advocacy efforts toward improved urban health and nutrition. As the needs of urban slum populations continue to grow and as awareness of and attention to urban health programming expands, the demand for evidence-based analysis, effective advocacy, and developing and sharing innovative solutions is growing substantially.