Recent decades have seen unprecedented population growth in the urban areas and according to United Nations’s prognosis in 2011, India will likely triple its population from 367 million in 2010 to 915 million in 2050. Urbanisation is a complex and dynamic demographic phenomenon which interacts with globalisation, economic growth, income inequality, climate change, health and sustainability.
The urban populations in India have limited access to healthcare facilities, especially when it comes to primary care. For example, NCT Delhi has merely eight Primary Health Centres (PHCs), no Community Health Centres (CHCs) and 134 tertiary care hospitals, which include general as well as speciality, super and multi-speciality hospitals.
Apart from these there are 33 dispensaries, which do not have any inpatient facility but only observation beds. The layer of primary healthcare system in urban areas is not as impressive as in rural areas. There are considerable challenges in reaching the poor and marginalizsed communities in urban areas and ensuring equitable health outcomes.
The policy focus so far has been mostly in rural and tribal areas on improving access to health services and strengthening the health systems. What’s been ignored are the poor and the marginalised in the urban areas facing the perils of ill-health whose numbers are multiplying by the day. The health and nutrition indicators in urban areas are as bad as that of their rural counterparts.
As per the National Family Health Survey (NFHS-4), 38 per cent of urban poor children under five years are stunted. The urban poor, which constitute for 26 per cent of the total urban population, have even worse health and nutrition outcomes as a result of lack of adequate services. Almost 36 per cent urban children miss full immunization which is as high as 58 per cent among the urban poor.
Urban population contributes to 65 per cent of India’s GDP, which will jump to 70-75 per cent in 2020 (Barclay’s report, 2014). The GDP per capita income for urban (Rs 56,347 pa) is almost double that of rural (Rs 30,342). In spite of this stark difference in economies, the health and nutritional status of urban areas is as poor as that of the rural; in fact, status of urban poor is worse than that of rural poor.
Inadequacy in Public Health Delivery System
Poor health-seeking behaviour leads to poor health and nutritional outcomes have been established by researchers and practitioners. Urban population, largely the poor and the marginalised, are “ghettoised” and “spaced out” because of the inadequacy in urban public health delivery system to reach them on account of location, their place of work such as constructions sites, etc.
In addition, ineffective outreach and weak referral system limit their access. Migrant population’s ability to navigate the complex landscape of a deeply fragmented health system has made them much more vulnerable to the ill-effects of health. A lack of economic resources and health insurance inhibits their access to the available private facilities.
Empowering Urban Governance
Urban governance matters the most in the effective delivery of health services. Multiple incarnations have taken place in the name of urban health policy since the 1990s; yet Urban Local Bodies (ULBs) —the third layer of democracy — remain weak in focus as well as delivery of health and nutrition services.
The 74th Amendment, also known as Nagarpalika Act, was framed for strengthening public health capacity of ULBs in 1992. This has not happened in its truest form. The Fifteenth Finance Commission must institutionalise the devolution process to ULBs so that the funds flow from state government is effectively used.
The ULBs should be encouraged and empowered to enhance their revenue generating capacity in these functional areas and build their capacities to use these resources on providing more such services. Empowering the ULBs with better financing options will overcome human resources challenges both for- implementation and monitoring.
Translating the rural health system approach into urban areas is not where a solution lies; but what we need is a new approach to tackle the complex and complicated urban health scenario. In 2013, the central government realised this challenge and the National Urban Health Mission (NUHM) was launched in the country.
The NUHM has systematically worked towards meeting the regulatory, reformatory, and developmental public health priorities. However, there is huge shortage of primary healthcare services in the urban areas and the scope of primary care should expand to preventive and promotive services along with curative. Linkages between ICDS and health services need to be explored. There are NGOs that have successfully implemented these unified approaches in urban areas, For example, SNEHA (Mumbai) runs maternal and child nutrition model successfully by involving volunteers who dedicates two hours per week for community outreach.
The mohalla clinics (primary health centres), an initiative of the Delhi government, is also an aspirational model that provides basic package of essential health services, including medicines, diagnostics, and consultation free of cost. Several ULBs of Mumbai, Surat, Ahmedabad, etc. have made concerted efforts to focus on both health and nutrition centres. Similar models/ ideas can be systemised with policy focus to encourage them and build on their efforts.
Need of the Hour
What we need in complex urban settings is a multi-pronged approach—a new unified strategy for improving health and nutrition. The focus should be on extending and strengthening the primary care delivery mechanism which will be a one-point centre for preventive, promotive and curative services.
Community awareness for the same in urban community can be generated through Jan Andolan, for improved service delivery and outreach. The HWC platform can be leveraged to integrate nutrition component through sensitisation, counselling, rehabilitation, etc. Similar unified approaches need to be supported by and coordinated with other non-health sectors such as housing and urban development, environment, road transport, education, water and sanitation, as well as CSRs, NGOs, development partners and experts.
It should cover all vulnerable population suffering from ‘urban penalties’ viz- pavement dwellers, rag-pickers, street children, rickshaw pullers, construction/ brick/ lime kiln workers, sex workers and other temporary migrants, etc. Public health thrust should be on food and nutrition, NCDs, mental health, sanitation, clean drinking water, vector control, etc. Moreover, since one size doesn’t fit all, disruptive models (similar to few NGOs and ULBs described earlier) according to demographic and cultural variations of all states should be explored so that all citizens enjoy health, nutrition and wellbeing.
(Alok Kumar is adviser (health and nutrition) and Khushboo Saiyed is young professional, NITI Aayog. Views expressed are personal.)
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