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Study of Urban Public Health Governance in Municipal Corporations of 3 Indian Cities PDF Print

Study of Urban Public Health Governance in Municipal Corporations of 3 Indian Cities (Mumbai, Chennai and Ahmedabad)

Dr. Priya Balasubramaniam Principal Investigators , Ms. Binira Kansakar Presenting research team , Ms. Akshaya Patil+, Dr. Mercian Daniel+, Dr. Subhash Hira* Public Health Foundation of India

Abstract

Background:

While India’s cities are vibrant sources of creativity, technology and resilient engines for economic revival, they are also sources of poverty, inequality, and environmental health hazards. The growth of new cities and the expansion of existing ones in the context of poor physical infrastructure, inadequate governance structures and poorly coordinated public amenities such as basic health and educational services, housing and water and sanitation facilities starkly underscores the need for focused attention on urban health.

Approximately one third of India’s population lives in urban areas and by 2050, half of the country’s population will reside in cities.1,2 India’s urbanization is driven by natural population growth, as well as rural to urban migration and spatial reclassification of cities3. Rapid urbanization has increased the size, density and diversity of populations requiring access to safe drinking water, primary healthcare and occupational health hazards for which municipal authorities are responsible. It also complicates the provision of basic services; legal and regulatory frameworks; and management of health and safety issues for urban residents which translates into poorer health outcomes. 4,5

Urban India has advanced farther along epidemiological transitions and constitutes obesogenic environments encouraging unhealthy lifestyles (including low levels of physical activity, unhealthy eating habits, and tobacco use) that increases risk for chronic, non-communicable diseases such as diabetes, hypertension and coronary heart disease. Urban growth has also escalated the potential for outbreaks of infectious diseases resulting from crowded settlements, poor sanitation, and waste generated by urban businesses causing health hazards (e.g. markets, slaughterhouses, and factories).

At present urban public health services in India are characterized by a multiplicity of actors delivering a range of services (including different types of local bodies, the health department, other government departments, and non-state actors in the private sector), leading to fragmentation of services and administrative chaos. Converging non-health related departments that have direct bearing on health outcomes is a governance challenge for India’s cities where the split between central, state and municipal authorities in terms of health policy and planning, health needs and health system capacity requires attention. This requires a well-designed interface between health departments of the State, the Municipal Corporation, and several other sectors.

India’s current (2015) National Health Policy (NHP) emphasises a renewed focus on urban health by improving the efficiency of urban public health systems through strengthening urban health governance structures. The National Urban Health Mission’s current focus on promoting urban primary health especially for the urban poor; enhancing public health activities related to sanitation, safe water, vector control and building public health capacity for urban local bodies provides an excellent opportunity to examine health governance in cities. As responsibility for urban health and health care policies are invariably split between central and local authorities, it is crucial to understand the functioning, evolution and management of events and actors in urban public health systems.6

While researchers continue to build on the evidence that where one lives has an independent effect on one’s health, the theoretical and empirical work of translating this research into effective health policy is relatively thin. This is especially the case in emerging economies where current urban policy discourse seldom draws on the role of social determinants, inter-sectoral coordination in urban health governance and the effects of the built environment on urban citizens that invariably affects their health outcomes.

Aims, Objectives and Rationale of the Study

Defining governance within the health sector is still relatively new suggesting that complex urban health governance structures with their varied organograms across different cities is seen as an area that requires in depth examination. For the present study three cities were selected based on population density and growth: Mumbai (megacity: 18.4 million), Chennai (Large Metro: 8.7 million) and Ahmedabad (medium to large: 6.2 million). In this study we attempt to examine Urban Health governance in India through a framework that recognizes the dynamics and interaction between the urban environment, urban society and urban health systems and consequently how this might impact the health status of urban populations.7

The key objectives of the study are to:

  • Map urban health governance structures and public health services in Municipal Corporations of 3 cities till ward level.
  • Examine the different urban agencies responsible for delivering public health services with focus on management on mosquito-borne diseases.
  • Identify key indicators to assess the performance of the urban health system.
  • Highlight key strengths and weaknesses in urban health governance.

Methodology:

This is a mixed methods study with purposive sampling. In this approach, qualitative data is collected, in first phase followed by secondary quantitative data. The second quantitative segment builds on the qualitative phase, where data is analyzed in sequence to supplement and elaborate on the qualitative results obtained in the first phase. The study identifies 85 key informants across three cities (Mumbai, Chennai and Ahmedabad) that include three identified stakeholder groups: policy makers, implementers and civil society/private providers. The quantitative section explores management and prevention of Mosquito Borne Diseases (MBDs i.e. malaria, chikungunya, dengue) over a 10-year period (2004-2014), across 4 broad indicators that include (i) prevalence and occurrence (ii) morbidity (iii) mortality and (iv) city level preventive interventions.

