A plan to improve health systems in cities: analysis
History is full of examples of disease outbreaks that alter cities and change lives. In 1849, a cholera outbreak in congested New York groups led him to recalibrate his infrastructure. In 1994, the Surat Municipal Corporation played a key role in overhauling its sanitation and hygiene systems after the city was hit by the plague. Coronavirus disease (Covid-19) has once again reminded the country that strong and resilient health systems act as the first line of defense, not only against outbreaks but also to address everyday health challenges.
It has highlighted weaknesses, inequalities and shortages of investment in urban health infrastructure and serious governance problems. The pandemic has taken root in cities and has proven to be the most powerful disruptive force for “engines of economic growth”. States with a higher proportion of urban populations are increasing the numbers. In India, while efforts have been made to create tertiary care centers at the district level, little has been done to reform municipal agencies in urban areas. It is important to distinguish between the two.
Having directed efforts towards rural India, today the country faces the reality of urban health care. About 60% of all hospitalizations in urban India are in the private sector, which may not be fully regulated in small urban slums. While the National Rural Health Mission (NRHM, 2005) was able to address some critical challenges in rural health care, Indian cities continue to struggle under the high burden of disease.
During this crisis, a stronger and more staggered primary health service structure in cities could have served as the first test and care points, easing some of the burden on tertiary systems. While the human and economic cost of this crisis cannot be emphasized enough, it is important that we consolidate learning and restructure the system. Here is a set of reforms.
One, the National Urban Health Mission (2013) launched to put primary health services within the reach of the urban poor. Between 2015-16 and 2017-18, modest progress was made under this program, although its potential remains untapped. Now is an opportune time to revisit the program. Having a strong network of primary and community health centers in cities, such as in rural India, can lead to more equitable health outcomes.
Two, we need to rethink the Smart Cities Mission. Launched with the goal of promoting cities that provide basic infrastructure, the construction of health infrastructure is currently a low priority in the 100 developing cities. Closer scrutiny of project data undertaken under the mission reveals that only 69 of the 5,861 projects were for health infrastructure and capacity building, representing just over 1% of total projects selected since 2015. This it is an opportunity to recalibrate this scheme and build sustainable cities, better equipped to handle disease outbreaks.
Three, we must remember the links between health and other determinants. Families in informal settlements lack a constant supply of clean soap and water and depend on poorly maintained community toilets and shared taps. With almost half of Mumbai’s population living in miserable conditions emerging as Covid-19 groups, Maharashtra has the highest burden of disease in the country. The Swachh Bharat Mission has been able to generate a shared understanding of the benefits of sanitation; we must expand this.
Even the Atal Mission for Rejuvenation and Urban Transformation can be better exploited to ensure adequate infrastructure and better sanitation channels and networks in cities. Similarly, we can link efforts with initiatives such as the National Clean Air Program (2019), which align policies against air pollution with those of the country’s climate change plan.
Four, we must take advantage of the strong digital infrastructure. There are many examples of how cities are doing it during the pandemic, including the Agra Smart City Mission e-Doctor Seva, a video and video consultation facility launched as a public-private partnership. In Chandigarh, there are “Covid Fighting Stations” with thermal screening, pedestal hand wash, soap dispensers. Recent telemedicine guidelines issued by the Ministry of Health and Family Welfare in collaboration with Niti Aayog and the Medical Council of India provide an excellent opportunity to enable the provision of medical care to the urban poor, even beyond the closing period. . With such use of digital technology, we can more effectively manage healthcare facilities and ensure better disease surveillance and data collection.
And finally, given the high proportion of patients seeking care in the private sector, it is important to take advantage of its large set of resources so that more people can access quality services. More public-private partnerships can ensure better regulation and monitoring so that protocols are followed.
According to an estimate by the Boston Consulting Group (2017), around 40% of India’s population will live in urban areas by 2025. It is imperative that the government reimagine these spaces to meet the needs of the people. By building or improving infrastructure, including a trained workforce, you can not only tackle epidemics, but also provide quality health care. India has the framework, it must act on it.
CK Mishra is secretary, ministry of environment, forest and climate change.
The opinions expressed are personal.