, Volume 55, Issue 1, pp 223–247 | Cite as

Differences in Child Health Across Rural, Urban, and Slum Areas: Evidence From India

  • Claus C. PörtnerEmail author
  • Yu-hsuan Su


The developing world is rapidly urbanizing, but an understanding of how child health differs across urban and rural areas is lacking. We examine the association between area of residence and child health in India, focusing on composition and selection effects. Simple height-for-age averages show that rural Indian children have the poorest health and urban children have the best, with slum children in between. With wealth or observed health environment held constant, the urban height-for-age advantage disappears, and slum children fare significantly worse than their rural counterparts. Hence, differences in composition across areas mask a substantial negative association between living in slums and height-for-age. This association is more negative for girls than boys. Furthermore, a large number of girls are “missing” in slums; we argue that this implies that the negative association between living in slums and health is even stronger than our estimate. The missing girls also help explain why slum girls appear to have a substantially lower mortality than rural girls, whereas slum boys have a higher mortality risk than rural boys. We estimate that slum conditions (such as overcrowding and open sewers), which the survey does not adequately capture, are associated with 20 % to 37 % of slum children’s stunting risk.


Child health Slum Urban Rural Sex selection 



We thank Seik Kim, Robert Plotnick, Judith Thornton, five anonymous referees, and participants at the Population Association of America annual meetings, Pacific Conference for Development Economics, Annual Conference of the European Society for Population Economics, DIAL Development Conference, and the Labor and Development Seminar at the University of Washington for their helpful comments. Partial support for this research came from a research grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R24 HD042828) to the Center for Studies in Demography & Ecology at the University of Washington, from the Office of Research and Development of National Chengchi University, and from the Ministry of Science and Technology of Taiwan Government (104-2914-I-004-009-A1).

Supplementary material

13524_2017_634_MOESM1_ESM.pdf (299 kb)
ESM 1 (PDF 298 kb)


