Why India’s Urban Poor See Worse Health Outcomes

“Our aim was to understand whether health outcomes and other health system indicators have evolved in a parallel manner in urban and rural areas respectively,” explains the lead author Indrani Gupta, visiting senior fellow at CSEP. Gupta is also professor of the health policy research unit at the Institute of Economic Growth, Delhi.

The study used the last three rounds of the National Family Health Survey (NFHS), the last four rounds of the National Sample Survey on health (52nd, 60th, 71st, and 75th rounds), the Longitudinal Ageing Survey in India (LASI), apart from other government data on cities and conducted an extensive literature survey.

“In the absence of any specific database on urban health, we adopted the approach of bringing together different strands of evidence from various available sources to construct a comprehensive narrative,” Gupta said.

To analyse the gaps, the study looked at infant and child mortality, prevalence of disease including fever, diarrhoea, tuberculosis (TB) and disability, and compared these outcomes across wealth quintiles--from the highest (richest 20%) to the lowest (poorest 20%).

The authors then looked at healthcare infrastructure and personnel--while urban areas are overall better off, evidence from multiple independent studies shows that they are difficult to access for urban slum-dwellers. This pushes them to seek expensive private care, spending large parts of their incomes on healthcare.

While the National Urban Health Mission was supposed to narrow these inequalities, fragmented governance, underfunding, and overstretched urban health systems increase disparities between the urban poor and non-poor, the study found, advocating for a unified administration and planning of urban healthcare and increased funding.

IndiaSpend reached out to Sushil Kumar Vimal, Deputy Commissioner of the National Urban Health Mission (NUHM); Punya Salila Srivastava, Secretary for Health and Family Welfare; and Aradhana Patnaik, Additional Secretary and Managing Director of the National Health Mission, seeking their responses on NUHM's declining budget allocation, urban-rural healthcare disparities, inequitable access in slums, and measures to reduce out-of-pocket healthcare costs. We will update this story when we receive a response.

Under-five mortality of urban poor worse off than Mozambique

The poorest urban children face higher under-five mortality rates (63.4 per 1,000 live births) compared to their rural counterparts (58.8 per 1,000), the study noted based on the fifth National Family Health Survey conducted during 2019-21 (NFHS-5). This is worse off than Mozambique (62), an African nation with a quarter of India’s gross domestic product per capita.

Similarly, infant and neonatal mortality rates are also higher among the urban poor, highlighting critical gaps in maternal and neonatal care.

The disparity is also higher among the urban poor: In rural areas, the under-five mortality rate among the poorest 20% households was 2.7 times that of the richest 20%; in urban areas, it was 3.3 times that of the highest quintile.

“In terms of health outcomes or even infrastructure, the comparison should be between the poor in both urban and rural areas. The better-off in both urban and rural areas can access healthcare, although they might need to travel further. However, the real issue is the lack of access for the poor in both areas, which is where the inequities lie,” explains Ritu Priya, professor, Centre of Social Medicine and Community Health, School of Social Sciences at Jawaharlal Nehru University and member of Jan Swasthya Abhiyan.

One in four children in India’s most populous cities was malnourished, and mother’s education, feeding patterns and government service delivery determine child nutrition in addition to household wealth, IndiaSpend reported in February 2018 based on a study by the Naandi Foundation, a Hyderabad-based non-profit. “Poor infant and young child feeding practices, compounded by the poor status of women, the prevalence of household poverty and lack of government service delivery centers seem to be three major drivers of stunting among urban children” the report had found.

“Poor urban dwellers face unique nutritional challenges around accessing nutritious food, adequate employment, social protection, and adequate water, sanitation, and hygiene facilities, all of which affect food security and nutrition,” a 2017 report said, as IndiaSpend reported in March 2017.

Urban poor more susceptible to disease

The urban poor also see higher tuberculosis rates (416 cases per 100,000 people) than the rural poor (376 per 100,000), a phenomenon linked to slum overcrowding and air pollution, the study finds. Diarrhoeal diseases affect 10% of urban poor children under five, compared to 8.9% in rural areas, reflecting gaps in sanitation and water access.

Tuberculosis is a ‘social’ disease in that the malnourished, living in areas with poor hygiene, are more vulnerable to the disease, as IndiaSpend reported in June 2024. The lack of nutrition and the risk of contracting TB are interrelated, research found, as IndiaSpend reported in October 2022. The lack of nutrition makes a person more susceptible to TB, while having TB increases the chance of malnutrition. Malnourished patients also find it harder to recover from TB.

Improving sanitation levels, and with that ensuring individual household toilets, is a key factor in reducing the spread of infectious diseases such as cholera, diarrhoea, dysentery and hepatitis A. For children under five, diarrhoea is the second leading cause of death, IndiaSpend reported in July 2017.

“While aggregate figures remain worse for rural areas for many of the indicators, the rural poor are catching up faster with their urban counterparts for many indicators, and inequalities are narrowing within rural areas as well, while urban inequalities are much higher,” explains Gupta.

"Poor environmental conditions in the slums along with high population density makes them vulnerable to lung diseases like asthma, tuberculosis etc.,” as IndiaSpend reported in July 2015 based on a report released in May that year. “Slums also have a high-incidence of vector-borne diseases and cases of malaria among the urban poor are twice as high as other urbanites.”

The study cited several papers which showed that this matrix of vulnerability led to a higher number of Covid-19 cases in urban slums. Giving the example of Mumbai’s Dharavi, the paper says, it “indicates what a high level of responsiveness from government machinery can achieve. The slum cluster saw the immediate implementation of strict containment measures, aggressive surveillance, and resources made available from government and private sectors to deliver essential services”.

