1. Promoting health
and well-being in
cities of India –
towards Healthy
Cities in India
UNHABITAT, State of the World Cities, 2008-09
Amit Samarth
MBBS MPH

2. Amit Samarth
Our collective purpose as a society
• To be economically progressive
• To be socially cohesive
• To promote health and well-being
• To enable individuals to achieve
their intellectual and physical
potential
• To ensure that citizens today and
tomorrow will be able to enjoy the
basic amenities of life in a
sustainable and eco-friendly way

3. Amit Samarth
Ecological model of Human Health
Dahlgren and Whitehead model Source: Barton and Grant, 2006
Human health should be seen in a physical, social, behavioural, and ecological context.
Health promotion activities should involve other sectors making a contribution to
health, such as education, food, nutrition, and environment.

4. Amit Samarth
Growth in urban population of India
• Population of India - increase from 1029 million to 1400
million in a period from 2001 to 2026
• Urban population – from 286 million to 575 million
• Increase in urban population will almost account for two-
thirds of population increase
• Slum dwelling population is also increasing - major
contributor
• Growth due to natural increase
• More than 40% population will be living in the urban
areas by 2026
• Change in population dynamics of India - major
implication for health and well being
4

5. Amit Samarth
What have our cities achieved?
• Drivers of economic growth
• Hubs of world class
education, commerce and specialized
health care services
Challenges –
• Rapidity of growth of urban population
• Pressure on basic infrastructure –
housing, water, sanitation, transport, gre
en cover, education, employment and
health services
What can we learn from the challenges of
present cities?
Source: India’s Urban Awakening. Building Inclusive cities , Sustaining Economic Growth

6. Half of us will be living in cities by 2030

7. Rapid growth of Indian Cities

8. Amit Samarth
Cities in India are of great contrast
• 90 million or more urban poor live in
cities of India
• Informal sector one of the key drivers
of economic growth
• Growing inequalities and growing
exclusion
• Poor living conditions
• Poor health outcomes
• Loss of productivity
• Increasing crime and violence
• Environmental degradation due to lack
of waste management
Source: India Urban Poverty Report 2009

9. Amit Samarth
Poor health status of the urban poor
• High infant and maternal mortality Urban areas in India
• High water-borne diseases have better specialized
• High vector borne disease like malaria healthcare services
and dengue but facilities for
• Higher incidence of chronic diseases like promotive and primary
hypertension, diabetes and coronary care are non-existent
heart disease
• Poor occupational health
• Higher mental illnesses
• Road traffic injuries
In Andhra Pradesh, there are 7500 slum localities but there are
only 250 Urban Healthcare Centres. Better primary care
services needed.
Source: Living conditions in 8 cities of India. NFHS-III Survey 2005-06

10. Amit Samarth
Epidemic of non-communicable diseases (NCDs)
 Triple burden of disease
 Diabetic capital of the world
 High prevalence of Hypertension
 Obesity and overweight is on the rise
 Nutritional transition
 More than 50 percent deaths occur in
India due to cardiovascular diseases
Reference – Report of National Commission
on Macroeconomics and Health, 2005
10

11. Amit Samarth
Population in India will Age..!
Projections for Old Population (>60 yrs) in India (in millions)
350
308
300
248
250
223
195
200
167
150
119
100 77
50
0
Yr 2000 Yr 2015 Yr 2025 Yr 2030 Yr 2035 Yr 2040 Yr 2050
% Population of Old (>60 years) of Total population in India Source:
25
20.14% Population
20
15.3% 16.7%
13.76% division,
15 12.22%
9.56% Department of
10 7.55%
Economic and
5 Social
0 Development,
Yr 2000 Yr 2015 Yr 2025 Yr 2030 Yr 2035 Yr 2040 Yr 2050 United Nations

12. Amit Samarth
Population Pyramid for India in year 2000 and projected for
year 2050
Source: Population division, Department of Economic and Social Development,
United Nations

