Background:
Pondicherry Science Forum, Sub-committee on health, held a round-table consultations on “Towards and Healthy City and the Right to Health.” at Svarnim Conference Hall on April 11th 2026.
This consultation was held to develop a deeper, shared understanding of the resolution on Towards and Health City, adopted at our bi-annual conference, and subsequently the appeal to political parties to generate the political will required for working towards making Puducherry a Healthy City, and for the realisation of the Right to Health, including the right to healthcare. The consultation also aimed to bring together and network a team of volunteers and public intellectuals who would be able to contribute to advocacy and implementation efforts and to develop a work-plan to develop and popularize these concepts wider. The work plan would include research, advocacy, popular health communication and people’s mobilization.
Proceedings:
The discussions were chaired by Dr D. Balasubramanian, and moderated by Dr T. Sundararaman.
The discussions were organised as two sessions. In the first session the focus was on the concept of health city and the social determinants of health. There were four presentations in this session and each of these are presentations are summarized below. In the second session the focus was on the right to healthcare and this was related to the achievement of universal access to health care based on a primary health care approach and financial and social protection against the costs of health care. There were three presentations in this session and these too are summarized below. The powerpoint presentations used by speakers on each of these topics is attached. A summary of the content of each presentation and the subsequent discussion is given below:
Session 1, Theme 1: Towards a Healthy City – Puducherry - Dr. Ismail Rifai
Introduction: The image of Pondicherry is as a highly attractive global tourist destination, that has shown successful economic growth and infrastructure expansion and which has been able to achieve successful sustained reductions in maternal and infant mortality and provide education to all. While this is true there is another darker side on health achievements with Pondicherry, having severe escalation in non-communicable diseases, a very high suicide rate ( 4th highest in the country), substance abuse problems, persistent spousal violence and even repeated outbreaks of communicable disease. The obesity rate is near 40 %, but there is also a child stunting rate of 20% and maternal anemia of 55%. Over 30 percent of men have either diabetes or hypertension. Premature mortality, especially in males is also excessive. All this makes it necessary for Puducherry to go beyond the smart city concept and aspire to become a Healthy City.
The Concept: The concept of a “Healthy City” as defined by World Health Organisation emphasizes continuous improvement of physical and social environments, and access to all health-related public services, enabling communities to achieve optimal health and well-being. It is based on the understanding that while access to medical services is important, it is not the number of hospitals and doctors that determine health outcome, but action on the underlying social and environmental determinants of health. Universal access to primary healthcare and financial and social protection is however also to be considered as one of the important underlying determinants of health.
The Process: We can consider this as happening in four stages.
- The municipal or corporation council decides to opt for certification as a Healthy City. This could be communicated to WHO if they seek a WHO certification. A steering committee for the project reporting to the mayor and municipal commissioner is usually required. Then a list of priorities are defined and the indicators that shall measure progress on each of these priority areas are agreed upon. This requires support of public health experts. Baseline measurements are made.
- Then in each priority area a road-map and work-plan is finalised in consultation with the community and other stakeholders and the persons responsible to drive progress in are fixed. This also requires technical consultations and expertise in specific areas like waste management, sewage etc as required. This is also the stage when the financing proposals are made and approved. Taken together, it should read as a visionary city development plan where the priority is equity, where no one is left behind and the objective is the wellbeing of all.
- Working groups with a nodal officer coordinating implement these plans. There has also mechanisms as required for coordination across sectors.
- One of the main efforts in this phase is every increasing levels of community engagement and public participation.
