Bangalore, November 21, 2021: A third of India's people now live in urban areas. India's urban population has seen rapid growth from about 18% (1960), 28.53% (2001), to 34% in 2019. Close to 30% of people living in urban areas are poor. COVID-19 has called for a big fix of our healthcare systems, but how much of this trickles down to the most vulnerable communities in our cities? 
The Azim Premji University, in collaboration with 17 regional NGOs across India,  has launched the 'Health Care Equity in Urban India' Report, a compendium of learnings that unpack health vulnerabilities and inequalities in cities in India.
The report explores understanding of health vulnerabilities of urban poor, availability, accessibility and cost of healthcare facilities and possibilities in future-proofing services in the next decade. It draws insight from data collected through detailed interactions with civil society organisations in cities and towns across Mumbai, Bangalore, Surat, Lucknow, Guwahati, Ranchi, and Delhi. This also included analysis of National Family and Health Surveys (NHFS), Census of India and inputs from state-level health officials on the provision of health care.  
Key findings
Apart from a call for significant investment in scaling healthcare facilities and infrastructure in cities, the report finds that there are critical factors that disrupt quality healthcare services to the poor. These are:

• Disproportionate disease burden on the poor: Governments and decision-makers must recognise the severe asymmetry in health across income groups. The life expectancy among the poorest is lower by 9.1 years and 6.2 years among men and women, respectively, compared to the richest in urban areas.
• Chaotic urban health governance: Complexities in defining urban boundaries in the urbanisation process and the multiplicity of health care providers both within and outside the government without coordination are challenges to urban health governance. The overlapping administrative jurisdictions such as municipal corporations (urban local bodies) and state health services and lack of coordination result in chaos in urban health. 
• Financial burden on the poor: Our evidence from Bengaluru shows that 30% of even the poorest quintile seek delivery care from private sources. Since there is a 10-fold difference in cost between public and private facilities, this significantly adds to their financial burden.
• Urban local bodies are less invested in health care: Although the 74th Constitutional Amendment, 1992 mandated the central role of ULBs, their healthcare leadership is hardly visible, except for parts in some metro-cities such as Bengaluru, Mumbai and Thiruvananthapuram. COVID-19 has shown the possibility of their health leadership, which needs to expand to health care governance.

 Working to address health care needs and setting clear pathways that target the urban poor can transition our services for the most vulnerable in the next decade. The report calls for:

• Strengthening community participation and governance
• Building a comprehensive and dynamic database on the health and nutrition status, including co-morbidities of the diverse, vulnerable populations 
• Strengthening healthcare provisioning through the National Urban Health Mission, especially for primary health care services and
• Putting in place policy measures to reduce the financial burden of the poor, better mechanism for coordinated public health care services and better governed private health care institutions

 As urbanisation is happening rapidly, the number of the urban poor is only expected to increase. A well-functioning, better coordinated and governed health care system is crucial at this point. The pandemic has brought to attention the need for a robust and resourced healthcare system. Addressing this now will benefit the most vulnerable and offer critical services to city dwellers across income groups. 
 "Urban health care has received relatively less research and policy attention. This report is an important contribution that enhances our understanding of the health vulnerabilities of the urban poor, unpacks the health system governance challenges in different cities and towns and provides a road map for how to reimagine our urban health systems. The report demonstrates why it is important to prioritise urban health and act now!" said Arima Mishra, Professor, Azim Premji University.
Find full report here: UHC report 1.5.indd (azimpremjifoundation.org)