Healthcare services have suffered due to spar between the State Government and the MCD. Though political equations remain the same, it is now expected that both will deliver
In the run-up to the Municipal Corporations of Delhi (MCD) elections; the mohalla clinics continued to hog a lot of limelight. The public spar between the State Government and the MCD on setting up of mohalla clinics is well-known. The parties in ruling positions blamed each other for the stalemate.
Now, the MCD election results are out and political equations stay unchanged. The only approach left is to find a middle-path and cooperation between the two agencies. The situation faced on setting up of mohalla clinics and other initiatives in the national capital might be foretelling on the future of such initiatives in other cities of the country where cooperation between State Governments and urban local bodies is needed.
Urban settings and health services provision: In India, health is a state subject, with the Union Government providing policy directives and running a few national programmes. The urban local bodies became the third major agency responsible, with one of their responsivities being for delivery of public health and primary healthcare services in urban areas, following 74th amendment in Constitution in 1992. With this arrangement, the Ministry of Urban Development (which is the nodal Ministry of urban local bodies) also became a stakeholder in delivering health services.
Over the years, the urban local bodies in different cities have attempted to deliver basic care to residents with a few financial rich corporations such as the Brihanmumbai Municipal corporation (BMC) setting up tertiary care facilities such as medical colleges, as well. Other agencies, including the Union Government and the State Governments, provide health services in the same areas to general population without much coordination. People essentially do not bother about the agencies delivering these services, they choose one which offers assured services and easily accessible.
Here is the flip side of such arrangement. First, similar type of services provided by multiple agencies and there is duplication of efforts at places, some services remains missing completely. Second, the public health services such as mosquito breeding control are responsibilities of urban local bodies which often these fails to do because of scarcity of resources (financial and human resources). Third, all three attempt to deliver range of curative services which have more visibility and popular amongst the electoral representatives while referring patients to doctors posted at these facilities
Most often public health services are sub-optimally delivered by urban local bodies because of shortage of funds while the State Governments often do not allocate sufficient resources for these services, citing that the responsibilities for urban areas is with urban local bodies. The situation comes to public attention only when the outbreak of diseases like dengue and chikungunya expose the weaknesses and agencies start shifting the blame.
Is this problem likely to increase in futureIJ With the increase in urban population and number and sizes of urban local bodies increasing across India, there would be increasing need for health services in urban areas, which are grossly in inadequate from different Government agencies. Currently, primary care services are provided largely by the private sector, while the public sector provides only one-fifth of total health services.
Second, as India aims to advance universal health coverage in the country, as envisaged in National Health Policy this year, there would be need for integrated approach to service delivery with convergence amongst the initiatives of multiple agencies working in urban areas.
What nextIJ There is need for improved coordination and convergence amongst three different agencies in delivery of health services. A joint action plan for health services with clear roles and responsibilities should be developed, approved by top officials and implemented. Such arrangement requires high level leadership from the Union and State officials, at least initially coordinated through the offices of the Prime Minister and the Chief Ministers, as appropriate, with engagements of the Ministers and Ministries of Health and Urban Development
Urban local bodies need to increase funding for public health services than what is being allocated. These services also need to be funded and priorities by State Governments.
The urban local bodies should consider handing over large hospitals to the State Government. The savings after such initiatives should be used to strengthen public health and primary health services may not be sustainable in long term.
Mohalla clinics initiative has given a possible insight into the challenges in scaling up urban health services. The challenges in urban settings cannot be wished away or rely on wish that there would be friendly Governments at all levels. Amicable and sustainable solutions have to be explored and devised by stakeholders through sustained engagement of key stakeholders. People would be watching how the State Government and the MCD reconcile differences to provide better healthcare and set an example for other parts of country. If they fail to do so, there would be serious doubts whether any of them is serious about providing better primary care to the people.
(The writer is a leading public health expert based in New Delhi)
