Nuhm

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Nuhm

  1. 1. National Urban Health Mission: An analysis of strategies and mechanisms for improving services for urban poor1 Mr D. John2, Mr S J Chander2, Dr N. Devadasan2BackgroundThere has been a progressive rise of urbanization in the country over the lastdecade. As per the Census 2001, there were 285 million populations living inurban areas. The decadal growth of population in rural and urban areas duringthe last decade (1991-2001) was 17.9% and 31.2% respectively. The urbanpopulation in the country, which is 28 percent in 2001, is expected to increase to33 percent by 2026. According to the population projections report (Office of theRegistrar General and Census Commissioner, 2006), out of the total populationincrease of 371 million during 2001-2026 in the country, the share of increase inurban population is expected to be 182 million. This unprecedented growth inpopulation poses challenges for the city governments in providing basic servicesin urban areas. Existing health and basic services like drinking water, housing,electricity, drainage, sewerage etc, are not accessible to most of urban poorpopulations living in slum or slum-like conditions.The increase in poverty in cities and towns has lead to urbanization of ruralpoverty. For example, for states of Maharashtra and Karnataka while thepercentage of rural population below poverty line stand at 29.6 and 20.8respectively, the similar figures for percentage of urban population stand at 32.2and 32.6 respectively (Planning Commission estimates based on NSSO 61stround)There exist multiple issues which limit the reach of basic provisions of health andbasic services to all in urban areas. These issues range across lack ofgovernment priorities in urban health, inadequate public health infrastructure inurban areas, varying socio-economic, environment and infrastructural conditionsamong vulnerable and non-vulnerable slums, increase usage of private healthservices by urban poor, and lack of social security mechanisms. Around 21 % ofthe total urban populations live in slums (National Commission of Population,2000), but many of slum populations also comprise of squatter populations,migrant colonies, pavement dwellers, families on construction sites, streetchildren, etc.This paper attempts to discuss the proposed National Urban Health Mission(NUHM). While doing this the paper also makes attempts to provide commentson the various strategies of the NUHM while suggesting essential and desirable1 Background paper for National Workshop on Urban Health and Poverty, 2-3 July 2008, New Delhi; organized by Ministry of Housing and Urban Poverty Alleviation, Government of India2 Faculty, Institute of Public Health, Bangalore
  2. 2. services for improving access and quality of healthcare services to urban poorpopulations.Summary of National Urban Health Mission3Problem statementNUHM recognizes both growth of urban areas and the growth of urban poor,especially those living in the slums. As a result there is pressure on the existinginfrastructure which is deficient. It recognizes the inaccessibility of the health carefacilities in the urban areas due to the following reasons; overcrowding ofpatients, ineffective in outreach and referral system and lack of standard andnorms for urban health care delivery system, social exclusion, lack of informationand assistance to access the modern health care facilities and lack of economicresources.They suffer from poor health status, as per NFHS-III the under five mortality rateamong urban poor at 72.7 is higher than the urban average of 51.9. More that50% children are underweight, and almost 60% of the children miss totalimmunization before completing 1 year. Poor environmental condition coupledwith high population density makes them vulnerable to diarrhoeal diseases,malaria, lung diseases such as asthma, tuberculosis etc.CoverageIn phase I, the mission aims to cover 430 cities with more than one lakhpopulation across the country. It proposes to cover district head quarters withless than one lakh population during phase II. On a priority basis the missionwould cover a list of 100 cities during the first year. Same norms will be appliedto all the cities, irrespective of the population. It intends to cover the urban poorpopulation living in listed and unlisted slums, all the other vulnerable populationsuch as homeless, rag-pickers, street children, rickshaw pullers, construction andbrick and lime kiln workers, sex workers, any other temporary migrants.The Government of India will allocate approximately Rs. 8600 crores from theCentral Government for a period of 4 years (2008-2012) to the NUHM.Goal of NUHMIt aims to address the health concerns by facilitating equitable access availablehealth facilities by rationalizing and strengthening the capacity of the existinghealth care delivery system. It proposes to address gaps with the support of nongovernmental organizations.3 MOHFW, Draft Urban Health Mission, Urban Health Division, Govt of India, 2008
