India is witnessing rapid urbanisation, and by 2030 the urban population is expected to reach 590 million from the current 377 million, implying that approximately 40% of the nation’s population will be living in urban areas.1,2 There is a substantial ongoing influx of population into environmentally deprived and overcrowded slums and decrepit slum-like habitations, with poor access to basic facilities, safe water, drainage and sanitation, electricity, cooking fuel, pucca houses and public transport.3,4 The extent to which India’s health systems can provide for the increasing population, especially in urban areas, will determine the country’s progress in achieving Sustainable Development Goals (SDGs) and thereby improving the national health indices. Indeed, growing industrialisation leads to urbanisation and economic growth, but the resultant socio-economic disparities due to diverse health systems have increased the urban poor and rich gap.5 To add to the extant situation, there has been an epidemiological transition from communicable to non-communicable disease owing to lifestyle and other factors.
The historical perspective of urban health
Public health in India has been focussing on rural health since the Bhore Committee (1946). Healthcare services to the rapidly expanding urban population lacked methodical and comprehensive planning. It has been seen since the first five-year plan (1951-56) which recommended different organisation levels of health care services for the urban and rural areas. About 126 family planning clinics and various health posts were introduced during this period.6,7 Subsequently, about 1800 family planning clinics were opened by the end of the fourth five-year plan (1969-1974). However, the focus was restricted to MCH-related services. A community-based approach to meet the healthcare needs was adopted in the sixth five-year plan following the Alma Ata Declaration (1978), resulting in significant improvement in the health status of the community. Despite this, the urban slums, backward tribal and rural areas still lacked these services. Until the launch of the first National Health Policy in 1983, the focus on preventive and promotive health aspects was minimal. The NHP put forth an integrated package of health services, including the preventive aspects, to effectively deal with public health issues.8 Also, various international forums further endorsed the role of providing preventive & social aspects of protecting community health and creating an organised network of health units at the primary care level.9 The importance of comprehensive urban health services was stressed as the existing urban health services were piecemeal, coupled with inadequate service delivery in the slum and vulnerable areas. This called for an urgent necessity for a well-framed conceptual framework for an integrated urban development programme.
The Krishnan Committee’s implementation plan to deliver primary healthcare needs in urban areas was a critical turning point in recognising their unique healthcare needs.10 The Twelfth schedule of the 74th Constitutional Amendment (1992) also gave urban local bodies empowerment and authority to ensure a holistic boost to urban health by defining eighteen public health functions, including urban planning, water supply, sanitation, and civil registration of births and deaths, to name a few.11 The ninth plan focussed on the development of PHCs within 1-3 km of the urban slums as the health indicators were poorer here than its rural and tribal counterparts.6 The same was impressed by the National Population Policy (2000), promoting intersectoral coordination to improve health.12 Reorganisation of the existing health system to an all-inclusive approach (NCDs, CDs and MCH services) was recommended by the tenth five-year plan. Thus, the efforts to synergise an urban health system were made gradually in India, but neither were they scaled up nor were they intended to be sustainable.7 An astronomical increase in urban population pushed the urban poor into unsanitary settlements and complex environments, making them vulnerable to many diseases. Although there are many secondary and tertiary care hospitals in metropolitan areas, the primary health infrastructure—which includes primary health centres and sub-centre remains deficient.
The launch of the National Urban Health Mission and the challenges trivialised
It was the eleventh five-year plan (2012-17) that introduced the National Urban Health Mission (NUHM) in addition to the National Rural Health Mission (NRHM) to form the “Sarva Swasthya Abhiyan” with the aim of inclusive growth. The NUHM, introduced in 2013, offered a unique opportunity and pragmatic mechanism to strengthen urban health scenarios.13 Eventually, the National Health Policy in 2017 identified the need to focus on poor and vulnerable populations in cities, including the homeless, street children, rag-pickers, rickshaw pullers, construction workers, sex workers, and temporary migrants in urban settlements, listed and unlisted slums. The policy stressed the role of convergence in addressing social determinants of health, primary and secondary prevention, adequate referral mechanisms, and inclusion of peri-urban areas as part of urban health strategy. The opportunity to work in collaboration with the private sector to operationalise urban health services was also part of the -policy framework to harness a more extensive array of essential healthcare services across the nation.These included diagnostic, rehabilitation, and palliation services, telemedicine, ambulance, and safe blood services.14
With enabling policies in place, an increase in the burden of non-communicable diseases, an unfinished agenda of universal immunisation, vulnerability mapping, specialist service provision, and convergence at the micro, meso, and macro levels remain the most pressing issues that require immediate attention.
