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Introduction
Programming Considerations
• Increased Information about Urban Child Health Needs
• Family Planning, Maternal and Neonatal Health
• Immunization
• Nutrition
• Infectious Diseases
• HIV/AIDS
• Malaria
• Water Quality, Sanitation and Diarrhea
• Exposure to Pollution and Toxic Waste
• Hazards and Accidents
• Integrated Management of Childhood Illness
• Platforms for Intervention
Resources and Websites
Introduction
Cities in developing countries will need to absorb over two billion new residents by 2025. Half will be born into poverty. As natural increase overtakes migration as the leading cause of urban growth, this means that more and more children will be raised in urban slums, without access to regular water supply, sanitation, health services and education.
The health needs of poor children in cities are often cloaked behind statistical averages that more readily reflect the privileges of children in upper class families than their own dire circumstance. Concrete data on the health status of poor urban children is remarkably difficult to find. However, where data does exist, it paints a stark picture. Infant and under 5 mortality rates amongst the urban poor are as bad and in some cases much worse than what we find amongst the poor in rural areas. The same holds true for statistics on malnutrition, immunization levels, prevalence of acute respiratory infections and diarrhea. As the ranks of the urban poor continue to explode, we must find ways to help cash-strapped cities give their children hope for a healthy and vital future.
Child Health Interventions in an Urban Context.
Increased Information About Urban Child Health Needs
There is a dire need for increased information about the health status of poor children in cities. We cannot effectively target our programs without readily identifying the location and nature of health needs. Existing child health surveys must disaggregate their results for urban areas and make a concerted effort to go out and locate the urban poor, whether they are living in slums or renting space on urban sidewalks. Expanding data collection efforts in urban slums and amongst the urban poor can provide policymakers and program staff with invaluable information as to how they can best reach this population.
Family Planning, Maternal, and Neonatal Health.
A growing consensus has emerged that spacing birth intervals between three and five years greatly improves child survival. While fertility rates are traditionally lower in cities than in rural areas, several cities, such as Dhaka and Mumbai, do not follow this pattern. Access to family planning services among the urban poor is significantly limited. The urban poor often earn a living by working away from the home, greatly increasing the need for childcare and therefore increasing the costs of having multiple children. Consequently, the need to limit the number and timing of pregnancies becomes crucial for child survival.
Equally important is the availability of adequate maternal health care. By ensuring the presence of skilled birth attendants, sanitary hygiene during childbirth, and education about referral for potential postpartum emergencies, development practitioners can save the lives of both mothers and their children.
Immunization.
Immunization is a key component of child survival in urban areas. Here, the challenges of missing data become clear. We often have contradictory coverage data on immunizations coming from government sources which claim immunization rates that is often quite high and NGOs who provide much more modest estimates. In some cases this reflects the legal status of slum areas as the government may not consider slum dwellers to be legitimate city residents and exclude them from the catchment area. Unfortunately diseases do not follow legal classifications in their infection train. We must be sure that our data reflects immunization coverage in the entire urban agglomeration.
Another challenge to be faced is that of ensuring that poor children receive complete the rounds required for full immunization. Keeping records on poor children who rely on ad hoc outreach mechanisms for services can be quite difficult. It is most difficult to ensure full immunization of children in temporary and illegal settlements who may not live in one place long enough to establish a routine relationship with a health provider. Outreach programs are vital to immunization programs in urban slums. Providers must ensure that they reach every part of the urban agglomeration with education and awareness campaigns. Urban care providers will need to pay special attention to the work and residential patterns of poor groups in order to effectively target their activities. Incentives can be provided to encourage participation and care providers should work to develop innovative ways of maintaining records on each child they serve including enlisting mothers and other caregivers as partners.
Nutrition.
Proper nutrition and vitamin intake are essential components to child health. Malnutrition underlies 60 percent of child deaths each year. Existing data sets consistently show that poor children living in urban areas suffer from severe malnutrition, stunting and wasting - again, showing numbers that are often worse than that of their counterparts in rural areas. Food insecurity is a serious challenge in cities. Urbanites rarely own enough land to subsist off the food they grow or the animals they keep. Instead, they rely on cash incomes to purchase food they need for survival. In times of economic crisis where there is hyperinflation and surging unemployment, poor families in cities often cut expenditures on nutrient-rich food vital to the health of their children.
