Urbanization, Migration, India’s Urban Poor and their Problem of Access to Well-being: Health, Sanitation and Housing

India’s economic growth hinges on the mobility of labour within the country. The contribution of the migrant workforce to India’s total national income is large. However, very little is done by the state governments, in terms of provisions for basic well-being, including healthcare services, sanitation, housing and social security for migrant populations living in urban areas.

Migration and the Urban Economy

About 34% of India’s population lives in urban areas. Around 120 million people have migrated to urban areas from rural areas, as they lack the resources and opportunities for employment. 

Due to lack of sufficient skills, knowledge and bargaining power, migrant workers are forced to work in informal sectors at low wages in the urban areas. Almost one-third of the Indian-urban population live in overcrowded slum settlements with poor facilities for basic necessities including water supply, electricity and toilets. The UN-Habitat has estimated India’s total slum population to cross 200 million by 2020.

Poor vs Urban poor: Who are the Urban Poor?  

When we conceptualise ‘poverty,’ our notions are drawn towards rural contexts. We tend to ignore the people who have migrated to urban areas. The urban sector has witnessed a sudden boom in the past two decades, mainly due to the increasing pace of development. 

As per the World Bank’s definition, ‘Urban Poor’ is a multidimensional term; those who live with multiple deprivations and limitations, such as limited access to educational opportunities and income; inadequate and secured housing; violent and unhealthy environments; little social protection; limited employment opportunities.

Poverty is a very broad term and in this context the word ‘poor’ is associated with their inability or lack of access to a wide range of services, including health, sanitation, education, social security, law and order, and so on. 

Access to Healthcare, Sanitation, Housing and Well-being

The onset of increasing migration and urbanization has led to a rise in unhygienic living conditions in urban areas, which are characterized by poor access to clean water, adequate sanitation, etc. These, in turn, affect economic productivity. Several preventable diseases and illnesses cause millions of deaths in these slums due to insanitation, unhealthy environment, and lack of preventive and curative medical health services. It is ironic that, on the one hand, India attracts medical tourism from developed nations due to affordable and accessible medical treatment and services. The medical tourism sector is growing at an annual rate of 30% (2015). But on the other hand, the poor in India do not have access to basic primary health care. Urban poor children suffer due to several health and sanitation problems. While 28 out of every 1000 in urban India die before reaching one month of age, this rate stands at 36.8 among the urban poor population. Besides, children living in slums are more likely to suffer from diarrhoea, malaria, and pneumonia, than those in non-slum areas.

Speaking of sanitation, the lack of toilets, poor drainage systems, lack of safe drinking water etc. are the main causes of concern. Urban slum-dwellers often rely on informal water supply services due to the lack of provision of water supply by the municipal bodies. In a 2016 report by WaterAid, India had the largest number of cities and people living without sanitation. Over 60 million people in the urban areas lack access to sanitation and more than two-thirds of the wastewater is left untreated into the environment, which pollutes the land, rivers, lakes, and other water bodies. Even the households that are connected to the public supply systems receive only 2 to 3 hours of daily water supply with a cap of 75 litres per capita.

The urban poor live in worst conditions in terms of provision and access to basic amenities for well-being. These settlements are overcrowded and unsafe to dwell, often constructed without any plans or rules, with several structural defects. Due to the problem of land ownership and very high prices in the urban formal housing sectors, the urban poor often stay in makeshift housing.

The way forward: What could be done?

In order to make growth inclusive and sustainable, it is necessary to transform migration into a more formal and rewarding opportunity. The urban population is dependent on access to public and private services to ensure social security and for their overall well-being. The three main broad aspects that need attention are: Health, Sanitation, and Housing.

Nearly the entire urban poor population in India have very limited access to healthcare facilities, immunization, antenatal care, etc. Child and infant malnutrition is very high among the urban poor population than the rural population. The National Urban Health Mission (NUHM launched in 2013) provided for a unique opportunity and concrete mechanism to deal with this situation and improve urban health, but has not worked out as expected due to the lack of efficient allocation of funds by the States and effective implementation at city-level. A large number of positions of health workers are vacant at the primary health centres, which are intended to serve the slum population. Due to the rising incidence and spread of vector-borne and non-communicable diseases, there is an urgent need to set up effective and efficient primary healthcare systems with more centres (PHCs), along with community healthcare centres (CHCs), to address these challenges, especially near the slums in the urban areas and their agglomerations. 

Thus, there are existing gaps in the current health care service delivery models which need to be addressed and filled in a comprehensive manner, which could possibly be achieved in the following ways: 

  • Setting up of better healthcare infrastructure in cities, especially in the slum areas and urban agglomerations, needs to be taken up seriously by the State Governments in order to cater to the larger and ever-growing urban population.

  • The state governments need to recruit more manpower in the Primary Healthcare (PHCs) units to provide basic clinical care, medicines and drugs with doorstep services in urban slums. Moreover, awareness needs to be created for preventive care and immunization amongst these populations.

  • There needs to be provision for public and private health coverage, mainly for primary and secondary health care services for the urban poor who work in the informal sector.

  • Smart-cards for health care services need to be distributed to every household in the slum areas of the cities that would guarantee them access to quality health treatment in the nearest clinics and public hospitals. These smart cards should have the names of each individual of the household along with their necessary details, which would help reduce the tedious and redundant formalities of hospitals that cause delays in the healthcare delivery system.

In addition, to respond to public health challenges in a more comprehensive manner, it would be imperative for Indian urban cities to address to the full sanitation cycle, i.e. access to safe drinking water, universal access to toilets with adequate and safe methods for collection and treatment of human excreta, and waste disposal facilities. Closer attention needs to be paid in all aspects, including effective public systems and creating awareness among households (NSSO, 2010). As per the United Nations Human Settlements Programme (2016) study, Indian urban centres are expected to witness some of the fastest growth rates in the world, with 7 Mega-cities accommodating over 10 million people by 2030. Resettlement into formal houses is believed to increase the health status, employability accompanied with better social security, status, and creditworthiness of these households, thus, there is an alarming need for arrangement of formal settlements with better sanitation facilities for the urban poor.

Manasvini Abhyankar