Urban Health Updates
The Limits and Possibilities of Prepaid Water in Urban Africa: Lessons from the Field, 2014.
Authors: Chris Heymans, Kathy Eales and Richard Franceys. Water and Sanitation Program.
This study explores the potential of prepaid meters for serving urban poor communities. It provides urban utilities, oversight agencies, and other stakeholders in Africa with a basis for decision-making on the suitability, introduction, and management of such meters. The need for the assessment emerged from prepaid meters.
Of the three applications, prepaid public standpipes seem most likely to enable water utilities to serve poor households better and offset investment and running costs. This capability is contingent on a distribution network with adequate pressure, the existence of convenient credit purchase points, and a strong customer service component to address faults promptly.
This report identifies and discusses key areas in which policy reform, improved regulation, and innovative operational practice could help make the use of prepaid water systems conducive to serving poor people. Key suggestions about the way forward include:
Be clear about the priority: Reaching people without their own connections. Prepaid systems’ core potential is in addressing the fact that many urban Africans still do not have their own water connections and remain outside the reach of subsidy regimes. Prepayment does not offer an obvious answer to these challenges, but some of these systems’ attributes may provide a tool for addressing them in certain circumstances.
Running water in India’s cities : a review of five recent public-private partnership initiatives, 2014. World Bank.
Authors: Kacker, Suneetha Dasappa; Ramanujam, SR; Miller, Tracey.
India is home to more than 370 million people in urban areas. Historically, almost all water supply provision has been managed by the public sector through municipal or state-level departments or parastatals. Benchmarking initiatives show that coverage through piped water supply ranges between 55 percent and 89 percent in urban areas. Per capita availability is fairly high, at 90 to 120 liters per day, but no city yet offers continuous water supply. Daily supply averages four hours, with many cities alternating supply every other day.
These challenges occur in a context of weak management systems and little data on existing assets, which makes it difficult to assess investment needs and time lines to improve service levels and operational efficiencies. While investment requirements are likely to be significant, it is recognized that investments alone will not be effective unless the country simultaneously addresses related issues such as complex and fragmented institutions with little accountability; lack of capacity to run utilities efficiently and meet performance standards; weak commercial orientation; interference in utility operations by external entities; and the absence of a regulatory framework focused on customer service and financial sustainability.
Vulnerability to Food Insecurity in Urban Slums: Experiences from Nairobi, Kenya. Journal of Urban Health,
Authors: E. W. Kimani-Murage, L. Schofield, F. Wekesah, S. Mohamed, B. Mberu, R. Ettarh, T. Egondi, C. Kyobutungi, A. Ezeh
This study describes the food security situation among slum residents in Nairobi, with specific focus on vulnerability associated with the 2007/2008 post election crisis in Kenya. The study found high prevalence of food insecurity; 85 % of the households were food insecure, with 50 % being severely food insecure. Factors associated with food security include level of income, source of livelihood, household size, dependence ratio; illness, perceived insecurity and slum of residence. The qualitative narratives highlighted household vulnerability to food insecurity as commonplace but critical during times of crisis.
Respondents indicated that residents in the slums generally eat for bare survival, with little concern for quality. The narratives described heightened vulnerability during the 2007/2008 post election violence in Kenya in the perception of slum residents. Prices of staple foods like maize flour doubled and simultaneously household purchasing power was eroded due to worsened unemployment situation. The use of negative coping strategies to address food insecurity such as reducing the number of meals, reducing food variety and quality, scavenging, and eating street foods was prevalent.
In conclusion, this study describes the deeply intertwined nature of chronic poverty and acute crisis, and the subsequent high levels of food insecurity in urban slum settings. Households are extremely vulnerable to food insecurity; the situation worsening during periods of crisis in the perception of slum residents, engendering frequent use of negative coping strategies. Effective response to addressing vulnerability to household food insecurity among the urban poor should focus on both the underlying vulnerabilities of households due to chronic poverty and added impacts of acute crises.
Levels & Trends in Child Mortality: Report 2014. UNICEF.
Substantial global progress has been made inreducing child deaths since 1990. The number ofunder-five deaths worldwide has declined from12.7 (12.5, 12.9)1 million in 1990 to 6.3 (6.1, 6.7)million in 2013. While that translates into around17,000 fewer children dying every day in 2013than in 1990, it still implies the deaths of about17,000 children under age five every day in 2013.
