How India can improve urban public health with lessons from COVID-19

Almost exactly a year ago, India recorded its first COVID-19 case. While the pandemic can arguably be considered a black swan event, it has exposed deeper cracks in its cities public health sector. COVID-19 is already projected to roll back progress on a number of socio-economic indicators; unaddressed, poor public health will exacerbate existing challenges.

Going forward, we need to take a closer look at the COVID-19 and non-COVID-19 disease progression in India’s cities, the lack of data, inadequate infrastructure and insufficient budgets.

The disease burden in cities differs compared to rural regions and is continuing to change. Pathologies such as cholera, tuberculosis, dengue, H1N1 and Ebola are still prevalent in urban India. A 2018 survey in Delhi revealed that 40% of its population has had dengue at least once in their lifetime owing to a certain mosquito found in urban areas.

The study also reveals that, while the spread of dengue depends on temperature and rainfall, the degree of urbanization is also a contributing factor. Specifically, poor housing conditions can lead to diseases being carried by insects and rodents, as well as respiratory infections from poor ventilation and low-grade cooking material. SARS and the novel coronavirus have also added to the disease burden, especially because of their spread in megacities and travel between them or rural-urban and urban-urban migration.

Going forward, healthcare data needs to become a policy focus for India. With the COVID-19 pandemic, there emerged a number of platforms to track case numbers, fatalities, hospital bed availability and so on. State governments such as that of Tamil Nadu built GIS platforms to track containment zones and hotspots of infection, thereby deploying the necessary resources to the areas that required them.

Similarly, covid19india.org, a volunteer-based, private platform on state-wise contagion rates and testing has been an important source of COVID-19-related information. However, such data is grossly lacking when it comes to other healthcare problems. Healthcare data in India is largely unavailable or fragmented.

This stems from the nature of delivery of health services in the country: citizens in urban and rural areas interact with the healthcare infrastructure through a number of private and public delivery points with no single system integrating and acting on the information, as has been done for COVID-19. Moreover, with allied issues such as rising pollution and inadequate sanitation leading to other illnesses, data on healthcare concerns, coupled with other city-level data, needs to be significantly ramped up and utilized for better policymaking.

COVID-19 has also laid bare several fissures in India’s public health infrastructure and investment, particularly in cities. During the last decade, less than 2% of India’s GDP has been invested in healthcare; China and the US’s healthcare investment hovers at around 5% and 17% of GDP, respectively.

At the local level, budgets have increased. Between 2015-16 and 2017-18, the healthcare budget in Mumbai and Delhi has gone up, each by 41% and 26%. However, the focus is unevenly on secondary and tertiary care, rather than primary care. While expenditure on hospitals was 74% of Mumbai’s health budget, only 26% was spent on dispensaries. Cities deserve specific attention: 75% of India’s current healthcare infrastructure can be found in cities, and every minute, 25-30 people migrate to urban areas from rural ones. If city-level healthcare services are not adequately scaled, the current disease burden will only be exacerbated.

We recommend improvements in data collection, infrastructure investment, budget alterations and personnel training in healthcare. Using big data in healthcare with electronic health records, government records, laboratories and insurance companies can provide a rich source of information to healthcare providers to assess clinical risk and genetic susceptibilities. Combining healthcare data with other parameters related to transport and housing, for instance, could be used to generate healthcare plans and deploy healthcare services in real time to those who need it the most.

Simultaneously, however, while framing healthcare data collection and usage, it is important to balance individual privacy and data protection with institutional transparency and accountability. Government documents were being shared on WhatsApp that outlined details of COVID-19 positive patients, including their names and home addresses. This practice began to discourage people from getting tested even if they exhibited symptoms to avoid stigmatization by their neighbours. The new National Health Stack will create extensive health profiles of individuals, but the health data management policy of the National Digital Health Mission must be followed.

As we rebuild from the pandemic, it becomes important to create and monitor certain thresholds for public health infrastructure based on population. For example, regardless of whether an area is classified as rural or urban, if it has a certain population level, it would benefit from having a hospital rather than a single physician clinic. Establishing such benchmarks (in terms of physical infrastructure, specialization of personnel, relevant support staff) and reworking them as necessary, can go a long way in building a population with a healthy life expectancy in India where low state capacity falls short of the demands of secondary or tertiary care.

Further, given the burden on urban healthcare systems, budgets need to be expanded to improve healthcare infrastructure supply aligned with the disease progression in cities. This must result from greater decentralization of finances and responsibilities, as well as revenue from health tourism.

Moreover, along with an increase in the budget, there needs to be capacity to manage that spending. With the increasing use of technology and healthcare analytics to treat diseases, healthcare professionals will have to acquire skills to harness data and interpret it to provide decision-making support to medical practitioners. Over and above this, as COVID-19 has highlighted the need for management of epidemics and pandemics, there must be a mandate for public health professionals in government.

These steps are not exhaustive and are not sufficient to tackle the current pandemic. However, with adequate planning, they can guarantee a more robust system to deal with the next one, and build a more healthy population and productive economy – along with resilient cities in the process.

(Kadambari Shah, Senior Associate, IDFC Institute, contributed to this article.)