India is rapidly becoming urbanised. By 2030, around 40% of the country’s population will live in urban areas. The extent to which India’s health system can provide for this large and growing city-based population will determine the country’s success in achieving universal health coverage and improved national health indices. According to an study Hypertension, an important risk factor for cardiovascular disease, was the most commonly diagnosed medical condition at urban primary care practices. Alarmingly, the researchers noted that one in five patients diagnosed with hypertension was younger than 40 years. These data accord with 2013 Global Burden of Disease findings that high blood pressure is the leading risk factor in attributable disability-adjusted life-years (DALYs) in India.2 That there are such high rates of hypertension in younger people has important implications for premature death and disability in the most productive years of life, with economic effects that would extend to the families supported by these people. Furthermore, there are national economic losses to consider with the premature death of people in the middle of their working lives.3
Urban India has a high concentration of health-care providers, yet, researchers explain, not everyone has easy access to health care. The data on patients’ characteristics highlight two urban health system issues that have received inadequate attention. First, more than half of patients visiting a doctor were male, despite the expectation that women would represent most of the patient load.4
There are several possible explanations for why there were fewer female patients than male patients reported. That gynaecologists were not included in the study sample meant that visits by women to this kind of practitioner were not captured by researchers. Second, issues such as lack of empowerment and financial barriers to accessing health care will affect women more than men. And third, the difficulty in accessing care from a female doctor might limit the willingness of women to seek care: one study5 estimated that only 17% of doctors in India are women.
Issues of access to health care also affect older people. Although national surveys show that reports of ailments increase with age, only 7–9% of the visits recorded by Salvi and colleagues1 were made by patients older than 60 years, suggesting that older people are under-represented in the study.4 Given the abundance of health-care providers in urban India, the reasons behind the low proportion of older patients reported might be because of physical impairments that make a visit to a health provider difficult, or the lack of financial resources to pay for health care. With life expectancy increasing across India, the issues of access and affordability of health care for older people will only become more important.
Interpreting the findings of the study is difficult because the included participants do not represent all urban providers, nor all patients. Researchers invited participants from a private register of health-care providers, and how well this sampling frame represents the population of primary care providers in India is difficult to judge. In turn, the patients and their health conditions included in analysis might not be representative of those in urban India. The study response rate of just over 50% also calls into question the representativeness of the study sample. Furthermore, the exclusion of informal private providers, who work mainly with the urban poor, limits the study findings to higher social and economic classes. These issues not only suggest caution in interpreting the findings, but also highlight the methodological problems of using practice-based samples in low-income and middle-income countries where there is incomplete information on the characteristics and location of health providers.
Practice-based studies such as the study can only provide a part picture of the state of urban primary health care. For one, the study tells us little about the health conditions or the socioeconomic profile of those who are not able to access health care. Several studies have reported greater ill health and low health-care use by India’s poor.6 Yet we know so little about the disease burden of the urban poor (for example, do they also have a high burden on non-communicable diseases?), or how well the health system caters to their needs. This study does not provide a full picture of urban primary care because it includes only qualified providers and their patients and ignores the large number of unqualified providers who populate the Indian health workforce.7, 8 One study5 estimated that 37% of doctors in India (63% in rural and 20% in urban areas) had inadequate or no medical training. Moreover, other studies have reported the poor quality of care offered by urban unqualified providers.9 Although the quality of health care accessed by the urban poor needs more research and policy attention, the large presence of unqualified providers in urban areas highlights the low quality health care that poor people in urban areas receive.
With the population of India becoming increasingly centred in cities comes the significant challenge to India’s efforts at universal health coverage. Government efforts to strengthen urban health systems have focused on programmes such as the National Urban Health Mission (now part of the National Health Mission). However, without a substantial increase in public funding for health (currently it is around 1% of GDP),10 India’s urban health system will have difficulty in meeting the challenge of achieving universal health coverage.
We declare no competing interests