A conceptual framework for urban health governance involving seven indicators was subsequently developed through a series of iterations involving a detailed background landscape review and consultative stakeholder meetings. A semi-structured interview tool was subsequently developed that focused on health governance issues in municipal corporations with emphasis on public health services and the management of MBDs.

methodologyThe development of the study tool underwent six elaborate sequential and interrelated processes that are illustrated in the flowchart and further described here.

Qualitative data will be analyzed using “ATLAS.Ti” software and emerging themes with relation to urban governance will be documented with supplemental evidence from the quantitative component. An analytical framework is developed for assessing quantitative data across three urban focus areas (i) city health systems (ii) municipal structures and (iii) city geography. Data will be extrapolated using SPSS software/R statistical software.







Emerging findings:

Municipal Corporations have varied evolutionary structures for different cities and are largely influenced by the political processes and stakeholder interests. While geographically urban and peri-urban boundaries are increasingly blurred, peri-urban areas often exist beyond a city’s administrative limits resulting in administrative challenges.

Some of the preliminary findings that emerge from this study include:

  • Urban health needs to be considered holistically, beyond the rubric of urban poverty: that takes into account the diversity of urban milieus and the dynamic human interactions created in congested urban settings.
  • To create healthier and more equitable cities, India’s urban health system needs to acknowledge urban poverty as a critical pathway to ill health. The challenge for urban health policy in the country therefore lies in addressing multiple social determinants responsible for stark health inequities within urban populations.
  • Poor primary care infrastructure and outreach services have pushed the burden of primary health on to tertiary hospitals and secondary level poly-clinics. Unlike rural areas, Indian cities do not have dedicated primary health facilities and services, with urban populations largely relying on the heterogeneous and unregulated mix of public and private care providers that dominate the urban landscape.
  • Urban Local Bodies (ULBs) have been side-lined in favour of other metropolitan development agencies that are entrusted with powers relating to planning and land use, thus causing interference in municipal affairs.
  • There is presently a disconnect between the urban planning process and city administrations where the city master plan ( the only statutory planning instrument) is drawn up at a central level by Urban Development authorities with little input from city Municipal Corporations and local government actors that implement these designs.
  • There is lack of institutional convergence in areas such as water supply and sewerage that are entrusted to different agencies (parastatals), while responsibility for solid waste management rests solely with local governments.8 There are also instances of different cities with one agency responsible for capital works (i.e. execution of projects) and another for operation and maintenance. As a result, the relationship between the city and state governments is invariably dominated by the latter.
  • There is a critical lack of data sharing between diverse inter-sectoral agencies challenging effective governance in cities.

As the study progresses we expect to gain greater insights into the various indicators (institutional vision, equity, accountability, coalition building, management, input of resources and feedback for systems effectiveness) of urban health governance across the three cities. These along with the management of MBDs will be potentially compared and include as a dashboard of governance indicators that could be used in assessing a city’s health systems.

References

1. Office of the Registrar General and Census Commissioner, India: (2001) Census Data of India 2001: National Summary Data. Government of India.
2. UN (2011). World population prospects: the 2006 revision and world urbanization prospects: the 2007 revision. Population Division of the Department of Eco-nomic and Social Affairs of the United Nations Secretariat.
3. Kundu, A (1983): "Theories of City Size Distribution and Indian Urban Structure – A Reappraisal", Economic and Political weekly, 18(3).
4. Katz, R., Mookherji, S., Kaminski, M., Haté, V., & Fischer, J. E. (2012). Urban Governance of Disease.Administrative Sciences, 2(2), 135-147.
5. Ministry of Health and Family Welfare (2014) National Health Policy 2015 Draft
6. Burris, S., Hancock, T., Lin, V., & Herzog, A. (2007). Emerging strategies for healthy urban governance. Journal of Urban Health, 84(1), 154-163.
7. Butsch, C., Sakdapolak, P., & Saravanan, V. S. (2012). Urban health in India. Internationales Asienforum, 43(1/2), 13-32.
8. India. Central Public Health and Environmental Engineering Organisation, Ministry of Urban Development.(2005). Status Of Water Supply, Sanitation and Solid Waste Management in Urban Areas. Research Study Series No. 88.

Authors:

Priya Balasubramaniam: Senior Public Health Specialist & Scientist- Health Systems, Urban Health , M&E ,PHFI Subash Hira: Distinguished Professor of Public Health & Infectious Diseases, PHFI Binira Kansakar: Research Fellow, PHFI Akshaya Patil: Project Associate, PHFI Dr. Mercian Daniel: Senior Research Fellow, PHFI
 
Last Modified : December 12, 2016, 12:41 pm