Why settlements on the edges of cities like Noida's Sarfabad fall in public health blindspots

A dozen deaths in a fortnight due to a seemingly mystery fever on the outskirts of Delhi in Sarfabad village, Noida, Uttar Pradesh, have been reported by the mainstream national media. The mystery will in all likelihood be solved by systematic epidemiological investigation. What is unlikely to be demystified is how a village in Sector 73 of Noida within 5 kilometers of the headquarters of the Noida Authority is bereft of any modicum of health services that is responsive to either routine needs or is capable to gear up to emergencies.

India’s rapid urbanisation, particularly in certain states, has been characterised by social compression and a proliferation of settlements that are commonly lumped together as peri-urban areas. Human settlements span a range of institutional structures in which the rural, urban and peri-urban co-exist with dynamic interdependencies.

“Urban” is defined on the basis of one or more of the following: administrative criteria, political boundaries, threshold population size, population density, economic function and the presence of urban characteristics like paved streets, electric lighting and sewerage. Definitions may vary from country to country and within a country over time. In common parlance, urban–peri-urban–rural is generally seen as a continuum. Developing countries witness frantic growth in cities with very high land conversion rates and population densities. All large cities in India are a testimony to this, including the National Capital Region.

Peri-urban and peri-urbanisation are generally loose definitions and describe newly urbanised zones at the fringes of cities, especially in developing countries. These are zones of interaction between urban and rural socio-economic systems marked by mixed land uses and rapid economic and social structural changes. In less affluent countries peri-urban is synonymous with poverty, informal settlements, slum-like living conditions and pollution of land and water.

The uneasy equilibrium

Webster succinctly summarises the phenomenon as an “uneasy equilibrium that is neither totally urban nor suburban”. Other scholars describe it as an “uneasy phenomenon, usually characterised by the loss of rural aspects or the lack of urban attributes” or “partially urbanised countryside or a dramatic new species of urbanism”. The determining character of a peri-urban area is flux. Here are rapid changes in land-use, built forms and economic activities. Here are mismatches between administrative structures and territory, influxes of new populations and conflicts between new and existing landholders. Peri-urbanisation also implies an increasing share of “rural administered urban areas” in India and encompass multiple urbanisation processes at work.

Census definitions do not determine governance structures. For example, all that is “urban” is not “municipal” and several towns may not have a municipality. There is a politics of classification and de-classification and health services have yet to gear up to this challenge.

Take a look at the two kinds of towns listed in the census. Census towns have a minimum population of 5,000 with a population density of 400 people per square kilometer and 75% of the male working population engaged in non-agricultural activity. Statutory towns are all places with municipalities, corporations, cantonment boards to notified area committees.

Scholars analysing the 2011 census have pointed to two key facts – that the absolute growth in urban population exceeds that of the rural component and that there is a three-fold rise in census towns as compared to a marginal rise in statutory towns.

At the all-India level, the share of new census towns to total urban population growth between 2001 and 2011 is about 30%. Kerala and West Bengal are among the larger states with highest contribution. The critical governance implication for census towns that are rural settlements with urban characteristics, is the fact that they do not receive any urban services as long as they do not qualify as municipalities. About a third of the population in these new census towns are in the proximity of Class I, towns but remain excluded from the municipal services.

Failure of health services

The National Urban Renewal Mission called for planned development of identified cities including peri-urban areas, outgrowths and urban corridors and to scale up delivery of civic amenities and the provision of utilities with emphasis on universal access to the urban poor. However, the mission’s guiding principles of “enhancing commercial viability and ensuring bankability of projects” often act as limiting factors to addressing needs of the peri-urban and small towns. The National Urban Sanitation Policy makes no mention of the peri-urban.

The National Urban Health Mission recognises that in some places, typically the highly urbanised peri-urban areas, services were weak before and they continue to be weak later. But these are fertile grounds for private practitioners and nursing homes. In a second pattern, where a rural area is being incorporated into a town, available rural services are withdrawn and human resources are re-deployed but urban area services are unable to take over. And in the third pattern, the handing over is relatively smoother and this is usually when both the new and old leadership is within the state health department.

The National Urban Health Mission aims to provide health services to 779 cities with a population of above 50,000 and all the district and state headquarters irrespective of population size. This size criterion excludes more than half the statutory towns and certainly the census towns. The urban local body as a unit of planning shall be centre stage in the mission but then the design of the mission is highly selective and fails to grasp the nuances of the urban transformation. Sadly, Sarfabad is perhaps one of the few situations that make it onto the media radar.

The writer is a professor at the Centre of Social Medicine & Community Health, Jawaharlal Nehru University, New Delhi and associated with the National Urban Health Mission. The views expressed are personal.