- There is also a parallel effort to implement the existing public health law and other laws as required to ensure implementation of the plans and assure health and healthcare rights
- There is feedback provided to the steering committee on a quarterly basis and the municipal council on an annual basis. Once in two to three years the overall plan can be externally evaluated and renewed
Priorities for Pondicherry: In this consultation we are making a preliminary identification of priority areas. At the level of individual determinants some of the main issues are: unhealthy dietary patterns, lack of physical exercise, obesity, alcohol and substance abuse. At the level of social factors are unemployment, lack of social security and support, isolation and poor mental health. At the level of built environment are dysfunctional or absent sewage and solid waste disposal, open drains, poor road safety, walkable environments and recreational spaces, and vulnerable coastal housing. And at the level of economy is the fluctuations of the tourism economy, high levels of indebtedness, much of it related to health care costs and the climate change risks and vulnerability. In subsequent presentations each of these will be discussed.
Session 1 Theme 2: Water & Sanitation Crisis in Puducherry -Mr. TP Raghunath
Background: Puducherry is facing a serious water and sanitation crisis, with over four decades of declining groundwater quality and increasing public health risks.
Key Issues
- Groundwater: increasing salinity due to seawater intrusion in coastal areas, and decreasing quality in terms of contaminants- both bacterial, dissolved solids and chemicals:
- Sewage: Does not cover many households and where it does there are problems of drinking water sources and poor performance of sewage treatment plants (STPs)
- Drinking water: unavailability on some areas, and risk of contamination of piped water, risk of contamination of groundwater used for drinking purposes.
- Tanks and Ponds: weak maintenance, leads to failure to recharge surface of groundwater
Public Health Impact
- Repeated Cholera and diarrheal outbreaks: over 700+ hospitalizations, reported- but actual toll likely to be higher. Also, persistent typhoid, leptospirosis, hepatitis A &E. Over 69881 of such diseases were reported in a one-year period. Deaths due to contaminated drinking water are persistent. High costs of illness and of treatment also cause considerable loss and suffering
- Risk of fluorosis and kidney-related diseases due to chemical contaminants
- Deaths and Hospitalisation in residential houses due to leakage of sewage gases into household toilets- unacceptable level of error and systems failure
- Increased vulnerability for all of the above among children and elderly.
Addressing Systemic Gaps in a healthy city road-map:
- Enforce regulations of groundwater extraction in all areas especially in coastal buffer zones. Publicise the regulations and build community awareness and involvement in its regulation. In urban areas bring this under the tasks of public health officers also.
- Ensure periodic frequent real-time water quality monitoring, both by department, and by public health officers and by citizen-monitors-volunteers linked to community organisations. The reports have to be in public domain with a protected disclosure system on report and action taken.
- Respond to all contamination reports by detecting source and fixing the leak, but also in parallel addressing problems of ageing and poorly maintained infrastructure, state-wide.
- Implement strict industrial effluent controls. Engage public health laboratories and suitable institutions in regular testing.
- Upgrade and relocate malfunctioning STPs, prevent leakage of sewage into tanks and ponds.
- Restore and protect traditional water systems (Eris/tanks) on the lines of the EU supported tank rehabilitation programme of 1999- 2009.
Session 1 Theme 3: Climate Change Adaptation & Heat Action Plan for Puducherry : Ms. Sankari Devi
Background
Climate change is increasingly affecting health outcomes in Puducherry through rising temperatures, extreme weather events, and changing disease patterns. Certain groups like the elderly population, children, outdoor workers and urban poor and slum populations are more at risk. Farmers and gig workers and fisherfolk are also more at risk.
Puducherry has four geographically unconnected districts and all of these are coastal with high climate risk. Coastal location on Bay of Bengal and Arabian Sea makes the UT highly cyclone-prone. The risk exposure index estimates range from 0.48 for Puducherry to 0.57 for Mahe. Puducherry government has adopted a climate change and human health plan. This is a welcome step. Some of the important problems identified and addressed by this climate adaptation plan are as follows:
- Puducherry has regular air quality index (AQI) pollution monitoring, and this shows relatively low pollution (below 50) as measured by AQI, but it is increasing. During Diwali there is a worsening peak when it rose to 319.
- There is a disease surveillance system in place, and there has been training given on climate risk adaptation to staff in health department and in local governments.
