For human beings, Health is the most important need along with food, clothing and shelter. Unfortunately, a city like Pune is unable to provide its citizens with this basic human right. We were the capital of the country for Swine Flu and then Covid. The city is a hotspot for epidemics, lifestyle diseases, air, and water-borne diseases and is also facing a mental health crisis. Cases of substance abuse and narcotics have increased significantly in recent years. Pune’s healthcare infrastructure is not built to meet the needs of today with growing concerns over disease outbreaks in post-COVID times.

Current Issues

• Pandemic City

The city is a hotspot for epidemics, including communicable diseases like dengue, malaria, and now, the added concern of COVID-19. Furthermore, lifestyle diseases such as diabetes, heart disease, and respiratory disorders are on the rise due to changing lifestyles and climate change. The onset of monsoon brings forth diarrhoea, typhoid, jaundice, dengue and malaria, with children in the city most affected. There is a 40% increase in gastroenteritis with rotavirus being the most common causing agent during this period. Apart from this, the number of fully immunized children in Pune in 2022 is just 40 percent! The current scenario necessitates a comprehensive and strategic approach to bridge the healthcare gaps and build a robust and inclusive healthcare system that can effectively address the evolving healthcare landscape post the COVID-19 pandemic. The access to healthcare services in Pune is unevenly distributed among various socio-economic groups. While some sections of the population can afford quality healthcare, a significant proportion, especially from lower-income strata, struggle to access basic medical facilities.

• General Health 

While the middle class and upper middle class of Pune is struggling with the same health issues as rest of urban India – obesity, diabetes, blood pressure, heart issues, PCOD and other non communicable diseases (NCD), the low income groups are facing these as well as a host of other medical issues. 40% of Punekars live in the 353 official and 211 unofficial slums. Their health index is much worse than that of people living in tribal areas in the state! Infant mortality, TB, HIV and lack of vaccinations are some of the main areas of grave concern.

• Mental Health

Mental health problems such as anxiety, depression and suicides have been escalating at an alarming rate. While Farmer suicides are often in the news we often forget that India is the world capital for suicide by young people. This is a significant public health concern, affecting individuals, families, and the community at large and leading to immeasurable suffering and loss of billions of dollars of productivity.

• Addiction

Recent years have witnessed a substantial increase in cases of substance abuse and narcotics in Pune. Substance abuse not only has adverse effects on physical health but also leads to socio-economic problems, making it a multifaceted challenge. The issue of drugs and narcotics is observed to be a youth problem considering the age bracket of addicts. The average age of exposure to narcotics is now 15-16 years compared to the 25 year olds which was the average age in the previous decade. How are we equipped to deal with all this?

Public Health System

Well to do citizens are able to afford the world class care given by Pune’s top private hospitals, clinics and doctors. But even the well heeled know that such top hospitals are almost always at full capacity, and getting one’s patient admitted can often depend on how influential you are, on ‘who you know’. And for the majority of Punekars who are not well to do or well connected, the story is even worse. The public health system of the PMC currently has merely 34 clinics, 14 maternity homes, and 2 hospitals. Today, there are only 3.5 hospital beds available for every 1000 Punekars. While this is higher than the national average, given Pune’s unique position as a disease hotbed, this number needs to be increased, especially because the available beds are mostly private healthcare which cannot be afforded by most people. We need One Urban Primary Health Care centre per 50 thousand population. The level of affordability and access to healthcare for all socio-economic groups in Pune is skewed.  Pune’s healthcare infrastructure is struggling to meet the current and emerging healthcare needs. The infrastructure is not sufficiently equipped to handle the growing concerns over disease outbreaks in post-COVID times. Hospitals, medical facilities, and the healthcare workforce face significant strain during health crises, hampering timely and effective response.  The increasing rate of urban poverty has also impeded access to healthcare services in the city. To remedy this the Urban Poor Health Scheme was started. This would enable people holding an Urban Poor card to access healthcare services at private hospitals included under the scheme for IPD treatment. A total of 125 private hospitals are included under this scheme to provide health services to the urban poor. Under this contributory health scheme beneficiaries can also get the required medications free of cost from the PMC dispensary. 41 such dispensaries are established across the city. PMC also provides free of cost immunization for infants, children and pregnant women under the National Health Programme.

Solutions: 

1. Environmental: 

Again, like everything in our civic life, Health too is interrelated with the other issues covered in this report. A better public transport system automatically has the effect of better air quality – which improves the health of all citizens. Better traffic also means better mental health for all. A greener city also has similar physical and mental health benefits. Water (quality and quantity), Sanitation are directly related to health. So for example when we talk about spending a few thousand crores on Buses, we should understand that the money is also saving us an almost equivalent amount in Public Health costs! (Please see Chapter 2 for in depth analysis of this and the issue of road accidents).

2. Access / Infrastructure / Capacity Building

Today, there are only 3.5 hospital beds available for every 1000 Punekars. While this is higher than the national average, given Pune’s unique position as a disease hotbed, this number needs to be increased, especially because the available beds are mostly private healthcare which cannot be afforded by most people. We need to

• Invest in the modernization and upgradation of healthcare facilities, including hospitals, clinics, and primary health centers. Ensure they are equipped with state-of-the-art medical equipment and adequate beds to handle a surge in patients during health crises.
• Enhance healthcare workforce training programs to meet the rising demand for medical professionals.
• Encourage medical students to specialize in fields critical to public health, such as epidemiology, to bolster the response to outbreaks.
• Foster collaborations between the government and private sector to augment healthcare infrastructure. Leverage private sector expertise and resources to build and manage healthcare facilities, expanding the overall healthcare capacity.
• Establish community health centers, tertiary health centers and deploy mobile clinics to reach underserved areas. These facilities can provide basic healthcare services, health education, preventive care, and vaccinations, ensuring healthcare accessibility to remote and vulnerable communities.

