Health Articles

Urban Health Care in India

India is an under developed country and 50% of the population live in urban areas in an extremely below the poverty condition. As they are lured by massive industrialization, economic and educational opportunities in cities like Chennai, Mumbai, Kolkatta and Delhi are over crowed and the statistics says about one fifth live in slums Most of the health problems in India are generated from these slums only.

Many are exposed to new types of risks associated with industrial pollution, road accidents, air pollution, poisonings, threat to child adolescent health etc.

Drainage system is poor in Chennai, Kolkatta and Mumbai which cause high incidence of infections disease and epidemics. High densities of dwellings and lack of internal roads cause poor accessibility for emergency and life saving services. New squatter settlements come up on the periphery often on inhabitable lands because of their low values and cause environmental hazards.

In the recent Bhopal gas tragedy, around 3000 persons mostly from the peripheral slums were killed and it clearly revealed the vulnerability of squatters.

Urban malaria, tuberculosis and pneumonia, leprosy, meningitis, preventable infections in children such as measles, whooping cough and polio, diarrhea diseases and intestinal worm infections are some of the most common health problems apart from higher morbidity and mortality due to accidents.

Central council of health was formed as per the constitution to check all health problems in India. Health survey and Development Committee was the first committee to be formed in India which laid foundations for several activities in all five year plans to attend to all health problems attaching the millions in India.

The ministry of health and family welfare is handled by secretary of the govt. of India. He is directed by the cabinet minister of state or by his deputy. The ministry is concerned with 1) maintenance of international health relations with other countries of the world and coordination among them 2) adoption of family welfare measures concerning population stabilization and family planning.

The Directorate General of health services as the technical wing to the ministry of health and family welfare and its activities cover the whole spectrum of medical care and public health apart from general administration. Other activities include establishment of drug standards, prevention of food adulteration, control of drugs and poison, coordination with state of health Authorities, implementation and monitoring of various health programmes and schemes etc.

At the state level we have the Directorate of Health Services to administer public health, medical services and medical education. Due to increasing responsibilities and abundant health problems some states have established more than one Directorate and separated medical care facilities and medical education from the public health. To boost the family welfare activities some states have set up separate Directorate of family welfare or state family welfare Bureau.

At the District level we have the District health office that is in charge of all activities concerning medical, public health and family welfare and district health administration. To lay more importance to family welfare programmes, a separate family welfare officer has been appointed.

In urban areas we have local self governing bodies having three tier administrations.

1. Medical officer in charge
2. Zonal office in charge
3. The chief executive in charge

Health Care Delivery in India

Among the major public health programmes, the Maternal and Child Health Services constitute an integral part of the family welfare programmes and occupy an important place in the socio economic development planning. It also plays a crucial role in human resource development and in improving the quality of life of the people. The Government has sponsored immunization schemes for infants and children against nutritional anemia among mothers and children and prophylaxis against blindness due to vitamin A deficiency are also in operation. Programme for oral rehydration therapy is another important child survival scheme. Diarrhea disease is a major health problem in India especially among children below five years of age.

To liberate the children from common communicable diseases, the expanded programme of Immunization (EPI) was started by the Governments of India in 1978. The objectives of the programme are to reduce morbidity and mortality due to diphtheria, pertussis and tetanus, poliomyelitis, tuberculosis and typhoid fever by making vaccination services available to all eligible children and pregnant women.

Universal Immunization Programme (UIP) is an important step towards achieving the goal of Health for All by the Year 2000. The programme was dedicated to the memory of the former Prime Minister, Mrs. IndiraGandhi. Under the UIP, it was proposed to cover all eligible infants and pregnant mothers by the end of 1990. A Technology Mission on Immunization has been launched covering all aspects commencing from research and development to actual delivery of services to the affected population.

Urban Malaria Scheme was initiated in November 1971. The main objective of the scheme is to control malaria transmission by eliminating aquatic stages of vector mosquitoes by weekly application of larvicides in breeding sources. The scheme has at present been sanctioned for 133 towns distributed over 17 states and two Union Territories.

National Filarial Control programme was taken up in urban areas from 1955 in order to contain the diseases. Anti-larval and antiparasitic measures are being taken in 199 towns distributed in 13 states and four Union Territories.

Tuberculosis is a major public health problem in the country. The National Tuberculosis Programme was launched in 1962. A total of about 46,000 beds are functioning in the country for treatment of seriously sick and emergent TB patients.

Leprosy control programme has been in operation since 1955 but it was only after 1980 that it received a high priority and it was redesigned as National Leprosy Eradication Programme (NLEP) in 1983 with the goal of arresting the disease in all known leprosy patients by the year 2000.

