1. Framing concepts and debates:
urbanisation, migration, urban health equity & HIV
5th Annual HIV-In-Context Research Symposium
Urbanisation, Inequality and HIV
School of Public Health, UWC, 13th March 2013
Jo Vearey, PhD Liz Thomas, PhD
African Centre for Migration & Society Centre for Heath Policy, Wits
University of the Witwatersrand Medical Research Council
jovearey@gmail.com liz.thomas@wits.ac.za

2. Aims
1. To explore the interlinked challenges of urbanisation,
migration, inequality and HIV in South(ern) Africa: key
concepts, trends.
2. To apply a social determinants of health lens to unpack
the complexity of the urban context: upstream determinants
and downstream consequences.
3. To provide suggestions for developing improved
responses to urban health: a focus on understanding and responding to
the complexity of the urban context.
4. To summarise the key issues for consideration in this
symposium.

3. The social determinants of health:
socioeconomic and political context; structural determinants; intermediary determinants
HIV
Migration and mobility
Urbanisation
The urban poor
Overlapping vulnerabilities:
gender; food insecurity; lack of cash; living on the periphery;
struggle to meet basic needs
Inequality Inequity
in the city in the city
Access to positive determinants of health in the city:
basic services; healthcare; housing; education;
secure livelihood activities; food security
Governance (response):
healthy urban governance; intersectoral action; health in all policies;
developmental local government

4. What is urban?
• No standard definition of urban
• Countries differ in the way they classify population as
"urban”
– Population size
• A population of > 2,000 is often considered urban.
– Population density
– Provision of public utilities and services
– Percent population not dependent on agriculture
– Type of local government
– Presence of administrative centres

5. What is urbanisation?
• Growth in the proportion of a population living in
urban areas:
1. Rural to urban migration.
2. Natural population growth of existing urban population.
3. Reclassification of rural areas into urban ones (changing
definitions).
• Urban v’s rural in South Africa
– Lack of clarity
– Continuum v’s dichotomy
– Population density; access to services; economic activities
• Urban, semi-urban, peri-urban, rural

6. Urban Agglomerations in 2009 (proportion
urban of the world: 50.1%)
Source: United Nations, Department of Economic and Social Affairs, Population Division: World
Urbanization Prospects, the 2009 Revision. New York 2010 6

7. Urban Agglomerations in 2025 (proportion
urban of the world: 56.6%)
Source: United Nations, Department of Economic and Social Affairs, Population Division: World
Urbanization Prospects, the 2009 Revision. New York 2010 7

8. Urbanisation levels per province
(2001)
Kok and Collinson, 2006

9. South(ern) Africa is associated with historical
and contemporary population movements.
– Internal > cross-border
– Heterogeneity
– Spatial variation

11. 44% of 28.1% of
4.4% of the
Gauteng’s Western Cape’s
South African
population were population were
population were
born in a born in a
born outside of
different different
South Africa
province province
2,199,871 people
were born outside
of South Africa
Census 2011

12. Percentage of international
migrants living in urban
settlement by District
Municipality

13. 7,4% of
Gauteng’s
population are
non-citizens
3.3% of Western
Cape’s
population are
non-citizens
3.3% of the
South African
population are
non-citizens
Census 2011

14. HIV
Migration and mobility
Urbanisation
The urban poor
Overlapping vulnerabilities:
gender; food insecurity; lack of cash; living on the periphery;
struggle to meet basic needs
Inequality Inequity
in the city in the city

15. The urban poor
(Mitlin & Satterthwaite, 2004: 15)
• Inadequate and often unstable • Inadequate provision of basic
income; services, including health services;
• Inadequate, unstable or risky asset • Limited or no safety net, such as
base; access to grants*;
• Poor-quality and often insecure, • Inadequate protection of poorer
hazardous and overcrowded housing; groups’ rights through the law;
• Inadequate provision of ‘public’ • Poorer groups’ voicelessness and
infrastructure (as this increases the powerlessness within political
health burden); systems and bureaucratic structures.
* It is important to recognise that the South African situation is different to many low-income country contexts. In
South Africa, a social welfare system exists that includes: disability grants, child support grants, child foster care
grants, care dependency grants and old-age pensions.

