At long last, the attention of health planners has turned to the task of strengthening urban health services to reduce the glaring health inequity that afflicts the urban poor.
The National Rural Health Mission (NRHM) is addressing the need to improve rural health services but the recent addition of an urban component, in the form of the National Urban Health Mission (NUHM), will transform it into a broader National Health Mission (NHM).
The assumption that urban health services are better equipped and organised, due to greater availability of health professionals and health care facilities, led to the long neglect of urban health planning.
The absence of a well-designed system of urban primary health care has resulted in fragmentation of health services, with the poor being denied basic care and the middle and upper classes overloading the secondary and tertiary care centres with problems that are best attended to in primary care facilities.
Urban health now presents an unacceptable mix of marked inequities in health indicators, serious inefficiencies in service delivery and avoidable escalation of health care costs.
The urban poor are the worst victims of this anarchy. Their health indicators are often as bad, and in some cases worse, than the rural population. Those migrating from rural areas bring with them the health burdens of rural poverty and soon acquire the ills of unhygienic urban living.
Cramped in crowded slums, without access to clean water and sanitation, they are forced to live with their own waste and have all the maladies of poverty magnified by the misery of their urban concentration camps - from childhood pneumonia and diarrhoea to drug resistant tuberculosis.
Over time, they also manifest the problems of their new environment - rising rates of high blood pressure, diabetes, multiple addictions (tobacco, alcohol, drugs), violence and mental illness.
The middle class too suffers. One only has to recall the appalling sight of panic stricken crowds being lathi-charged outside large hospitals in Delhi, during the scare of the H1N1 epidemic, to realise how the absence of easily accessible community health centres denied the benefit of primary care and counselling to the many who did not have a serious illness.
Ailments that should have been handled by nurses or family medicine practitioners land up in the long queues of public hospitals or expensive clinics of private doctors.
The NUHM proposes to target the urban poor and other vulnerable groups and promote their access to affordable and good quality preventive, promotive and primary services.
It intends to develop a public investment plan for primary and secondary health care services in small, medium, large and mega-cities by clearly defining the roles of the Centre, State and Urban Local Bodies (ULBs).
While integrating various vertical disease programmes, it will define 'essential health care packages' for each level of health care and design effective referral procedures.
While these are laudable objectives, urban health cannot be viewed as selective health services for the poor, separated from the social determinants of health - water, sanitation, nutrition, housing, electricity, environment, livelihoods, gender relations are among the obvious.
While prioritisation of the poor is fully justified, their health services have to be integrated into a cohesive urban development plan that serves the whole city, rather than confining the poor to sub-optimal services in a ghettoed environment that does not bridge the rich-poor health equity gap.
The poorly resourced, feebly empowered and badly governed ULBs also need to be strengthened to coordinate the combined delivery of essential health and civic services, with affixed accountability.
When was it that we last saw a Mayor or a Municipal Corporation being hauled up for poor performance in health or sanitation? Who checks and controls the pollution in air, water and food?
Urban living brings forth a plethora of health challenges: infectious diseases, non-communicable diseases; road traffic accidents and violence; addictive behaviours; disabilities; a spectrum of nutritional disorders ranging from under nutrition to overweight and obesity.
Health services have to develop a broadband capacity to deal with all of these. The vision must encompass health beyond health care, by providing a clean environment, potable water, good sanitation, safe pedestrian pathways and cycling lanes and open areas for safe and pleasurable recreation and physical activity.
Urban health services need not be costly. Primary health care services can be effectively provided by trained nurse practitioners, with intermittent physician support and reliable referral linkages.
Technology enabled community health workers can provide outreach services to the community. Promoting health literacy can empower citizens to protect, preserve and promote personal and family health.
Urban health should become an integral component of Universal Health Coverage and draw upon a responsive public sector, a responsible private sector and a resourceful voluntary sector to create a strong and well regulated architecture for urban health.
Care must be taken to ensure that lack of a legal civic identity for the urban poor, especially seasonal migrants who come to cities only for a part of the year, does not become a barrier for delivering promised entitlements. NUHM is a good beginning but there is much else that needs to follow.
The writer is president, Public Health Foundation of India
The Public Health Foundation of India (PHFI) is a think-tank which aims to strengthen India’s public health systems.
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