Kala-azar which was almost on the verge of eradication, reappeared in Bihar in 1970s and in West Bengal during 1977. Later it spread to more states. The Kala azar unit of National Malaria Eradication Programme (NMEP) is monitoring the Kala-azar situation along with the incidence of Japanese Encephalitis in the country.

National AIDS Control Programme has emerged as a devastating fatal disease. Up to April 1989, as many as 2, 55,589 risk persons were screened. Of these, 941 have been HIV positive. Amongst these, as many as 29 are the full blown cases of AIDS which include 11 foreigners. The Government of India constituted a task force in the year 1985 under Indian Council of Medical Research and established two surveillance centers, viz., National Institute of Virology, Pune, and Christian Medical College, Vellore to screen high risk people for AIDS. An AIDS cell has been established in the Directorate General of Health Service to coordinate all activities pertaining to AIDS control. At present, 40 surveillance centers and four referral centers are available in the country.

Apart from the above national health programmes, there are programmes like, National Programme for Control of Blindness, National Mental Health Programme, Sexually Transmitted Diseases Programmes and National Goiter Control Programme.

Poor Macro Micro Environment

Overcrowding, poor housing, choked drains, high density of insects and rodents, lack of garbage disposal facilities, poor personal hygiene, and hygienic conditions are hall marks of urban slums in India. Unplanned and rapid urbanization put a strain on the already dwindling civic amenities. Under such conditions gastroenteritis and other infectious diseases are rampant. Children affected by serious diarrhea diseases are likely to spend 20 percent of their first two years of life suffering from serious diarrhea with a median number of 4.9 episodes per child per year. Studies from urban slums of Ludhiana show that children under two years of age had 3.8 episodes of diarrhea per year.

Failure of Urban Health Care System

Health Care System in India in the last 45 years has focused on increasing coverage in the rural areas. There has been little or no development of organized health care services for the vast urban areas. The 3,600 odd cities and towns of India with some 40 million people living in slums have to depend largely on private practitioners (mostly quacks) for their health care needs. Out of the 3,000 plus urban local bodies in India only about 100 have been some semblance to a health care service while the rest have only a sanitary inspector or even a lower functionary to look after the health care system.

From the foregoing discussion it would be obvious the prevalence of malnutrition in urban areas particularly in the urban slums would he quite high.

A study by environmentalists from Bombay, Calcutta and Madras shows prevalence of malnutrition to be very high as given in Table below.

Prevalence of Mal-nutrition
City Prevalence of Malnutrition
Male Female
Bombay 63.6
(N = 958) 73.1
(N = 862)
Calcutta 75.9
(N = 667) 75.0
(N = 710)
Madras 67.8
(N = 846) 77.8
(N = 883)

In a 30,00 urban population of Ludhiana, mostly from the slums, it was found over all prevalence of malnutrition, in children under five years to be 67 per cent for males and 69 per cent for females. Further, the analysis of 280 deaths in children aged 1-5 years mostly from urban slums showed that malnutrition was an associated cause in two-third of the deaths.

Although urbanization is one of the indicators of development, very fast growth of urbanization in developing countries has created problems of proliferation of slums. Slums have become the unavoidable and evil symbols of industrial and urban growth. The rate of urban growth cannot match housing, educational and health service facilities including drinking water and sanitation.

Initially, rural to urban migration is limited to males. A rural migrant is deprived of his membership of his kin group in the village, suffers from loneliness and faces problems of residential accommodation. A slum gives him shelter and anonymity in urban area. This often leads to alcoholism and prostitution. A migrant getting cash wages is expected to save and support his family in the village. He, therefore, tries to save on food and gets malnourished.

Slums vary greatly from each other. But the universal characteristics refer to overcrowding and congestion, extremely poor sanitation, lack of civic amenities and deviant behavior. It is reported that in Delhi slums, 400,000 people live on one square mile. In Bombay it is common for ten persons to live in a room-ten by fifteen feet. However, slum cannot be defined only by housing. In India, temporary structures raised with the use of material such as rags, plastic pieces, rusted pieces of iron, pieces of canvass cloth, and places where there is almost total absence of tap water, latrines and roads are identified as slums. There may be very high density of population per square mile but if people are staying in multi-storied permanent structures sharing inadequate civic and sanitary facilities, these are not popularly identified as slums. Slums culture is marked by apathy, insecurity, social isolation and disease.

In India, more than nine million people live in slums of which 12,50,000 are in Bombay, 11,00,000 in Calcutta, 9,00,000 in Madras and 7,00,000 are in Delhi. It is no wonder that slum dwellers should be the victims of airborne and water-borne infections, and should suffer from nutritional deficiencies as also from undiagnosed mental illness. The disorganizations in various aspects of life breed apathy and psychology of defeat which is manifested in fatalism, crime or lack of enthusiasm about preventive aspects of health, although offered free of charge.

