Dilemmas of municipal health care provision in an evolving health care market in Pune, India: An ethnographic study

Objective: Rapid urbanization in developing countries is associated with exclusions from health care for the urban poor. Yet upgrades to municipal health services are often incommensurate with urban growth, alongside expanding private health care of variable quality. Municipal health care providers thus confront a mounting tension between their delimited mandate and unmet needs among the urban poor. This study examines how municipal providers negotiate this tension and its implications for urban health in Pune, a city of 3 million whose population has increased by 80% since 1991.

Methods: Observation at municipal clinics and semi-structured interviews were used to study how providers resolve work dilemmas and relate to the communities they serve.

Findings: Preliminary analysis shows that municipal providers perceive the poor as largely unresponsive to health counseling, but simultaneously state that clinic-based tasks overtake community outreach. Reflecting upon the use of private services among the poor, municipal providers discern changed expectations of care: patients might unreasonably demand prompt clinical attention at municipal facilities, but tolerate similarly long waits when paying for private services. Attributing such demands to popular misinformation and overvaluation of private services, providers respond by fulfilling essential formal responsibilities, finding that personal initiative goes unrewarded by both health authorities and the community.

Conclusion: In evolving urban markets, private health care can displace municipal services not only in quantity, but also by subverting municipal providers’ incentive to reach the poor. The poor further disengage from limited but more rational municipal services, potentially exacerbating adverse effects of inequality on health.