Addressing Urban Health Challenges in India: Shifting Focus to the Urban Poor

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Executive Summary

The 21st century has witnessed the transformation of the world from predominantly rural to predominantly urban, presenting many challenges that are unique to urban areas and require separate focus. In India, the 2011 Census data show that the urban population has increased to more than 31%, and the number of towns has grown by about 200% between 1961 and 2011. Occasional surveys and research have established that many urban health issues emanate from and impact sectors outside the health sector. One common theme that has emerged is the inequity in health outcomes and accessibility of health services between the urban poor and the non-poor.

This paper examines the growing challenges of urban health in India, focusing on the disparities between the urban poor and non-poor populations. The study utilises multiple data sources, including the National Sample Survey (NSS), National Family Health Survey (NFHS), Longitudinal Ageing Study in India (LASI), and government health statistics, to analyse trends in health outcomes, access to services, treatment-seeking behaviour, and out-of-pocket spending on health. The analysis compares urban and rural areas, emphasising inequalities across wealth quintiles and highlighting the increasing vulnerability of urban slum dwellers.

The research reveals a complex and concerning picture of urban health. While child mortality rates have generally improved across India, the urban poor experience significantly worse outcomes compared to their rural counterparts and the urban non-poor. This disparity is evident across various health indicators, including neonatal, infant, and under-five mortality rates, as well as the prevalence of diseases like fever, diarrhoea, tuberculosis (TB), and disability. While rural areas have shown greater improvement in these indicators, urban inequalities have widened, indicating a concerning trend of divergence.

The study also demonstrates significant gaps in health service coverage and access in urban areas. Although urban areas appear better served than rural areas based on aggregate statistics of healthcare personnel and infrastructure per population, the distribution of these resources within urban areas is highly unequal. Slum populations often lack access to nearby public health facilities, necessitating longer travel distances and potentially delaying treatment. This uneven distribution, coupled with perceptions of lower-quality care in public facilities, contributes to the greater reliance on private healthcare by urban residents, including the poor.

The increased utilisation of private healthcare services by the urban poor translates into higher out-of-pocket health expenditures, exacerbating their financial vulnerability. Despite government initiatives like the National Urban Health Mission (NUHM), public health insurance coverage remains lower in urban areas compared to rural areas, further contributing to the financial burden on the urban poor. The paper argues that inadequate funding for the NUHM and fragmentation in healthcare governance and administration have hampered its effectiveness. State-led initiatives like Mohalla Clinics and Basti Dawakhanas, while laudable, often operate in isolation and face scaling challenges.

The study also provides a detailed analysis of the precarious situation of urban slum dwellers. The literature reviewed highlights the multi-dimensional vulnerabilities of slum residents, who often lack access to basic amenities such as clean water, sanitation, and adequate housing. These deprivations, combined with limited access to quality healthcare and occupational hazards, contribute to a higher disease burden, including both communicable and non-communicable diseases.

The paper concludes that urgent and focused attention is needed to address the growing urban health crisis in India. It emphasises the need for structural and administrative reforms, particularly within the NUHM, to ensure equitable distribution of health resources and improved service delivery. The study advocates for a unified administrative body to oversee urban health planning, research, coordination, and implementation. Furthermore, a substantial increase in health allocations, specifically for urban health initiatives, is crucial to address the considerable health needs of India’s rapidly growing urban population. Without such interventions, the health disparities between rural and urban areas, and between the urban poor and non-poor, are likely to worsen, with potentially devastating consequences.

Q&A with authors

What is the core message conveyed in your paper?

The 21st century has seen the transformation of our world from mostly rural to mostly urban, and the phrases “Urban Age” and “Urban Century” are now often mentioned when describing this transformation. India too has seen rapid growth (200%) in the number of towns during 1961-2011 with huge variations across states and cities in the extent of urbanisation, demography, land-use patterns, education, health, and a host of other indicators. This paper finds that while inequality in health outcomes across economic categories is high in both rural and urban areas, and the overall, the poor in urban areas are doing worse on all fronts compared to their rural counterparts.

What presents the biggest opportunity?

The continued focus on rural areas via the National Rural Health Mission (NRHM) and now the National Health Mission (NHM) is evidenced to have benefited rural health systems in India. A similar and urgent focus on urban health is required, accompanied by structural and administrative changes in how health inputs like infrastructure and personnel are supplied to different urban areas. A unified administrative body to oversee urban health planning, research, coordination, and implementation is the need of the hour, in addition to a substantial increase in health allocations for urban India.

What is the biggest challenge?

Urban health can best be addressed by adopting a multi-sectoral and multi-stakeholder approach, with a significantly augmented level of funding. The social determinants of urban health require planning and coordination across ministries and administrative bodies, and a strong political will that prioritizes urban health enough to work with different stakeholders, cutting across party and administrative lines. This approach seems somewhat of a challenge in the current context. Finally, raising financial resources for addressing urban health may also not be easy given the low and static share of health expenditure in total health expenditure of the government, even after the COVID pandemic.