The leading causes of death among childrenunder age five include preterm birth complications (17 percent of under-five deaths),pneumonia (15 percent), intrapartum-relatedcomplications (complications during labour anddelivery; 11 percent), diarrhoea (9 percent) andmalaria (7 percent). Globally, nearly half of under-five deaths are attributable to undernutrition.
The global under-five mortality rate is fallingfaster than at any other time during thepast two decades. The global annual rateof reduction has steadily accelerated since1990–1995—more than tripling from 1.2percent to 4.0 percent in 2005–2013.
Designing the next generation of sanitation businesses: a report by HYSTRA for the Toilet Board Coalition, 2014.
Fortunately, a number of market-based models have emerged in both rural and urban areas to address the sanitation crisis. They all serve the Base of the Pyramid in a sustainable manner by offering improved solutions, at a price that the poor are willing and able to pay. In this Report, we analyze two models that combine an aspirational value proposition for low-income families and a strong potential for financial sustainability: projects that facilitate the creation of a local, sanitation market in rural areas and enterprises servicing home mobile toilets in urban areas.
Based on an in-depth analysis of 12 projects representative of these two models, the Report suggests strategies to overcome challenges to sustainability and scale. Finally, the Report explores how these models would benefit from corporate and industrial expertise and resources, opening up opportunities for large corporations to contribute to solving the sanitation crisis.
Population and Health Dynamics in Nairobi’s Informal Settlements, 2014. African Population and Health Research Center (APHRC).
This report documents the living conditions and health risks of slum-dwellers across Nairobi’s informal settlements a decade after the Nairobi Cross-sectional Slums Survey of 2000 (NCSS 2000). It aims to not only highlight the needs of slum-dwellers but also inform policymakers on the changes that have occurred in the living conditions of Nairobi’s urban poor since 2000, considering development interventions by the Government of Kenya (GoK) and its development partners. The primary objective of the NCSS 2000 report was to document population and health problems among the residents of Nairobi’s informal settlements and to compare these with indicators from national surveys for other sub-groups of the Kenyan population. The survey report, Population and Health Dynamics in Nairobi‘s Informal Settlements, for the first time brought to light the plight of slum residents in Kenya.
Hitherto, this plight had remained hidden in national data systems and urban averages. In particular, the survey brought to focus the excess mortality and disease burden among the urban poor compared to any other subgroup in the country; their limited access to health care and family planning services; and the debilitating environment that characterizes their physical living conditions, including inadequate access to water and sanitation, poor housing conditions, poor livelihood opportunities and the near-absence of public sector services. A decade after the NCSS 2000, it became critical to revisit the slums of Nairobi to take stock of the changes that had taken place since 2000. The current report is guided by these key questions:
- Are the needs of the slum-dwellers still the same?
- What has really changed since the last report?
- What are the new areas of focus to improve the well-being of the slum-dwellers?
Urbanization and health in developing countries: a systematic review. World Health Popul. 2014;15(1):7-20.
Authors: Eckert S, Kohler S. Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Center, Berlin, Germany.
BACKGROUND: Future population growth will take place predominantly in cities of the developing world. The impact of urbanization on health is discussed controversially. We review recent research on urban-rural and intra-urban health differences in developing countries and investigate whether a health advantage was found for urban areas.
METHODS: We systematically searched the databases JSTOR, PubMed, ScienceDirect and SSRN for studies that compare health status in urban and rural areas. The studies had to examine selected World Health Organization health indicators.
RESULTS: Eleven studies of the association between urbanization and the selected health indicators in developing countries met our selection criteria. Urbanization was associated with a lower risk of undernutrition but a higher risk of overweight in children. A lower total fertility rate and lower odds of giving birth were found for urban areas. The association between urbanization and life expectancy was positive but insignificant. Common risk factors for chronic diseases were more prevalent in urban areas. Urban-rural differences in mortality from communicable diseases depended on the disease studied.
CONCLUSION: Several health outcomes were correlated with urbanization in developing countries. Urbanization may improve some health problems developing countries face and worsen others. Therefore, urbanization itself should not be embraced as a solution to health problems but should be accompanied by an informed and reactive health policy.