  1. Aizer, A. (2010). The gender wage gap and domestic violence. American Economic Review, 100, 1847–1859.CrossRefGoogle Scholar
  2. Alderman, H., Hoogeveen, H., & Rossi, M. (2009). Preschool nutrition and subsequent schooling attainment: Longitudinal evidence from Tanzania. Economic Development and Cultural Change, 57, 239–260.CrossRefGoogle Scholar
  3. Basta, S. S. (1977). Nutrition and health in low income urban areas of the third world. Ecology of Food and Nutrition, 6, 113–124.CrossRefGoogle Scholar
  4. Bhan, G. (2013). Planned illegalities—Housing and the “failure” of planning in Delhi: 1947–2010. Economic & Political Weekly, 48(24), 58–70.Google Scholar
  5. Bhan, G., & Jana, A. (2013). Of slums or poverty. Economic & Political Weekly, 48(18), 13–16.Google Scholar
  6. Bocquier, P., Madise, N. J., & Zulu, E. M. (2011). Is there an urban advantage in child survival in sub-Saharan Africa? Evidence from 18 countries in the 1990s. Demography, 48, 531–558.CrossRefGoogle Scholar
  7. Dye, C. (2008). Health and urban living. Science, 319, 766–769.CrossRefGoogle Scholar
  8. Ezeh, A., Oyebode, O., Satterthwaite, D., Chen, Y-F., Ndugwa, R., Sartori, J., . . . Lilford, R. J. (2017). The history, geography, and sociology of slums and the health problems of people who live in slums. Lancet, 389, 547–558.Google Scholar
  9. Fields, G. S. (1980). Education and income distribution in developing countries: A review of the literature. In T. King (Ed.), Education and income: A background study for world development (pp. 231–315). Washington, DC: World Bank.Google Scholar
  10. Fink, G., Günther, I., & Hill, K. (2014). Slum residence and child health in developing countries. Demography, 51, 1175–1197.CrossRefGoogle Scholar
  11. Fotso, J.-C. (2006). Child health inequities in developing countries: Differences across urban and rural areas. International Journal for Equity in Health, 5, 9.
  12. Fotso, J.-C. (2007). Urban-rural differentials in child malnutrition: Trends and socioeconomic correlates in sub-Saharan Africa. Health & Place, 13(Special Issue), 205–223.CrossRefGoogle Scholar
  13. Fry, S., Cousins, B., & Olivola, K. (2002). Health of children living in urban slums in Asia and the Near East: Review of existing literature and data (Environmental Health Project Activity Report 109). Washington, DC: U.S. Agency for International Development.Google Scholar
  14. Günther, I., & Harttgen, K. (2012). Deadly cities? Spatial inequalities in mortality in sub-Saharan Africa. Population and Development Review, 38, 469–486.CrossRefGoogle Scholar
  15. Gupta, K., Arnold, F., & Lhungdim, H. (2009). Health and living conditions in eight Indian cities (National Family Health Survey (NFHS–3), India, 2005–06 Report. Mumbai, India: International Institute for Population Sciences.Google Scholar
  16. Haddad, L., Ruel, M. T., & Garrett, J. L. (1999). Are urban poverty and undernutrition growing? Some newly assembled evidence. World Development, 27, 1891–1904.CrossRefGoogle Scholar
  17. India Office of the Registrar General and Census Commissioner. (2013). Primary census abstract for slum (Technical Report). New Delhi, India: Office of the Registrar General and Census Commissioner.Google Scholar
  18. International Institute for Population Sciences (IIPS), & Macro International. (2007). National Family Health Survey (NFHS–3), 2005–06: India, Vol. 1. Mumbai, India: International Institute for Population Sciences.Google Scholar
  19. James, W. P. T., Ferro-Luzzi, A., & Waterlow, J. C. (1988). Definition of chronic deficiency in adults—Report of a working party of the International Dietary Energy Consultative Group. European Journal of Clinical Nutrition, 42, 969–981.Google Scholar
  20. Jorgenson, A. K., & Rice, J. (2010). Urban slum growth and human health: A panel study of infant and child mortality in less-developed countries, 1990–2005. Journal of Poverty, 14, 382–402.CrossRefGoogle Scholar
  21. Jorgenson, A. K., & Rice, J. (2012). Urban slums and children’s health in less-developed countries. Journal of World-Systems Research, 18, 103–116.CrossRefGoogle Scholar
  22. Jorgenson, A. K., Rice, J., & Clark, B. (2012). Assessing the temporal and regional differences in the relationships between infant and child mortality and urban slum prevalence in less developed countries, 1990–2005. Urban Studies, 49, 3495–3512.CrossRefGoogle Scholar
  23. Kennedy, G., Nantel, G., Brouwer, I. D., & Kok, F. J. (2006). Does living in an urban environment confer advantages for childhood nutritional status? Analysis of disparities in nutritional status by wealth and residence in Angola, Central African Republic and Senegal. Public Health Nutrition, 9, 187–193.CrossRefGoogle Scholar
  24. Keusch, G. T., Rosenberg, I. H., Denno, D. M., Duggan, C., Guerrant, R. L., Lavery, J. V., . . . Brewer, T. (2013). Implications of acquired environmental enteric dysfunction for growth and stunting in infants and children living in low- and middle-income countries. Food and Nutrition Bulletin, 34, 357–364.Google Scholar
  25. Levine, B. (2007). What does the population attributable fraction mean? Preventing Chronic Disease, 4(1), 1–5.Google Scholar
  26. Lin, M.-J., Liu, J.-T., & Qian, N. (2014). More missing women, fewer dying girls: The impact of sex-selective abortion on sex at birth and relative female mortality in Taiwan. Journal of the European Economic Association, 12, 899–926.CrossRefGoogle Scholar
  27. Maluccio, J. A., Hoddinott, J., Behrman, J. R., Martorell, R., Quisumbing, A. R., & Stein, A. D. (2009). The impact of improving nutrition during early childhood on education among Guatemalan adults. Economic Journal, 119, 734–763.CrossRefGoogle Scholar
  28. Marx, B., Stoker, T., & Suri, T. (2013). The economics of slums in the developing world. Journal of Economic Perspectives, 27(4), 187–210.Google Scholar