13. Amit Samarth
Population of India will Age
• By 2040, 248 million people > 60 yrs
of age
• By2050, 308 million people > 60 yrs
of age
– Constituting 20 percent of overall
population
• With rapid urbanization most of this
population will be living in urban
areas
• Need to build our cities to become
age-friendly and create settlements Need to design/develop
which will help promote well-being cities for them too…!
across all age-groups

14. Amit Samarth
WHO launches Global Network of Age-friendly Cities
• Launched in 2010
• Part of a broader response to the rapid
ageing of populations
• By 2050, it is estimated that 80% of the
expected 2 billion people aged 60 years or
over will live in low or middle income
countries
• The Network aims to help cities create urban
environments that allow older people to
remain active and healthy participants in
society
• WHO has also established formal agreements
with the French government, the Irish Ageing
Well Network and the Slovenian Network of
Age-friendly Cities to develop affiliated
national programmes
Source: http://www.who.int/mediacentre/news/releases/2010/age_friendly_cities_20100628/en/

15. Amit Samarth
Poorly planned transport system
• Only 2 per cent cities have low air pollution
on the basis of PM10
• In 80 per cent of cities at least one criteria
pollutant exceeded the annual average
ambient air quality standards
• Exponential growth in private vehicles in last
few years -17 million vehicles in last 7 yrs
• Personal vehicles – cars and two-wheelers --
use up more than 75 per cent of the road
space, but meet only 20 per cent of the
city’s commuting demand Are we creating more
• Transport study for Hyderabad – Multi space for cars rather
mode Mass Rapid Transport can achieve than for people?
30% reduction in Vehicle Kms Travelled per
day
Source: State of Air Pollution in Indian Cities 2007, Centre for Science and Environment

16. Amit Samarth
Dramatic motorization of India
Source: Road Traffic and Injury Prevention in India. NIMHANS and WHO India. 2004-05

17. Amit Samarth
Poor Road Safety in India
• Results in deaths of > 100, 000
people in India
• Results in 2 million
hospitalizations
• 7.7 million minor injuries
• Road traffic accidents next
only to cardio-vascular
diseases
• Affect age group 5 to 44 yrs –
most productive years
• Man-made epidemic
Source: Road Traffic and Injury Prevention in India. NIMHANS and WHO India. 2004-05

18. Amit Samarth
Poor Road Safety – Role of urban planning
• Road safety – a complex
problem
• Road accidents are preventable
• Urban design and engineering
has a major role to prevent
accidents
• Designing urban spaces to
reduce environmental factors
responsible for accidents
Car/motor-cycles are equal to an weapon on unsafe and ill-
designed roads….We need to make our roads safer and nicer
for everyone in the city…currently there is too much of priority
on the roads for cars/motor-cycles

19. Amit Samarth
Promoting and protecting health has become a challenge…..
• Poor waste management
• Poor housing
• Poor sanitation
• Lack of good footpaths
• Absence of dedicated cycling
paths
• Lack of green spaces
• Lack of sports and recreation
facilities
• Lack of social space

20. Amit Samarth
Green cover and social space is important
• To improve air quality and reduce
pollution
• To reduce heat island effects
• To improve physical activity
• To improve opportunities for social
interaction
• Reduce urban heat island effect
To address Cardio-respiratory
diseases, mental illnesses and
Cancer

21. Temperature related
Modulating
Pathways by which influences
illness and death
climate change Extreme weather
related health
affects human effects
Contamination
health Pathways Air pollution related
Transmission health effects
Human Exposure dynamics
Regional Weather Water and food
Climate changes borne diseases
Change •Heat waves
•Extreme weather Changes in agro- Vector-borne and
•Temperature ecosystems and rodent borne
•Precipitation hydrology diseases
Effects of food and
water shortages
Socioeconomic Mental, nutritional
and demographic infectious and other
disruption health effects
Source: Climate Change and Human Health – Risks and Responses, Summary.
http://www.who.int/globalchange/climate/en/ccSCREEN.pdf, WHO 2003 Amit Samarth