Sustained high incidence of injuries from burns in a densely populated urban slum in Kenya: An emerging public health priority
Sustained high incidence of injuries from burns in a densely populated urban slum in Kenya: An emerging public health priority. Burns, Volume 40, Issue 6, September 2014, Pages 1194–1200.
Authors: Joshua M. Wonga, et al.
Introduction – Ninety-five percent of burn deaths occur in low- and middle-income countries (LMICs); however, longitudinal household-level studies have not been done in urban slum settings, where overcrowding and unsafe cook stoves may increase likelihood of injury.
Methods- Using a prospective, population-based disease surveillance system in the urban slum of Kibera in Kenya, we examined the incidence of household-level burns of all severities from 2006–2011.
Results – Of approximately 28,500 enrolled individuals (6000 households), we identified 3072 burns. The overall incidence was 27.9/1000 person-years-of-observation. Children <5 years old sustained burns at 3.8-fold greater rate compared to (p < 0.001) those ≥5 years old. Females ≥5 years old sustained burns at a rate that was 1.35-fold (p < 0.001) greater than males within the same age distribution. Hospitalizations were uncommon (0.65% of all burns).
Conclusions – The incidence of burns, 10-fold greater than in most published reports from Africa and Asia, suggests that such injuries may contribute more significantly than previously thought to morbidity in LMICs, and may be increased by urbanization. As migration from rural areas into urban slums rapidly increases in many African countries, characterizing and addressing the rising burden of burns is likely to become a public health priority.
The urban water supply guide: service delivery options for low-income communities, 2014.
Water and Sanitation for the Urban Poor.
Providing improved water supply to low-income urban communities is a difficult challenge faced by water utilities throughout Africa and Asia. This guide provides an introduction to available options for serving these communities. The guide draws on sector experience in general, and more particularly on WSUP’s extensive experience of implementing urban WASH programmes in sub-Saharan Africa and elsewhere.
This guide is aimed primarily at executive and technical staff in water utilities and related organisations, such as asset-holders and regulators. It will also be useful for WASH professionals working in governments, development agencies, funding agencies or civil society organisations.
Metabolized-water breeding diseases in urban India: Socio-spatiality of water problems and health burden in Ahmedabad
Metabolized-water breeding diseases in urban India: Socio-spatiality of water problems and health burden in Ahmedabad, 2014.
Subramanian, Saravanan V., et al. Center for Development Research, University of Bonn.
The paper brings together urban metabolism, political ecology and anthropological studies to examine how the material flow of water is socially constructed and reconstructed through everyday water problems and its health burden in Ahmedabad city, India. The article geo-references the water problems and occurrence of diseases and through interviews documents the socio-spatial characteristics of water problems and health burden in two case study wards. The paper provides a situated understanding of the everyday practices that exposes the water infrastructure through leakages, reveals the citizens desire for better water quality and struggle to gain access to water using diverse ‚pressure‘ tactics.
It is this social-material construct of infrastructure that gives structure and coherence to urban space, which spatially coincides with the occurrence of diseases. The analysis reveals the socio-political drivers of the water problems, spatial inequity in water access, and identify potential hypothesis of the hotspots of disease emergences. Attempts to bring about a desired change have to be collective and incremental that takes into consideration the diffuse interplay of power by diverse actors in managing the flow of water. The methodology offers a way forward for researchers and development agencies to improve the surveillance and monitoring of water infrastructure and public health. By bringing ‚place-based‘ and ‚people-based‘ approach, the analysis charts out avenues for incorporating the socio-spatiality of the everyday problems within the field of urban metabolism for improving resource use efficiencies in cities of rapidly growing economies.
Unintended Pregnancies among Young Women Living in Urban Slums: Evidence from a Prospective Study in Nairobi City, Kenya
Unintended Pregnancies among Young Women Living in Urban Slums: Evidence from a Prospective Study in Nairobi City, Kenya. PLoS One, July 2014.
Donatien Beguy, et al.
