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Lessons from Covid19 –Need to focus on urban public health infrastructure.

The present pandemic of Covid 19 has thrown up several challenges for our public health system. While the front-line responsibilities are handled by the medical and paramedical personnel, it is the responsibility of the local bodies to provide public health infrastructure that will prevent the spread of the disease and promote a healthy living environment.

Public health along with sanitation is a State subject as per the Indian Constitution. As per the 73rd/ 74th amendment, the responsibility of formulating and implementing various programmes in respect of the subjects listed in the schedule 11 and schedule 12 are to be devolved to the panchayats and urban local bodies. Public health is listed in both schedule 11 and schedule 12. Thus Constitutionally it becomes the duty of the local bodies to provide and maintain public health infrastructure.

The prevalence data of covid19  shows that our metropolitan cities have reported the maximum concentration of infection. Within these metropolitan cities it is the slums that have borne the brunt of the disease burden.  Therefore in this short blog I am focusing only on urban public health.

According to the 2011 census that total urban population of our country is about 38 crores. That comes to about 31% of the total population. Presently this proportion would be about 34%.  Out of this, about 25% is living in slums. Translated to absolute numbers it comes about 10 crore people living in slums. Urbanization is an inevitable aspect of economic development.  The number of people living in slums will go on increasing in the years to come. Therefore it is high time to plan and implement a focused programme for transforming urban public health infrastructure with a view to prevent epidemic outbreaks in the urban areas.

There is a common perception among laymen that public health is all about providing health services, namely medical treatment facilities through primary health centers and hospitals. This common perception is further reinforced by the general tendency among the health sector professionals and health administrators to stress on the expansion of the number of health centers as a strategy for strengthening health services. They hardly refer to the issues of waste disposal, solid waste management, quality and availability of drinking water and unhygienic living conditions. These are left to another set of people working for the Public Works Department, Conservancy, and water supply. They operate from different compartments under different supervisors. The coordination between these different streams in the administrative set up is also weak. Each stream has their own priorities and budgets and separate controlling authorities. The coordination is expected to be done at the senior most level of the urban local body like the Commissioner. But unfortunately the Commissioners are transferred frequently. They are given very short tenures and by the time they take interest in a specific project and start the process of implementing it they are shifted out.  Even the elected members have no assurance of continuity. They also look for short term achievements that can secure instant publicity. Many of our civic bodies also suffer from political infighting and paralyzed decision-making process.

Public health has a much wider connotation. It goes beyond the provision of medical treatment facilities. It also goes beyond preventive medical steps such as immunization. The concept of public health extends to several aspects of social infrastructure such as housing, sanitation, solid waste management, potable water supply, food adulteration, health economics and so on. Some experts have defined public health as the interaction between epidemiology and management. The epidemiological experts will give us the nature and spread of the disease. But the management of the epidemic will require interventions that call for providing the required staff, the supply of medicines and disposables and allocation of budget.  The latter aspects touch upon human resource management, procurement and logistics and making available the required financial resources to the implementing agencies. An official or body responsible for implementing public health programmes must have these managerial skills.

We have been implementing various urban development programmes. These programmes cover health, housing, slum improvement etc. The focus of the health related programmes is on expanding the network of health centers and support staff. There is more attention to the medical cure of the diseases, rather than on items such as solid waste management which contribute to ensure healthy living conditions. Very often the urban development programmes aim to tackle several problems at the same time. There are multiple objectives in many of these programmes. For instance, the Smart Cities project of 2015 aims at (a) adequate water supply, (b) assured electricity, (c) sanitation and solid waste management, (d) transportation, (e) affordable housing, (f) robust IT connectivity, (g) good governance (h) sustainable environment, etc. When a programme has multiple objectives, the focus gets distributed among all, leading to the inability of the implementing agencies to achieve good results in all these sectors. It is advisable to have one objective in one programme. For example, the pulse polio programme was implemented with the single objective of eradicating polio. The entire health infrastructure was involved in the pulse polio initiative, resulting in its success.

The absence of a well organised solid waste collection and management system is the most noticeable feature of our urban landscape. When you travel around the country you are likely to come across several instances of domestic and commercial waste lying along the roadside. Even States that claim to be highly literate is no exception.  We tend to blame the media which publicizes the vivid picture of these garbage dumps without addressing the underlying cause. Some civic bodies have issued orders for imposing penalties for throwing waste on the streets. While there can be no objection to imposition of penalty for violators, it is important to remember that if there was a well organised system for collection and disposal of waste, most people would be ready to co-operate and deposit the waste in the designated collection bins. It is difficult to understand why most civic bodies are unable to maintain a good system for collection and disposal of solid waste, which is the primary function of an urban civic body. Why wait for a National programme for solid waste management?  This core function of a civic body should get a much higher priority than construction and maintenance of roads.

– K.S. Sugathan IAS (Rtd)

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