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COMMENTARY
Year : 2018  |  Volume : 62  |  Issue : 3  |  Page : 214-217  

Urban health: Needs urgent attention


1 Ex-Advisor, Public Health Planning and Evidence, National Health System Resource Centre, Ministry of Health and Family Welfare, New Delhi, India
2 Director, International Institute of Health Management Research, New Delhi, India
3 Deputy Commissioner (Urban Health), Ministry of Health and Family Welfare, Government of India, Nirman Bhawan, New Delhi, India

Date of Web Publication12-Sep-2018

Correspondence Address:
Sanjiv Kumar
International Institute of Health Management Research, Sector 18 A, Plot 3, Phase 2, Dwarka, New Delhi - 110 075
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_90_18

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   Abstract 


Urban population in our country has increased at an annual rate of 2.7% during the last decade and it is estimated that by 2031, there would be about 600 million people living in urban India. The fast pace of urbanization has come to stay with increasing proportion of urban poor and vulnerable with health indicators much worse than their rural counterparts. The need to provide health care to urban poor has been emphasized in the past in various health committees' reports and National 5-year Development Plans, but no significant dent was made to improve the urban health scenario of the country. The National Urban Health Mission launched in May 2013 provides us a concrete mechanism to address special health needs of urban population with focus on urban poor. There is a strong need to set up primary healthcare system in urban areas and systematically deal with urban health challenges in terms of vector-borne diseases, rising incidence of noncommunicable diseases, air pollution and acute respiratory infections, road traffic accidents, trauma, and injuries. The initiatives to address these challenges do not remain confined to health sector alone but also need to be supported by sectors other than health such as social welfare, women and child development, road transport and highways, school education, drinking water, and sanitation. We really need to address wider and social determinants of health to effectively improve the urban health scenario.

Keywords: Burden of disease, National Health Policy, National Urban Health Mission, road traffic injuries, urban health care infrastructure, urban poor and vulnerable, urban Primary Health Centre (PHS)


How to cite this article:
Kumar S, Kumar S, Gupta B. Urban health: Needs urgent attention. Indian J Public Health 2018;62:214-7

How to cite this URL:
Kumar S, Kumar S, Gupta B. Urban health: Needs urgent attention. Indian J Public Health [serial online] 2018 [cited 2018 Dec 16];62:214-7. Available from: http://www.ijph.in/text.asp?2018/62/3/214/241104




   Introduction Top


With rapid urbanization and influx of population into slums and shanty habitations, a large chunk of poor population has moved into environmentally deprived urban areas which are overcrowded, have no access to safe water, sanitation, and safe accommodation, and often lack access to basic services. The urban population in India is increasing rapidly. It is projected to increase from 31% (2011) to 46% (2030).[1] It is estimated that 30%–40% of population in metros lives in slum or slum-like habitation.[1] The health indicators of this segment of population are worse than those in rural areas. The healthcare services of urban slum population and urban poor need urgent attention to improve overall health indicators of India which are stagnating as compared to many less developed neighboring countries. The National Health Policy (NHP) 2002 acknowledged the need to focus on urban population. National Urban Health Mission (NUHM) was launched in 2013 but has been very slow to take off and gain momentum. The NHP-2017 covers this subject more extensively and emphasizes the need for moving from token interventions to on-scale assured interventions to organize primary health care and referral services and collaboration with other sectors.[2] It includes advocacy for scaling up NUHM to cover entire urban population, with focus on the poor and the vulnerable, in next 5 years with sustained financing.