Background: Despite the significant proportion of young people residing in slum communities, little attention has beenpaid to the sexual and reproductive health (SRH) challenges they face during their transition to adulthood within this harshenvironment. Little is known about the extent to which living in extreme environments, like slums, impact SRH outcomes,especially during this key developmental period. This paper aims to fill this research gap by examining the levels of andfactors associated with unintended pregnancies among young women aged 15–22 in two informal settlements in Nairobi,Kenya.
Methods: We use data from two waves of a 3-year prospective survey that collected information from adolescents living inthe two slums in 2007–2010. In total, 849 young women aged 15–22 were considered for analysis. We employed Cox andlogistic regression models to investigate factors associated with timing of pregnancy experience and unintended pregnancyamong adolescents who were sexually active by Wave 1 or Wave 2.
Findings: About two thirds of sexually experienced young women (69%) have ever been pregnant by Wave 2. For 41% of adolescents, the pregnancies were unintended, with 26% being mistimed and 15% unwanted. Multivariate analysis shows asignificant association between a set of factors including age at first sex, schooling status, living arrangements and timing ofpregnancy experience. In addition, marital status, schooling status, age at first sex and living arrangements are the only factors that are significantly associated with unintended pregnancy among the young women.
Conclusions: Overall, this study underscores the importance of looking at reproductive outcomes of early sexual initiation, the serious health risks early fertility entail, especially among out-of school girls, and sexual activity in general among young women living in slum settlements. This provides greater impetus for addressing reproductive behaviors among youngwomen living in resource-poor settings such as slums
Shelter from the Storm: Upgrading Housing Infrastructure in Latin American Slums, 2014.
Sebastián Galiani, Paul Gertler, Ryan Cooper, Sebastián Martínez, Adam Ross, Raimundo Undurraga. InterAmerican Development Bank.
This paper provides empirical evidence on the causal effects that upgrading slum dwellings has on the living conditions of the extremely poor. In particular, we study the impact of providing better houses in situ to slum dwellers in El Salvador, Mexico and Uruguay. We experimentally evaluate the impact of a housing project run by the NGO TECHO which provides basic pre-fabricated houses to members of extremely poor population groups in Latin America. The main objective of the program is to improve household well-being. Our findings show that better houses have a positive effect on overall housing conditions and general well-being: treated households are happier with their quality of life. In two countries, we also document improvements in children’s health; in El Salvador, slum dwellers also feel that they are safer. We do not find this result, however, in the other two experimental samples. There are no other noticeable robust effects on the possession of durable goods or in terms of labor outcomes. Our results are robust in terms of both internal and external validity because they are derived from similar experiments in three different Latin American countries.
Urbanisation Concepts and Trends, 2014.
Authors: Gordon McGranahan, David Satterthwaite. International Institute for Environment and Development.
There is an emerging consensus that urbanisation is critically important to international development, but considerable confusion over what urbanisation actually is, whether it is accelerating or slowing, whether it should be encouraged or discouraged, and more generally what the responses should be. This Working Paper reviews some key conceptual issues and summarises urbanisation trends. It ends with a brief review of urbanisation and sustainable development, concluding that while urbanisation brings serious challenges, attempts to inhibit urbanization through exclusionary policies are likely to be economically, socially and environmentally damaging. Moreover, with the right support urbanisation can become an important element of sustainable development.
Fecal Sludge Management Services in Lusaka: Moving Up the Excreta Management Services, 2014. Water and Sanitation for the Urban Poor.
Despite most residents of African and Asian cities depending on non-sewered sanitation, only a handful of sanitation authorities have addressed the management of faecal sludge from these systems. This Practice Note describes the launch of a faecal sludge management (FSM) service in the peri-urban area of Kanyama.
March 9-12, 2015 – International Conference on Urban Health, Dhaka, Bangladesh – Urban Health for a Sustainable Future: Post 2015 Agenda
ICUH 2015 will be unique. Why? Because this will be the first ICUH in South Asia, and Bangladesh is very important to the region’s development.
The hosting of the conference in Bangladesh is meaningful at a time in the country’s development with the realization of importance of urban health for sustainable development. The conference will also have significant relevance globally.ICUH 2015 will promote the idea that we need to think of urbanization with its impact on environment, economy and social factors which will benefit all segments of the population. It will aim to address to sustain urbanization in such a way that promotes equality, development and health.
