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Introduction
Programming Considerations
• Data
• Reaching the Urban Poor with Health Services
• Choosing Appropriate Interventions
• Working with the Private Sector
• Platforms for delivery
Resources and Websites
Introduction
By the year 2015, 59 per cent of the world's population will live in urban centers. Developing cities will need to absorb over 2 billion new residents in the next three decades. Half will be born into poverty. While aggregate health statistics paint a rosier picture of the health of urban dwellers compared to those living in rural areas, there is a large and growing gap between the health status of the upper/middle class urban residents and those living at the margins.
Eight hundred thirty-seven million urbanites currently reside in densely populated, overcrowded unsanitary conditions often lacking access to basic health, water and sanitation services. We have very little data on the health status of this population. However, the little evidence we have suggests that they face severe health challenges that inhibit their ability to be active, productive and prosperous members of society. Disaggregated urban data (where we can get it) shows that infant and under-five mortality rates for the poorest 40% of the urban population are most often as high - if not higher - than those found amongst similar groups in rural areas. Urban residents, while better nourished on average, are extremely vulnerable to macroeconomic shocks that undermine their earning capacity and lead to substitution towards less nutritious, cheaper foods. The urban poor are particularly vulnerable in that they are not likely to have savings, large food stocks that they can draw down over time or access to land upon which they can grow produce and nutrient-rich foods. The nutritional vulnerability of the urban poor is evidenced by the fact that, where data is available, the number of children that show evidence of malnutrition and stunting amongst the urban poor is, again, the same, if not higher than that amongst the rural poor. Respiratory infections from both indoor and outdoor air pollution and diarrheal diseases, two of the world's greatest challenges to child survival, are also a daunting challenges in urban areas.
Urban slums are also home to a wide array of other infectious diseases (including tuberculosis, hepatitis, dengue fever, pneumonia, cholera, and malaria) which easily spread in highly concentrated populations where water and sanitation services unlimited and the population is unaware of simple, life-saving prevention measures. AIDS and HIV prevalence rates are high and growing in urban areas - exceeding 50 per cent in some African cities. Increasingly cities are beginning to feel the socio-economic impact of the crisis in terms of lost wages and productivity costs. In cities where the HIV/AIDs epidemic has taken its toll, local governments must now find a way to support and nurture a vast and growing population of orphans.
Healthy cities require safe, easily accessible, and affordable water; sanitation; safe home and work environments; clean air; and reduced exposure to disease pathogens. Poor housing conditions, exposure to excessive heat or cold, diseases, air, soil and water pollution along with industrial and commercial occupational risks, exacerbate the already high environmental health risks for the urban poor. Lack of safety nets and social support systems, such as health insurance, as well as lack of property rights and tenure, further contribute to the health vulnerability of the urban poor.
Programming to Reach the Poor
Data
Appropriate, affordable and accessible health-care for the urban poor cannot be implemented without a clear understanding of the health challenges facing this population. Unfortunately, policymakers at the local, national, and international levels simply do not have enough information on the health conditions of the urban poor. Where there is data specific to the health of the urban populations, it often suffers from at least three weaknesses. First, health data is usually aggregated to provide an average of all urban residents - wealthy and poor - rather than disaggregated by income or a wealth index. It thus masks the health conditions of the urban poor. Second, the urban poor are often overlooked altogether. The informal or often illegal status of low-income urban settlements contributes to the fact that public health authorities often do not have the means or the mandate to collect data on urban poor populations. Further, health data are usually based on household surveys. This means that most surveys do not count the homeless. This has a particular relevance in urban areas where housing and space are at a premium and there are large numbers of people sleeping without shelter or any permanent residence. Obtaining accurate data on the health of the urban poor will require innovative interventions that build on the traditional data collection tools of public health authorities.
Existing data on the health status of the urban poor suffers from a third weakness derived from the difficulties of identifying the poor from which we wish to take our sample. Policy makers must find a more satisfactory balance between the comparability of data between rural and urban locals and its accuracy in measuring the reality faced by the poor in each location. If we are to accurately measure the health status of the poor we must first be able to locate and identify the poor. Poverty is experienced differently in urban vs. rural settings. The most important difference between urban and rural poverty is the high cost of services and cash dependency experienced in urban settings. Where services are not provided through public institutions water must be drawn from a private vendor at multiple times the rate. This means that the tariff structure for water in urban areas is in fact regressively graded. The urban poor may be able to gain increased access to services (i.e., illegally tapped electricity) just because of their location. However, this may have little to do with their food security, access to health services, income level, vulnerability during times of disaster and/or political marginality. Perhaps the most devastating aspect of urban poverty is the sustained exposure to environmental hazards as the poor are forced to live in their own excreta, surrounded by uncollected - and often hazardous - solid waste, exposed to industrial pollution, and forced into cramped spaces where personal safety and mental health is seriously jeopardized. Policy makers must find a way to incorporate these elements into their index of poverty.