In addition to the problem of economic vulnerability, lack of education about the elements of good nutrition is a serious problem among the urban poor. Studies have found that improving nutritional education among mothers can improve children?s health status as much as increases in income. Expanding programs to educate families about healthy and balanced nutrition, increase awareness about the importance of breastfeeding, and the provision of key micronutrients, such as vitamin A, can do much to improve child health in urban areas. In addition, teaching families about urban agriculture and helping host countries implement policies that encourages agricultural production in urban areas can reduce a family's dependence on cash, thereby strengthening food security for the urban poor (here we have to be sure to encourage techniques that do not increase a family's risk of malaria). Finally, policy-makers can find innovative ways to partner with the private sector to fortify the foods most often consumed by the poor. Governments can not only promote food fortification as a marketable good, but they can give special incentives to private sector producers who target poor populations with educational ad campaigns.
Infectious Diseases.
The overcrowded living quarters of many urban slums increase the chance of transmitting communicable diseases such as tuberculosis and pneumonia. Poor sanitation and lack of easy access to water for essential disease prevention activities, such as hand-washing, increase the risk of infectious diseases. Strengthening health systems, expanding immunizations, improving access to clean water and educating the urban poor about the causes and means of transmitting infectious diseases would do much to reduce child mortality rates. See Urban Environmental Health Brief
HIV/AIDS
Children in urban areas have been impacted by the spread of HIV/AIDS inat least two ways. First, many have received the virus from their parents and must face the physical, psychological and social difficulties of infection. Second, children with HIV+ parents face significant health risks because HIV/AIDS decreases parents? productivity, resulting in fewer resources to spend on improved housing, sanitation, education and food. When these parents die, the AIDS orphans face serious barriers to healthy physical and psychosocial development. To address the needs of these vulnerable children, cities must bolster effective prevention and treatment programs. In addition, they must establish a reliable foster care system that supports healthy child development for those orphaned and lacking extended family to care for them. Programs to address HIV/AIDS in urban settings must work with local governments to help them find innovative, inexpensive ways to ensure that AIDS orphans have a fighting chance for a healthy and productive life. See USAID/OVC Page
Malaria
Infants, young children and pregnant women are the groups most affected by malaria. The severity of malaria as an urban problem varies from country to country. In some countries, malaria is almost unheard of in urban areas. In others, its effect is devastating. In Ghanaian cities, for example, malaria is the number one killer of children. Where malaria is a serious problem in urban areas, we must be sure that poor communities are explicitly targeted with education campaigns, preventative and curative services. Public education programs can increase knowledge of ways to reduce the risk of malarial infection. Teaching people about the dangers associated with standing water as well as promoting insecticide treated-bednets can reduce the rate of infection, thereby preventing child deaths. Furthermore, bolstering health services and expanding parental education to increase awareness about malarial symptoms could improve treatment of the disease, limiting its negative impact.
WaterQuality, Sanitation and Diarrhea
Annually, an estimated 1.5 million diarrheal deaths occur in developing countries in children under five due to poor water quantity and quality, lack of sanitation and poor hygiene practices. While urban residents, on average, are more likely to have access to potable water and sanitation services, this is not the case for poor and slum populations. Data on access to water and sanitation often does not reflect the access or quality of services in poor neighborhoods. In fact, the urban poor often must stand in long lines (some in the middle of the night) to access poor quality water from public standpipes that provide water intermittently, at best. Others purchase water from the private sector at many times the rate charged to those who are linked to formal systems. A similar set of challenges are faced around access to sanitation. Many slum areas are without any access to sanitation services at all. Those that are lucky enough to have public latrines, are often unable to use them because the facilities are rarely well- maintained.