The major objective of the ICUH is to gather scientists, practitioners, policy makers and community organizations across disciplines and geographic boundaries (high and low-income settings), to exchange ideas and advance research and practice that promote the health of individuals who are in urban regions, including those individuals who belong to disadvantaged groups. The conference aims to promote trans disciplinary and collaborative research, policy, and interventions, to foster international discussion of urban health issues, to build networks among individuals engaged in urban health, and to promote the understanding of the impact of urban areas on health and behavior. ICUH 2015 aims to focus on post 2015 development agenda on urban health.
Urban Development in Sub-Saharan Africa: Bearer of Goods and Risks. PLoS Medicine, July 2014.
Authors: Fahad Raza, et al.
Sub-Saharan Africa remains the least urbanized region of the world and more than 60% of the population, 570 million people, still live in rural areas . Over the next few decades Africa will be one of the most rapidly urbanizing regions , and with this transition is an expected rise in cardiovascular risk factors and disease (CVD) . Across sub-Saharan Africa, many adults migrate back and forth from rural home communities to more urban areas for work and education; others have moved to urban areas; and in still other cases, rural communities themselves have urbanized.
In this issue of PLOS Medicine, a study by Riha and colleagues is directly concerned with the latter scenario within the context of urbanizing rural Uganda . As the authors aptly note, the crude dichotomy of urban-rural difference obscures the changes occurring within rural regions themselves, as characteristics of urban environments, defined as urbanicity , become more prominent. Urbanization is a complex worldwide phenomenon and challenges global populations to re-calibrate a set of far reaching behaviors as the meaning of communities change, networks widen, and globalization influences attitudes and access to new resources. Some of these phenomena are likely to be health promoting, while others expose formerly rural populations to new risks.
Diarrhoea in slum children: observation from a large diarrhoeal disease hospital in Dhaka, Bangladesh.
Diarrhoea in slum children: observation from a large diarrhoeal disease hospital in Dhaka, Bangladesh. Trop Med Int Health, 2014 Jul 18. doi: 10.1111/tmi.12357. |Order information|
Authors: Ferdous F1, Das SK, Ahmed S, Farzana FD, Malek MA, Das J, Latham JR, Faruque AS, Chisti MJ.
1International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh; Department of Clinical Trial and Clinical Epidemiology, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan.
OBJECTIVES: To determine and compare socio-demographic, nutritional and clinical characteristics of children under five with diarrhoea living in slums with those of children who do not live in slums of Dhaka, Bangladesh.
METHODS: From 1993 to 2012, a total of 28 948 under fives children with diarrhoea attended the Dhaka Hospital of icddr,b. Data were extracted from the hospital-based Diarrhoea Disease Surveillance System, which comprised 17 548 under fives children from slum and non-slum areas of the city.
RESULTS: Maternal illiteracy [aOR = 1.57; 95% confidence interval (1.36, 1.81), P-value <0.001], paternal illiteracy [1.37 (1.21, 1.56) <0.001], mother’s employment [1.59 (1.37, 1.85) <0.001], consumption of untreated water [2.73 (2.26, 3.30) <0.001], use of non-sanitary toilets [3.48 (3.09, 3.93) <0.001], 1st wealth quintile background [3.32 (2.88, 3.84) <0.001], presence of fever [1.14 (1.00, 1.29) 0.047], some or severe dehydration [1.21 (1.06, 1.40) 0.007], stunting [1.14 (1.01, 1.29) 0.030] and infection with Vibrio cholerae [1.21 (1.01, 1.45) 0.039] were significantly associated with slum-dwelling children after controlling for co-variates. Measles immunisation [0.52 (0.47, 0.59) P < 0.001] and vitamin A supplementation rates [0.36 (0.31, 0.41) P < 0.001] amongst children 12-59 months were lower for slum dwellers than other children in univarate analysis only.
CONCLUSIONS: Slum-dwelling children are more malnourished, have lower immunisation rates (measles vaccination and vitamin A supplementation) and higher rates of measles, are more susceptible to diarrhoeal illness due to V. cholerae and suffer from severe dehydration more often than children from non-slum areas. Improved health and nutrition strategies should give priority to children living in urban slums.