  3. 3. It aims to evolve a model out of diverse facilities available. It hopes to synergizethe mission with the existing progammes such as JNNURM, SJSRY and ICDSwhich have similar objectives to NUHM.Key strategies♦ Strengthening existing primary public health systems♦ Public private partnership♦ Communitised risk pooling / insurance mechanism with IT enablement♦ Monthly health and nutrition day♦ Capacity building of key stakeholders♦ Special provision to include the most vulnerable♦ Monitoring of quality of services♦ Community participation in planning and management♦ Identification of target group, through distribution of Family/Individual Health Suraksha CardsModelThree-tier system of health care I. Community Level Community Outreach Services Mahila Arogya Samitees (MAS) Urban Social Health Activist (USHA) II. Urban Health center level Strengthening existing public health facility Empanelled private providers III. Secondary/Tertiary level Public or private empanelled providersIt aims to provide community level care with the support of USHA and MAS. Inurban poor settlements, promote position of one USHA for 1000-2500 populationcovering about 200 to 500 households and ensure community participationthrough community-based institutions, through one MAS for 20-100 householdsand Rogi Kalyan Samitees. These mechanisms will make sure communityparticipates in planning and management.Community risk pooling and health insurance will be organized through MAS.MAS members would be encouraged to save money on monthly basis formeeting health emergencies. MAS would decide the lending norm and rate ofinterest, and NUHM would provide a seed money of Rs.2500 @ Rs.25 per head.It would also provide incentives based on targets achieved. It envisages earningincome from interest on small loans and interest on saving. The premium forhealth insurance would be paid from the fund.
  4. 4. The mission would promote an urban health insurance model for hospitalization.Premium would be subsided through the mission. The insurance would beimplemented through risk pooling with the partnership of center, state, UrbanLocal Bodies (ULB) and communities. Under this scheme a SmartCard/Individual or Family Health Suraksha card will be given to a family for fivefor a premium of Rs.600. Additional cost is expected to be contributed by state orUrban Local Bodies or Beneficiaries. The insurance project aims to cover boththe urban below poverty line groups as well as the above poverty line groups.The collected pooled premiums will be paid to IRDA approved InsuranceCompany/TPA; but the subsidy for slum populations will be provided by theMission. The benefit package includes coverage for hospitalization. surgery, andambulatory surgery expenses. Pre existing condition/diseases including maternaland child hood illnesses would also be covered, with minimum exclusions.Services will be accessed from the accredited empanelled providers from bothpublic and private sectors. There will be a mobliser or an administrator, maybepart of the insurer who will be responsible for implementation. IRDA approvedinsurance company will be assigned the job. The premiums will be self financedfor APL populations while the BPL populations will be provided subsidy from thecenter.NUHM will follow similar system to NRHM and use health missions at city andstate level for operationalization. It proposes to strengthen the role of urban localbodies. For the purpose of promoting transparency and accountability it proposeto incorporate elements such as health service delivery charter, health serviceguarantee and concurrent audit; audit at the level of funds released and utilized.It proposes the convergence of both the communicable and non communicabledisease progammes at the city level through integrated planning. The existingIDSP structure would be leveraged for improved surveillance.It proposes to promote decentralized governance by vesting the powers to theurban heath centers for converge of all the programmes at the urban healthcenter level.It recognizes the need for additional human and financial resource and itpurposes to ensure that it would be taken care. Over 800 crores has beenallocated and function as 100% centrally sponsored programme during the firstyear and it expects the state and the local bodies would contribute and own theprogrammes initiated by the mission.Comments on the proposed strategiesKey strategy - 1Improving the efficiency of public health system in the cities by strengthening,revamping and rationalizing urban primary health structure