The absence of universal sanitation and limited accessibility to water sources leads to numerous health problems, including high rates of diarrhea. If we are to seriously reduce the incidence of hygiene-related illnesses suffered by children in urban slums, policy-makers must promote creative ways integrate programs to improve the quality of water and sanitation infrastructure in slums at the same time they reach poor populations with hygiene education and other health services. See Water and Sanitation Briefs
Exposure to pollution and Toxic Waste
Urban areas of less-developed countries are often home to highly degraded environments contaminated by improperly disposal of industrial pollutants. High levels of air pollution worsen acute respiratory infections and lead to premature deaths among children. An estimated 300,000 to 700,000 premature deaths a year might be avoided in less-developed countries if unhealthy levels of suspended particulates were reduced to levels that the WHO determines as safe. Other toxins, such as lead, have been proven to cause physical and developmental damage to exposed children. A lack of efficient regulations regarding the management of hazardous waste - including hospital waste - and toxic pollutants has exacerbated the breadth of environmental problems to be faced in developing cities, seriously jeopardizing the health and well-being of children over the long-run. Local governments need assistance in establishing firm guidelines and enforcing existent environmental regulations. Success in this area would do much to improve the health of affected children living in poor urban areas. See UEM and Environmental Health Brief
Hazards and Accidents
Poor children in urban areas are especially susceptible to injury and death due to accidents. Lacking access to reliable childcare while at work, parents must often either lock their children inside their homes or allow them to roam the neighborhood freely. In this unsupervised environment, children are exposed to a variety of dangers. Children have been killed in fires caused by exploding cooking stoves because they were locked into their shack while their mother went to work. It is questionable whether would have been any safer roaming polluted and congested city streets in their bare feet. Challenges to childcare are often difficult to overcome in an urban environment where social networks may be weak and the extended family may be absent altogether. Parents may be forced to choose between supervision of their children and earning enough to be able to feed their families. Child health interventions in cities must inevitably deal with the challenge of supervision and care. Slumdwellers can be recruited to work in local daycare centers for which they can be paid a stipend from those using their services. Cities may want to find ways to augment their salaries by providing targeted subsidies. These care facilities can become loci for a variety of other interventions from the distribution of nutritional supplements to immunizations and hygiene education. Outreach campaigns can also be initiated to educate parents about the dangers facing their children in a particular location.
Integrated Management of Childhood Illness
IMCI combines improved case management of childhood illness in high quality health facilities with aspects of disease prevention, nutrition, immunization, and promotion of healthy growth and development. Towards this end, IMCI interventions work to improve the skills of health workers, the quality of health systems and health practices at the household and community levels. Good child health is the result of a number of different interventions and care practices adequately delivered over time. In its ideal form, IMCI allows the practitioner to take an integrated view of the necessary interventions and work with a number of partners to ensure that a child receives appropriate care at each phase of his or her life. IMCI makes as much if not more sense in cities as it does anywhere else. It is not only easier to locate and support integrated service delivery mechanisms in cities where it is possible to take advantage of scale economies, but the consequences of not adopting an integrated approach are more costly as urban child health interventions require the assistance of specialized partners who may or may not be used to working together. See IMCI Powerpoint
Platforms for Intervention
As expressed in the urban health brief [make this a link], there are a number of unique platforms that must be utilized in a coordinated fashion if we are to successfully implement child health interventions in cities. We must ensure that available health facilities are actually accessible to the urban poor. We must reach the urban poor with education and outreach services. We must find ways to encourage cooperation between different governmental layers and departments who affect the well-being of urban populations. All of these things are equally true in our interventions on behalf of poor children in cities. We must also ensure that NGOs serving children in poor areas are given the resources they need to accomplish their goals. In many cases they have neither the organizational capacity nor the necessary materials to have a real effect on these children. Most importantly we must find ways to bring diverse sets of officials and development professionals together to deal with the intersection between the environment and the health of children. High population densities in urban areas mean that our objectives will fail if we do not give children a safe environment in which to live and grow into happy productive adults.
Resources and Websites
Centre for Policy Studies and the Woodrow Wilson International Center for Scholars
2001. AIDS Orphans in Africa: Building an Urban Response Johannesburg: Centre for Policy Studies.
JHU Center for Communication Programs
2002. Population Reports, Birth Spacing: Three to Five Saves Lives. Baltimore: JHU CCP.
Opolot, Samson James, ed. 2002. Building Healthy Cities: Improving the Health of Urban Migrants and the Urban Poor in Africa. Washington: Woodrow Wilson International Center for Scholars.
Ruel, Marie, Margaret Armar-Klemesu and Mary Arimond
2001. A Multiple-Method Approach to Studying Childcare in an Urban Environment: The Case of Accra, Ghana. FCND Discussion Paper No. 116. Washington: International Food Policy Research Institute.
Satterthwaite, David, Roger Hart, Caren Levy, Diana Mitlin, David Ross, Jac Smit and Carolyn Stephens.
1996. The Environment for Children. New York: UNICEF.
UNAIDS, UNICEF and USAID. 2002. Children on the Brink 2002: A Joint Report on Orphan Estimates and Program Strategies. http://www.dec.org/pdf_docs/PNACP860.pdf
USAID. 1998. Reducing the Threat of Infectious Diseases of Major Public Health Importance: USAID?s Initiative to Prevent and Control Infectious Diseases.
http://www.usaid.gov/pop_health/id/idstrategy.pdf
World Bank HNP/Poverty Thematic Group
2000. Socio-economic Differences in Health, Nutrition and Population . http://www.worldbank.org/poverty/health/data/index.htm#lcr
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