Poverty and poor health in India: Is there really an "urban health advantage"?

Over half the world's population now lives in urban areas; urbanization in low- and middle-income countries (LMICs) has been particularly recent and rapid. The health of urban residents is generally better than that of rural residents, but averages mask wide socioeconomic disparities. In fact, it is well known that the health of the urban poor is often significantly worse than that of the rest of the urban population; UN-HABITAT reports that in Bangladesh, Ethiopia, Haiti and India, child malnutrition in slums is even comparable to if not worse than that in rural areas. Rapid and unplanned urbanization in LMICs has led to dramatic increases in urban poverty and deprivation which are linked to exposure to environmental hazards, crowded living conditions and lack of potable water and sanitation. Using India's most recent National Family and Health Survey (NFHS-3), child height for age (WHO standardized) is compared across urban and rural areas. Urban residents are further divided into slum and non-slum dwelling by an index created from 1) Nondurable housing, 2) Insufficient living area, 3) Unimproved water source, 4) Unimproved sanitation, 5) Insecurity of tenure, to avoid aggregating over urban health differentials. This study should inform policy discussions around India's proposed National Urban Health Mission, which is intended to provide affordable, accessible and acceptable health services to the urban poor. More generally, the finding that the supposed “urban health advantage” may not extend to all urban residents is an important step towards improving both urban and population health.