22. Amit Samarth
Built Environment
• The built environment encompasses land-use patterns and all
buildings, spaces and elements that people construct or modify
• This includes homes, schools, workplaces, parks, recreation
areas, green spaces, business districts and transport systems
• Urban design is an aspect of urban planning that focuses on
creating a desirable environment to live, work and play
• Conditions in the built environment can both negatively and
positively affect participation in physical activity
• Need to design the built environment for people
• Street layout, land use, the transport system and the location of
recreation facilities, parks and public buildings, are all
components of a community that can either encourage or
discourage active living
• Growing dependence on cars and motorization is a serious
concern

23. Amit Samarth
Built Environment
• Urban sprawl has been correlated with higher body weight, obesity
and associated chronic diseases
• Crowded city centres and a resurgence of urban living may make
finding room for green spaces difficult, especially in
older, established cities
• In many countries, cycling and walking have been marginalized in
transport decision-making
• Traffic injuries and fatalities resulting from high vehicular
speed, heavy traffic flow and a lack of separate lanes, tracks and
paths are major reasons why people do not walk or cycle in cities
• Factors like lack of quality lighting; a lack of access to open spaces
and to sports and recreation facilities; rundown houses and
neighbourhoods; poor aesthetics; and locked stairwells in
workplaces and public buildings also discourage physical activity
• Cycling or taking public transport to work may be seen as a sign of
lower status since affluent people typically drive to work

24. Amit Samarth
Impact of Built Environment on health
Built environment can address issues like:
• Obesity
• Non-Communicable diseases
• Mental health
• Air pollution
• Road Traffic accidents
• Safety to women, children and old people
• Availability of nutritious food
• Helping cities to become more energy efficient
• Easy access to recreational facilities
• Easy access to healthcare and educational facilities
• Healthy ageing
• Waste disposal and Recycling
• Water borne diseases

25. Amit Samarth
Impact of built environment on our health

26. Amit Samarth
What we need
to do in
emerging cities
of India to
promote and
protect health…?

27. Amit Samarth
Embedding health in all policies
Good urban
governance &
healthy urban
planning
Improve
availability Healthy Improve
and access to Urban health and
healthcare Population social equity
services
Improve
living and
working
condition

28. Amit Samarth
Make Healthy Choice – The Easy Choice
Community Basic
services
Information Housing Good water
& Education Healthcare quality
services Sanitation
Government Education and
Social & services employment
Cultural Waste
activities Good air Health and
management
quality Social equity
Healthy Environment leading to
Green Healthy Urban
Cheap Spaces Population
Lightings Cheap and
Cheap nutritious
transport
Roads Access to
Clean
food
Infrastructure
Energy Nutrition
28

29. Make Healthy Choice –
Amit Samarth
The Easy Choice in cities of India
Present cities Promoting health in urban India Future cities
Basic services
Good water
Community
Affordable quality
Information Housing Sanitation
& Education Healthcare Education &
Government services employment
services
Social & Cultural Waste management Good air
activities quality
Embedding health in ‘ALL Policies’
Cheap Green
Spaces Cheap and
Cheap nutritious
Clean Access to
Public Lightings
transport food
Energy Roads
Nutrition
Infrastructure
Multi-disciplinary & multi-sectoral approach
Human and environmental health are intricately linked

30. Amit Samarth
Urban planning and promotion of health
 Reduce obesity
 Provide better Reduce carbon Reduced levels of
public transport emissions and air cardiovascular
 discouraging use pollutants diseases
of private vehicles  Improve air  Reduced
 Facilitate more quality respiratory diseases
walking and  Increased  Improved social
cycling physical activity capital
 Improved social  Reduce road
capital traffic accidents
 Mitigate climate
change
Source: Margalit Younger, Heather R. Morrow-Almeida, Stephen M. Vindigni, Andrew L. Dannenberg. The Built Environment, Climate Change, and Health
Opportunities for Co-Benefits