  5. 5. The availability of healthcare services in urban areas is currently inadequate. Anevaluation study conducted by Shekhar and Ram (2005) indicated that the lowersocio-economic population pockets of urban areas tend to have higher unmetneed for healthcare. In spite of having better health-care services, there arestudies that show people residing in Mumbai are not having proper access tohealth-care services as 32 per cent of the reported ailments remained untreated(Nandraj et al, 1998). The main reasons mentioned for not utilizing services ofpublic sector at Mumbai were inconvenient location and timing for not utilizingservices of public sector at Mumbai (Nandraj, et al, 2001; CORT, 2000).According to NSSO 60th round, the percentage of treated ailments receiving non-hospitalized treatment from government sources in urban areas has decreasedto 19 in 2004 as compared to NSSO 52nd round (1995-96) and NSSO 42nd round(1986-87); whereas for hospitalized ailments in urban areas, the share of publicinstitutions were 382 cases out of 1000 in 2004 (NSSO 60th round) while thecorresponding figures have been 431 in 1995-96 (NSSO 52nd round) and 603 in1986-87 (NSSO 42nd round).The Constitution (74th Amendment) Act, 1992 has mandated grassroots leveldemocracy in urban areas by assigning the task of preparation andimplementation of plans for economic development and social justice to electedMunicipal councils and wards committees, including public health facilities. Acomparison of per capita spending on core services (these include public healthservices) by the Metropolitan MCs in terms of the Zakaria Committee normsindicates that the level of under-spending on an average works out to be about76 percent (Mohanty et al, 2007). According to MOHFW (2008), financially andadministratively stronger municipal bodies, such as Ahmedabad, Chennai, Surat,Delhi, Mumbai, Thane, etc, were found to be more efficient in managinghealthcare facilities.The NUHM proposes to strengthen and revamp the existing urban health postfacilities into a “Primary Urban Health Centre” (PUHC) with outreach and referralfacilities, to be functional for every 50,000 population on an average. Dependingon the spatial distribution of the slum population, the NUHM cites that thepopulation covered by a PUHC may vary from 5000 for cities with sparse slumpopulation to 75,000 for highly concentrated slums. The PUHC may cater to aslum population between 20000-30000, with provision for evening OPD,providing preventive, promotive and non-domiciliary curative care (includingconsultation, basic lab diagnosis and dispensing). The mission intends to useGIS maps for establishing referral mechanisms.EssentialsFor increasing demand of service towards the urban public health servicesvarious sectors must work together, such as health, housing, education,
  6. 6. sanitation etc. There is also need to support public health infrastructure, such asadequate and capable workforce, supplies, equipments, drugs etc.There is weak coordination among various service providers such as StateHealth Department, Municipal Corporation Health Bodies, ICDS, NGOs, privatehospitals etc, for providing services to the urban poor. There is little coordinationbetween these agencies and often service areas of different agencies overlapwhile there are large areas where there are no services (Agarwal, 2007). There isneed for improving coordination and synergies through partnerships models andresource pooling mechanisms for working in a complementary manner.The lack of an organized referral system from primary healthcare level to tertiarylevel care results in overcrowding of public hospitals with minor ailments andunder-utilization of dispensaries where the latter should actually be treated(Yesudian, 1988). This means that for effective and efficient delivery of urbandelivery services, there is need for referral protocols and service deliverylinkages at all levels of care for all kinds of ailments.And finally it appears that the NUHM will promote PPP to ensure the availabilityof PUHC. This means that the private practitioners should be exhorted to not limittheir services to curative care. They should also provide promotive andpreventive care as well as out reach services. This is an important requirementfor empanelment. Also the NUHM managers should ensure that the careprovided is accessible 24x7, affordable and acceptable to the people. Medicinesand diagnostics should be available and the staff attitudes should be patientcentred.DesirablesThe 12th Schedule introduced in the Constitution by 74th Amendment Actenvisages that functions like ‘safeguarding the interests of weaker sections ofsociety, including the handicapped and the mentally retarded’, ‘slumimprovement and upgradation’ and ‘urban poverty alleviation’ belong to thelegitimate functional domain of urban local bodies. However, there are nocommensurate resources with these institutions to discharge these functions. InMumbai, there are 16 Ward Committees in place, however, all are not into goodwork and many are ridden with corruption. Some of these committees have noNGO representation or the nominated have no social backing or are not reallyaware of citizens’ grievances and cannot see eye to eye with Councillors.Moreover, with no right to vote and with no financial powers, these nominatedmembers find that their hands are tied. For efficient civic administration, apartfrom an enlightened citizenry, there has to be a suitable local governmentstructure.Key Strategy – 2