- The plan has an organizational framework with state, district, block and village level nodal officers-
- The number of heat days are monitored, and reported and alerts are issued. as few.
Key Concerns
- Increasing heat wave trends and rising temperatures. Recorded rise is 0.014 degrees C per year since 1969 and a current average peak at 42.7 C. High humidity is leading to dangerous heat index levels– and effective temperatures, what it feels like should be seen as ten degrees C higher. Above 40 C heat cramps, syncope (fainting),exhaustion and stroke become widespread.
- Currently heat alerts are only based on measuring temperature. But if humidity is 85% which is common for Pondicherry, a temperature of 37C feels and affects like 57C. Currently this is not reported on. As a result, only April to June is considered hot months. If this was included the heat wave precautions period would extend from March to mid-September at least.
- Growth in vector-borne diseases such as dengue, chikungunya, Encephalitis, scrub typhus increase. Of this major increases are in dengue.
- High burden of water-borne diseases – over 70,000 reports cases in a year.
- Air pollution contributing to respiratory illnesses (asthma, COPD etc),increased skin diseases and allergies.
Addressing the System Gaps
- Need to strengthen the health action plan: This should include provisions for”
- monitor and reportig the heat index, not just the temperature and put out public advisories and alerts on a regular basis- including daily advisories during the peak period
- Provide cooling spaces, drinking water, and public awareness. Inspect heat-vulnerable work places like construction sites to ensure this is strictly followed. In such places there should be regular hydration reminders, and peak hour avoidance with breaks given from 11. Am to 4 pm. Light, breathable clothing should be encouraged. In residential areas and other work areas there should be access to community cooling spaces and a buddy system where elderly and the lonely can look after each other. Special measures are suggested for construction workers, gig worker and family workers and elderly and children( refer to attached powerpoint).
- Promoting green buildings: consistent with building codes for the same
- Better preparedness of public health systems to respond to heat crisis and to extreme weather events.
- Strengthen surveillance of climate-sensitive diseases
Session 1: Theme 4: Strengthening Puducherry Public Health Act - Dr.Jayachandran
Context: Puducherry faces a dual burden of communicable and non-communicable diseases, increasing environmental risks, and emerging public health threats such as climate change and pandemics. Much of this burden of disease would decrease if the underlying and proximate social determinants of health as outlined by earlier presentations were addressed. Failure to address these issues is a violation of the obligation of the State to protect the health of the people, a right that flows from General Comment 14, of the International Covenant of Social, Economic and Cultural Rights, to which India is a signatory. To fulfil these obligations, state governments need to enact a public health law that assures that these public health threats are in addressed. There are only six states in the country that have done so, and one of these is Puducherry.
The Legal Situation in Puducherry. The Puducherry Public Health Act, 1973 has been part of the legal framework for public health governance in the Union Territory for over five decades. This Act, which is modelled on the Tamil Nadu Public Health Act of 1939, provides provisions for disease control, sanitation, water safety, food regulation. The Act empowers Health Officers to take necessary action during public health emergencies. While the Act was progressive at the time of enactment, the rules were never framed and over these decades there is almost no example of the Act having been used to take legal action against violations of public health. This is unlike Tamil Nadu, Andhra Pradesh and Kerala where there is a considerable body of legal actions and case law that now exist.
Puducherry’s Public Health Law: In the evolving health landscape, there is a need for urgent legal reforms. The current Act focuses largely on communicable diseases and sanitation. It needs to include provisions addressing non-communicable diseases, mental health, digital health systems, or environmental health challenges. One of the most critical concerns is the outdated penalty structure. The fines prescribed under the Act (₹200–₹400) have remained unchanged since 1974, making enforcement weak and ineffective. Additionally, certain provisions such as compulsory smallpox vaccination have become obsolete and require revision. The most worrying aspect is the failure to create and notify the rules under the Act. There is also no public health cadre which is charged with implementation of the law. Only a well-trained and organised team of public health officers under the department of health can ensure implementation of the law. The Law envisages elected local bodies as responsible for implementing its various provisions. The delay in elections and the long absence of any elected local bodies also undermines the effectiveness of the Law. There is also an overlap with newer legislations such as the Clinical Establishments Act, leading to regulatory ambiguity. Moreover, the Act follows a largely administrative and coercive approach, whereas modern public health frameworks emphasize a rights-based, community-centered approach.
