The Indian Metropolis: Deconstructing India's Urban Spaces

In May 2020, Tejinder Singh was anxiously searching for a government health centre with hygienic facilities in Bathinda. The city has four urban healthcare centres (based out of Lal Singh Basti, Dhobiana Basti, Janta Nagar and Jogi Nagar) run by the Punjab government, but they seemed to be in a state of abject neglect, with significant staff shortages and inadequate infrastructure.2 Despite a target population of 40,000, and a prior multi-crore spend on constructing such centres, there was clearly insufficient spending on ensuring adequate staff and medical equipment.3 Such centres were witness to low utilization, given less staff and a lack of provision of appropriate medical services. Local doctors simply cited that the requirements had been shared with the state health department multiple times, and yet nothing was really done.

India’s healthcare system is heterogeneous in nature, with a variety of organizations offering healthcare services, ranging from individual providers to small groups to large corporates. There is significant variation in healthcare quality, particularly in an urban context, across states and union territories, and even within states. The healthcare delivery system is fragmented in nature, with no single infrastructure element that links all the providers—although the government is seeking to make a start at this with the national health ID card. Regulation at the centre and the state level, along with its cousin, governance, have been constraints on India’s healthcare system, giving rising to service delivery gaps. Over the past two decades, the liberalization of the Indian market has also led to a liberalization of the healthcare services market, leading to increased investment and a greater absorption of technological innovation. And yet, this has not been completely transformative. Instead, an odd hodgepodge exists, with run-down primary health centres (PHCs) existing with super-speciality private hospitals. Healthcare delivery is expanding across different segments, with certain players attracting the affluent, whereas others seeking to target the downtrodden. Many of the upcoming business models in healthcare delivery in India are increasingly world class, with much to offer in best practices; however, the large public healthcare system and its underlying delivery model, organization structure, governance and financing arrangements remain mostly unchanged since Independence. Meanwhile, as the private sector has grown, it has been dominated primarily by solo practices, notwithstanding the growth in the corporate subsegment; in this sector, paying consultation fees and premium charges for treatment, post-operative care and medicines is de rigueur. Given the fragmentation of the sector, provider performance is notoriously hard to measure. There are few, if any, linkages between the public and the private hospitals, with both sectors having productivity and efficiency issues. Health System for a New India: Building Blocks, Niti Aayog, November 2019, https://bit.ly/3G6JGcb. 5 Ultimately, ordinary Indian citizens have to fend for themselves, with high out of the pocket spending, and yet having potentially poor outcomes. Altering this will require a transformative change in the way India’s healthcare system operates. This change will not be a single model that fits every metro, town or village, but will require customization across the urban hierarchy. India has done well in recent years, putting down the building blocks for crafting a robust and universal healthcare system. Non-contributory government-sponsored health insurance schemes (for example, Pradhan Mantri Jan ArogyaYojana [PM-JAY]) have been expanded to cover over 500 million people (the government continues to expand these to cover other population segments). The National Health Mission (NHM) has invested ~$20 billion to bolster the public delivery system between 2005 and 2019. This has included the hiring and deployment of ~900,000 community health workers (colloquially known as Accredited Social Health Activists [ASHAs]). The government’s push for integrating the local system of medicine under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) has also expanded healthcare capacity.6 Such providers have been integrated into existing allopathic care practices.