Most vulnerable populations underserved by public healthcare

Urban health systems fail to reach the poor despite better infrastructure, with women in cities reporting lower contact with health workers (25.9%) than rural women (34.7%), the study found. Rural vaccination rates surpassed urban levels, while urban mosquito net usage lagged, revealing gaps in preventive care and vector control.

“This shows that health facility coverage is not aligned with population density,” says Alok Kumar Singh, research associate with CSEP and co-author of the study. “According to LASI WAVE I data, distances to health facilities for urban residents often exceed 5 km, indicating uneven distribution.”

One primary health centre (PHC) serves 36,000 people in rural areas compared to 9,000 in urban areas, while rural doctors serve 29,000 patients versus 7,000 in cities, according to Rural Health Statistics 2021-22. These ratios mask uneven urban distribution, particularly between slums and non-slum areas, the study says.

“Rural areas are much less heterogeneous in nature compared to their urban counterparts, and therefore, have seen improvements through initiatives like the National Rural Health Mission (NRHM),” says Gupta. “The urban arm of the National Health Mission--National Urban Health Mission--has correspondingly not done as well in improving access, availability and quality of services in urban areas.”

In Chennai for example, half of sampled slums lacked accessible urban primary health centres, with residents traveling three times the recommended distance to reach care, a 2021 spatial analysis found. A 2023 West Bengal study using geographic information system mapping revealed 42% of state-supported facilities in municipal areas “turned out to be part of the rural health system and were not included as part of the urban landscape”.

As a result, households end up seeking expensive private care. The study looked at data from LASI for health-seeking behavior and found that private care is being accessed more than public care in both rural and urban areas for both in-patient and out-patient care, with the richest and urban residents accessing more private care. “Simply put, neither the volume nor the quality of public services is sufficient to ensure accessible and affordable services to urban residents,” the study noted.

“Even if we assume hospitals are sufficient in numbers--which they are not--the critical gap lies in primary and secondary care,” says Gupta. “A substantial part of out-of-pocket health spending is attributed to primary care, such as outpatient visits. Yet, urban slums face severe shortages in primary care facilities, exacerbating inequities in access.”

Spending out of pocket

The study used NSS data to explain inequality in outpatient spending and found that urban inequality persisted from 2014-2018, while rural inequality declined. Urban poor face higher financial strain, compounded by lower public insurance coverage (23.6% vs rural 27.6%).

IndiaSpend looked at out-of-pocket expenses for hospitalisation. Broadly, urban India sees higher in-patient costs than rural India, according to data from National Health Profile. While non-medical costs are slightly lower in cities, the medical expenditure gap persists across income groups. The richest urban quintile spends Rs 47,103 per hospitalisation--three times the poorest urban quintile (Rs 15,845)--while rural disparity is lower.

Government schemes

The NUHM faces governance fragmentation and funding constraints, while state initiatives like Mohalla Clinics operate in limited areas, the study said.

"After the administration changed in 2014, the National Health Mission, seen as a UPA [United Progressive Alliance] flagship programme, lost priority,” explains Ritu Priya, the professor at Jawaharlal Nehru University and member of Jan Swasthya Abhiyan. “By 2018, the government shifted focus to Ayushman Bharat, which leans toward private-sector involvement. There’s also a prevailing belief that urban areas already have enough doctors, hospitals, and nursing homes, making further investment seem unnecessary. Given resource constraints and an agenda that favours privatisation, rural areas--where the formal private sector is largely absent--became the priority."

"Unlike rural areas, where NHM strengthened existing facilities, urban public health infrastructure would have required entirely new setups, which NHM was never designed to create. Mapping all vulnerable groups and pockets in the city was also not undertaken. So NUHM did not take off," she added.

“NUHM started with the same architecture as NRHM but has failed to achieve its initial targets,” said Singh, the co-author of the study. PM – Ayushman Bharat Health Infrastructure Mission was meant to create 11,024 PHCs in urban areas, he explained, but Union government allocations during 2023-25 remained at 58% of required levels. “NUHM has struggled across multiple levels: manpower, infrastructure, and financing,” he added. “Municipalities, which were expected to play a key role in establishing PHCs, have not been streamlined to deliver services effectively. The result is fractured governance and a fragmented administrative system that has hindered NUHM’s ability to function as intended.”

The way forward

Urban healthcare needs urgent focus on the lines of the National Rural Health Mission and the National Health Mission, “accompanied by structural and administrative changes in how health inputs--like infrastructure and personnel--are supplied to different urban areas”, the study said.

For instance, Thailand’s city healthcare system offers a model to provide affordable care with a mix of public and private institutions. The government pays these providers a fixed fee for routine care to encourage prevention, and for hospital stays to prevent overcharging. Out-of-pocket spending fell to 11% of health spending, from 27% at the turn of the century.

However, one key aspect that experts point out to the success of such models is that government health expenditure in countries such as Thailand is higher, enabling universal healthcare.

“India needs to increase health spending significantly. Successful international models typically allocate at least 5-6% of GDP to healthcare, while India hasn’t even reached 2%,” Gupta says. “This limited funding gets stretched thin across both rural and urban needs. Countries like those in Europe, East Asia, and even neighbouring Thailand perform better because they invest adequately in infrastructure, health workers, medicines, and systems.”

Since 2018-19, the National Health Mission utilised all the funds allocated to it by the Union government. Yet, in 2022-23, funding for the Mission fell, leading to a parliamentary standing committee expressing “serious concern”, as IndiaSpend reported in April 2024. On the other hand, funds for Ayushman Bharat, the flagship health insurance scheme, more than doubled in the Modi government’s second term. Experts say this indicates a shift in priorities, from a universal healthcare model to an insurance-led model.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.