India’s urban health is governed by a complex mix of stakeholders including the Ministry of Health and Family Welfare, Urban Local Bodies, and respective state governments. That health is a state subject, and that urban areas are hubs of private healthcare delivery, an area that is very lightly regulated, adds two layers to the existing complexity. It is well acknowledged that overlapping jurisdictions and autonomy amongst the stakeholders has led to reduced accountability and ineffective planning and delivery of healthcare service to the urban poor.
Urbanisation is often used as a synonym for progress. In India, it is marked with migration of people from rural to urban areas as well as transformation of villages into towns and cities. In terms of health outcomes, there is a massive divide in urban and rural areas, leading many to believe that the urban health systems are far better. However, the latest Common Review Mission revealed that the fund absorption capacity in India’s urban health system just as bad as the rural counterpart, with NUHM fund utilisation only up to 67%. This raises questions on the governance structures set in place and the coordination amongst multiple decision makers. The roundtable jointly organised by ORF and World Health Organisation’s India office saw participation of subject experts, bureaucrats and researchers from Mumbai, Chennai, Hyderabad, Bengaluru and Delhi, and broadly discussed three themes:
- The need to strengthen and rationalise existing urban primary health structures in the context of Ayushman Bharat.
- The need for strong financial governance to help minimise underutilisation of funds.
- Lack of effective Monitoring, Surveillance and Accountability systems among diverse stakeholders.
Multiple issues were interrogated starting with the utility of population norms, and the nature of care seeking behavior of communities which largely determines the extent to which health services in urban areas will be utilised. Multiple health service facilities are currently underutilised because either the centers fail to adopt a patient centric approach or they are ill-equipped, which requires immediate rectification. Installing a system of gatekeeping has become pertinent as advised by National Health Policy 2017, otherwise the secondary and tertiary health service centers will be overcrowded. The need for convergence and integration amongst UPHC and ANM’s, Anganwadi workers and Swasthya Sevikas among others was also highlighted.
Rationalising administrative boundaries and community structures, including innovative models of mobile health units was advised that would lead to effective and timely referrals and follow-ups. The idea of incentivising private sector to provide primary healthcare was also floated, as a large percentage of urban population prefers private health facilities over public, which also makes private health sector regulation an imperative. Streamlining technology in the working of public health sector was recommended.
Diversity of health situations in different cities points to the need for capacity building within ULBs with better access to funds. How to integrate different actors within healthcare service provision is a major concern. Combining health and social care, with specific focus on urban needs is important as characteristics of public health services cannot be reduced to just medical health services.
Two disconnects were identified in the course of the discussion, one at the governance level between the Urban local bodies and the state’s Department of Health and the other between supply and demand of healthcare services, which heavily emphasised on the need to understand the necessities of the urban population and to come up with optimal approaches to cater to that need.
With the aim of optimising health equity in the decentralised structure, the devolution of powers in governance has empowered the Urban Local Bodies with tools to regulate any stakeholder within health sector. However, there is little incentive for the state governments to engage with the ULBs. The flow of funds from NHM to State governments to ULBs has created a protracted mesh of approvals, bureaucratic friction and unnecessary delays.
The formation of a separate Urban Health Directorate that functions under the Ministry of Urban Development, was suggested as a possible coordinating authority. Involvement of the political representatives will bring in more accountability as local political class is often more responsible and accountable to the population from their constituency. Intern-sectoral coordination within the health sector must have multi stakeholder participation.
There is a political consensus to make investments to respond to challenges regarding high costs of medicines and diagnostics. However, there is still a lot of potential in partnerships between the private sector and municipal corporations responding to the demand side of healthcare seeking to transform patient behavior more pro-actively, optimising public health goals. This can be strengthened by creating robust referral networks involving both public as well as the private sector, where such need exists. NGOs too can play an even bigger role as a stakeholder facilitating community-provider-policymaker interfaces and there is a greater need to acknowledge their work in connecting needy people to services in both public and private sector at discounted rates.
Communication and coordination mechanism are badly required in the urban health systems. There are inefficiencies in the existing 3 tier system due to the pressure that has been created by the ‘inverted pyramid’ type of demand on the existing health institutions. A rationalised system optimised for access and quality which facilitates and incentivises smooth two-way information flows is the need of the hour. Effective monitoring, surveillance and accountability can only be held up through a more direct, streamlined flow of governance that promotes social audits and strengthens the roles of NGOs and communities.
Cooperation between different stakeholders and institutions is required for India to achieve the health Sustainable Development Goal (SDG) — not just to make the best use of finite resources, but also to capitalise on synergies and ensure policy coherence to achieve systemic change. Acknowledging health as a central component of urban planning and governance by the policymakers will help translate the vision of sustainable urban development for all into ground level action. – ORF Online