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Making the invisible visible

By Siddharth Agarwal

Health, nutrition and wellbeing disparities in urban India are stark. Under-5 children in the most vulnerable sections of the urban poor are 2.5 times more undernourished than the urban rich. And their mortality rate is significantly higher than the urban aggregate. The urban poor are in fact far less likely to avail of ICDS and other schemes than the rural poor

In 2008, for the first time in human history, the world’s urban population surpassed its rural population (1). Between 2011 and 2030, the world’s population is expected to increase from 7.0 billion to 8.3 billion (2). With urbanisation being the defining feature worldwide, the population living in urban areas is projected to gain 1.4 billion, increasing from 3.6 billion in 2011 to 5 billion by the year 2030 (3).

India’s urban population has increased from 285 million in 2001 to 377 million (31%) in 2011. It is expected to increase to 535 million (38%) by 2026 (4). The United Nations estimates that 875 million people will live in Indian cities and towns by 2050. If urban India were a separate country, it would be the world’s fourth largest country after China, India and the United States of America.

According to data from Census 2011, close to 50% of urban dwellers in India live in towns and cities with a population of less than 0.5 million, while the four largest urban agglomerations -- Greater Mumbai, Kolkata, Delhi and Chennai -- are home to 15% of India’s urban population.

Urban poverty in India

Cities are centres of a multitude of commercial activities, with the urban component of India’s economy contributing close to 70% of the country’s GDP. However, behind the glitter of urban life is a large segment that is hidden, voiceless, deprived, hungry, with poor access to healthcare and basic services like sanitation, drinking water, housing, education.

Based on Monthly Per Capita Expenditure (MPCE), the Tendulkar Committee’s (set up by the Planning Commission, Government of India) 2009 Report of the Expert Group to Review the Methodology for Estimation of Poverty used 2004-05 National Sample Survey (NSS) data to determine a poverty line of INR 578.8 MPCE in 2005. The committee also used 1993-94 NSS data as a preliminary exercise to calculate poverty rates that could be compared to the 2005 numbers (5). The Tendulkar Committee’s 2009 report revealed that in 1994, 31.8% of India’s urban population was below the poverty line, amounting to 74.5 million urban poor residents.
In 2005, urban poverty was at 25.4%, amounting to 80.8 million urban poor residents. The Planning Commission’s 2011-12 Press Note on Poverty Estimates calculated an updated poverty line of INR 1,000 MPCE using the detailed analysis and methodology outlined in the 2009 Tendulkar Committee report. Evaluated together, these reports show an unambiguous trend. The Planning Commission’s 2012 press note revealed an urban poverty rate of 13.7%, amounting to 53 million urban poor residents in 2012.

Thus it would appear that between 1994 and 2005, although urban poverty increased in absolute numbers it decreased as a proportion of the urban population, and between 2005 and 2012 it decreased significantly, in both absolute and relative terms, to below 1994 levels. These results lead one to conclude that urban poverty has in fact reduced drastically.

These urban poverty figures are misleading, however, because they adopt what C P Chandrasekhar calls a “minimalist notion of survival”. According to the World Bank, USD 2/day represents the international median poverty line across developing nations, while USD 1.25/day represents extreme poverty. India’s INR 1,000 MPCE poverty line converts roughly to USD 0.57/day (INR 33/day), which, when crudely compared, is significantly lower than the World Bank’s standard for extreme poverty. Thus, in adopting a “minimalist notion” of what it takes to survive, the Indian government has adopted a maximalist definition of poverty -- ie in order to qualify as being poor in India one must be in the absolute depths of poverty by most global standards.

This clearly suggests that the Government of India’s urban poverty ratio of 13.7% is a gross underestimation of the real proportion of urban poor and vulnerable. The National Food Security Act 2013, issued by the Ministry of Law and Justice in The Gazette of India dated September 10, 2013, designates 50% of India’s urban population vulnerable and eligible for a minimum quantity of assured foodgrain per month at highly subsidised prices (6). With India’s urban population in 2014 estimated at over 400 million, this translates to approximately 200 million officially designated vulnerable in urban areas.

Health, nutrition and wellbeing disparities in urban India

Maternal health:In the poorest quartile of India’s urban population, only 54% of pregnant women received at least three antenatal care visits compared to 83% for the rest of the urban population. Also, a very small proportion of mothers within the poorest quartile are adequately served in most states.

