The evolving challenge of urban health

10 June 2019 | Views | By Shama Karkal and Bhumika Nanda

Urban transformation is affecting health in India’s cities—what can we do to tackle this?

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Urban economies are rapidly changing: 52% of the world is now urbanized (compared to 39% three decades ago), and India’s urban population is projected to reach additional 300 million more by 2050 (World Cities Report-2016). Urban India contributed 63% of India’s GDP in 2014 and is expected to contribute three-fourths of the GDP by 2020. At around the same time, the number of India’s urban poor is expected to hit 200 million (National Population Policy 2000).

All of these changes impact the health of urban residents in complex ways: migration, climate change, transitioning disease burden, unhealthy built environments and inadequate urban systems to cope with this rapid growth all have a role to play. At the same time, the goal of an emerging economy should be to create truly enabling environments for occupantsaccording to Hancock and Duhl, “A healthy city is one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing the functions of life and in developing to their maximum potential.” In other words, a healthy city is one which allows its population to flourish, and the health sector can’t ensure that on its own.

A panel at Urban Arc 2019, an annual conference by the Indian Institute for Human Settlements (IIHS) in Bengaluru, discussed this pressing issue: how evolving urban economies are affecting health, and some interesting solutions to the problems that have arisen as a result. I had the opportunity to chair this panel, and the following post highlights the key discussions of the panel.

What are the key issues in ensuring health of urban populations today?

I set the context by pointing out the good news in urban health in India today: access to low-cost generic medicines and medical technologies, a growing skilled health workforce and a thriving private sector, government schemes for health and social protection, and improving quality of service provision in healthcare. Yet, this is not the reality for much of the urban population, and especially the urban poorseeking better health is time-consuming and expensive, health systems are bewildering to access, formally trained providers not just expensive but unfriendly, the physical environments in which they live increase their risk of infection, poor nutrition and injuries, and the increasing burden of lifestyle diseases can be prevented or managed, but not cured.

The panelists particularly pointed out three key considerations and their work in that regard:

1. How the health system is governed

Mukesh Sharma, Program Director at Population Services International (PSI), explained that availability of accessible and quality primary health services is a necessity to improve the health of the urban poorand the National Health Mission (NHM) has just this objective in mind. However, buy-in from local governments (Urban Local Bodies, or ULBs) and State governments, who are responsible for healthcare, is crucial to how the NHM gets implemented. Mukesh leads the Challenge Initiative for Healthy Cities (TCIHC), which tries to strengthen existing urban primary healthcare systems across three states by stimulating greater attention, involvement and investment from these bodies.

Strengthening health systems governance also requires filling some key gaps in information and implementation. The first step is to identify the health needs of the urban population. One part of this is identifying who the most vulnerable residents of cities and towns are, and where they livesince they may not live in areas currently recognised as slumswhich the TCIHC initiative does. Along with who is vulnerable, it’s important to determine what the specific vulnerabilities are. Dr Damodar Bachani from the Building Healthy Cities (BHC) Project pointed out that understanding these health vulnerabilities requires assessments of not just the health system, but a political economy analysis, analysis of non-communicable disease risk factors, data use and systems, and an environmental analysis of the city! This information helps to identify and fill key program gaps: For example, one of BHC’s risk survey studies revealed that there was high prevalence of obesity and hypertension in the community and less than 1% ever screened for cancers. This led them to add lifestyle screening camps along with health promotion activities to the project framework.

2. The capacity of the health system

After the health needs are understood, urban health programmes need to be strengthened to ensure that effective health services are available to address the identified needs. Existing primary health centres need to be ‘activated’ in terms of accessibility, quality and consistency of service delivery. This part of the process remains complex and relatively opaque, particularly due to the risks posed by bureaucracy and everyday urban politics.

It is in this sphere that technology is proving to be transformative. Anand Panjiyar, Program Specialist at WISH Foundation spoke about the Mohalla Clinics in Delhi that provide comprehensive primary health care and generate high quality data through state-of-the-art IT solutions in a modular cabin. They are also exploring the use of Artificial Intelligence to make processes more transparent. Swasti Health Catalyst’s ‘Invest 4 Wellness’ program is another model that uses technology — particularly point of care diagnostics — to create a disruptive model of accessible and high-quality service provision in primary healthcare.


3. The catastrophic costs of health

In order to be truly accessible, healthcare needs to be not just easily available, but also affordable. Catastrophic out-of-pocket expenses on healthcare drive pushes more than 40 million people below the poverty line every year. The Government of India’s flagship Ayushman Bharat scheme looks to address both demand and supply sides of this issue, by strengthening primary healthcare centres (as ‘Health and Wellness Centres’) and providing insurance to the poorest in India. Yet healthcare costs are not just catastrophic for those living below the poverty line — how are these populations to be protected from the financial burden that comes with illness?

Dr Ajay Singh, from the Partnerships for Affordable Healthcare Access and Longevity (PAHAL) project led by IPE Global, suggested two important pathways. First, at the macro level, private and philanthropic capital could be innovatively mobilised to help finance the system strengthening that will help achieve the Sustainable Development Goals. And second, at the micro level, insurance schemes that are tailored to the needs of poorer and middle-income households can help alleviate the financial burden on families when illness occurs — enabling them to seek care as soon as they need it, rather than when it can no longer be avoided.

As engines of our economy, urban spaces will need our collective thought and effort in terms of creating spaces that allow productivity and efficiency and this necessarily means that we must look at well-being of people who occupy these spaces. Realising the goal of healthy cities needs a convergence of public and private systems, for preventing illness and promoting wellness which go far beyond the delivery of medical care. Working together to address the multitude of factors — infrastructure design — residential or commercial spaces, mobility and transportation, spaces for play and recreation, supply of food and water, maintain air quality, redistributing and conserving water resources etc — is the critical need of the hour.


Shama Karkal is a public health expert and Chief Executive Officer at Swasti Health Catalyst. Bhumika Nanda is a Technical Specialist at Catalyst Management Services.


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