Intra-urban health inequalities

The majority of the world’s population now reside in cities and this trend is set to continue – by 2050 the World Health Organization (WHO) estimates that 70 per cent of the world’s population will be living in urban areas. City living can provide opportunities, and in some countries, people living in urban areas experience better health, on average, compared to those in rural areas. However, this average masks the marked inequality that exists within urban areas, perpetuated by underlying political, economic and social factors. 

Living conditions in low-income urban settlements are often inadequate, with overcrowding, substandard housing, poor access to affordable quality food, insufficient safe recreation spaces, and a lack of amenities, including water, electricity, sanitation and sewerage systems, refuse collection, and public health facilities. For residents of low-income urban settlements, living in such spaces is associated with a lack of engagement in health-related policy and over-exposure to particular health challenges.

Unequal gender relations further enhance this inequality. Women in low-income urban settlements are marginalised and excluded from health services and related policy processes according to case studies looking at access to HIV services in Kibera and Majengo in Nairobi, Kenya and at sexual and reproductive health and rights (SRHR) for indigenous women in Shillong, India. Women in Shillong often internalised the notion of being second-class citizens and of not having any role in politics and policy. This marginalisation and inequality prevented women from asserting their rights and demanding access to sexual and reproductive health (SRH) knowledge and services.  

Historical and/or underlying political factors can entrench intra-urban health inequalities. Apartheid in South Africa legitimised disparity, unfair resource distribution, inferior education and unequal access to health. This legacy still has a profound impact on health, the development and provision of infrastructure for health services, and in health policy formulation. The case study on SRHR and ICTs in South Africa demonstrates that this inequality is echoed through poor access to ICT, with low-income urban settlements experiencing poor network coverage, weak satellite signals, insufficient bandwidth and voice capacity. Underlying this, there are significant factors which limit women’s use and access to ICT, including illiteracy. Patterns of inequality cannot be addressed simply through access to technology - special policy measures are needed to support infrastructural and other developments in low-income urban settlements.

Policy recommendations

  • It is important to recognise the multifaceted nature of intra-urban inequalities, which impact on the health of women and girls in low-income urban settlements. Poverty, gender, and issues of place all contribute to intra-urban health inequalities and act as barriers to access to health services.
  • The informal nature of some low-income urban settlements mean that governments may not officially recognise or take responsibility for services in these areas, in part due to lack of formal addresses and official paperwork. Governments need to treat people living in informal and low-income urban settlements as citizens, acknowledging and realising their rights to basic services, including health

What is a low-income urban settlement?

The places in a city or town where poor people most often live are called many things – slums, ghettos, colonies, inner city, informal settlements, peri-urban areas, and townships – with stigmas and stereotypes attached. The United Nations identifies five characteristics defining a slum: inadequate access to safe water; inadequate access to sanitation and infrastructure; poor structural quality of housing; overcrowding; and insecure residential status. However, within and across different countries, living standards within these areas can vary. In this briefing, we use the term ‘low-income urban settlements’.