Only half of all births among the poorest quartile of India’s urban population were assisted by health personnel in 2005-06, as against 83% for the rest of the urban population. The percentage of assisted births was particularly low among the poorest quartile of urban populations in Uttar Pradesh, Delhi, Bihar and Rajasthan. This proportion is likely to have increased between NFHS 3 and now, thanks to incentives provided to mothers to give birth at a government (or accredited private) hospital.

Source: Analysis of NFHS 3 by UHRC 2008

Childhood undernutrition: Undernutrition among the urban poor is 1.5 times higher than the rest of the urban population. The fact that nearly 54% of under-5 (U5) children were chronically undernourished (or stunted) among the poorest urban quartile, as per the most recent NFHS, illustrates the extent of the deprivation. Re-analysis of urban samples from NFHS 2005-06 shows that stunted U5 children in the poorest urban quartile is 2.5 times as high as those in the richest urban quartile.

Source: Analysis of NFHS 3 by UHRC 2008

Childhood mortality and immunisation: Re-analysis of NFHS 3 data reveals that the Under-5 Mortality Rate (U5MR) among the urban poor was at 72.7, significantly higher than the urban aggregate of 51.9. Similarly, only 40% of children were completely immunised in the poorest quartile, compared to 65% for the rest of the urban population. The percentage of children completely immunised was particularly low among the poorest quartile of urban populations in Uttar Pradesh, Bihar, Rajasthan and Jharkhand; it was also only 40% in Delhi. Complete immunisation in Rajasthan and Uttar Pradesh was less than 50%.

Source: Analysis of NFHS 3 by UHRC 2008

Access to piped water:Among the poorest quartile of India’s urban population in 2005-06, 81.5% did not have access to piped water at home; among the rest of the urban population, 62% had access to piped water at home.

Even in better-performing states, only half the population in the poorest quartile had piped water in their homes; the all-India figure was less than 20%, and in Delhi, the capital and one of the wealthiest cities, it was only 30%. In Bihar, just 2% of the poorest quartile had access to piped water at home. In Uttar Pradesh, the state with the largest urban population, it was just 12%.

Source: Analysis of NFHS 3 by UHRC 2008

Access to sanitary flush or pit latrines:Among the poorest quartile of India’s urban population in 2005-06, 52.8% did not use a sanitary flush or pit toilet; among the rest of the urban population, 96% used a sanitary toilet.

Considering a low 47.3% of people use pit or flush latrines, the proportion of people with flush toilets would be much lower as pit latrines are still very common in urban areas. In Bihar, Madhya Pradesh and Jharkhand, more than two-thirds of the poorest quartile did not use a flush or pit toilet to dispose of excreta. In Delhi, one-third of the poorest quartile did not have access to a sanitary toilet. Women and girls are the worst off under such conditions. Women in slums tend to eat less and drink much less water than they should, to avoid having to attend to frequent calls of nature in the absence of proper facilities and shrinking open spaces (personal observations and interaction with women during slum visits).

Source: Analysis of NFHS 3 by UHRC 2008

Data from an eight-city study:A study entitled ‘Health and Living Conditions in Eight Indian Cities’ (NFHS 2005-06: Ministry of Health and Family Welfare, Government of India) looked at a range of health, maternal health and healthcare, and environmental health indicators. With regard to undernourished children, a high proportion was stunted (height-for-age) in all the cities (as was the case in urban populations of the states, as discussed earlier). When considering total city populations, Chennai had the lowest percentage of stunted children (25.4%), while Mumbai had the highest (45.4%). Across all eight cities, the proportion of stunted children was highest among the poorest population and also consistently higher in slum populations compared to non-slum populations.

Source: Eight-City Study, NFHS 3, 2005-06

In Delhi, Meerut and Nagpur, 10-20% of slum households had no toilet facilities. In Delhi, Meerut, Indore and Nagpur more than 30% of the poorest households had no toilet facilities.

Source: Eight-City Study, NFHS 3, 2005-06

Operational challenges

Poor access to healthcare despite physical proximity
Re-analysis of the urban component of NFHS 3, presented above, clearly illustrates the disparity in access to basic healthcare that the poorest urban quartile faces. In spite of physical proximity to world-class health facilities, economic and social barriers often inhibit the urban poor from accessing these services.