Reaching the Urban Poor with Health Services
Healthcare facilities are overwhelmingly concentrated in urban areas. As a result, urban populations - on average - have greater access to formal healthcare services. There are, however, a number of barriers to the ability of the poor to make use of these services. Cost is an obvious challenge. Social factors, such as the lack of cultural appropriate services, language/ethnic barriers, and prejudices on the part of providers play a role. There are also significant blockages to providing increased health education in slums. Donors and governments alike may assume that outreach and education are not necessary in urban areas, confusing the existence of health facilities and educational services in middle and upper class neighborhoods, with widespread access to information. The urban poor may not have access to these channels of communication. There may also be barriers to the education of slum populations because health outreach workers are afraid to work in slums. What is clear is that there is a consequent lack of outreach services in slum areas leading to an inability to identify symptoms and seek appropriate care on the part of the poor. In Bangladesh, for example, surveys have shown that slum dwellers will seek medical care for diarrhea but not for pneumonia. Pneumonia is considered to be a spiritual disease so the poor turn to spiritual healers for assistance, slowly watching their children die.
Urban health interventions must work to connect the urban poor with health education and services. Policymakers need to ensure - through targeted subsidies, community-based insurance plans and/or other economic incentive structures - that healthcare payments of the urban poor do not exceed their ability to pay. They also need to ensure that the cost of healthcare does not lead families to cut back on foods that provide vital nutrition for their children. Outreach programs must be initiated that target urban slums. Efforts should also be made to sensitize health care providers to the needs and cultural traditions of the people they serve in poor areas. Health care services are more likely to be available in urban areas. Work must now be done to connect the urban poor with those services.
Choosing Appropriate Interventions
Successful implementation of urban health interventions requires a multi-sectoral approach involving a fairly diverse set of stakeholders. However, it may take a while to get all the vested partners to see the importance of interventions of this kind. Governments may be concerned that they will attract migration by delivering services to existent slum populations. Municipal officials may not be used to working with personnel in other departments and may be afraid that they will compromise their legitimacy as an agency by doing so. Politicians may or may not see the value in working with poor urban populations. Some slums are privately owned or controlled by landlords that would raise the rent if additional improvements were made to a particular slum area. This could, in fact, have the opposite effect from that which we are trying to create in that the targeted population might be forced to leave and occupy a tract of land that might be more marginal than the first. Institutionally based changes, geared towards improving the access of poor populations to health services and environmental infrastructure, will take time and a great deal of effort on the part of committed participants, be they donors, governments, or slum dwellers themselves.
While it is vital that we solve urban health challenges through improved institutional relationships, this should not stop us from promoting strategic and well-targeted interventions in the meantime. There are several ways that we can impact the health of the urban poor through more narrowly targeted interventions:
| • | Strengthen the capacity of existing NGOs to bring high quality health interventions to slum neighborhoods. |
| • | Target slums with well-focussed education campaigns designed to spread important information about the prevention, diagnosis and treatment of disease. Billboards, radio shows, religious organizations, CBOs and peer networks can be used to promote safe storage of water, hygienic behaviors, the balanced consumption of nutritious foods, increased ventilation, safer mechanisms for collecting and disposing of solid waste and the elimination of other feeding grounds for disease vectors. |
| • | Appropriate technologies can be provided for improved, more structurally sound and healthy housing design, on site water purification and sanitation (see the Water and Sanitation briefs), improved drainage, increased the safety of cooking facilities and appropriate fuel options. |
| • | Provide pooling mechanisms to help communities jointly invest in low cost infrastructure improvements that will benefit everyone. Find ways to augment available resources. |
| • | Strengthen local institutions (private and public) and find ways to link them to resources and facilities that can help them gain the attention and collaboration of policy makers who can effect their long-term status in the community. |
Working with the Private Sector
There are a number of reasons that we must work with the private sector to accomplish urban health goals. First, in many developing countries the urban poor receive at least half of their health services from the private sector, be it from practitioners of traditional medicines (including birth attendants), MDs, or local pharmacies. In some cases the quality of these services are quite good. However, in many cases there is considerable room for improvement. Improvements in the health of the urban poor can be achieved just by improving the quality of services they receive from the providers they already frequent.