Trends in childhood mortality in Kenya: The urban advantage has seemingly been wiped out. Health & Place, Sept 2014.
Authors: E.W. Kimani-Muragea, et al.
Background – We describe trends in childhood mortality in Kenya, paying attention to the urban–rural and intra-urban differentials.Methods - We use data from the Kenya Demographic and Health Surveys (KDHS) collected between 1993 and 2008 and the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) collected in two Nairobi slums between 2003 and 2010, to estimate infant mortality rate (IMR), child mortality rate (CMR) and under-five mortality rate (U5MR). Results - Between 1993 and 2008, there was a downward trend in IMR, CMR and U5MR in both rural and urban areas. The decline was more rapid and statistically significant in rural areas but not in urban areas, hence the gap in urban–rural differentials narrowed over time. There was also a downward trend in childhood mortality in the slums between 2003 and 2010 from 83 to 57 for IMR, 33 to 24 for CMR, and 113 to 79 for U5MR, although the rates remained higher compared to those for rural and non-slum urban areas in Kenya. Conclusions - The narrowing gap between urban and rural areas may be attributed to the deplorable living conditions in urban slums. To reduce childhood mortality, extra emphasis is needed on the urban slums
Peri-Urban Sanitation and Water Service Provision: Challenges and opportunities for developing countries
Peri-Urban Sanitation and Water Service Provision: Challenges and opportunities for developing countries, 2014.
Jennifer McConville and Hans Bertil Wittgren (eds). Stockholm Environment Institute.
The challenges facing peri-urban areas may seem daunting, especially because many of them are interlinked and subject to frequent change, which brings greater complexity. However, when problems are interconnected, there can also be opportunities for synergetic and cross-cutting solutions, and rapid change creates space for effective innovation.Thus, despite the challenges, peri-urban areas can also offer rich opportunities. Decentralization of institutional arrangements has had the effect of slowly increasing the mandates and capacity of local government in PUAs, and there is growing recognition of the role that informal and community-based sectors play in urban economics and development. The lack of services in PUAs can present market opportunities for new actors, while weak regulations and competition Anna Norströmfor resources can stimulate innovation.
PUAs can provide openings to change existing, often ineffective, approaches to service delivery. There is room to develop new regulatory procedures, approaches to planning, financing schemes and innovative governance. Many peri-urban residents are already resorting to alternative approaches to service provision, which can be improved and up-scaled to meet demands. There are also opportunities to make the most of the urban-rural divide.
Maternal health care utilization in Nairobi and Ouagadougou: evidence from HDSS. Global Health Action, July 2014.
Authors: Clementine Rossier, et al.
Background: Maternal mortality is higher and skilled attendance at delivery is lower in the slums of Nairobi(Kenya) compared to Ouagadougou (Burkina Faso). Lower numbers of public health facilities, greater distance to facilities, and higher costs of maternal health services in Nairobi could explain these differences.
Objective: By comparing the use of maternal health care services among women with similar characteristics in the two cities, we will produce a more nuanced picture of the contextual factors at play.
Design: We use birth statistics collected between 2009 and 2011 in all households living in several poor neighborhoods followed by the Nairobi and the Ouagadougou Health and Demographic Surveillances Systems (n3,346 and 4,239 births). We compare the socioeconomic characteristics associated with antenatalcare (ANC) use and deliveries at health facilities, controlling for demographic variables.
Results: ANC use is greater in Nairobi than in Ouagadougou for every category of women. In Ouagadougou,there are few differentials in having at least one ANC visit and in delivering at a health facility; however,differences are observed for completing all four ANC visits. In Nairobi, less-educated, poorer, non-Kikuyuwomen, and women living in the neighborhood farther from public health services have poorer ANC and deliver more often outside of a health facility.
Conclusions: These results suggest that women are more aware of the importance of ANC utilization inNairobi compared to Ouagadougou. The presence of numerous for-profit health facilities within slums inNairobi may also help women have all four ANC visits, although the services received may be of substandardquality. In Ouagadougou, the lack of socioeconomic differentials in having at least one ANC visit and in delivering at a health facility suggests that these practices stem from the application of well-enforced maternal health regulations; however, these regulations do not cover the entire set of four ANC visits.