Addressing Widening Health Inequities: Urgent Need to Fix the Urban Healthcare System

The inequity in the availability and accessibility of health facilities, especially for urban poor, had prompted the expansion of the National Urban Health Mission (NUHM) with a focus on primary healthcare services to serve the under-served.  However, despite 10 years of the implementation of NUHM, primary healthcare provisioning is not only highly inadequate but also fragmented in urban India.

Improving access to affordable and quality health services has been a major theme in health programmes and policies in India.  The National Rural Health Mission, subsequently subsumed under National Health Mission, has been instrumental in changing the rural health system positively, improving access, availability and affordability of services for rural India.  The inequity in the availability and accessibility of health facilities, especially for urban poor, had prompted the expansion of the National Urban Health Mission or NUHM with a focus on primary health care services to serve the under-served.  However, despite 10 years of the implementation of NUHM, primary health care provisioning is not only highly inadequate but also fragmented in urban India.  There is fragmentation in both financing and governance due to a complex multi-layered administrative structure that govern the running and funding of health systems in urban India.  This is in addition to the sparse funding for health in general and primary care in particular – with less than 2% of health expenditure out of the country’s GDP being spent on health.   

This analysis attempted to piece together the story of urban health by focusing on the extent of inequities in healthcare access and outcomes among the urban poor, drawing data from multiple databases, including the National Sample Survey (NSS), National Family Health Survey (NFHS), Longitudinal Ageing Study in India (LASI), and government health statistics, to compare and validate the results.  Additionally, a literature review was conducted on the availability and accessibility of health care in urban slums, especially for the urban poor.  Finally, the challenges of urban spaces during COVID-19 are explored using literature review method to understand their dynamics and role in determining health and health-seeking behaviour during the pandemic. 

While inequalities in health outcomes across economic categories are high in both rural and urban areas, the inequalities are higher in urban areas relative to rural areas. These inequalities seem to have increased somewhat over the years—the progress made by rural areas has been comparatively better.

The results indicate that while inequalities in health outcomes across economic categories are high in both rural and urban areas, the inequalities are higher in urban areas relative to rural areas. These inequalities seem to have increased somewhat over the years—the progress made by rural areas has been comparatively better. There are gaps that remain in service coverage, access, and health coverage in urban areas for some of the key parameters. Overall, the poor in urban areas are doing worse on all fronts compared to their rural counterparts.  

Inadequate attention has been paid over the years to administrative and governance structures that are required to address urban health.  The challenges have been compounded by the phenomenal growth in urban populations and the emergence of million-plus cities, resulting in the current and static health infrastructure being stretched beyond limits.

Inadequate attention has been paid over the years to administrative and governance structures that are required to address urban health.  The challenges have been compounded by the phenomenal growth in urban populations and the emergence of million-plus cities, resulting in the current and static health infrastructure being stretched beyond limits.  

Urban health requires a focus similar to the NRHM urgently, but accompanied by structural and administrative changes in how health inputs—like infrastructure and personnel—are supplied to different urban areas.  

If the NUHM is the main plank on which urban health planning has to be implemented, a new approach would be required.  All urban health facilities need to be brought under one umbrella, whether in an existing ministry or by creating a separate body for urban health. A unified administration can be responsible for planning, research, coordination, and implementation. The finances can be from a diverse set of sources, but the planning for the finances for urban health needs to be done in an integrated manner.   

Also, the allocations to NUHM have remained too modest to make any difference to the sizeable needs of cities and towns.  The four post-COVID budgets do not indicate any increase in government health spending out of the total spending of the government.  With this level of health financing, it seems unlikely that the situation will change anytime soon unless the state governments take the initiative and plan for urban health in a major way. 

It is hoped that policymakers will take note of the urgent needs of cities, especially of the urban poor.  Unless that happens, health outcomes and inequities can only widen between rural and urban areas and between the poor and the non-poor in the urban areas.