Although needs of urban population are similar to that of rural population, the following challenges need special attention in Urban areas:


   Lack of Primary Healthcare Infrastructure Top


Since independence, focus of public health has been on rural areas which is clearly reflected in the famous Joseph Bhore's report in 1946.[3] This resulted in neglect of systematic planning for health care infrastructure and delivery of comprehensive healthcare services for urban population. There were sporadic and scanty efforts such as World Bank-funded India Population Projects. These were never planned to be sustainable and taken to scale. The rapid increase in urban population due to migration stretched the infrastructure often moving the neo-migrants and the poor into unhygienic settlements and risky environment making them more vulnerable to diseases, increasing their need for healthcare which is neither within their reach nor affordable for them. Although a large number of secondary and tertiary care hospitals exist in cities, the primary health infrastructure remains grossly inadequate in urban areas in terms of subcenters and primary health centers.

What is the solution?

Health infrastructure was created under Urban Revamping Scheme (1983) and India Population Projects.[1] However, the NUHM framework provides directions for comprehensive planning for urban healthcare infrastructure. The funds allocated by the Ministry for NUHM are not being used by most states. The state governments need to give a high priority to plan and set up primary healthcare infrastructure in urban areas by establishing urban PHCs, recruit workforce to provide preventive, promotive, and basic clinical care at doorsteps and provide referral services to those who need it. The planning and implementation of services should include mapping of vulnerable population, mapping the available health facilities set up under various government schemes, nongovernment organizations, and private sector. The gaps existing should then be addressed in a comprehensive manner. We may cite an example of Surat city to demonstrate a model of comprehensive urban health care duly incorporating elements of primary health care The Gujarat Urban Development Mission was established in 2005–2006 to fast track urban reorganization and planned development. There has been considerable emphasis on urban healthcare reforms with a uniform urban primary healthcare system for urban areas with each urban health center catering to a population of 100,000. There are 32 urban health centers (UHCs) in Surat of which 11 are maternity homes, providing a range of services such as outpatient departments, inpatient departments, maternal care, national health programs, registration of births and deaths, health education, immunization, and disease surveillance.[4] The basic health worker is responsible for vector control activities. There is also considerable focus on convergence from sectors outside health to ensure improvements in water supply and sanitation impacting on health status of population in terms of declining morbidities and mortalities on account of water-borne diseases.


   The Urban Lifestyle and Burden of Diseases Top


The current lifestyle(s) of an average city dweller includes fast-paced life with sedentary jobs, a stressful environment, and unhealthy food habits predisposing them to noncommunicable diseases such as obesity, diabetes, and hypertension. The real question is this – are we as individuals and as care providers ready to face the consequences resulting from a poor lifestyle? The answer is no, and this is where seeking a solution to the question raised has become utmost important. India has also become a diabetic capital of the world, and we often face seasonal outbreaks of vector-borne and water-borne diseases such as malaria, dengue, chikungunya, diarrhea, and jaundice due to poor water supply and sanitation. Many of these diseases spread much faster due to dense population in cities, especially slums and slum-like areas.

What is the way forward?

Health is an outcome of contribution from many sectors outside health. The government should engage other ministries to promote healthy lifestyle such as promotion of nonmechanized transport and encourage physical activities and healthy dietary practices in schools, colleges, and workplaces. The cities have pockets where safe water sanitation is not available, resulting in water-borne diseases and outbreaks. Another example is mosquito-borne diseases. The cities have many sites where water collections result in breeding of mosquitoes resulting in dengue, chikungunya, and malaria. Discourage tobacco and alcohol use is one more example of role of other sectors in improving health. India has done well in reducing tobacco consumption and has recently received an award from the WHO for this. The government must expand insurance coverage in both public and private sector organizations and for those employed in informal sector and for urban poor through scale-up of schemes such as Rashtriya Swasthaya Bima Yojana and other health protection schemes run by the state governments. It is heartening to note that the central government has recently launched Universal Health Protection Scheme which aims at providing health insurance coverage to about 10 million poor families in the country. Moreover, health awareness for various government initiatives such as Yoga and “Swachh Bharat Abhiyaan” can also contribute to improving urban health by promoting physical exercise, modifying lifestyles, and preventing diseases.