Grounds for optimism: In 2020 there is Supreme Court ruling that called for states to implement public health laws, and the ruling positively noted the existence of the law in this UT. Also during the Covid 19 pandemic the law was applied for certain regulatory measures. As outbreaks of water-borne disease become commonplace there is an increasing public outcry. However, in the absence of a public understanding, this outcry results in a call for more medical facilities in an already over-crowded medical scenario and not for better public health law. However the increasing emergence of civil society groups, like Makkal Nalvazhvu Iyakkam, PSF, Svarnim, Association for Good Governance etc is leading to increased public awareness and increasing pressures to amend the act and frame the rules to cover the gaps that were noted and to implement it adequately. Strengthening the Public Health Act is essential to build a address the underlying social and environmental determinants of health and to move towards the vision of a “Healthy Puducherry,” and the Right to Health.
Session II- The Right to HealthCare:
One of the important components of the right to health, is the right to healthcare. Access to quality healthcare services with financial protection is itself an important determinant and achieving this may require a right to healthcare as well as the establishment of universal access to health care services. In this session Dr Arun Krishna summarises the current issues related to access to primary healthcare, Dr Sundararaman discusses the challenges of financial protection and Ms Revathi discusses the need for social security through a better function ESI or similar mechanisms.
Session II Presentation 1: Strengthening Primary Health Care in Puducherry – Dr. Arun Krishna
Background: Primary Health Care (PHC) forms the foundation of an equitable and effective health system. It emphasizes accessible, affordable, community-based care that addresses the majority (80–90%) of health needs across an individual’s life. In Puducherry, despite a relatively strong health infrastructure that includes a network of PHCs and Ayushman Bharat Health and wellness centres, several systemic and utilization challenges persist, impacting health outcomes. While health outcomes are better than many states, Puducherry still has major gaps in many health outcomes as highlighted in the first presentation in session 1. There is also a very high -of-pocket expenditure (91.6%) and catastrophic health expenditure (26%). One of the reasons for this is due to the poor social determinants- a fact that was discussed in three earlier presentations. In this presentation we focus on where healthcare services fall short. We also know from health camps that we have conducted that there is a high proportion of latent diabetes, hypertension and many other chronic illness for which care is foregone. High mortality in cancers is most often due to late detection which itself is reflective
Challenges in Primary Health Care Delivery: These observations are based on studies done in two PHCs, one rural and one urban, the following limitations are noted:
- Limited Diagnostic Facilities: Absence of basic laboratory services leads to unnecessary referrals which wastes time and increases costs
- Human Resource Constraints: The staff is not adequate to cope with the increased caseloads. More the burden of excessive administrative work, especially as related to data recording and reporting, reduces clinical efficiency.
- Inadequate Service Availability: Limited OPD hours and lack of essential medicines. There is also a trend to refer more and resolve less. Part of this is related to the lack of skills in general practice/family medicine. Much of it is also related to the selective health care approach, where the emphasis was only on maternal and child health and a few communicable diseases. Under the Health and Wellness centre programme this menu of available services was expected to be expanded to 12 service packages- but in practice this has not happened.
- Low Public Preference for PHCs: Due to lack of services for many conditions and lack of clarity on what care is available and what is not, patients prefer tertiary institutions. There is also the perception that tertiary care hospitals provide more reliable access to specialists.
- Weak Continuity of Care: Referrals from primary care centres are not facilitated with special timings or attention or even case history transfers. Nor are there reverse referrals from higher centres to primary care centres. Even for continued access to medication for any chronic illness, whether it be diabetes and hypertension, or epilepsy or psychoses, repeat medications require tertiary care visits and are not made available at PHCs.
