Meeting the Poorv-Pradhan

Dressed in a crisp white dhoti and kurta, hovering around in his sprawling home garden, 78-year-old Prem Kumar*, is respectfully referred to as “pradhan ji” by a trickle of men and women coming in to meet him.  In his soft-spoken tone, he clarifies, “poorv-pradhan”.  Prem Kumar, had been the Pradhan (Headman) for the village of Aadeshpur* in Uttar Pradesh, serving the as their elected representative for several years, having tiptoed into local politics back in 1968.  In 2022, as Aadeshpur became part of a newly legislated Nagar Panchayat, overnight, Prem ji became the Poorv Pradhan, shortly replaced by a “Chairperson” for the Urban Local Body (ULB) with a population of less than 25,000, a cluster of now-erstwhile villages. 


Prem Kumar Ji reminisces of days when he would actively participate in the health and well-being of the community. “ASHAs and ANMs would come to me very often with problems. Sometimes certain people would be reluctant when it came to immunising their children- then I would intervene. People see me as an elder and when I convinced them that immunization is absolutely safe, they would listen to me.”

The transition of the village, still largely dependent on agriculture for livelihood, to an urban area, makes it part of India’s 4000 plus cities and towns.  India’s rate of urbanisation is steep, with more than one-third of its population residing in urban areas as per census 2011, and recent estimates suggest the urban population could be over 50 per cent.  While our mega-cities continue to expand, through demographic growth and migration, processes of rural to urban transition far from the ‘urban’ centre are much faster than most of us can currently imagine. 

The rural health system- its actors, stakeholders, processes and provisions, have been very clearly defined over the years, often responding to the evolving healthcare needs and challenges of rural communities. In the last decade or so, efforts have also shifted focus to the urban, primarily cities with a population of over 50,000. However, urban areas like the newly formed Nagar Panchayat, have fallen between the cracks when it comes to a health policy focus. 

Gram Panchayats, of which Prem Kumar Ji, was the head, played a pivotal role in governance, planning and implementation of schemes to ensure socio-economic and human developments in the villages that they governed. Specifically, in healthcare, the representatives of the Panchayat took an active role in organising targeted service delivery, ensuring health services reach the most vulnerable groups in the village. They were also mandated to provide local level leadership to community-level institutions like the Jan Arogya Samiti (JAS) and the Village Health Sanitation and Nutrition Committee (VHSNC), platforms which pioneered convergent planning and implementation across different stakeholders. And while the constitution and functioning of such platforms in rural areas may not have been fully realised across the country, the local representatives do become increasingly accountable to the needs of the community, ensuring the efficient delivery of various health schemes and benefits while also contributing to promoting health awareness in the village. 

So, while it is understandable that transitioning geographies will only gradually adapt to being urban, the gap is policy solutions for such transitioning areas, especially in critical aspects of health, nutrition and education, have the potential to derail decades of engagement and efforts to improve lives of people. 

Policy Exclusions and Losing Gains in Communitisation 

On being asked about the VHSNC and the Jan Arogya Samiti in these transitioning urban areas, the question elicits confused expressions from most local government officials, as these platforms ceased to exist as the Panchayati Raj Institutions were dissolved. The frontline health workers (FLWs), still grappling with the governance overhaul, find themselves struggling, “When we run meetings, people want to see their local leaders and representatives in these discussions. If it’s just us imparting knowledge, it has little impact on communities”, said an ASHA worker in one Focus Group Discussion in the Nagar Panchayat area. The confusion, most likely stems from the inconsistencies with regards to policies in rural and urban health in India. 

The National Urban Health Mission (NUHM), approved by the cabinet in 2013, is designed to meet the health care needs of the urban population with the focus on urban poor, ensuring access to essential primary health care services and reducing their out of pocket expenses for treatment. However, the NUHM covers cities/towns with a population of 50,000 and above, and as of May 2023 was being implemented in only 1213 cities and towns. Although the NUHM was designed to address the gap in national health planning for urban areas governed by Municipal Corporations, Municipalities, Notified Area Committees, and Nagar Panchayats, the latter category, representing transitioning urban spaces continues to lack a comprehensive policy framework.

Since the beginning of policy planning in healthcare, communities have been at the centre in healthcare design in India; and very active role of community-driven platforms and local governance is enshrined in public health. The term ‘community participation’ was included in the Alma Ata declaration of 1978 as one of the key principles of the Health for All movement. India’s commitment to include communities in health planning and implementation was only strengthened by the Alma Ata Declaration and has continued to feature strongly in the subsequent National Health Policies. 

India’s epidemiological burden is complex, with communicable and non-communicable diseases both posing challenges to the health systems, across urban and rural geographies. The role of communities in combating infectious diseases and Non-Communicable Diseases (NCDs) is critical to ensure a healthy future. Very rightly, the NUHM has reiterated the need for Mahila Arogya Samitis (MAS) (50-100 households) and Rogi Kalyan Samitis in urban areas, in addition to Frontline Health Workers (FLWs) like the ASHAs and ANMs. However, in the transitional urban geographies, functional Jan Arogya Samitis (JAS) and practices of communitisation are withering away quickly for the lack of policy direction and impetus. 

Conclusion

As India envisages an increasingly urban future, policy exclusions like the case of its newly-formed Nagar Panchayats can derail the efforts of strengthening health systems and processes and improving health outcomes for the country’s most vulnerable.  Prem Kumar, the poorv-pradhan of Aadeshpur appears to be an embodiment of a spirit and practice of community engagement and action, somewhat born, innovated and perfected over decades of efforts to strengthen healthcare in rural India. However, rather than being a remnant of the past, the relevance of making communities part of health policies, implementation and local action in urban India is as crucial as ever. 

As experts, policymakers, researchers and practitioners in urban health put their heads together to build community processes in the complex demographic compositions of “urban” India, one must turn to rural India for lessons and learnings, while ensuring policies are increasingly designed with a focused understanding of transitioning urban spaces, ensuring continuity in providing policy solutions for India’s very diverse urbanization trajectories, supporting urban local bodies, health and other line departments as well as communities in continuing their journeys towards health and well-being; instead of creating roadblocks wherein efforts of decades go in vain. 

*Names of persons and places have been changed for anonymity.