  7. 7. Partnership with non government providers for filling up of the healthdelivery gapsAccording to an estimate by the Independent Commission on Health in India,more than 7000 NGOs are working in the field of healthcare. The Directory ofHospitals published in 1988, estimates the number of hospitals in the not-for-profit sector to be 937 (10% of all hospitals) and the total number of beds 74,498(13 % of all beds) in India. It also showed that 17% of all private hospitals werenot-for-profit and 42% of all beds were in this sector. Not-for-profit organizationsthat are presently delivering curative services range from faith-based tocommunity-based organizations working at the primary and secondary levels,and also a few at the tertiary level. In addition, big business groups have alsoestablished hospitals as trusts or societies, which qualify them for taxexemptions. At the other end of the spectrum we have trust hospitals locatedmostly in urban centres providing secondary or tertiary care. Many charitableinstitutions venture into providing specialized services for communicablediseases at the primary level.The primary health care facilities in urban areas are currently functioning sub-optimally. Existing Urban Family Welfare Centers (UFWCs) and Urban HealthPosts (UHPs) are not able to cover the entire urban population. As per the TaskForce Report (NRHM, 2005), there were only 1954 UFWCs/Health Postsavailable for catering to the population of about 285 million in the country. Thereare only 1083 Urban Family Welfare Centers and 871 Health Posts functioning inthe country. However, only 10 states and union territories have presence of theurban health posts. Only about 77% of the UFWCs and UHPs are fully functional.Even within cities there are several pockets which have no government facilities.Urban health facilities are marred by inadequate medical and non-medicalmanpower. The NUHM proposes to leverage the existing non governmentproviders to improve access to curative care. It is seen that in many cities nongovernment agencies/ civil society groups are playing a significant role incommunity mobilization. The NUHM thus also proposes to forge partnership withthis sector to promote active community participation and ownership.There are a number of initiatives in the country with regard to Public PrivatePartnerships (PPPs) initiatives for urban health services. These include coveringa wide range of services for contracting the management of the Urban HealthCenters to NGOs, contracting in private practitioners/specialists for public sectorfacilities, providing outreach services, contracting delivery of health services inun-served areas to NGOs, social franchising/social marketing, community healthinsurance/health vouchers, partnership with corporate sector and formation ofcommunity based organizations under the MNGO/SNGO scheme.Essentials
  8. 8. A prerequisite for building partnerships is that there should be free and faircompetition in the selection of partners (Baru & Nundy, 2008).There is need to create institutional structures and mechanisms for ensuringaccountability by both public and private non-profit partners.Where there is a weak managerial capacity at State and/or Municipal levels, itneeds to be strengthened to ensure that such partnerships are well-managed,are of acceptable quality, and expand access to under-served groups and toservices not available in the public sector.In certain cases, the existence of NGOs in areas of implementation is not knownto the government authorities, as was seen in case of RNTCP implementation(Rangana S, et al). There is need for process for mapping of health servicesprovided by various NGOs in various urban areas before initiating a dialogue andpartnership between NGOs and government machinery.DesirablesIn their regulatory and stewardship role, governments need to evolve standardprotocols of care and establish mechanisms of quality control. There ought to belegislation governing the entry of any private player or a specific public-privateinteraction through licensing and registration.There should also be recourse for consumers of such PPP health facilities forcomplaint and redressals mechanisms, through consumer protection laws.Key strategy – 3Promotion of access to improved health care at household level throughcommunity based groups: Mahila Arogya SamiteesUrban slum communities lack a sense of strong collective and cohesive unit dueto the heterogeneity among slum dwellers. This lack of collectivity in urban slumscomes in their way for mechanisms for collective demand for government healthservices.The NUHM proposes the creation of Mahila Arogya Samitee (MAS) a communitybased federated group of around 20 to 100 households, depending upon the sizeand concentration of the slum population, with flexibility for state leveladjustments, and be responsible for health and hygiene behaviour changepromotion and facilitating community risk pooling mechanism in their coveragearea. The Urban Social Health Activist (USHA) will provide the leadership andpromote the Mahila Arogya Samitee. The USHA on the lines of ASHA, wouldpreferably be a woman resident of the slum– married/widowed/ divorced,preferably in the age group of 25 to 45 years. She would be chosen through arigorous community driven process involving ULB Counsellors, community