   The Accidents and Injuries Top


Alarming statistics of about 17 deaths and 55 road injuries that happen per hour in India have recently been reported.[5] The fast-paced drive on crowded roads can cause traffic accidents including road rage. In India, about one lakh forty-six thousand deaths take place every year due to accidents and injuries.[5] Many more are incapacitated life-long. Most of these deaths are preventable. The preventive action lies in the domain of other ministries and organizations such as road and transport, urban affairs, industry, municipalities, and urban local bodies

What is the way forward?

The government should implement strict norms for issuing driving licenses, safety standards for the vehicles, and safe spaces for pedestrians and cyclists on the road. To provide prompt emergency medical care should be made mandatory and should include emergency first aid, quick transportation, and treatment in hospitals, without wasting any time, using standard treatment protocols and standard operating procedures. The government should also provide a compulsory health insurance coverage for emergency medical care of all accident victims.


   Air Pollution and Related Diseases Top


Work stress, unhealthy lifestyle, and polluted food intake are responsible for a variety of communicable and noncommunicable diseases including cancers. Cancers seem to be tightening its grip on India, and a million new cases of cancer are being reported every year. These are expected to rise rapidly and will increase fivefold by 2025. One cannot wait for a long time to receive the right treatment.

Owing to thinning of green cover and toxins in the environment, respiratory disease cases have risen to 5 million since 2012. As many as 2932 people died due to acute respiratory infection in 2014 as against 3513 in the previous year.[6] Is it in our hands to deal with the wide array of serious health effects for which air pollution alone is responsible? To seek an effective and sustainable measure to get permanent relief from the health menace caused by air pollution remains one of the most relevant and daunting challenges before urban health planners, administrators and public health professionals today.

What is the way forward?

The concerned ministry should restrict industries from causing environmental pollution and creating hazardous effluents or polluting elements and enforce strict emission norms for automobiles. By way of restricting the number of personal vehicles per home and encouraging initiatives such as carpools, odd-even vehicle number drives can go a long way in improving such situations. It may be pointed out that the Government of Delhi has in the past taken recourse to efforts to decongest vehicular traffic in Delhi by implementing “odd-even number” policy on movements of vehicles on specific days. The state government of Delhi has also taken various measures to control air pollution in the city. For example, the entry of heavy trucks to the main city was banned by diverting their route to highways. National Green Tribunal restricts industrial activities and bans waste burning in Delhi. Furthermore, the government has announced more metro trips and increased the number of public transport buses to reduce the level of air pollution in Delhi.

It is proposed that the government should collect a tax from individuals owning multiple vehicles and contribute to create a unique health insurance cover for the accident victims. It is not just the responsibility of the government but also the local communities to raise awareness about cancer by conducting rallies, awareness drives and mobilizing fund contributions to fight this menace. Furthermore, the government should issue a very exclusive, affordable, and universal health insurance coverage for those suffering from cancer as is done in some states such as Tamil Nadu and Kerala.


   Lack of Engagement of Medical Colleges in Urban Health Top


Medical colleges can play a very important role in evidence-based implementation of national health programs. Currently, their engagement is minimal and ad hoc and that too not in a systematic manner. The medical colleges are engaged in providing education to future doctors and delivery of healthcare services to the population. Almost all of them are located in cities and can become nucleus of providing health care services with referral linkages to primary- and secondary-level care institutions around them. Their expertise in evidence generation to improve service delivery and treatment compliance is grossly underutilized.

What is the way forward?

The NUHM division of the Ministry of Health and Family Welfare has engaged medical colleges in supporting urban healthcare services. A National Workshop was organized on “Role of Medical Colleges to Strengthen the Initiatives under NUHM” on October 25, 2017, in partnership with professional bodies such as Indian Association of Preventive and Social Medicine and Indian Public Health Association. The medical colleges need to work closely with the state governments in providing technical support in the areas identified to improve healthcare services in urban areas. The active involvement of medical colleges in national health programs will also ensure that their teaching and research activities remain relevant, useful, and sensitive to the changing health needs of the community and growing requirements of the healthcare delivery system.

