## Reflections/notes on urban health in India (10 Sep) - Need to re-imagine health services to work for urban areas given that primary health care systems have largely conceptualised around rurality, remoteness, "lack of access" and such. how do we now make it work in a very different, dynamic and heterogeneous setting? (KS) - How does one deal with *health and wellness center* implementation in urban areas? it is a big challenge - community engagement in urban areas is also a big challenge - NUHM --> NHM; 2017 NHP's identification of urban health ans a priority; HWC implementation even in terms of just re-naming & superficially converting into HWCs is lagging in cities; - From BB - Need to understand health services organisation in urban areas; different types of governance - some by ULBs, some by state, some by central & diff departmenst of both, some by NGOs, private for-profit sector ---and many of these provide primary health care & specialist care; new "migrants" to cities access to healthcare is very poor despite having so many buildings; huge inefficiencies in delivery of services; despite huge infrastructure in cities, in accessible to those in informal/unorganised sector - sex workers, rickshaw pullers, homeless, recent migrants especially in low income jobs, religious minorities, sexual minorities; huge data gaps - even policymakers think of "cities is not a problem", "urban is alright" - the *invisible* populations; limited clarity on where to go - unclear jurisdictions; new habitations & extensions are not *included* into any of the existing jurisdiction --> pointing to inefficient steering/stewardship of urban health--> - need mechanisms for data-driven decision-making because it will *visibilise* the populations that are now flying under the radar; many *human settlements* are not even properly recognised and allocated to specific HWCs/PHCs.....government tends to think allocation will *legalise* them...so contested urban land tenure affects health (cf. Adivasi health and contestations with forest rights) --> in this sense data-driven issues can help with politically visibilising the rights of the populations that have been invisibilised by neglect & structural issues (largely socio-economic with intersections with caste) - Building localised capacity for research in the various health-related research-capable institutions like medical/nursing/other colleges but dont seem to be engaging in IR/HSR/HPSR --> greater focus on the culture of research, partnerships between academia & ULBs/healthcare institutions in cities --> sustained HSR in urban areas that is localised & contextual - Is the urban poor neglect a sub-set of a larger neglect/invisibilisation of the urban poor or is it at all related to the urban health service organisation...what if it is not at all related to HSO but to urban governance....weak power/influence to convene/attract attention to the core issues of urban poor; NUHM-->NHM: how does that pan out for urban health? Does it mean there is a lessening of priority for urban health or is it an opportunity to leverage the full mission for urban health? - Is the health systems predilection to *allocate* a person to a specific facility (rural PHC legacy) hindering UHC in urban areas - because of underlying issues with poor definition of boundaries in urban areas? - The fact that rich urban neighbourhoods will NOT get HWCs does it mean that these are for the urban poor? What shall be urban health position for wealthy who are largely seeking private care and financing it from their own pockets? - On the issue of awareness of services for the urban poor - the idea of putting signboards on where they should seek care --> why is this information needed only for the urban poor? What are we doing for helping EVERYONE with which facility they OUGHT to be going to? - There is a certain comfort with informal providers & private providers - 15th FC reforms in terms of higher decision-making & invovlement of ULBs - NGO sector tends to specialise in specific areas rather than CPHC...this is neglected & people pay OOP - [[Paper mill]]! [![[Screenshot 2024-09-10 at 11.31.04 AM.png]][ ](https://site.bbmp.gov.in/departmentwebsites/Health/org_chart.html#) See for example the organisation charge of BBMP which does not include PHC-leve conceptualisation of health - Ultimately the different pieces of work needs to help us (re)think design of urban primary health care - Changing nature of commercial entities & how the health market pluralism defines/shapes urban health; see for example private equity & its evolution and how those large investments from private capital shape urban health/health --> the macroeconomic drivers of urban health that get invisibilised within the micro-urban phenomena that occupies us most of hte time - What are the contours of urban (health) governance? lot of it is undefined, mixed/overlapping jurisdictions, unclaimed jurisdiction.... - Triple loop learning: Actions, policies/goals/approaches, structures/norms/processes (idea of learning health systems) --> Idea is what does research (projects) eave behind within the system\ - being action-oriented--> find solutions for practical challenges - being deliberative --> dialogue, engage...create platforms that do this - being insight-driven --> create/adapt action, but also build intelligence/insights on how the action happened - What is an ideal urban (health) learning site? - ward? population? neighborhood? a health center's practice area? - NHM CRM reports as an important background document for understanding urban health too. The latest (2022) CRM is here: https://nhsrcindia.org/sites/default/files/2024-01/15th%20CRM%20Report%20-2022.pdf - *Mahila Arogya Samiti* as an arena for CE in urban health; huge intersections in cities between health & sanitation and the fact that *pourakarmikas*/sanitary workers are managed by ULBs while health workers are anchored within health centers & the fact that Dengue & SWM are intersectional/intersectoral areas makes this an important area to act/study --> another inter-sectoral area/MSA area is food safety - Arima Mishra, Aditya Pradyumna & Edward Premdas Pinto (APU) on [Health Care Equity in Urban India](https://azimpremjiuniversity.edu.in/publications/report/health-care-equity-in-urban-india) ## Conceptualising urban health & urban primary health care - See the question about what is urban about urban health (q3 in [[Paper mill]]? - The legacy of urban health being shaped by the fact that rural health was planned whereas health in cities was not really a problem & *allow* them to evolve - Ganapathy et. al book in the 1980s with a chapter by Rishikesh Maru (Maroo? - look up), work by Roger Jeffrey and others too? cf. rural area inspired primary health care models shaped by thinking of Halfdan Mahler, D Banerjee & others some of it from rural India # Reflections from the Sep 2025 workshop - Many "cities" in India have both urban and rural catchment areas. See for example, Kanpur data presented by SV. - Direct access to pharmacists as a "problem". Tension with access to medicines for the poor. Needs to be fixed keeping in mind that the fixing shoudl nto cause new access barriers - Legacy "CHCs" in cities - needs a fix. Why struggle to fill specialists in legacy CHCs whereas urban PHC may need more tiered referral structure - Focus on upgrading infrastructure/services/equipments at UPHCs by the system - contrasts with need for a PHC system on ground with linkages to CHWs - What is the UPHC/population ratio for cities - this needs to be characterised across major cities in India - The tensions between who has to run "primary health care" in cities - local governments (which seem better able to run dispensaries & hospitals) vs state health departments which seems better capacitated for state health departments - In Bhubhaneshwar, municipal hospital run by the city corporation whereas NUHM/state runs 4 UCHCs (4), UPHCs(22) and UHWCs(18). State govt runs a capital hospital (tertiary care) and central govt runs AIIMS and perhapss even ESI primary care dispensaries. - Fragmented care in cities requires us to consider the issue that many of the secondary and teritary care centers in cities are also providing primary health care - Is the city health mission a platform for engaging the city govt in the city's PHC system? UPHCs may be run by state but the city health mission exercises some degree of "control"/overight (or may be a dummy body). See Bhubaneshwar's example of CPMU. - Huge/emerging private capital investment in real estate and other sectors in Bhubaneshwar - Bhubaneshwar city via NUHM & Odisha has PPP in PHC (4 UPHCs under PPP with NGOs) - Odisha & Assam stand out in terms of public health sector utilisation; remains somewhat more public sector driven in these 2 states - the "retreat" of the state health has not yet begun or is not yet as advanced as in other states - Societies/RWAs become an "arena" for action - Bhubaneshwar has 81 ANMs for 8L population - full coverage of 1 ANM for 10,000 population! Amazing coverage! - 240 ASHAs for 8L population - 1 ASHA for3-4000 population - WOW! (cf. Bangalore) - Huge strain of solid waste management by urban sanitary workers - is this primary health care - but NOT managed by health department - Convergance bwetween urban sanitation systems and health services seems to be an important agenda in some cities (efforst in Bhubaneshwar? Ahmedabad?) but clearly not the case in BLR - The huge financial opportunities provided by the 15th Finance Commission funding directly to the urban local bodies and rural local governments/Panchayats - perhaps 16th FC will follow suit? - ## Updated resources/guidelines related to Urban Primary health care This is a relatively unstructured and aims to be an annotated reading list of resources for urban primary health care. - [Guidelines for organising urban primary health care services by NHSRC (2018)](https://nhsrcindia.org/sites/default/files/2021-07/Guidelines%20for%20Organizing%20UPHC%20Services.pdf) - -