  9. 9. groups, self-help groups, Anganwadis, ANMs. A team of five facilitators may beidentified in each UHC catchment area with the help of an NGO, through aconsultative process, for facilitating the selection of the USHA. The facilitatorswould preferably be women from local NGOs; community based groups,Anganwadis or Civil Society Institutions. In case none of these is available in thearea, the officers of other Departments at the slum level/local school teachersmay be taken as facilitators. The USHA would actually be the nerve centres fordelivering outreach services in the vicinity of the door steps of the beneficiaries.EssentialsMaintaining such a close-to-client (CTC) system for USHA and MAS is not aneasy task. Along with National leadership, it is vital that it is coupled with capacityand accountability at local level (WHO, 2001).There is need to avoid political appointments for such community-level workerspositions, as is being currently seen in the appointment of AnganwadiSupervisors in urban areas.DesirablesCommunity-programs should look at communities and community members asresources with a sense of being partners having ownership of the process, ratherthan being looked up as “passive recipients” as seen in most current cases.The program effectives of such PPCP (Public Private Community Partnerships)require careful selection of the lower-level staff, their training and supervision,and logistical support. These issues become critically important in scaling upprogram activities to larger populations, and they require a well designed,ongoing stable support structure of professional leadership, long term planning,and financial support (APHA, 2008).Key strategy – 4Strengthening public health through preventive and promotive actionThe focus of urban healthcare has been primarily on family welfare services withgreater focus on family planning. Most of the focus of the municipal corporationshas been on curative care, while primary and preventive care was neglected. Itwas left to urban NGOs who as service delivery agents provide health services,promotive health education, and other non-health components such as financial,legal, health advocacy services. Access to basic amenities in urban areasreflects 9% deficiency in drinking water, 26% in latrine and 23% in drainage(Census of India, 2001).The NUHM promotes the strengthening of promotive action for improved healthand nutrition and prevention of diseases. The Mission would also provide a
  10. 10. framework for pro active partnership with NGOs/civil society groups forstrengthening the preventive and promotive actions at the community level. TheUSHA, in coordination with the members of the MAS would promote proactivecommunity action in partnership with the urban local bodies for improved waterand environmental sanitation, nutrition and other aspects having a bearing onhealth.EssentialsThe Sub-Mission to the Basic Services to Urban Poor (BSUP), Jawaharlal NehruNational Urban Renewal Mission (JNNURM) and other related schemes of theMinistry aim to provide for improving water, sanitation, drainage, housing androads in urban slum localities. These services will go a long way into improvingthe environmental conditions of the slum populations.Existing community groups as being formed under SJSRY for promotinglivelihoods could be linked to MAS and utilized for promoting health in slumcommunities.DesirablesBudgetary allocations for Municipal Public Health Budgets and NUHM shouldhave a greater focus on preventive and promotive healthcare. In case of Mumbai,85% of the Municipal Public Health Budget is spent of the 3 Municipal TeachingHospitals.Key Strategy – 5Increased access to health care through risk pooling and community healthinsurance modelsAccording to WHO, private health expenditure in India accounts for 80% of thetotal health expenditure in the country (WHO, 2004), and most of this expenditureflows directly from households to the for-profit private healthcare sector. Withonly 10% of the total population have some sort of health security most peoplehave to rely on out-of-pocket expenses for paying health expenses. The lack offinancial resources makes many people forgo medical treatment. According toNSSO 60th round, around 6-8% of the population did not seek care due tofinancial reasons. Among those who sought care, around 24% of hospitalizedcases get impoverished each year (Peters et al, 2002). According to WorldDevelopment Report (2004), medical care remains the third most cause ofimpoverishment in the country and each year an additional 3.7% of thepopulation is impoverished due to medical causes (van Doorslaer, 2006). Arecent study by Dev and Ravi (2008), shows that the total poverty ratio in Indiaincreases from 28 to 36 percent (for year 2004-05) if private expenditures oneducation and health are included.