The current scenario
Presently, the NUHM is implemented in 35 states and union territories of India, across cities and towns with a population over 50,000, district/state headquarters with more than 30,000 population and seven metropolitan cities, viz. Ahmedabad, Bengaluru, Chennai, New Delhi, Mumbai, Hyderabad and Kolkata, as per the 2011 census. A total of 1162 cities are covered under the Mission.15 The Urban Primary Health Centres (UPHCs) for 50,000 population near urban slums for primary health care services, and Urban Community Health Centres (UCHCs) for 2.5 lakh population in non-metros and 5 lakh in metros, for secondary health care services are functional under NUHM.16 Front-line workers in the form of one Accredited Social Health Activist (ASHAs) for a 1000-2500 population and one ANM for a 10,000 population function as an effective, demand–generating a link between the health facility and the community. In addition, urban health and nutrition days (UHND) and special outreach camps are provisioned for easy accessibility to community-based services.17
The focus on health improvement in urban areas was further bolstered by the launch of the Ayushman Bharat scheme by the Government of India (GoI) in 2018, wherein the establishment of one and a half lakh Health and Wellness Centres (HWCs) is envisioned by transforming existing Health Sub-Centres and Primary Health Centres in rural and urban areas through a package of twelve services ensuring comprehensive delivery of primary health care. These HWCs aim to improve access, universality, and equity close to the community while providing a broader range of services to meet the primary health requirements of the people. With communities involved and people empowered to make healthy decisions, the likelihood of developing acute and chronic illnesses and their associated morbidities is reduced significantly.18
Revamping Urban Health Infrastructure amidst COVID 19
The global pandemic of COVID-19, which afflicted the metros and other urban cities of India in unprecedented proportions, bared the vulnerability of the millions of migrants and urban poor as well as the upper and lower middle class residing in these areas to the deadly impact of the virus. It highlighted the lacunae in health systems, viz. the apparent lack of timely access to primary care within the close reach of urban communities, glaring gaps in prompt specialist consultations, appropriate treatment at secondary care and diagnostics, critical care and referral services. It has also reiterated the urgent need for strengthening the public health functions and disease surveillance in urban areas that did not cover the urban population, especially the non-poor lower, middle and classes of the upper wealth quintile.19
The Government of India promptly responded to meet these imminent needs of the country. The “India COVID-19 Emergency Response and Health Systems Preparedness Packages” (ECRP-I and ECRP-II) were launched to support states/UTs in the development of dedicated COVID hospitals, isolation blocks, ICUs with ventilators, pediatric ICU beds, augmentation of oxygen supply in hospitals, and strengthening of laboratories as an effective and rapid response to the pandemic. Support was also extended for creating prefabricated structures for strengthening the existing UPHCs, and establishing field hospitals (50-100 bedded units) in tier-II or tier-III cities and district HQs.20
Taking cognisance of the gaps mentioned earlier, the Government of India announced PM Ayushman Bharat Health Infrastructure Mission (PM ABHIM) in 2021 to develop and augment primary, secondary, and tertiary care infrastructural capacities, strengthen existing national institutions, detection and cure emerging diseases.21
Moreover, it was felt that the Urban and Rural Local Bodies need to be more effectively engaged with the health system, especially to leverage their resources and governance potential to address social and environmental determinants.22 The XV Finance Commission has extended financial grants amounting to Rs. 70,051 crores through urban and rural local governments over the five years (2021-26) to strengthen specific health sector components at the grass-root level. For urban areas, support has been provided for establishing Urban Health and Wellness Centres (Urban-HWCs), specialist UPHCs/Polyclinics in close collaboration with Urban Local Bodies (ULBs) and support for diagnostic infrastructure at UPHCs.23
Urban Health and Wellness Centres- Strengthening Primary Health Care
With the holistic approach of decentralised healthcare, the government has committed to creating new Urban Health and Wellness Centres (UHWC) and Polyclinics under PMABHIM, which will aid in bringing healthcare closer to the people. The creation of 11,024 AB-HWCs in urban areas for every 15,000-20,000 population and the provision of rotational speciality services through at least one upgraded UPHC for a population of 2.5-3 lakhs have been envisioned.16
This is a hallmark for urban health as it would enable decentralised delivery of primary health care services through the ULBs. It is envisaged that the engagement of ULBs would create a convergence mechanism for representatives of Mahila Arogya Samitis (MAS) and Resident Welfare Associations (RWAs) in the urban localities to disseminate information, perform public health functions as suggested in the 74th CAA, and create awareness of public health issues.
The road ahead
The exponential growth of the urban population and expansion of peri-urban and slum settlements have posed diverse health challenges that call for systematic, sustained and multisectoral efforts for the health system’s readiness. This recalls the resolution made in the World Health Assembly in 1991 to develop, reorient, and strengthen urban health services and decentralise responsibilities. Following the Sustainable Development Goals (SDGs) 2015, which offers a framework for urbanisation in which fifteen of the seventeen goals are directly or indirectly related to urban health, the New Urban Agenda at Habitat III at the United Nations Conference on Housing and Sustainable Urban Development, 2016 and urban poverty has lately been brought to the forefront of the global development agenda.24
To move ahead, there has been a revolution in health digitalisation wherein the Ayushman Bharat Digital Mission aims to integrate the digital infrastructure by creating ABHA ID to link individual health records (with informed consent) across multiple systems. However, these initiatives need to be rolled out on a larger scale. Moreover, there has been digitalisation of health financing through Public Financial Management Systems and Progress Monitoring Systems; still, the capacity at the implementation level needs acceleration.
Almost a decade after the launch of NUHM, a systematic and comprehensive study evaluating the impact of urban health in India, particularly on the urban poor, would help understand positive outliers to inform policy, practice and future strategies that can work using a positive public health approach. Analysing available data will also guide the national and state program reviews to make them more evidence-based and positive. It is also believed that the NUHM implementation framework needs to be revisited to meet current demands and match the most recent developments in health nationally and worldwide.
Leveraging the enablers, there is a need to put urban health high on the social and political agenda underpinning the core principle of health in all policy, improved participatory governance and engaging with different departments to address the social determinants of health which are exclusive to urban areas. Beyond the conventional acumen, there is a need to strengthen the health mission in urban areas and also understand the fact that there is an individual level of vulnerability besides existing social, residential, and occupational vulnerability and hence the scope of expanding the public health services and functions is not limited to specific but to all the urban population needs to be pondered upon.
Funding
None.
Authorship
All authors contributed to the development of the manuscript and approved the final version.
Disclosure of interest
The views expressed in this paper are those of the authors and do not necessarily reflect the views of the organisation.