A second reason to work with the private sector is that, in many cases, they are able to bring additional resources to bear upon a problem of considerable magnitude. SEWA - an NGO in Gujarat, India - was able to leverage the resources of soap manufacturers who sponsored educational campaigns around water, sanitation and hygiene as part of an ad campaign to get slum dwellers to use their soap. It is possible to work with private water vendors to ensure good water quality and efficiency improvements that might lower the cost of water purchased by poor consumers. Where there is such a convergence between the goals of the private sector and that of the public sector, partnerships should be actively pursued.
Finally, there may be many ways in which private sector activities could be altered to improve the lives of all city residents. Governments and donors should work with the private sector to help them find cost-effective ways of reducing the emission of pollutants that damage the health of city residents. Public/private partnerships can be developed to ensure that factory labor is given a healthy environment in which to work.
Platforms for delivery
A clear understanding of the roles and responsibilities of different layers of government is an important first step to more effectively delivering health services to the urban poor. Effective interventions in urban areas require the cooperation of a complex set of stakeholders who may or may not be used to working together. The relationship between the central, state and local governments must be examined. At the same time, we must understand the relationship between departments - the environmental and the health offices, for example. An important component of this initial assessment will be an analysis of the platforms from which urban health interventions are or could be launched. A final analysis should consider existing and potential roles of public and private sector providers (including traditional healers), bilateral/multilateral donors, NGOs and CBOs.
Decentralization can present a particularly significant challenge to the equitable delivery of health services in urban areas. There are many benefits to placing service delivery in the hands of local governments, as they are the officials that are most easily accessed by community leaders and most likely to understand the context in which services must be delivered. However, there is legitimate concern that local government officials be given the skills they need to effectively and equitably manage the delivery of services in a participatory manner. Programs should support the education of local governments as to local public health needs, prioritization and strategic management of health service delivery, storage and distribution of pharmaceuticals, and in low cost interventions that can be used to positively impact poor and marginalized populations in their communities. [See Service Delivery brief]
Resources and Websites
ID21 Communicating Development Research (2001) Sick Cities? Evaluating Healthy Cities Projects http://www.eldis.org and http://www.id21.org
Hellen Keller International - Asia Pacific (2001) Monitoring the Economic Crisis: Impact and Transition, 1998-2001 http://www.hkiasiapacific.org/_downloads/NSS%201998-2000.pdf
IFPRI (2001) Achieving Urban Food and Nutrition Security in the Developing World
http://www.ifpri.org/2020/focus/focus03.htm
Population Information Program (2001) Population Growth and Urbanization: Cities at the Forefront Population Reports Newsletter. Center for Communication Programs, Johns Hopkins University School of Public Health http://www.jhuccp.or
Wang, Limin; (2002) Health Outcomes in Low-Income Countries and Policy Implications: Empirical Findings from Demographic and Health Surveys Policy Research Working Paper World Bank, Environmental Division
World Health Organization (WHO) (1996) Creating Healthy Cities in the 21st Century Background Paper, UN Conference on Human Settlements: Habitat II, Istanbul 3-14 June, 1996
WHO (2001) Private Sector Involvement in City Health Systems proceedings of a WHO conference meeting 14-16 February 2001 Dunedin, New Zealand http://www.who.int
World Bank (2002) Getting the Best from Cities World Development Report 2003 World Bank Group, Washington DC http://econ.worldbank.org/wdr/wdr2003/
World Resources Institute (WRI) Urban Environment and Human Health Chp. 2 in The Urban Environment 1996-1997 Oxford University Press, New York. (a joint publication of WRI, UNEP, UNDP, and the World Bank) http://www.wri.org/wr-96-97/index.html
Websites
Environmental Health Project
http://www.ehproject.org
Johns Hopkins
http://www.jhuccp.org/pr/urbanpre.shtml
PAHO
http://www.paho.org
World Bank Urban Division
http://www.worldbank.org/urban
World Bank Poverty Net
http://www.worldbank.org/poverty
World Bank Poverty and Health Page
http://www.worldbank.org/poverty/health/index.htm
World Health Organization, Healthy Cities Initiative
http://www.who.int
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