16. Urban inequality:
urban inequities in health
0.76 0.75 0.75
0.74 0.74
0.74 0.73
0.72 0.72 0.72
Gini coefficient
0.72
0.7
0.68 0.67
0.66
0.64
0.62
rg
n
rg
th
an
n
d
wn
ia
ei
do
an
bu
bu
e
or
b
nt
To
ab
on
ur
R
et
es
itz
fo
iz
e
D
Pr
st
L
nn
m
ar
ap
El
Ea
st
oe
m
ha
C
Ea
rt
er
Bl
Po
Jo
et
Pi
(Figure adapted from UN-HABITAT, 2008: 72)

17. Urban informal settlements and HIV

18. Percentage of households by dwelling type
What’s missing?
How to define informal: land tenure?
Access to services?
e.g. GP – 5% drop in informal (24% - 19%)
StatSA, 2012

19. Urban informal settlements

20. Urban informal settlements:
overlapping vulnerabilities = inequities in health
food fragile
insecurity livelihood
activities
HIV gender
access to housing
services density

21. Higher HIV prevalence in urban
informal settlements
25
20
15
10
Urban Informal
Urban Formal
5
0
HSRC 2002 HSRC 2005 HSRC 2008 MRC MRC THUSA NW
SA SA SA Buffalo City Capricorn
Wkp EC DM Wkp Lp
Thomas, 2011

22. HIV by quintile?
• What do we know?
• What are the implications for new policy and
action?

23. HIV in urban SA by quintile
100%
3 11
90%
Richest 5
80%
70% 32 4
60% 3
50%
27 2
40%
30% Poorest 1
65%
20%
38 65% of the urban SA HIV
10% epidemic is in the
0% poorest 40% of the
population
Source Cleary et al 2011
HIV

24. Developmental response to HIV requires:
addressing understanding and act: upstream
Need to the upstream drivers and the downstream
drivers andconsequences of infection
downstream consequences of
HIV infection
Upstream Downstream
Consequences
individual, of infection,
household, HIV wellness,
mitigate impacts
community,
macro -
infection at individual,
household,
community,
structural health system
economy etc

25. HIV in slum settings (Grief et al 2010)
Upstream Downstream issues /
impacts
Age of debut
Wellness/
HIV
Physical progression
environment
Riskier Low
sex
Social condom
WHY? Treatment
use
transmission
environment
Economic
Rights and
environment
Dignity
MSP
SLUM SETTING
Structural inequities
Deprivations, gender, education, market forces ,global & macro policies

26. Ranking of urban HIV epidemics (ESA) among national epidemics
Est. number Adult Est. number Adult
PLHA (2007) PLHA (2007)
1 South Africa 5,400,000 21 Ghana 250,000
2 Nigeria 2,400,000 22 Myanmar 240,000
3 India 2,300,000 Maputo Maputo 220,000
Gauteng Gauteng 1,550,000 23 Carribean 220,000
4 Mozambique 1,400,000 24 Mexico 200,000
5 Kenya 1,400,000 Lusaka Lusaka 185,000
6 Tanzania 1,300,000 25 Angola 180,000
7 Zimbabwe 1,200,000 26 Chad 180,000
8 USA 1,100,000 Nairobi Nairobi and Dar 180,000
9 Zambia 980,000 Dar Es Salaam 180,000
10 Russian Fed 940,000 27 Swaziland 170,000
11 Ethiopia 890,000 28 Colombia 160,000
12 Malawi 840,000 Port Elisabeth Port Elizabeth 155,000
13 Uganda 810,000 29 Italy 150,000
Durban Durban 730,000 Addis Abeba 150,000
14 Brazil 710,000 30 France 140,000
15 China 690,000 31 Spain 140,000
16 Thailand 600,000 32 Central African Republic 140,000
17 Cameroon 500,000 33 Rwanda 130,000
18 Ukraine 430,000 34 Argentinia 120,000
19 Cote d'Ivoire 400,000 35 Burkina Faso 120,000
Cape Town Cape Town 315,000 36 Togo 120,000
21 Vietnam 290,000 Kampala Kampala 110,000
22 Botswana 280,000 East London 105,000
23 Indonesie 270,000 …
20 Lesotho 260,000 Pakistan 94,000
Harare Harare 260,000 Bulawayo 90,000
UK 77,000
Source: Luanda 70,000
UNAIDS 2009 Henk van Renterghem

