Anyone who grew up, like I did, in post-independence India, remembers Mahatma Gandhi’s oft-cited quote that the future of the country “lies in its villages.” Politicians and academics would base their policies and research work on this assertion.
However, over the past two decades India’s economic growth has not been driven by agriculture in rural areas, but rather by industry and services in cities.
By 2030, urban cities could generate 70% of all new jobs created and account for more than 70% of Indian GDP. The UN forecasts that if India continues urbanizing at the current pace, 46% of the country’s population will be living in cities in 13 years.
People who live in India’s highly congested slums have very limited access to safe water and sanitation. Lung infections and vector-borne diseases spread quickly. More than 46% of children of the country’s urban poor are underweight, and almost 60% of poor urban children miss total immunization before their first birthday.
While statistics offer useful insights to design health interventions, they mean little to the slum dweller struggling daily to eke out a living. The choice to visit a doctor is considered a prohibitive luxury that should be put off till a crisis occurs, and preventive care is rarely a lifestyle option.
Equitable access to quality healthcare
To address this urban health emergency, the Indian government launched in May 2013 the National Urban Health Mission (NUHM), an ADB-assisted nationwide urban health program focused on poor people living in both listed and unlisted slums, as well as other vulnerable groups like street children and sex workers. To further strengthen the NUHM, the 2015 National Health Policy stressed strategic preventive care and referral support in urban slums.
After four years, we can draw some lessons learned on innovative approaches toward service delivery from this program. Among them are the importance of incentives for medical facilities in informal communities for early diagnosis and treatment, and the key role of digital technology to fill information gaps in the health profiles of poor communities.
The program aims to provide equitable access to quality health care through a revamped public health system, public-private partnerships, and community based mechanisms.
To improve convergence with existing programs, NUHM brings all the national disease control programs under the umbrella of the city health plan. All services are to be made available at a single point, the Urban Primary Health Centre that is set up within or near a slum, to serve 50,000 people.
Given that in India nearly 70% of all outpatient and 60% of inpatient care is provided by the private sector, engaging with it to serve the urban poor is essential. On the other hand, the growing incidence of catastrophic expenditure due to surging health care costs is considered one of the major contributors to chronic poverty.
Patient-friendly technology leads to better treatment
Mumbai, a city where more than half the population inhabit slums, offers an interesting example of how this program is making a difference in the fight against tuberculosis (TB).
Out of 24 municipal wards, 15 with high slum populations are, not surprisingly, also high-risk for TB. A proliferation of diverse informal private health care providers, often the first point of contact for many slum dwellers, results in inaccurate and delayed diagnosis, unregulated over-the-counter sale of anti-TB drugs, and poor treatment adherence.
Enter what we call “patient-friendly technology,” coupled with a proven voucher finance model that is being implemented through a Private Provider Interface Agency (PPIA).
In Mumbai, the Bill & Melinda Gates Foundation contracted the international health nonprofit PATH to act as a PPIA, and align TB diagnosis and treatment with national standards.
The project targets informal medical practitioners, chemists, laboratories, and hospitals serving the urban poor. Appropriate incentives and patient subsidies are offered to encourage providers to diagnose TB early, and refer TB cases to a formal provider at a hub hospital for appropriate treatment.
Ravi is an auto rickshaw driver from Bihar who five years ago moved to Dharavi, one of Mumbai’s largest slums. When he was diagnosed with TB, an NGO provided vouchers for free X-rays, medicines, and follow-up treatment with private doctors.
After he takes the prescribed dose of medicine, Ravi calls a toll-free number. If he forgets to take the dose, a message is automatically sent to the local slum health worker, who then reminds him.
Ravi’s adherence to his daily treatment regimen is logged in a virtual dashboard reviewed by his doctor, who counsels him accordingly.
The pilot is being integrated with the national TB program for scale up across five Indian states. The shift in TB treatment to a daily regimen, along with financially tested models for the urban poor, can help India reduce its TB burden, currently among the highest in the world.
Closing the health information gap
Assessing the health profiles and living conditions of the urban poor is another enormous challenge in India. Data on unlisted and listed slum population characteristics, migration numbers, disease profile, water and sanitation conditions, are at best a guesstimate.
Digital innovation is helping fill the information gap. In Bengaluru, the country’s ICT hub, the NUHM uses geographic information system (GIS) technology to map urban poor settlements using a public, single-window transform to host all health-related data.
The GIS maps, supported by physical surveys, assist informed decision-making for the urban poor. GIS mapping helps chart health facilities along with key attributes such as the facility description, resources available, equipment, capacity, coverage area, population disease profile, and density down to the administrative ward level.
The data allows planners to better understand the current situation, and identify possible improvements. Route and community health program planning options (e.g. for community vaccination programs) are also helpful.
While these technological innovations may not solve all of India’s urban poor health woes, they do provide a fresh impetus, and encourage health professionals to work toward smarter, affordable and equitable urban health solutions.