The ‘National Urban Health Mission Implementation Framework’ issued by the Ministry of Health and Family Welfare, Government of India, in May 2013, after approval by the Union Cabinet on May 1, 2013, states that most existing primary health facilities, namely Urban Health Posts (UHPs), Urban Family Welfare Centres (UFWC), and dispensaries function sub-optimally due to problems with infrastructure, human resources, referrals, diagnostics, case load, spatial distribution, and inconvenient working hours. According to a report ‘Urban Health Schemes’ by the Department of Family Welfare, Government of India, 2006, distribution of ICDS (Integrated Child Development Services) and urban public health services is worse in smaller cities. Besides lack of availability, urban health centres are often not located close to slums and many are marred by inadequate health equipment and manpower (personal observations in several cities). Availability is likely to be worse at the city peripheries (Kundu N K, Kanitkar T. ‘Primary Healthcare in Urban Slums’, Economic and Political Weekly, Vol XXXVII, No 51, December 21, 2002). Similarly, anganwadi centres are often not located in or near slums and there are far fewer centres in a slum than are required to serve the entire population (personal observations in several cities). Access to a wide network of private healthcare facilities in urban areas may be an advantage only for the relatively better-off.

The ‘Evaluation Report of Integrated Child Development Services’, prepared by the Programme Evaluation Organisation, Planning Commission, Government of India, states on pages 48-49, quoting an NCAER study, that about 26% of rural mothers and 41% of rural children received ICDS services, compared with 11% of urban mothers and 18% of urban children.

Lack of services along with a degraded environment, overcrowding and high mobility within slums increases the vulnerability of slum-dwellers to infectious diseases.

Research and knowledge/information gaps
Urban health data is usually available as aggregate data masking disparities in health conditions among different segments of the urban population. Being informal or ‘illegal’, a large proportion of low-income urban clusters are not on the official slum lists and hence not represented as part of the urban poor population. As a consequence, they are often missed out in surveys and assessments. Consequently, health planning is not based on a complete understanding of the needs of the community. Lack of optimal systems for data-collection in slums results in ineffective planning, resource allocation and monitoring for infrastructure provision, programme efforts and assessment of progress.

Large proportion of urban poor not enumerated
A significant number of the urban vulnerable remain unnoticed for various reasons. According to the 65th Round (2008-09) of the NSSO, 49% of slums are non-notified in India (Ministry of Statistics and Programme Implementation, Government of India, 2008). Owing to long delays in updating official slum lists many slums remain unlisted for years and continue to be deprived of services due to their illegal status. The Urban Health Resource Centre’s (UHRC) study in Indore in 2004 showed that there were 438 officially recognised slums but a process of mapping found an additional 101 slums in 2004 (Agarwal and Taneja, 2004). In 2011-12, when the UHRC updated Indore’s slum list and estimated population for the District Health Department of Indore, it revealed a total of 633 slums in the city with an estimated population of 918,575, nearly 50% of Indore’s population. According to 2011 Census data, Indore’s population in 2011 was 1,960,631, of which 590,257 people lived in slums, accounting for around 30% of the population (Directorate of Central Operations, Madhya Pradesh, Bhopal 2011).

This trend of underreporting extends to other large cities as well. Census 2001 estimated that 49% of Mumbai’s population lived in slums. In 2006, it was estimated that 100-300 new families arrive in Mumbai every day. According to Census 2011, Greater Mumbai has a slum population of 5,206,473. However, in 2011,the Municipal Corporation of Greater Mumbai reported a slum population of 6.5 million out of a total population of around 12.5 million, amounting to roughly 52% of the population. According to Jan Nijman (Professor of Urban Studies at the University of Amsterdam), in 2008, over 50% of Mumbai’s 12 million people lived in slums (7). Given this apparent consensus, the Census 2011 slum population figure for Mumbai is very likely an underestimation.

Low awareness and weak community capacity to demand and access healthcare
Another contributing factor to poor health among slum-dwellers is low awareness and practise of recommended behaviours as well as low utilisation of services that may be available. This, coupled with little confidence, contributes to a weak demand for services. Utilisation of available government health services by recent migrant groups is particularly low. Social heterogeneity, cultural diversity, fewer extended family connections, and more women engaged in work contribute negatively to building the urban slum community as a strong collective unit. Improving access therefore constitutes a major demand-side public health challenge. Migratory trends among this segment of the population also present a problem in service delivery.

