Health care for urban poor falls through the gap

Abstract

The slums of Mumbai and the favelas of Rio de Janeiro are images of urban poverty so extreme that they are indelibly stamped on the identity of those cities. But urban poverty now goes far beyond these notorious icons. The world is becoming more urbanised overall (fi gure). 2008 was a demographic turning point—for the fi rst time, according to the UN Population Fund (UNFPA), more people lived in urban areas than in rural ones. Yet these new urbanites, especially in develop ing countries, are overwhelming cities that were never designed to have so many inhabitants, and therefore simply do not have the infrastructure to cope. These people struggle on a daily basis with poor housing, a lack of basic services such as electricity and water, and extreme overcrowding that often leads to infectious disease epidemics. They do not have the capacity to aff ord health care that wealthy city dwellers access but neither do they benefi t from health programmes run by nongovernmental organisations (NGOs) or governments in the way that rural areas do. In short, they fall through the cracks, living in the hinterlands of health care. Developing nations and foreign donors have ignored the problem to an extraordinary degree. Governments such as China and Vietnam have responded to growing urbanisation by instituting draconian measures to stop migration from villages to cities. Donors, meanwhile, have continued to focus on the rural poor, in part because these populations are easier to target through vertical health programmes. But the problem of extreme urban poverty is becoming harder to wish away. The UN says that most of the world’s future population growth will be in cities in low-income and middleincome countries. Asia and Africa are projected to double their urban populations from 1·7 billion in 2000 to 3·4 billion in 2030, according to the 2007 UNFPA report: State of the world’s population: unleashing the potential of urban growth. The urban poor rarely fare better than their rural counterparts when it comes to health. Infant mortality