The following health programs need to be strengthened:

• Routine Immunization
• Maternal and child Care services
• TB control program
• Non Communicable Diseases surveillance and treatment
• Geriatric health Services
• Mental health programs

3. Affordability

• Implementing a universal healthcare coverage system that ensures access to quality healthcare services for every citizen, irrespective of their socio-economic background. Introduce healthcare vouchers or subsidies for individuals from economically disadvantaged backgrounds, enabling them to avail essential healthcare services without financial strain.
• Make access to existing state and union government schemes easy and automatic.
• Private hospitals registered under charity commission should provide free of cost health services to the poor as per the law of the land. Government system must be vigilant about these services.
• Experiment with insurance companies to provide universal coverage to vulnerable and poor sections but also to the lower and middle income groups. Medical Insurance coverage in India is very low and we need to create massive awareness about it. For example, a city wide campaign to facilitate medical insurance for household help by their employers where insurance companies draw up specific products for this where multiple households will pay a fraction of the premium.

We should remember that, according to the World Health Organisation, every rupee we invest in health infrastructure, gives us returns of seven rupees as a society! So we should be generous and in fact invest not for just for today’s requirements but also for future needs. If countries like Vietnam can do this, why can’t we!?

4. Pandemic Preparedness: 

• Disease surveillance mechanism to arrest the spread of infectious diseases like covid, swine flu etc.
•  Invest in advanced disease surveillance systems to monitor and manage disease outbreaks effectively. Utilize technology to predict and prepare for potential epidemics, enabling a swift response and containment strategies.
• The number of fully immunized children in Pune in 2022 was only 40 percent. Surely we must focus on increasing this number substantially.

5. Preventive Social Medicine: 

Prevention is of course always better than medicine.

• Launch comprehensive public health campaigns to raise awareness about lifestyle diseases and communicable diseases.
• Educate the public about preventive measures, healthy lifestyles, and regular health check-ups to reduce the burden on the healthcare infrastructure.
• Run a city wide campaign on the importance of nutrition by bringing together schools, colleges, corporates, offices, dabbawalas, restaurants and so on to make nutrition easily accessible.
• Run a similar campaign around the importance of exercise by turning this city in to a walkers, joggers, cyclists haven. A city wide movement around ‘Move It’ to get everybody from children to senior citizens to add activity in their daily routines.
• Ante Natal and Post Natal Care should be available for all new mothers.

A. Mental Health:

• First step is to remove the taboo associated with mental health issues with a massive social awareness campaign.
• We need to Integrate mental health services into the primary healthcare system including PHCs.
• Train healthcare professionals to identify and provide initial support for mental health issues
• Establish counseling centers and helplines to offer assistance and guidance to those in need especially women and children who are often ignored.

B. Substance Abuse and Narcotics:  Implement targeted prevention programs in schools, colleges, and communities to educate individuals about the dangers of substance abuse. Raise awareness through campaigns highlighting the physical, psychological, and social consequences of drug abuse. Establish rehabilitation centers equipped with professional staff to aid individuals in overcoming substance addiction. Additionally, create support groups and helplines to provide guidance and support to individuals and families affected by substance abuse. Strengthen law enforcement efforts to combat drug trafficking and illegal distribution. Enforce stricter regulations and penalties for drug-related offenses, creating a deterrent effect and reducing the supply of illicit substances.

Conclusion: Since health is a state subject, the state government needs to come out with a holistic plan to integrate, upgrade and enhance the city’s healthcare system. This work is too large and too critical to be left to the PMC or private sector alone. The state government must intervene with substantial financial, legislative and systemic help.

A transformative campaign uniting stakeholders, especially the medical community, CSR resources and all citizens to demand good health (treatment as well as prevention) as a basic human right and make it a top priority of the city.

 

Suggested best practices: 

Chennai

• The main aim of the Public Health Department in the Chennai Corporation… is to reduce health inequalities throughout the city of Chennai targeting resources, programs, and attending to high need neighbourhoods in the city.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453934/ https://www.thehindu.com/news/national/tamil-nadu/national-health-mission-selects-tns-mentoring-concept-as-best-practice/article33649224.ece

 

Manchester

• Manchester’s City Verve Project, Integrated Care Records, Mental Health Support, Health Innovation Manchester, Active Travel Initiatives.

 

Singapore

• Universal health care: Singapore has a universal health care system, which means that all citizens have access to health care regardless of their income. This system is funded by a combination of taxes and individual contributions. https://www.commonwealthfund.org/international-health-policy-center/countries/singapore

• Strong emphasis on prevention: Singapore places a strong emphasis on prevention. This includes programs to promote healthy living, such as exercise and nutrition education, as well as vaccination programs.
• Use of technology: Singapore uses technology to improve its public health system. For example, the government uses data analytics to identify at-risk populations and to target interventions.
• Public-private partnerships: Singapore uses public-private partnerships to deliver health care services. This allows the government to leverage the expertise of the private sector to deliver high-quality care at a lower cost.
• Continual improvement: Singapore is constantly looking for ways to improve its public health system. This includes investing in research and development, as well as benchmarking against other countries.
• Well-trained workforce: Singapore has a well-trained workforce of doctors, nurses, and other health care professionals. This is due to the government’s investment in education and training.
• Modern infrastructure: Singapore has modern infrastructure, such as hospitals, clinics, and laboratories. This infrastructure is essential for providing high-quality health care

Delhi

• Mohalla Clinics are perhaps the most famous public health initiative in recent times. What can Pune learn from this system?