31. Amit Samarth
Urban planning and promotion of health
 Local markets
 Urban  Reduced obesity
 Improved and
agriculture  Reduced levels of
better balanced
 Promote locally cardiovascular
nutrition
grown food diseases and
 Cheaper diabetes
 Provide healthy agricultural
food options and  Mitigate climate
produce
information change
 Reduced carbon
 Restrict fast  Sustainable
emissions
food restaurants development
and advertising
Source: Margalit Younger, Heather R. Morrow-Almeida, Stephen M. Vindigni, Andrew L. Dannenberg. The Built Environment, Climate Change, and Health
Opportunities for Co-Benefits

32. Amit Samarth
Healthy City Concept

33. Amit Samarth
Attributes of Healthy City (WHO)
• A clean, safe physical environment of high quality
(including housing quality)
• An ecosystem that is stable now and sustainable in the long
term
• A strong, mutually supportive and non - exploitative
community
• A high degree of participation and control by the public over
the decisions affecting their lives, health and wellbeing
• The meeting of basic needs ( for food
, water, shelter, income, safety and work) for all the city’s
people

34. Amit Samarth
Attributes of Healthy City (WHO)
• Access to a wide variety of experiences and resources, with
the chance for a wide variety of contact , interactions and
communications
• A diverse, vital and innovative city economy
• The encouragement of connectedness with the past, with
the cultural and biological heritage of city dwellers and with
other groups and individuals
• Urban form that is compatible with and enhances the
preceding ch aracteristics
• An optimum level of appropriate public health and sick care
services accessible to all
• High health status (high levels of positive health and low
levels of disease)

35. Amit Samarth
Athens declaration on Healthy Cities
• Based on key principles of
equity, sustainability, intersectoral cooperation and
solidarity
• Political commitment to reducing the health gap
between and within our cities
• Implementing ecological policies for the environment
• Maximizing the added health value of all municipal
programmes through systematic assessment of the
health impact of all policies
• Determined in making Healthy Cities a global movement
• Will develop city health development policies, strategies
and plans that set out to improve the
social, environmental and economic determinants of

36. Amit Samarth
Athens declaration on Healthy Cities
Especially address issues related to,
• health needs of children and young
people, women, ethnic minority groups and older
people;
• links between poverty and health;
• needs of populations at risk;
• dangers which arise from tobacco abuse, addiction to
drugs and alcohol, pollution and violence; and
• other concerns connected to urban planning, ecological
management and social support

37. Amit Samarth
Cities should
have a
Health/Wellness
Plan
Case Study - Well London Strategy

38. Amit Samarth
Well London Strategy – was developed with
• Extensive consultations and discussions with
stakeholders
– London Food Strategy
– Children and Young People Strategy
– Older People’s Strategy
– London: Cultural Capital
– Strategic framework on mental health and well-being in London
– Delivery plan for London Olympics and Paralympics
– Economic development strategy
– London plan for sports and physical activity
• Targeted interventions in 20 communities across London

39. Amit Samarth
Well London Strategy
Projects directed towards
improving
• Healthy eating
• Physical activity
• Mental health and well-
being
• Access to open space
The outcomes of all the
projects are measured using
SMART indicators

40. Amit Samarth
University of Central Lancashire - Healthy Settings Unit
• Development, delivery and management of externally-
funded settings-based health promotion programmes
• Research, evaluation and knowledge transfer training
• Academic teaching
• Healthy Settings module leadership and co-ordination of
UCLan’s Healthy University initiative
• Co-ordination of the English National Healthy Universities
Network
• Co-ordination of the UK Healthy Cities Network
• Chairing the International Union of Health Promotion and
Education’s Global Working Group on Healthy Settings
contributing to the development and management of WHO’s
Health in Prisons Project
Source :http://www.uclan.ac.uk/schools/school_of_health/research_projects/hsu/introduction.php

