When we talk about healthcare in India, most of us assume it about rural health, given that urban areas supposedly have better and more accessible health infrastructure and facilities, particularly after the pandemic.
But Dr Indrani Gupta, a Visiting Fellow at the Centre for Social and Economic Progress (CSEP), New Delhi, and Alok Kumar Singh, Research Associate at the CSEP, disagree.
In a working paper titled ‘Urban Health: Slipping Through the Cracks’, published by the CSEP, they argue that owing to “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.”
Professor Gupta points out that while rural areas certainly deserve more attention, the fact that urban populations have been growing rapidly across the world also needs to be factored into any healthcare policy.
‘According to the 2011 Indian Census, the urban population comprises 31.2% of the total population or about 377 million or more individuals (Bhagat, 2018). Of these, 70% live in cities, i.e., towns with more than 100,000 people, Thus, in sheer volume, the urban population is very large in India, and they also live in complexly defined areas with varied structural, administrative, and financial management systems,’ says the report.
‘The Covid pandemic was a wake up call,’ she says, because it happened mostly in the densely populated urban areas, and it exposed the massive fault lines in the existing urban healthcare system.
Alok Kumar Singh adds that their research indicate that the “burden of disease is far higher in the urban areas, particularly among the urban poor, when compared with the rural poor.”
This is because the urban poor are not only susceptible to what many describe as lifestyle, non-communicable diseases, but they also have diseases which are typically seen among the rural poor, caused by poor sanitation and other issues.
She also makes the point that when we talk about urban healthcare, we should not ignore those who live in slums and unauthorised shanties with poor water, sanitation and other facilities which impact their health negatively.
Noting that healthcare can be divided into primary, secondary and tertiary tiers, she says there’s a distinct lack of primary health care facilities in urban areas, which are mostly focused on tertiary, or hospital care.
“So if someone has malaria, or fever, or even a minor injury, you need to go your nearest primary care provider. That is mostly missing in urban areas.”
Rural areas, on the other hand, have a structure, which begins with a primary health centre and then moves up the chain. “That structure is missing in the urban areas,” she says. Which means people usually skip or bypass their first tier of healthcare, and thus put more pressure on the other two.
There’s also fragmentation in the definition, structure, allocation and administration of urban healthcare, adds Singh. For instance, different ministries and departments offer similar programs targeting the same population, with different sources of financing, he says. In rural areas, greater homogeneity across these dimensions has allowed a sharper policy focus and better implementation, adds Singh.
Fixing the definition of ‘urban’ is critical, adds Professor Gupta. “You have different authorities dealing with different kinds of urban population. And they don’t talk to each other,” she says. “It is high time that urban health comes under an umbrella of one multi-sectoral authority, because water, sanitation, housing are all equally important for urban health.”
Then of course there is finance, with municipal bodies dependent on the whims and fancies of the state and the central governments for meagre funds.
In fact, in many areas, the rural poor are doing better than the urban poor, she says. You can prevent hospitalisation by good primary care. In fact, during the pandemic, the pressure on the secondary and tertiary healthcare could have been significantly eased if there had been sufficient primary healthcare facilities, she says.
So given the way we handled the massive vaccination drive, and the fact that we actually exported vaccines for free to various other needy nations during the pandemic, how prepared are we for the next one?
The answer is chilling. According to the two authors of the report, the government’s own statistics in terms of shortfalls across various health sectors show that we are totally and abysmally unprepared.
But then, with a shameful and embarrassing 1.1 percent of GDP allotted to healthcare to begin with, what else can we expect?
To understand these shortfalls in urban healthcare, and also explore some solutions to this major problem which could cripple India in case of another sudden pandemic, watch the full interview.
(The views expressed here are those of the authors of the paper, and do not necessarily express those of the CSEP)
