Urban Health: Slipping Through the Cracks
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A large volume of evidence sharply highlights the rural-urban divide in health outcomes in India, along with the differences in availability, accessibility, and affordability of healthcare services between rural and urban areas. This paper attempts to address the challenges of urban health in India. It reviews current definitions of ‘urban,’ administrative and governance challenges, major government initiatives, and the success of decentralisation—an important factor for improving urban indicators—via the 74th Constitutional Amendment. The paper finds that India is far from reaching the goal of effective self-governance of local bodies in urban areas, and one casualty of this gap has been the lack of a coherent and cogent approach towards urban health. Urban health outcomes remain adverse, especially for the urban poor, and service provision remains woefully inadequate for all, with a disproportionate burden on the less privileged. The lack of equitable and available primary care services, coupled with overburdened secondary and tertiary care services with inadequate availability of human resources and infrastructure, has led to high out-of-pocket expenditures for many households without financial protection. Sensibly addressing urban health requires an urgent overhaul of institutional, administrative, and governance structures that often work in parallel without converging. Such reform would have a far-reaching impact on not only the health sector but on sectors such as education, labour, water, and sanitation as well.
Q&A with the authors
- What is the core message conveyed in your paper?
Even though policy changes that have been advocated, formulated, and operationalised over the years for addressing urban health concerns in India including major government initiatives like the National Urban Health Mission, and the success of decentralisation via the 74th Constitutional Amendment, the findings indicate that India currently lacks a coherent and cogent approach towards urban health. There is fragmentation both at the administrative and governance levels with diverse set of rules and policies across different urban entities in the country.
- What presents the biggest opportunity?
To realistically address urban health, there is a need to work on two fronts simultaneously; 1) to bring all urban health facilities under one umbrella, whether in an existing ministry or creating a separate body for urban health. The administration can be unified and would be responsible for planning, research, coordination, and implementation. The finances can be from a diverse set of sources, but the planning for the finances for urban health needs to be done in an integrated manner.
In a parallel fashion, a multisectoral team can start an exercise of mapping the various sources of service provision and their finances, to assess the gaps therein and draw out a plan for human resources, infrastructure, and financing for urban health with roles and responsibilities of the major actors and players. To implement these effectively, a separate administrative body should be set up for urban health and a time-bound plan should be drawn out and implemented in a pre-planned manner.
2) There needs to be a policy initiative aimed at reducing the dependence of ULBs on the state and central governments for finances, as well as directives on how to utilise the funds. In addition to this, there is also an urgent need to increase overall public health spending in India.
Besides these, a robust health information system for urban areas that also provides the size of the target population in each category would be beneficial in the effective monitoring and evaluation of the National Urban Health Mission (NUHM).
- What is the biggest challenge?
The horizontal and vertical fragmentation in urban health administration and governance is one of the biggest challenges in achieving equity in urban health outcomes. Several programs within and across ministries lack a coherent health coverage program covering basic health services, especially for informal sector workers.
Indrani Gupta
Alok Kumar Singh
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The Centre for Social and Economic Progress (CSEP) is an independent, public policy think tank with a mandate to conduct research and analysis on critical issues facing India and the world and help shape policies that advance sustainable growth and development.