41. Amit Samarth
European cities involved in Healthy Cities Network
• Austria • Greece
• Belgium • Hungary
• Bosnia and Herzegovina • Israel
• Croatia • Italy
• Cyprus • Latvia
• Czech Republic • Lithuania
• Denmark • Netherlands
• Estonia • Norway
• Finland • Poland
• France • Portugal
• Germany • Russian Federation
Source: http://www.euro.who.int/en/what-we-do/health-topics/environment-and-health/urban-health/activities/healthy-
cities/national-healthy-cities-networks/network-of-national-healthy-cities-networks-coordinators

42. Amit Samarth
European cities involved in Healthy Cities Network
• Slovenia
• Spain
• Sweden We should also
• Switzerland be having many
• Turkey
of our Indian
• Ukraine
• United Kingdom of Great
Cities in this
Britain and Northern Ireland network
• United Kingdom of Great Where are We?
Britain and Northern Ireland
Source: http://www.euro.who.int/en/what-we-do/health-topics/environment-and-health/urban-health/activities/healthy-
cities/national-healthy-cities-networks/network-of-national-healthy-cities-networks-coordinators

43. Amit Samarth
Healthy Cities - Belfast City
Health Impact Assessment of the City Master Plan
Based on -
• Traffic calming – to prioritize pedestrian
linkages and encourage “people not cars”
• Pedestrian and cycle facilities
• Quality public spaces – mixed land use
• Encouraging a 24-hour environment
• Destination creation
• Commercial attractiveness
• Employment generation
• Affordable housing

44. Examples are many, but we
need some action..!
We need to do similar for our
cities in India
“Knowing is not enough; we must
apply. Willing is not enough; we must
do” - Goethe

45. Amit Samarth
Develop a
Center for
Healthy Cities in
India

46. Amit Samarth
Activities of the Center for Healthy Cities
• Advocating “Health” as the important driver of
planning process
• Develop observatory – urban health observatory – to
systematically collect information
• Use of information for policy, planning and advocacy
• Research on impact of built environment on health in
Indian Cities
• Health impact assessments of City Master Plans
• Developing Joint Learning Network
• Communicating the information to stakeholders

47. Amit Samarth
Developing partnerships
• WHO Healthy City Project
• WHO Center for Healthy Development
(WKC), Kobe, Japan
• WHO SEARO and India
• Ministry of Health and Family Welfare
• Ministry of Urban Development
• Indian Council of Medical Research
• National Institute of Epidemiology
• Public Health Foundation of India
• Urban Health Society of India

48. Amit Samarth
Activities of Joint Learning Network
• Practitioner to Practitioner Learning
– Get people who have developed and implemented healthy
cities concepts
– Directly talk to the practioners in India
– Motivate and support their work
• Researchers to Practitioner Learning and Vice-Versa
– Develop evidence
– Create actionable measures from the evidence
– Support the practitioners in implementation
– Document the findings

49. Amit Samarth
Need for systematic data collection on
• Urbanization
• Urban population
• Social determinants of health
• Physical determinants of health
• Environmental determinants of health
• Health services
• Health outcomes
• Slum populations
• Urban transport

50. Amit Samarth
Objectives of the Urban Health Observatory
• Collect information from various urban local bodies
• Collect information from other government agencies
• Secondary research and review of literature on urban
issues and urban health
• Conduct primary research to close information gaps
on key issues

51. Amit Samarth
Objectives of the Urban Health Observatory
• Collect information and data from the major Tier
I, II and III cities across India
• Create a reporting framework of urban health
indicators
• These indicators will be cutting across various
social, economic and physical aspects of urban
environment
• Some of the indicators will directly be related to
urban poor

52. Amit Samarth
Possible indicators
• Air pollution indicators from various cities
• Number of two wheelers sold in one year
• Number of four wheelers sold in one year
• Proportion of people using cycle
• Proportion of people using footpaths
• Proportion of people using public transport
• Number of slums in the city - notified/non-notified
• Access to water and sanitation in the slums
• Prevalence of diseases chronic and communicable
diseases in these cities

53. • We really need to do this kind of work
• Kindly provide your thoughts and comments
dramitsamarth@gmail.com
+91-9959751351