Poor family support system and weak social cohesion in slums
Unlike in rural settings, women and children do not enjoy a socially well-knit community that ensures them physical safety, a fair level of food security, and the availability of social support, often from extended family connections, for childcare. Without these safeguards, women's mobility in urban areas is limited, compromising their ability to avail of healthcare services for themselves and their children when required.

Inadequate public health infrastructure in urban slums
A single primary healthcare facility in an urban area caters to a much larger population than the norm of one centre for every 50,000-60,000 people (based on detailed situation analysis of Agra, Indore, Dehra Dun and Ranchi, conducted by a UHRC team). From the providers’ perspective, service delivery in slums constitutes a huge challenge given the large and sometimes mobile population that is usually covered by one health worker. This leaves them little scope to persuade target families to follow appropriate behaviour patterns. Also, there is an imbalanced focus on curative care and a consequent near-total neglect of preventive and promotive care. In most cities, particularly in large ones, too much emphasis is put on super-specialty care centres in the private sector which are clearly out of the reach of the urban poor.

High staff turnover, frequent transfers, absenteeism, inadequately skilled staff and lack of supportive supervision hinder effective implementation of services. The large number of medical and paramedical staff positions, absence of modalities and adequately maintained records also contribute to a weakness of services.

Poor coordination among different stakeholders
State health departments, municipal bodies, JNNURM or Rajiv Awas Yojana Urban Poverty Alleviation Cells in urban local bodies, ICDS, NGOs and charitable organisations are all responsible for providing services in urban areas. There is poor coordination between the agencies, and service areas often overlap, with large areas offering no services at all. The absence of a well-plotted updated city map indicating slums, informal settlements, pavement-dwellers, small poverty clusters and facilities leads to the crowding of primary care facilities in a small area of the city, usually its centre (personal observations after city mapping in several cities). Slums/deprived settlements located on the fringes are often served neither by rural nor urban health staff (author’s personal observations in Indore, Agra, Dehra Dun).

How can the urban healthcare system be better designed and operationalised?
The reach and quality of health and wellbeing services vary across urban settings. A number of factors, in different contexts, impact the health and wellbeing of urban disadvantaged populations. Illness identification at the household level, prompt care-seeking, and care delivery are three constituents essential for effective utilisation of healthcare services. Fundamental public health services such as vaccination, safe water supply and sanitation, oral rehydration therapy, timely antenatal care, safe deliveries, newborn and infant care, and childhood immunisation continue to be important. Data-collection at the primary urban health centre and at the city level is necessary to properly understand the needs of the urban community and generate precise data to improve implementation, resource allocation and resource utilisation.

Addressing social determinants of health through coordinated interventions
There are a number of different sectors and avenues through which strategic interventions may be used to positively influence the health of urban disadvantaged populations:

  • Physical, environmental and infrastructure services.
  • Health, nutrition and food subsidy services.
  • Poverty-alleviation and livelihood-improvement programmes.
  • Gender inequity, alcoholism, domestic violence and other social ills.
  • Building social capital among slum communities and associated governance-improvement efforts.

Generating community demand for healthcare services
The more communities know about which health services are available, and which are relevant to them, the more likely they are to seek these out.

Establishing public private partnerships to coordinate efforts
Partnerships between the private sector and NGOs is emerging as an important strategy in improving access to services for vulnerable and neglected sections of the urban population.

Building the capacity of slum communities
While each of these recommendations is important, it is crucial to enable urban slum/vulnerable communities to overcome four socio-behavioural issues: an attitude of resignation; weak demand for rights; low social cohesion; a sense of powerlessness.

Translating words into action
While urban health has been recognised by the government as a thrust area since implementation of the National Population Policy (NPP) 2000 and National Health Policy (NHP) 2002, actual progress has been slow. The Tenth Five-Year Plan (Planning Commission, 2002) and the Reproductive and Child Health Programme, Phase II (RCH II) clearly recognised the failure of the existing health delivery system in India’s urban areas to effectively address the health needs of vulnerable urban populations living in slums, informal settlements, construction sites, brick and lime kilns and other disadvantaged habitations.