27. Nairobi, Kenya
Inner city variation / epidemic patterns
Higher prevalence in more densely populated
neighborhoods / slums
Kibera : estim.
HIV prevalence
16%
19/03/2013 HIV and slums UNAIDS and UN-HABITAT discussion paper CHP Academic meeting Jan 2011 27

28. Clinics in Buffalo City
– percentage of all
HIV tests positive
varies within city –
(green circles) shown with population

29. 12 Urban focussed strategies
100.0 districts
Very high HIV and high 12 districts
Low HIV and High urbanisation eg Metros
urbanisation – many in – mainly Gauteng and
Response to HIV in urban
TARGET INFORMAL SETTLEMENTSand
Urban
80.0 Western Cape - strategy KZN- prevention
areas needs to vary based on
prevention mitigation – urban
informal focus
the characteristics of the
60.0
district : Series4
6 districts Population shifts , HIV 21
districts
40.0
epidemic, informal
Rural
Low HIV and low Very high HIV and low
settlements, poverty, econom in
urbanisation – Northern urbanisation – many
Cape - strategy KZN rural – prevention
20.0
prevention
y – ie KYE mitigation/ rural
and
development
Rural focussed strategies
0.0
Low 0.0 5.0 < 25 ANC HIV prevalence > 25
10.0 15.0 20.0 25.0 30.0 35.0 High
40.0 45.0

30. The social determinants of health:
socioeconomic and political context; structural determinants; intermediary determinants
HIV
Migration and mobility
Urbanisation
The urban poor
Overlapping vulnerabilities:
gender; food insecurity; lack of cash; living on the periphery;
struggle to meet basic needs
Inequality Inequity
in the city in the city
Access to positive determinants of health in the city:
basic services; healthcare; housing; education;
secure livelihood activities; food security

31. The social determinants of health
Living
environment
Urbanisation
Broad social and
economic determinants
Inequality Socio economic status,
eg HIV
social class Behaviour Medical
interventions
Migration
gender, education, income etc
Treatment
Source: Closing the Gap: policy into practice on Social determinants of Health , 2011, Brazil, quoting from Solar and Irwin 2010

32. The social determinants of health:
socioeconomic and political context; structural determinants; intermediary determinants
HIV
Migration and mobility
Urbanisation
The urban poor
Overlapping vulnerabilities:
gender; food insecurity; lack of cash; living on the periphery;
struggle to meet basic needs
Inequality Inequity
in the city in the city
Access to positive determinants of health in the city:
basic services; healthcare; housing; education;
secure livelihood activities; food security
Governance (response):
healthy urban governance; intersectoral action; health in all policies;
developmental local government

33. Healthy urban governance
• What’s needed?
– A clear understanding of HIV as a development issue
– Need for integrated prevention strategies and responses at multiple
levels
– Intersectoral action (ISA)
• Missed opportunities?
– National Planning Commission
– National Strategic Plan: SANACs; PAC; DACs; LACs
– Integrated Development Plans
– District Health Plans
– Developmental local government

34. Urbanisation, inequality and HIV
Understanding the complexity of Responding to the complexities of
the urban context the urban context
• Healthy Urban Governance
• HIV as a developmental issue – More than government
– Interdisciplinary research – An enabling policy environment
– > biomedical response – Developmental local government
– Address inequity
• Social determinants of health
– Overlapping vulnerabilities • Multi-sectoral action and multi-
level responses
– Short-term (humanitarian); long-term
• Spatial approach (developmental)
– Different spheres of government
– Intra-urban – Who takes a lead? Role of health sector?
– Urban penalty v’s urban advantage – Alignment of sectoral plans: common
understanding to inform responses
• Know your epidemic; Know your
response (KYE, KYR)
– Local responses

35. The social determinants of health:
socioeconomic and political context; structural determinants; intermediary determinants
HIV
Migration and mobility
Urbanisation
The urban poor
Overlapping vulnerabilities:
Commission 3:
gender; food insecurity; lack of cash; living on the periphery;
spaces of
vulnerability to meet basic needs
struggle
Inequality
and
opportunity
Inequity
Commission 2:
Commission 1: in the city falling city
in the
people on the between the
move cracks
Access to positive determinants of health in the city:
basic services; healthcare; housing; education;
Commission 5:
secure livelihood activities; food security
dignified
Commission 4: politics human
of participation and
representation Governance (response): settlements
healthy urban governance; intersectoral action; health in all policies;
developmental local government