India is rapidly urbanizing. The healthcare needs of the urban population have not received adequate attention in the past. The government has launched NUHM to create comprehensive healthcare infrastructure in a planned manner. However, the states are not proactively using the central funds to address needs of urban population. The special needs of urban population such as unhealthy lifestyle, leading to higher prevalence of noncommunicable diseases including diabetes, hypertension, and cancers, outbreaks of seasonal diseases, accidents and injuries, and diseases resulting from air pollution need to be addressed in the healthcare service delivery system in towns.


   Conclusion Top


Fast pace of urbanization in India poses many important health challenges that require collective efforts and multisectoral approach to deal with the situation. Growing proportion of urban poor and vulnerable population presents with many health and development indicators that are much worse than that of their rural counterparts. There is a strong need to set up a primary healthcare system that links community with urban Primary Health Centre (PHCs), Community Health Centre (CHCs), and higher healthcare centers to deal with special healthcare challenges and special needs of urban population. These are spelled out in terms of vector-borne diseases, noncommunicable diseases, especially diabetes, and hypertension that are aggravated by unhealthy lifestyles, air pollution, and road traffic accidents and injuries. The NUHM launched in 2013 provides us a unique opportunity and concrete mechanism to deal with the situation and improve urban health. We have to address wider and social determinants of health to effectively address these challenges. Medical colleges – most of them being located in urban areas – can conveniently provide important academic, research, and referral support to improve urban health and strengthen various initiatives that are launched under NUHM. It is going to be a Win–Win situation for medical colleges since their engagement with national health care programs would make their teaching and service programs more relevant, effective, useful, and sensitive to the changing health needs of the community and growing requirements of the healthcare system.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Ministry of Health and Family Welfare, Government of India. National Urban Health Mission-Framework for implementation; May 2013. Available from: http://www.nhm.gov.in/images/pdf/NUHM/Implementation_Framework_NUHM.pdf. [Last accessed on 2018 Jan 05].  Back to cited text no. 1
    
2.
Ministry of Health and Family Welfare, Government of India. National Health Policy (Para 3.3); 2017. p. 7. Available from: http://www.cdsco.nic.in/writereaddata/National-Health-Policy.pdf. [Last accessed on 2018 Jan 05].  Back to cited text no. 2
    
3.
Government of India, Ministry of Health. Report of Health Survey and Development Committee; P. 1-523. Available from: https://www.nhp.gov.in/sites/default/files/pdf/Mudalier_Vol.pdf. [Last accessed on 2018 Jan 05].  Back to cited text no. 3
    
4.
Surat Municipal Corporation, Public Health Department. Urban Health Center and Maternity Home. Available from: https://www.suratmunicipal.gov.in/Content/Documents/rtiact/15/disc15_healthcenters.pdf. [Last accessed on 2018 Jan 05].  Back to cited text no. 4
    
5.
Government of India, Ministry of Road Transport and Highways, Transport Research Wing. Road Accidents in India; 2016. p. 117. Available from: http://www.indiaenvironmentportal.org.in/files/file/Road%20accidents%20in%20India%20201.pdf. [Last accessed on 2018 Jan 05].  Back to cited text no. 5
    
6.
Respiratory Disease Cases Rose by 5m Since; 23 September, 2012. Available from: https://www.timesofindia.indiatimes.com/life-style/health-fitness/health-news/Respiratory-disease-cases-rose-by-5m-since-2012/articleshow/49071641.cms. [Last accessed on 2018 Jan 05].  Back to cited text no. 6
    




 

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  In this article
    Abstract
   Introduction
    Lack of Primary ...
    The Urban Lifest...
    The Accidents an...
    Air Pollution an...
    Lack of Engageme...
   Conclusion
    References

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