Medical and Health Facilities in Urban India: Infrastructure and Gaps

India’s cities are growing at an unprecedented pace, bringing new challenges to urban healthcare delivery. With over 35% of the population now living in urban areas, the demand for accessible, quality medical services has never been higher. Yet urban health infrastructure remains a complex puzzle of government norms, evolving policy initiatives, and persistent staffing gaps that affect millions of citizens daily.

Understanding urban health infrastructure norms 🔗

India’s public healthcare system operates on a three-tier model designed to ensure layered access to medical services. In urban areas, the National Health Mission has established specific population-based norms for setting up health facilities. One Urban Primary Health Centre (U-PHC) is recommended for an urban population of 30,000 to 50,000, while one Urban Community Health Centre (U-CHC) should serve every 2.5 lakh population in non-metro cities with populations above 5 lakh.

For metropolitan cities with larger populations, the norms are adjusted accordingly. Metro cities are expected to establish one U-CHC for every 5 lakh population. These facilities serve as referral centres for U-PHCs and provide specialist consultations, obstetric care, and secondary-level services.

The role of U-PHCs and U-CHCs 🔗

Urban PHCs primarily cater to populations living in urban slums, with the population covered varying from 50,000 for cities with sparse slum populations to 75,000 for highly concentrated slums. These centres function differently from their rural counterparts, focusing more on ambulatory care with limited staff and infrastructure while delivering outreach services typically associated with sub-centres.

U-CHCs are set up as referral facilities for every 4-5 U-PHCs, catering to populations between 2.5 lakh and 5 lakh, with metro city UCHCs expected to have 100 beds. They provide specialist services and act as the bridge between primary and secondary care in urban areas.

Health and Wellness Centres: a transformative initiative 🔗

The Ayushman Bharat programme launched a significant transformation of India’s primary healthcare landscape through Health and Wellness Centres (HWCs). In February 2018, the Government of India announced the creation of 1,50,000 Health and Wellness Centres by transforming existing Sub Centres and Primary Health Centres.

These centres represent a fundamental shift from selective healthcare to comprehensive service delivery. Under this initiative, HWCs are designed to deliver Comprehensive Primary Health Care that is universal and free to users, with a focus on wellness and an expanded range of services closer to the community.

Services offered at Health and Wellness Centres 🔗

HWCs go beyond traditional maternal and child health services. These centres aim to provide Comprehensive Primary Health Care by expanding Reproductive and Child Health services, including care for Non-Communicable Diseases such as hypertension, diabetes, and screening for oral, breast, and cervical cancers. The services are being incrementally expanded to cover mental health, ENT care, ophthalmology, oral health, geriatric and palliative care, and trauma care.

India achieved the target of 1,50,000 operational Ayushman Bharat Health and Wellness Centres before December 31, 2022. This milestone represented significant progress in strengthening primary healthcare infrastructure nationwide. These centres have facilitated over 8.5 crore teleconsultations through e-Sanjeevani, with nearly 4 lakh teleconsultations taking place daily.

Staffing at HWCs 🔗

For PHCs being strengthened to HWCs, support includes training of PHC staff such as Medical Officers, Staff Nurses, Pharmacists, and Lab Technicians, along with equipment for Wellness Rooms and necessary IT infrastructure. A new cadre of Community Health Officers leads the primary care team at Sub Centre-level HWCs, typically professionals with backgrounds in community health or nursing trained through recognized programmes.

Current infrastructure status 🔗

As per the quarterly MIS data from June 2024, India has 1,67,275 Sub Centres, 26,636 Primary Health Centres, 6,155 Community Health Centres, 759 District Hospitals, and 970 other district-level health facilities functioning across the country. The number of First Referral Units, which provide comprehensive obstetric and emergency care, has grown substantially from 940 in 2005 to over 3,100 in 2024.

However, data from the Rural Health Statistics 2021-22 reveals that facilities are overburdened, with each Sub Centre catering to an average of 5,691 people (against the norm of 3,000-5,000), each PHC serving 36,049 people (against the norm of 20,000-30,000), and each CHC covering 164,027 people (against the norm of 80,000-1,20,000).

Staffing shortfalls: the critical gap 🔗

Despite infrastructure expansion, staffing shortfalls remain a persistent challenge in urban health facilities. Data from the Rural Health Statistics 2021-22 reveals significant vacancies across key positions.

