Contents
Introduction
Economic Survey 2025-26 reframes urbanization as economic infrastructure, noting that governance deficits in Urban Local Bodies (ULBs) impair health outcomes. Budget 2026-27’s record ₹1.06 lakh crore health allocation emphasizes that standalone projects must yield to system performance.
Governance Deficit
- India’s urban governance framework remains colonial in structure and post-74th Amendment in intent.
- The 74th Constitutional Amendment (1992) envisioned empowered ULBs with 18 functional items including public health, sanitation and slum improvement.
- Yet, most states have transferred only partial functions, retaining control through parastatals (water boards, development authorities) and special purpose vehicles.
- This creates a persistent agency problem, i.e., responsibility without authority, that has deepened over decades of rapid, unplanned peri-urban expansion.
Institutional Fragmentation and its Impact on Public Health
- Coordination Gaps: Water supply (state boards), sewerage (municipal corporations), solid waste (ULBs/private contractors) and drainage (development authorities) operate in silos. For Example- Dengue/Cholera outbreaks in Delhi, Bengaluru and Chennai repeatedly expose delayed or incoherent response.
- Capacity & Fiscal Constraints: ULBs generate, compared to 5–8% in OECD and BRICS countries; dependence on state transfers limits proactive investment in sanitation, vector control or air-quality monitoring. For Example- Many municipalities rely heavily on state transfers rather than own-source revenues such as property tax.
- Accountability Vacuum: No single entity is answerable for health outcomes. Master plans remain symbolic; 65% of urban settlements lack enforceable plans (NITI Aayog 2025). Peri-urban zones become concentrated disadvantage sites with poor WASH coverage. For Example- Suburban expansion in cities like Gurugram and Noida has outpaced municipal capacity to provide essential services.
- Climate-Health Linkage: Urban flooding and heat islands amplify vector-borne and respiratory diseases. Fragmented planning prevents integration of “Sponge City” drainage with public health surveillance. For Example- Urban flooding in Chennai and Bengaluru has triggered outbreaks of water-borne diseases.
Fiscal Outlays vs. Structural Reforms
- Budget 2026-27’s ₹1 lakh crore Urban Challenge Fund and Finance Commission grants (₹3.6 lakh crore over five years) signal recognition of urban health needs. Yet fiscal flows alone cannot compensate for design flaws:
- Funds are often under-utilised due to weak project preparation and execution capacity.
- Competitive project selection risks elite capture and neglect of low-capacity ULBs.
- Without functional devolution, additional money reinforces parastatal dominance rather than empowering elected municipal bodies.
- Structural reforms are therefore non-negotiable:
- Full devolution of the 18th Schedule functions, functionaries and finances.
- Unified metropolitan governance through empowered Mayors-in-Council.
- Creation of specialised urban public-health cadres within ULBs.
- Mandatory health-integrated master plans with citizen participation via ward committees.
Way Forward
- Constitutional vitalization by strengthening the 74th Amendment to ensure mandatory devolution of Health and Sanitation functions, functionaries, and finances.
- Utilizing the Fiscal Health Index 2026 benchmarks to tie health grants to tangible improvements in sanitation and air quality metrics.
- Pilot “Health-in-All-Policies” urban governance in 100 smart cities by 2028.
- Establish inter-agency Urban Health Coordination Committees at metropolitan level.
- Mandate annual public health outcome audits tied to municipal budgets.
- Scale participatory WASH planning through community health volunteers and ward sabhas.
Conclusion
Resilient cities safeguard national wellbeing. Strengthening institutions, not merely finances, will transform urban governance into a cornerstone of inclusive and sustainable public-health security.