- Entitlement and Empanelment: Families are not aware of who their primary care provider is and where the entitlement to free care can be exercised. Many families have made an ABHA card and some also have a PMJAY card, but these are seldom useful to access entitlements.
One of the important directions of reform that PSF calls for is to enact a right to healthcare act which calls for registration with a proximate primary care provider. This registration makes the family eligible to a set of preventive, promotive and curative services and to follow up care in chronic illness. It also acts as the entry point or pathway to accessing assured, free or subsidized secondary and tertiary care.
Session II: Presentation 2: Eliminating Financial Hardship Due to Healthcare Costs in Puducherry- Dr T. Sundararaman
Context: One of the biggest problems faced by the majority of families in Pondicherry is a very high level of indebtedness and financial distress- and one of the top two or three causes for this is the very high personal expenditure on healthcare. Evidence shows that a significant proportion of households are forced to take loans to meet healthcare expenses, pushing them deeper into poverty. Data from Puducherry indicates that nearly one-fourth of families experience financial hardship due to health-related costs. Out-of-pocket expenditure on healthcare not only affects access to treatment but also forces families to compromise on essential needs such as food, education, and housing. This undermines the overall socio-economic development of the community and violates the fundamental principle of the right to health.
The root causes of high healthcare expenditure include:
- Inadequate availability of free services in public facilities.
- High costs of care in private sector and excessive and often inappropriate care provision.
- High and ever increasing prices of medicines and diagnostics
- Poor delivery of financial coverage by insurance schemes, even for those eligible and enrolled.
To address these issues, a multi-pronged approach is required. First and foremost, all essential healthcare services in government facilities must be provided free of cost, including medicines and diagnostics. Strengthening primary healthcare and ensuring services are available close to communities can significantly reduce unnecessary expenditures. Rationing of care should be avoided by referrals to nearest site for financially protected health care is available.
Secondly, there is a need for strict regulation of the private healthcare sector to ensure transparency in pricing and adherence to standard treatment guidelines. Expanding access to affordable generic medicines through schemes such as Jan Aushadhi can further reduce costs. Price control mechanisms on medicines and medical devices also need to be strengthened.
Health insurance schemes must also be strengthened to eliminate exclusions, ensure cashless treatment, and prevent denial of services. Universal coverage and awareness about entitlements are critical for their success.
Reducing out-of-pocket expenditure is not just a health sector priority but a social and economic necessity. Ensuring financial protection in healthcare is a key step towards achieving equity, reducing poverty, and building a healthier society.
Session II- Presentation 3: Strengthening the ESI Scheme in Puducherry – Ms. Revathi Ramachandran.
The Employees’ State Insurance (ESI) Scheme is one of India’s most important social security initiatives, designed to provide healthcare and financial protection to workers and their families. In Puducherry, the scheme plays a crucial role in supporting the organized workforce by offering medical care, maternity benefits, and income security during illness or injury. As per reports, the scheme covers close to 1.2 lakh insured persons or about 4 lakh beneficiaries which is close to 40 percent of the population. Yet its impact is very limited.
The limitations are due to several factors. One problem is the lack of awareness among workers regarding their rights and entitlements. Many eligible workers remain excluded due to non-registration by employers or lack of proper documentation. The wage ceiling for eligibility is also very low. Administrative inefficiencies further hinder access to benefits. Delays in claim processing, inadequate hospital infrastructure, shortage of medical personnel, and weak grievance redressal systems reduce the trust and usability of the scheme. Additionally, services are often concentrated in urban areas, leaving workers in peripheral regions underserved. Another significant concern is the exclusion of workers in the informal sector, who constitute a large portion of the workforce. Expanding coverage to include these workers is essential for achieving universal social security.