Vacancies at Urban PHCs 🔗

Urban PHCs currently face a shortage of 18.8% of doctors, 16.8% of pharmacists, 16.8% of lab technicians, and 19.1% of staff nurses. These vacancies directly impact service delivery, particularly for populations dependent on public healthcare in urban slums and low-income settlements.

Shortfalls at Urban CHCs 🔗

The situation at Urban Community Health Centres is equally concerning. Urban CHCs encounter a shortfall of 46.9% of total specialists, 14.7% of General Duty Medical Officers, 49.3% of radiographers, 3.9% of pharmacists, 7.2% of lab technicians, and 5.3% of staff nurses.

According to official data, Urban CHCs had around 1,568 General Duty Medical Officers, 358 radiographers, 840 pharmacists, 902 lab technicians, and 6,121 nursing staff as of March 2022. Vacancies stood at 32.2% for radiographers, 18% for pharmacists, 19.1% for lab technicians, and 19.3% for nursing staff.

The specialist crisis 🔗

The shortage of specialist doctors presents the most acute challenge for secondary care delivery. There is a shortfall of 83.2% of surgeons, 74.2% of obstetricians and gynaecologists, 79.1% of physicians, and 81.6% of paediatricians at Community Health Centres compared to requirements. The Health Dynamics of India report for 2022-23 shows only 4,413 specialist doctors were available against the 21,964 needed in rural CHCs, indicating a shortfall of nearly 80%.

Only 541 of the 5,480 functioning CHCs have all four required specialists: a surgeon, physician, gynaecologist, and paediatrician. This severely limits access to essential secondary care services, particularly emergency obstetric care and surgical interventions.

Urban-rural health workforce disparities 🔗

The distribution of health workers between urban and rural areas shows a significant imbalance. Evidence indicates that 66.91% of all health workers serve urban areas where only 33.48% of the population resides, while just 33.09% serve rural areas containing 66.52% of the population.

The urban-rural density ratio varies by profession: 10.5 for dental practitioners, 2.67 for allopathic doctors, 1.80 for nurses, 3.6 for ancillary health professionals, and 3.2 for pharmacists. This disparity reflects both push and pull factors in health workforce distribution.

Addressing the gaps: government initiatives 🔗

The National Health Authority continues to work on strengthening health infrastructure through multiple initiatives. The Pradhan Mantri Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) supports infrastructure development for Sub-Health Centres, Urban Health and Wellness Centres, Block Public Health Units, Integrated District Public Health Laboratories, and Critical Care Hospital Blocks.

Under National Health Mission, high-focus states can spend up to 33% and other states up to 25% of their NHM funds on infrastructure. The Indian Public Health Standards 2022 provide revised guidelines for quality of infrastructure, human resources, drugs, diagnostics, equipment, and governance requirements.

Quality standards for urban facilities 🔗

The National Quality Assurance Standards for Urban Primary Health Centres include 35 Quality Standards under eight areas of concern, measuring infrastructure adequacy, staffing quality, and service delivery. These standards help states assess and improve facility performance systematically.

The path forward 🔗

Addressing the infrastructure and staffing gaps in urban health facilities requires sustained investment and innovative solutions. Key priorities include filling critical vacancies especially for specialists, improving working conditions to attract and retain health workers in public facilities, leveraging technology through telemedicine to extend specialist access, and strengthening referral linkages between different tiers of care.

Urban health infrastructure must keep pace with rapid urbanization. With projections indicating that nearly half of India’s population will live in urban areas by 2047, building robust, adequately staffed health facilities becomes essential for achieving universal health coverage.

What do you think? How can India bridge the gap between health infrastructure norms and ground reality in rapidly growing cities? What role should private healthcare play in complementing public health services in urban areas?

References

1. https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=1220&lid=190
2. https://ruralindiaonline.org/en/library/resource/rural-health-statistics-2021-22/
3. https://nha.gov.in/PM-JAY
4. https://www.pib.gov.in/PressReleasePage.aspx?PRID=1896950
5. https://nhm.gov.in/images/pdf/guidelines/iphs/iphs-revised-guidlines-2022/02-CHC_IPHS_Guidelines-2022.pdf