Meanwhile, policy developments have continued:

  • MoHFW’s Urban Slum Health Project Guidelines issued in 2004.
  • MoHFW’s National Task Force to Advise the National Rural Health Mission on strategies for urban healthcare (2005-06).
  • National Urban Health Mission (NUHM), beginning 2006 and announced several times, including more recently in 2013.
  • Basic services to the urban poor component of the Jawaharlal Nehru National Urban Renewal Mission (2006 onwards) and the more recent Rajiv Awas Yojana (RAY), 2010, of the Ministry of Housing and Urban Poverty-Alleviation which includes provision of resources for preventive health action.
  • Amendments in the approach of the ICDS scheme to integrate urban deprived areas and shift some focus towards the urban poor (Government of India, 2013).
  • The Supreme Court’s order for anganwadis to be on ‘demand’ in slums and informal settlements.
  • Continued mandate and resource allocation for urban health, with a focus on slums and deprived urban settlements in the government’s Tenth, Eleventh and Twelfth Five-Year Plans have helped bring urban deprivation to light.

It is encouraging to see direct policies and programmes now focusing on vulnerable segments of India’s booming cities, as a consequence of which the situation of the urban poor should, hopefully, improve. Now that NUHM has been accepted and is ready to be rolled out, the emphasis should be on increasing availability, inclusive access and acceptability of public health services particularly in slums and vulnerable urban areas. There is no need to reinvent the wheel through technical task forces, consultations, deliberations. It is time to build on existing experiences and lessons to develop and expeditiously implement effective and efficient programme processes that set context-specific examples of what success and good practices look like in a wide variety of urban Indian settings.

(The author acknowledges the views contributed by slum communities from a large number of cities, the insight gained through interaction with stakeholders from municipal/city health and other departments/ministries, and the assistance of Vivek Bhatnagar and Neeraj Verma in updating the data cited in this paper)

(Siddharth Agarwal is a physician by training and works in research and programming in public health, nutrition, community empowerment, urban health and policy support. He is Director of the Urban Health Resource Centre, that addresses the health and nutrition of 500,000 disadvantaged urban-dwellers through demonstration programmes in partnership with slum communities and government departments. He has assessed and observed urban health and wellbeing programmes in Nairobi, Ethiopia, Bangladesh and New York. He has been a member of several committees and expert groups on urban health. He is Adjunct Faculty at Johns Hopkins Bloomberg School of Public Health and in the Department of Global Health at George Washington University School of Public Health and Health Services, and has served as Guest Faculty at the University of California, Berkeley, TERI University, Indian Institute of Public Health, Delhi)

1 United Nations Population Fund, 2007
2 United Nations, 2011
3 World Urbanisation Prospects, 2011 Revision
4 Report of the Technical Group on Population Projections constituted by the National Commission on Population
5 Government of India. Planning Commission. ‘Report of the Expert Group to Review the Methodology for Estimation of Poverty’. New Delhi. Planning Commission, 2009.
6 Government of India. Ministry of Law and Justice. The National Food Security Act, 2013. New Delhi. The Gazette of India, September 10, 2013.
7 Nijman, Jan. ‘Against the Odds: Slum Rehabilitation in Neoliberal Mumbai’. Cities 25.2 (2008). 73-85

United Nations Population Fund, 2007

United Nations, 2011

World Urbanisation Prospects, 2011 Revision

Report of the Technical Group on Population Projections constituted by the National Commission on Population

Government of India. Planning Commission. Report of the Expert Group to Review the Methodology for Estimation of Poverty. New Delhi. Planning Commission, 2009.

Government of India. Ministry of Law and Justice. The National Food Security Act, 2013. New Delhi. The Gazette of India, September 10, 2013.

Nijman, Jan. ‘Against the Odds: Slum Rehabilitation in Neoliberal Mumbai’. Cities 25.2 (2008). 73-85

Urban Health Resource Centre. Health of the Urban Poor in India. Key results from the re-analysis of NFHS 3, 2005- 6 data by wealth index quartiles (wall chart). New Delhi, India. Urban Health Resource Centre, 2008. Available from: Accessed June 2014

Pain, Paromita. ‘Urban Health Resource Centre, Empowering Women to Work for Health’. TerraGreen Magazine, March 2013. Web: June 6, 2014

Kundu N K, Kanitkar T. ‘Primary Healthcare in Urban Slums’. Economic and Political Weekly, Vol XXXVII, No 51, December 21, 2002, October 2014


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