  29. Menon, P., Ruel, M. T., & Morris, S. S. (2000). Socio-economic differentials in child stunting are consistently larger in urban than in rural areas. Food and Nutrition Bulletin, 21, 282–289.CrossRefGoogle Scholar
  30. Montgomery, M. R. (2009). Urban poverty and health in developing countries. Population Bulletin, 64(2), 1–16.Google Scholar
  31. Montgomery, M. R., & Hewett, P. C. (2005). Urban poverty and health in developing countries: Household and neighborhood effects. Demography, 42, 397–425.CrossRefGoogle Scholar
  32. Moulton, B. R. (1990). An illustration of a pitfall in estimating the effects of aggregate variables on micro units. Review of Economics and Statistics, 72, 334–338.CrossRefGoogle Scholar
  33. Mullick, M. S. I., & Goodman, R. (2005). The prevalence of psychiatric disorders among 5–10 year olds in rural, urban and slum areas in Bangladesh. Social Psychiatry and Psychiatric Epidemiology, 40, 663–671.CrossRefGoogle Scholar
  34. Murthy, S. L. (2012). Land security and the challenges of realizing the human right to water and sanitation in the slums of Mumbai, India. Health and Human Rights, 14(2), 61–73.Google Scholar
  35. Paciorek, C. J., Stevens, G. A., Finucane, M. M., & Ezzati, M. (2013). Children’s height and weight in rural and urban populations in low-income and middle-income countries: A systematic analysis of population-representative data. Lancet Global Health, 1, e300–e309. CrossRefGoogle Scholar
  36. Pitt, M. M. (1997). Estimating the determinants of child health when fertility and mortality are selective. Journal of Human Resources, 32, 129–158.CrossRefGoogle Scholar
  37. Pörtner, C. C. (2016). Sex-selective abortions, fertility, and birth spacing (World Bank Policy Research Working Paper No. 7189). Washington, DC: The World Bank.Google Scholar
  38. Pradhan, J., & Arokiasamy, P. (2010). Socio-economic inequalities in child survival in India: A decomposition analysis. Health Policy, 98, 114–120.CrossRefGoogle Scholar
  39. Rice, J., & Rice, J. S. (2009). The concentration of disadvantage and the rise of an urban penalty: Urban slum prevalence and the social production of health inequalities in the developing countries. International Journal of Health Services, 39, 749–770.CrossRefGoogle Scholar
  40. Rosenzweig, M. R., & Stark, O. (1989). Consumption smoothing, migration, and marriage: Evidence from rural India. Journal of Political Economy, 97, 905–926.CrossRefGoogle Scholar
  41. Saikia, N., Singh, A., Jasilionis, D., & Ram, F. (2013). Explaining the rural-urban gap in infant mortality in India. Demographic Research, 29(article 18), 473–506. CrossRefGoogle Scholar
  42. Sastry, N. (1997). What explains rural-urban differentials in child mortality in Brazil? Social Science & Medicine, 44, 989–1002.CrossRefGoogle Scholar
  43. Sastry, N. (2004). Urbanization, development and under-five mortality differentials by place of residence in São Paulo, Brazil, 1970–1991. Demographic Research, S2(article 14), 355–386. CrossRefGoogle Scholar
  44. Satapathy, B. K. (2014). Safe drinking water in slums: From water coverage to water quality. Economic & Political Weekly, 49(24), 50–55.Google Scholar
  45. Sen, A. (1990, December 20). More than 100 million women are missing. New York Review of Books, 37. Retrieved from
  46. Smith, L. C., Ruel, M. T., & Ndiaye, A. (2005). Why is child malnutrition lower in urban than in rural areas? Evidence from 36 developing countries. World Development, 33, 1285–1305.CrossRefGoogle Scholar
  47. Spears, D. (2013). How much international variation in child height can sanitation explain? (World Bank Policy Research Working Paper No. 6351). Washington, DC: The World Bank.Google Scholar
  48. Spears, D, (2014). Increasing average exposure to open defecation in India, 2001–2011 (Working Paper 21). New Delhi, India: Research Institute for Compassionate Economics.Google Scholar
  49. Strauss, J., & Thomas, D. (1995). Human resources: Empirical modeling of household and family decisions. In J. Behrman & T. N. Srinivasan (Eds.), Handbook of development economics (pp. 1883–2023). Amsterdam, the Netherlands: Elsevier Science.Google Scholar
  50. Subbaraman, R., O’Brien, J., Shitole, T., Shitole, S., Sawant, K., Bloom, D. E., & Patil-Deshmukh, A. (2012). Off the map: The health and social implications of being a non-notified slum in India. Environment and Urbanization, 24, 643–663.CrossRefGoogle Scholar
  51. Thomas, D., & Strauss, J. (1997). Health and wages: Evidence on men and women in urban Brazil. Journal of Econometrics, 77, 159–185.CrossRefGoogle Scholar
  52. Timæus, I. M., & Lush, J. (1995). Intra-urban differentials in child health. Health Transition Review, 5, 163–190.Google Scholar
  53. UN-Habitat. (2013). State of the world’s cities 2012/2013: Prosperity of cities. New York, NY: Routledge.Google Scholar
  54. UNICEF. (2013). Improving child nutrition: The achievable imperative for global progress (Report). New York, NY: UNICEF.Google Scholar
  55. United Nations. (2015). World urbanization prospects: The 2014 revision (Report). New York, NY: United Nations, Department of Economic and Social Affairs, Population Division.Google Scholar
  56. van de Poel, E., O’Donnell, O., & van Doorslaer, E. (2007). Are urban children really healthier? Evidence from 47 developing countries. Social Science & Medicine, 65, 1986–2003.CrossRefGoogle Scholar
  57. van de Poel, E., O’Donnell, O., & van Doorslaer, E. (2009). What explains the rural-urban gap in infant mortality: Household or community characteristics? Demography, 46, 827–850.CrossRefGoogle Scholar

Copyright information

© Population Association of America 2017

Authors and Affiliations

  1. 1.Department of Economics, Albers School of Business and EconomicsSeattle UniversitySeattleUSA
  2. 2.Center for Studies in Demography and Ecology, University of WashingtonSeattleUSA
  3. 3.Graduate Institute of Development StudiesNational Chengchi UniversityTaipei CityTaiwan

Personalised recommendations