Dr Gayathri Raghuraman
Health and wellness in cities are intricately linked to urban infrastructure especially in the case of the urban poor living in informal settlements. For instance, studies have shown that the urban poor have a high prevalence of lifestyle diseases like hypertension, diabetes and heart disease; and most often suffer from multiple morbidities ( Pakhare et al., 2021; Sinha,Kerketta, Ghosal, Kanungo, & Pati, 2022). India has the highest number of tuberculosis (TB) cases in the world and accounted for 26% of the world’s cases in 2023 (World Health Organization, 2024).TB is closely associated with undernutrition and presence of overcrowding both features of urban informal settlements.
There have also been increasing occurrences of dengue in the cities caused by increase in temperatures and excessive rains due to climate change (Pandey, 2024). Climate change because of rising temperatures has resulted in floods in monsoon and heat waves during the summers. Informal workers using public spaces to earn their livelihood like the street vendors, construction workers, the city cleaners, etc are the most vulnerable to the extremes of weather. High temperatures not only increase the vulnerability of elderly and children to heat strokes, they also may exacerbate conditions like hypertension, diabetes and even mental illness resulting in hospital admissions.
In addition to the above, the National Mental Health Survey (2015-16), the urban population also has a higher prevalence of mental disorders than rural areas. In addition, about 72-90% of the cases remain untreated in the country.
In such a scenario, the urban poor can only turn to the urban local bodies (ULBs) for solutions. Under the 74th amendment, 18 functions were to be devolved to the ULBs. The CAG report in 2022 found that ULBs were currently solely responsible for just 5 functions of the 18. Within the function of ‘Public health, Sanitation conservancy and Solid waste management’ the ULBs had a very limited role with overlapping jurisdiction with the health and family welfare department. This was also true for the function for ‘Provision of urban amenities and facilities such as parks, gardens, playgrounds’ which are important to promote physical and mental health of the citizens (Comptroller and Auditor General of India, 2022).
The ULBs are limited to implementing centrally sponsored schemes like the National Urban Health Mission (NUHM) and any other state specific initiatives and drives for the state health department. Municipal finances speak to this limited role with very little details on public health expenditures, although, bigger municipal corporations have higher capability to perform public health tasks (Janaagraha Centre for Citizenship and Democracy, 2023; Open Budgets India, n.d.; Raghuraman, Sarah, Rao, Minni, & Jha, 2019).
ULBs in recent times have also seen a shrinking of their own source revenue post GST and due to factors like inefficient collection and poor updating of current important revenue sources, like property taxes. Municipalities are able to spend only a third of their revenue on operations and management(Comptroller and Auditor General of India, 2024; Verma, Bazaz, & Dubey, 2022). The CAG also points out that 60% of the ULBs studied from the 17 states did not have an active elected council. This paints a grim picture about the state of our ULBs and their ability to provide for the needs of the urban poor.
In the absence of efficient governing systems, it is the citizens’ voices that are needed to strengthen it. Community based Organisations (CBOs) and Non-Governmental Organisations (NGOs) have long been the voices of the people in the cities. Many of the problems in our cities are the result of poor knowledge and capacity building of our citizens and office bearers alike. In addition, the problems of the urban poor remain largely unheard. CBOs and NGOs can bridge this critical gap in cities and can give voices to the people as well as provide knowledge. For e.g., citizen groups, especially residents’ associations have been vocal about protecting green and open spaces in the cities from encroachment.
In Bengaluru, lakes are being desilted and public parks sport exercise equipment which is a good endeavour in making fitness accessible to all.
However, not all citizens deem demolition and evacuation of informal settlements as ignoring fundamental rights of the most vulnerable who share the city with us. It begins with states treating people in informal settlements as outsiders and squatters forgetting the very important role played by the informal economy in the state’s financial success. As an individual this thought is cemented when we forget that our maid, the neighbourhood tailor, our society’s plumber, security person, or electrician and our regular vegetable seller all lead very precarious lives wherein, one day their houses and livelihoods can suddenly be lost.
Therefore, although health is a fundamental right for all, in the face of loss of livelihood and a place to live, the concerns of living a healthy life may seem trivial for the urban poor.
References
- Comptroller and Auditor General of India. (2022). Performance Audit of Efficacy of Implementation of 74th Constitution Amendment Act, 1992. Chapter IV : Devolution of Functions & Empowerment of Urban Local Bodies. Retrieved from https://cag.gov.in/uploads/download_audit_report/2022/7-Chapter-4-0642ac153c73ee5.47372920.pdf
- Comptroller and Auditor General of India. (2024). Compendium of Performance audits on the implementation of the 74th Constitutional Amendment Act, 1992 : Landscape across India Volume I. Delhi. Retrieved from https://cag.gov.in/uploads/StudyReports/SR Compendium-067346fdd7000e9-76046538.pdf
- Janaagraha Centre for Citizenship and Democracy. (2023). Landscape Study on the Role of Urban Local Bodies in Primary Health Care. Retrieved from https://www.janaagraha.org/wp-content/uploads/2023/03/Landscape-Study-on-the Role-of-ULBs-in-primary-health-care.pdf
- Open Budgets India. (n.d.). Municipal Budgets – Budget Basics. Retrieved August 29, 2025, from https://budgetbasics.openbudgetsindia.org/municipal-budget
- Pakhare, A. P., Lahiri, A., Shrivastava, N., Joshi, A., Khadanga, S., & Joshi, R. (2021). Incident hypertension in urban slums of central India: a prospective cohort study. Open Heart, 8(1), e001539. https://doi.org/10.1136/OPENHRT-2020-001539
- Pandey, A. (2024). Climate change and the rising incidence of dengue in India. Retrieved August 24, 2025, from https://www.orfonline.org/expert-speak/climate-change-and-the rising-incidence-of-dengue-in-india
- Raghuraman, G., Sarah, M. A., Rao, M. B. V., Minni, P., & Jha, J. (2019). Public Expenditure on Health in Maharashtra. Bengaluru. Retrieved from http://cbps.in/wpcontent/uploads/Public-Expenditure-on-Health-in-Maharashtra-Report-6Jan2021.pdf Sinha, A., Kerketta, S., Ghosal, S., Kanungo,
- S., & Pati, S. (2022). Multimorbidity Among Urban Poor in India: Findings From LASI, Wave-1. Frontiers in Public Health, 10, 881967. https://doi.org/10.3389/FPUBH.2022.881967
- Verma, M., Bazaz, A., & Dubey, M. (2022). Indian Municipal Finance 2022: An Update. Retrieved from https://iihs.co.in/knowledge-gateway/wpcontent/uploads/2023/01/Indian-Municipal-Finance-2022.pdf
- World Health Organization. (2024). Global Tuberculosis Report 2024. Retrieved August 24, 2025, from https://www.who.int/teams/global-programme-on-tuberculosis-and-lung health/tb-reports/global-tuberculosis-report-2024/tb-disease-burden/1-1-tb-incidence
About the Author
Dr Gayathri Raghuraman is a Public Health Consultant based in Bengaluru.
Acknowledgment: This article was posted by Urvashi Singhal, Research Intern at IMPRI.
Disclaimer: All views expressed in the article belong to the author and not necessarily to the organisation.
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