To strengthen the ESI Scheme, the following measures are necessary:
- Increasing awareness among workers and employers
- Ensuring strict enforcement of employer registration and compliance
- Improving healthcare infrastructure and service quality
- Simplifying administrative procedures and digital systems
- Expanding coverage to informal sector workers
- Strengthening grievance redressal mechanisms
Trade unions, government agencies, employers, and civil society organizations must work together to improve coordination and accountability.
A strengthened ESI system will not only improve worker welfare but also contribute to economic productivity and social equity. Ensuring accessible and effective social security for workers is a key pillar in building a just and healthy society:
Summary of Demands;
At the end of each session there was an in-depth round table discussion involving all participants. After deliberations, a consensus was reached on the following priorities:
- Immediate public health priorities:
- Ensure safe drinking water by repairing pipelines, preventing sewage mixing, and starting regular water quality testing with public disclosure
- Launch a Heat Action Plan with early warnings, cooling centers, and public awareness for vulnerable groups
- Strengthen Primary Health Centres (PHCs) with essential drugs, basic diagnostics, and extended OPD services
- Enforce ESI registration and awareness drives for workers and employers
- Provide free essential medicines and diagnostics in government facilities to reduce out-of-pocket expenditure
- Initiate inter-department coordination task force (Health, Urban, Environment, Labour)
- Focus: System strengthening and policy integration
- Develop and adopt a “Healthy City Policy Framework” integrating health into urban planning, transport, housing, and environment
- Upgrade sewage treatment systems (STPs) and enforce industrial pollution control (ZLD norms)
- Expand Health and Wellness Centres with NCD screening, mental health services, and preventive care
- Strengthen disease surveillance systems (climate-sensitive and water-borne diseases) with digital integration
- Improve ESI healthcare infrastructure, grievance redressal, and service quality
- Promote community participation through local bodies and civil society (Jan Arogya Samitis)
- Structural reforms and sustainable health systems
- Enact and implement a Right to Health Act ensuring universal and equitable healthcare access
- Amend and modernize the Puducherry Public Health Act (1973) to include NCDs, climate health, digital systems, and stronger enforcement
- Reorient urban planning towards health equity, environmental sustainability, and resilience to climate change.
- Achieve universal health coverage by reducing dependence on private care and strengthening public systems
- Restore and protect traditional water bodies (Eris) and ensure sustainable groundwater management
- Build climate-resilient health systems integrated with long-term urban and environmental planning
- Expand social security (ESI-like coverage) to informal sector workers
Overall, the consultation called for a phased, coordinated approach—starting with urgent public health measures, followed by system strengthening, and culminating in structural reforms—will enable Puducherry to transition into a sustainable, equitable, and people-centered Healthy City where people have realized the right to health.
Next steps for the Health Sub-committee:
- There is a need to create working groups in each of these six areas-coordinated by the health committee of the PSF. The working groups should try and include volunteers and resource persons from outside of PSF, especially those in MNI and in academics , or who are in public service.
- Through study and consultations the working groups can develop a written understanding that describes the crisis, exposes the problems and their roots ands proposes alternatives. Both the critical assessment and the alternatives should be based on evidence. One of the areas where creative work is required is with
- The PSF/MNI shall publish a series of three or four booklets that can explain the crisis, and what needs to be done. The booklets would build public awareness on how to safeguard ones own health, how to improve access to services, and how to act on the social determinants.
- In coordination with MNI Build campaigns on specific demands- especially when an opportunity, which has drawn public attention to the problem arises.
- Make use of community institutions- JAS, VHCs, Management committees, district health assemblies, public inquiries, ESI bodies etc to push for awareness and change- and expand such consultative spaces.
- Also conduct health education and awareness sessions and health camps for children, for workers, for women members of self-health groups.
- Advocacy with decision makers- politicians, bureaucrats, policy community along with larger network on the slogan of towards a health city and the right to health. This could take the form of specific demands on one of these sub-themes, and at times could take the form of a larger convention.
- It could also involve catalysing the engagement of state/UT governments with WHO to make this process official and part of local governance.
