Last year, UNICEF EAPRO’s health team visited an urban poor community in Pnom Penh. While we walked around a community living in small, temporary looking shacks, we met a small boy. He was delicately walking over fragile wooden planks, suspended a couple of metres above ground, in search of water.
When I looked at him, tears fogged my eyes. I couldn’t help ask myself how many children are having such life in our region, where rapid urbanization is emerging.
What would the situation become by 2030, when the urban population is expected to reach 72% in East Asia and the Pacific?
In 2016-2017, UNICEF’s health teams visited many urban poor communities throughout the region to help reach more urban poor with basic health services.
For me, every visit left some pain deep in my heart. Children were living and playing in dirty, hazardous environments. I wondered what might happen to that little boy had he fallen off the wooden plank.
We listened to many frustrated mothers. The stories we heard were at times overwhelming; the struggle was so big that at times I just wished I had a magic power to help lift them into comfort and safety.
Parents were rarely able to take their children to a clinic for vaccinations. Perhaps it was because they had too much to do at home, or they couldn’t take time off from their insecure jobs and be left with nothing to feed their families. Their day-to-day reality was exhausting and suffocating and even though – like all parents – they wanted the best for their children, thinking beyond today’s meal was just too difficult.
Growing pressure on social systems
We also observed challenges faced by health centres that provide essential services to urbanizing communities. Boundaries of cities were rapidly expanding and communities were fast growing while health centres remained the same, with the same workforce and budget.
A dedicated public health nurse told us: “When I saw many migrants were not vaccinated in my area, I was feeling pain. But what more could I do? I am here alone to take care of 15 communities with a lot of migrant families. The population has doubled in the last five years.”
“Even though it’s difficult, we never take our hearts and eyes away from the poor families,” another nurse told me. “We plan regular outreach services. Often, when we reach informal settlements, we see young children we did not know before. However we can’t vaccinate them as no adults are around.”
Health programme managers at district and provincial levels in different countries all faced similar challenges. It is hard to know how many children live in rapidly urbanizing locations. Several managers told me that they made tremendous efforts to register migrant children, but the task is just too much for the health sector to deal with alone.
We knocked on the doors of some city managers and planners. During our discussions we realized that in urbanizing settings, urban development planning did not necessarily take evolving health needs into consideration.
In those fast-changing settings there are many players, public and private, and it appeared to be unclear who was accountable for meeting the health needs of migrants, particularly the unregistered individuals.
We learned that health centres were mainly funded based on the officially registered population. In one location, we saw more and more houses climbing over a hill, far beyond its old city boundary. Migrant families there had to travel over 10km to get their children vaccinated, and many of them hesitated to travel that far for a single vaccine.
The wanting eyes of that little boy, the environment surrounding him, struck us deeply – we felt a burning responsibility to help him out, and help many like him.
The question is: how? and who?
Bringing essential services to the urban poor
We believe that if any decision maker witnessed what we saw, they would feel the exactly same as us: sharp pain and burning responsibility. They will need help from health managers to understand the real situations and barriers in the social systems. To do so, accurate and updated data and decent analysis and insights are needed.
Our visits also taught us that different urban poor communities are not the same, they all have diverse social and cultural backgrounds. They think differently, and cope with their daily lives differently. It will not be possible to find a one-size-fits-all solution. Decent on-the-ground work will be essential to better understand the underlying reasons behind low uptake of essential services and find feasible resolutions.
Bringing essential services to the urban poor, many of whom are unregistered migrants, is beyond what the health sector alone can cope with. Indeed, it is not just a health issue. Rather, it’s a reflection of social distance between social systems and those communities. Resolving it requires collective actions from the whole society, from national level to community, public and private.
Any solution, to be sustainable, will require attention from central level as it is often where laws, regulations and policies are initiated. For any solution to be feasible, it will require concrete actions from provincial and district governments, as it is often where planning and budget decisions take place.
Any solution, to trigger a real change, will require strong ownership and engagement of communities, starting from community leaders. Children are the most vulnerable group in a society, and those from urban poor communities are among the most fragile. They need special care and protection.
Let us join our wisdom, share our responsibility and act now for a common goal: leaving no child behind.
Part 1 : Case Studies
Part 2 : Thematic Analysis
Wang Xiaojun is Health Specialist at UNICEF East Asia and Pacific Regional Office