There is constant deprivation, particularly of children among urban poor. Deteriorated houses crowded together, open sewer, uncollected garbage, poor sanitation, files, starling water and poor lighting are common. People face threat of eviction if they are squatting on someone elses land. Joblessness and alcoholism make men angry or hopelessly drunk and lead to abandoned wives and children. Women must go to work to survive without a male breadwinner or to help him make both ends meet. For some of them, domestic service and prostitution are virtually the only options. Older children, some no more than 10 year old, take care of their younger siblings while the adults are away.

Consequently, children remain undernourished and underweight with their growth stunted from insufficient food. Diarrhea, gastro enteritis and respiratory ailments are common illnesses to which many succumb during their first year of life.

Urban areas continued to develop being the seats of power, money and intellect. They also became the first places to experiment with ideas. As a result, various agencies of health representing municipal, provincial and national levels developed simultaneously with voluntary, private and philanthropic institutions. However, curative aspect got precedence over preventive and promotional aspects. Health care system continues to veer around doctors, drugs and patients. Piped water supply and modern sanitation also developed but in selected urban localities. However, the water supply is almost always intermittent, and in most of the cities / towns drainage often gets clogged for one reason or another.

It is not uncommon to see medical colleges and hospitals belonging to various medical systems such as modern, ayurveda and homeopathy in one Indian city. India provides an excellent example of medical pluralism. People follow home remedies, spiritual remedies and treatment from various medical systems simultaneously or one after another. Metropolitan urban areas provide medical facilities which are available in developing countries such as cardiac surgery, treatment of all kids of cancers, or in brief, for the diseases which are associated with affluence. The major diseases identified in South East Asia Region under WHO are malaria, filarial and other mosquito borne diseases, diarrhea diseases, leprosy, tuberculosis, sexually transmitted diseases, poliomyelitis and other children diseases, tetanus, nasopharyngeal and cervical cancers, visual impairment and blindness, etc.

The organized sectors in urban areas such as employees of government and public undertakings bargain for medical benefits like Employees State Insurance Scheme and Government Health Schemes. In same cases, medical expenses are reimbursable if treated at recognized hospitals. At the same time, there is a lot of overlap and even the private medical practitioners seem to thrive well simultaneously. However, the unorganized sector such as domestic workers, self-employed, porters, cart-pullers, load-carriers and urban poor mostly living in slums do not get these benefits. They are also deprived of piped water and modern sanitation, or in any case, the facilities are woefully inadequate.

Urban poor whose hallmark in expenditure is cheapness get adulterated food and drugs. On an average, milk milk-products, edible oils, wheat flour, spices and even tea leaves are adulterated to the tune of 50 per cent.

Mental health has yet to receive due attention in India. While westernized urban elite require the services of psychiatrists in increasing number, for others family continues to provide psychic treatment. If crime rate, suicide, divorce, riots and indiscipline are considered as parameters of mental health, urban area need urgent attention.

It is often said that a large proportion of population suffers from protein calorie malnutrition. However, the range of nutrition in which people can function efficiently without getting nutritional deficiencies is wide and what are commonly given as recommended quantities for intake of nutrients are much higher than what are required.

Urban poor are unfortunately use bottle feeding and baby feeds under the influence of commercial advertising on radio, television, and through other popular media like films.

The revolution in drugs coincided with freedom from colonial rule. The drug industry has developed out of proportion in comparison with basic amenities like potable water and sanitation.

Pharmaceutical industry measures developed out of proportion of country in terms of intakes of per capita consumption of drugs. In India, drugs are only consumed among 20 per cent urban people. The per capita consumption is perhaps the lowest in the world. However, this code does not represent the correct picture in view of the fact that about 75 per cent population in rural areas and urban poor has yet to have access to drugs. Major share of these drugs are taken away by vitamins, tonics, and antibiotics. It is estimated that out of the total production 25 per cent was taken away by vitamins and tonics, and 20 per cent by antibiotics.

Primary health care is available to the whole population, with at least the following:

- Safe water in the home or within 15 minutes walking distance, and adequate sanitary facilities, in the home or immediate vicinity;

- Immunization against diphtheria, tetanus, whooping cough, measles, poliomyelitis, and tuberculosis;

- Local health care, including availability of at least 20 essential drugs, within an hours walk or travel; and

- Trained personnel for attending pregnancy and child-birth, and caring for children up to at least one year of age.

The nutritional status of children is adequate, in that:

- At least 90 per cent of new born infants have a birth weight of at least 2000 gm;

S. Chakarapani
Age:56
Occupation: freelance journalist from india
chakrapani.s@nlcindia.com

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