This paper illustrates how these issues can affect municipal public health services, and how some of their negative impacts on health outcomes can be mitigated. It looks at the organization of these services in Chennai and Delhi, two of India’s major metropolitan cities. The paper focuses largely on Chennai, which offers some lessons on ways to mitigate these constraints on public health services. Examples from Delhi illustrate how severely these issues can hinder service delivery.

Service delivery in the Municipal Corporation of Delhi (MCD) is quite sharply affected by these problems. It is also affected by factors unique to Delhi, notably (a) the complex administrative relationship between the central government, Delhi’s state government, and the MCD, and (b) that Delhi is surrounded by the National Capital Region, which has heavy traffic to and from Delhi, but is administered by three other states. The MCD was also split in 2012 into three bodies (for North, South, and East Delhi) − but organized as before, so the MCD discussed here refers to both the pre-2012 and the trifurcated MCD. Problems arising from these unique aspects of Delhi are not discussed here. This paper explores problems with the MCD’s public health services arising from the issues summarized above, which apply across much of the country.

The functioning of the Chennai Municipal Corporation (CMC) illustrates how Indian municipalities can mitigate some of the systemic handicaps they face. The Tamil Nadu state administration keeps some pressure on CMC public health service delivery by (a) professional management within the CMC, and (b) technical support and monitoring by the State Health Department. That these efforts are helpful is suggested by Chennai’s relatively good health and sanitation outcomes compared to other major metropolitan cities (Figures 3 and 4, Table 1).

This paper summarizes lessons from Chennai, which are reproducible in other Indian municipalities. These help to mitigate the health impact of poor slum sanitation and devolution of service delivery. However, more needs to be done to address the issue of service fragmentation, in particular by giving the CMC’s public health department greater authority and responsibility to assure better sanitation and public health engineering in the city.

This paper focuses on municipal public health services, complementing earlier papers that discussed public health management in Tamil Nadu’s districts.<sup>10</sup> It is based on extended field interviews and secondary data, as described in Appendix 1. Section 1 discusses the issue of unequal resource distribution, and how the CMC mitigates its health impact. Section 2 discusses the problems arising from devolution and fragmentation of service delivery, followed by a discussion of how some of these problems are mitigated in the CMC. Section 3 concludes.

# **Section 1: Very unequal allocation of resources**

Economically and politically privileged groups in India – as in most countries − tend to corner public resources, so their areas receive better civic services.<sup>11</sup> For example, Delhi has huge disparities in the _<u>planned</u>_ provision of water to different sub-populations, let alone its actual provision.<sup>12</sup> In 2013, a quarter of Delhi’s population was being supplied water from tankers, at an average of 3.82 liters per day per capita, although the norm was 172.<sup>13</sup> In 2014-15, only 6% of unauthorized slums had some sewerage facilities, rising to 14.6% by 2016-17.<sup>14</sup> This sharply increases slum residents’ exposure to disease, exacerbating vulnerabilities arising from crowding, poor housing, poverty, and lower access to health care.

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