The state of urban health in India

Environment and Urbanization, April 2011

The state of urban health in India; comparing the poorest quartile to the rest of the urban population in selected states and cities

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Siddharth Agarwal, Urban Health Resource Centre (UHRC), siddharth@uhrc.in; sids62@yahoo.com

India has the world’s second largest urban population (after China). This paper shows the large disparities within this urban population in health-related indicators. It shows the disparities for child and maternal health, provision for health care and housing conditions between the poorest quartile and the rest of the urban population for India and for several of its most populous states. In the poorest quartile of India’s urban population, only 40 per cent of 12 to 23 month-old children were completely immunized in 2004—2005, 54 per cent of under-five year-olds were stunted, 82 per cent did not have access to piped water at home and 53 per cent were not using a sanitary flush or pit toilet.

The paper also shows the large disparities in eight cities between the poorest population (the population in the city that is within the poorest quartile for India’s urban areas), the population living in settlements classified as “slums” and the non-slum population. It also highlights the poor performance in some health-related indicators for the population that is not part of the poorest quartile in several states — for instance in under-five mortality rates, in the proportion of stunted children and in the proportion of households with no piped water supply to their home.

Maternal and neonatal health expenditure in mumbai slums (India)

BMC Public Health. 2011 Mar 8;11:150.

Maternal and neonatal health expenditure in mumbai slums (India):  A cross sectional study.

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Skordis-Worrall J, et al. UCL Centre for International Health and Development, Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK. j.skordis-worrall@ucl.ac.uk.

BACKGROUND: The cost of maternity care can be a barrier to access that may increase maternal and neonatal mortality risk. We analyzed spending on maternity care in urban slum communities in Mumbai to better understand the equity of spending and the impact of spending on household poverty.

METHODS: We used expenditure data for maternal and neonatal care, collected during post-partum interviews. Interviews were conducted in 2005-2006, with a sample of 1200 slum residents in Mumbai (India). We analysed expenditure by socio-economic status (SES), calculating a Kakwani Index for a range of spending categories. We also calculated catastrophic health spending both with and without adjustment for coping strategies. This identified the level of catastrophic payments incurred by a household and the prevalence of catastrophic payments in this population. The analysis also gave an understanding of the protection from medical poverty afforded by coping strategies (for example saving and borrowing).

RESULTS: A high proportion of respondents spent catastrophically on care. Lower SES was associated with a higher proportion of informal payments. Indirect health expenditure was found to be (weakly) regressive as the poorest were more likely to use wage income to meet health expenses, while the less poor were more likely to use savings. Overall, the incidence of catastrophic maternity expenditure was 41%, or 15% when controlling for coping strategies. We found no significant difference in the incidence of catastrophic spending across wealth quintiles, nor could we conclude that total expenditure is regressive.

CONCLUSIONS: High expenditure as a proportion of household resources should alert policymakers to the burden of maternal spending in this context. Differences in informal payments, significantly regressive indirect spending and the use of savings versus wages to finance spending, all highlight the heavier burden borne by the most poor. If a policy objective is to increase institutional deliveries without forcing households deeper into poverty, these inequities will need to be addressed. Reducing out-of-pocket payments and better regulating informal payments should have direct benefits for the most poor. Alternatively, targeted schemes aimed at assisting the most poor in coping with maternal spending (including indirect spending) could reduce the household impact of high costs.

Using formative research to develop MNCH programme in urban slums in Bangladesh

BMC Public Health. 2010 Nov 2;10(1):663.

Using formative research to develop MNCH programme in urban slums in Bangladesh: experiences from MANOSHI, BRAC.

Ahmed SM, Hossain A, Khan MA, Mridha MK, Alam A, Choudhury N, Sharmin T, Afsana K, Bhuiya A.

Research and Evaluation Division, BRAC 75 Mohakhali, Dhaka 1212, Bangladesh. ahmed.sm@brac.net.

BACKGROUND: MANOSHI, an integrated community-based package of essential Maternal, Neonatal and Child Health (MNCH) services is being implemented by BRAC in the urban slums of Bangladesh since 2007. The objective of the formative research done during the inception phase was to understand the context and existing resources available in the slums, to reduce uncertainty about anticipated effects, and develop and refine the intervention components.

Examining the ‘‘Urban Advantage’’ in Maternal Health Care

PLOS Medicine – September 2010 | Volume 7 | Issue 9 | e1000327

Examining the ‘‘Urban Advantage’’ in Maternal Health Care in Developing Countries

Full-text: http://www.plos.org/press/plme-07-09-channon.pdf

Zoe¨ Matthews1, Amos Channon1*, Sarah Neal1, David Osrin2, Nyovani Madise1, William Stones3

1 Division of Social Statistics and Centre for Global Health, Population, Poverty, and Policy, University of Southampton, Southampton, United Kingdom, 2 UCL Centre for International Health and Development, Institute of Child Health, London, United Kingdom, 3 Aga Khan University, Nairobi, Kenya

Summary Points

• Although recent survey data make it possible to examine inequalities in maternal and newborn health care in developing countries, analyses have not tended to take into consideration the special nature of urban poverty.
• Using improved methods to measure urban poverty in 30 countries, we found substantial inequalities in maternal and newborn health, and in access to health care.
• The ‘‘urban advantage’’ is, for some, non-existent. The urban poor do not necessarily have better access to services than the rural poor, despite their proximity to services.
• There are two main patterns of urban inequality in developing countries: (1) massive exclusion, in which most of the population do not have access to services, and (2) urban marginalisation, in which only the poor are excluded. At a country level, these two types of inequality can be further subdivided on the basis of rural access levels.
• Inequity is not mandatory. Patterns of health inequality differ with context, and there are examples of countries with relatively small degrees of urban inequity.
• Women and their babies need to have access to care, especially around the time of birth. Different strategies to achieve universal coverage in urban areas are needed according to urban inequality typology, but the evidence for what works is restricted to a few case studies.