  11. 11. In recent years, community health insurance (CHI) has emerged as a possiblemeans of: (1) improving access to health care among the poor; and (2) protectingthe poor from indebtedness and impoverishment resulting from medicalexpenditures (Devadasan et al 2004). As per ILO estimates (2007) there are 75such schemes in the country covering around 7,000,000 populations. The TaskForce on Exploring New Health Financing Mechanisms (MOHFW, 2005) hassuggested community health insurance as a means of mobilizing communityresources for financial access of healthcare.The National Urban Health Mission (NUHM) recognizes that state/city specific,community oriented, innovative and flexible insurance policies need to bedeveloped. While the private insurance companies may be encouraged to bringin innovative insurance products, the Mission would strive to set up a risk poolingsystem where the Centre, States and the local community would be partners.This would be done by resource sharing, facility empanelment and regulation ofadherence to quality standards, establishing standard treatment protocols andcosts, apart from encouraging various premium financing mechanisms. NUHMencourages setting up of Mahila Arogya Samities (MAS), to act as the unit ofuser group as well as for designing and managing a need-based and affordablehealth insurance scheme.EssentialsThe Ministry of Labour has recently announced the Rastriya Swasthya BimaYojana (RSBY) to cover the unorganised sector BPL populations. In suchcontext, there is no need to announce a separate health insurance scheme forBPL populations in urban areas under NUHM. Apart from other benefits, theRSBY covers transport expenses and also for pre and post-hospitalizationexpenses. The urban health insurance model in NUHM does not provide theseexpenses.In the urban health insurance model the premium is proposed to be fixed byULB/district/state through a tendering process involving insurance companies. Asseen in the experience of community health insurance schemes under NRHM,most state governments do not have the inherent capacity to develop suchschemes and neither do they have capacity to negotiate with private insuranceproviders for pro-poor benefit package.Unlike RSBY, the insurance model aims to cover above-poverty populationsthrough self-financed mechanisms. In the urban areas, both the schemes couldbe merged to cover the entire populations.Desirables
  12. 12. The smart card being provided to BPL families under the insurance scheme ofthe NUHM could also be linked to use of free OPD services in public healthcarefacilities.The insurance model and smart card could be linked to other state-specificschemes, such as Jeevandai Yojana4 for provision of high-risk but expensivehealth services.Key strategy – 6IT enabled services (ITES) and e- governance for improving accessimproved surveillance and monitoringIn 1983, Indian Journal of Public Health commented in the editorial on the needfor HMIS in India, “A good health service superstructure can be built only on asolid base provided by the reliable health statistics collected through a wellorganised infrastructure”. The lack of awareness by health policy-makers andprogramme managers of the strategic importance and practical usefulness ofhealth information for planning and management results in a low demand forinformation. In the paper, “Evaluation of Health Management Information System(HMIS) in India” (Bodavala, 2005), the existing HMIS system in the country hasstructural, procedural, technological and human resource related issues. There islack of proper maintenance of medical records by Municipal Corporation healthfacilities and private doctors result in poor tracking of epidemiological diseases inall cities. There is no proper system with the regard of notification of non-communicable diseases and the interaction between various levels (includingprivate and public) is virtually non-existent or only at times of epidemics.The NUHM aims to provide software and hardware support for developing web-based HMIS for quick transfer of data and quick action. The NUHM envisions theintegration of GIS into a system of reporting alerts and incidence of diseases ona regular basis and will be synchronized with the IDSP surveillance system.EssentialsIt is imperative that the private health sector which is currently accessed by amajority of urban populations be linked to the HMIS system.DesirablesCivil Society initiatives such as Online Complaint Management Systems (OCMS)developed by Praja Foundation in Mumbai, which aims at monitoring theprogress of complaints’ complaints in a holistic manner, could be utilized for aneffective health governance structure.4 In Maharashtra State, the Jeevandai Yojana (a 100% State share scheme) provides free super-speciality surgical treatment for ailments of heart, brain, spinal cord and nervous system, kidneyand cancer to below poverty line or economically backward patients, residing in Maharashtra.
  13. 13. Community-based monitoring structures through linkages with communityorganisations, NGOs etc, could improve the governance mechanisms ofprogramme implementation.Key strategy – 7Capacity building of stakeholdersProfessional management of urban local bodies is an important reform that isneeded to improve civic service delivery in the country. The ULBs, especially thesmaller ones, have limited capacity to develop public-private partnerships andneed to be assisted by specialized state agencies.NUHM proposes to build managerial, technical and public health competenciesamong the health care providers and the ULBs through capacity building,monetary and non monetary incentives, and managerial support.EssentialsTraining Needs Assessment to be conducted at all managerial levels of publichealthcare providers and ULBs and suitable training curriculum needs to bedeveloped to enable those that are in-charge for effective administration andimplementation of programme. Training institutions such as All India Local Self-Government (AIILSG) could be utilized for this purpose.DesirablesTraining of civil society members, community organisations and citizenorganizations regarding public health is also needed.Key strategy - 8Prioritizing the most vulnerable amongst the poorVarious population groups which are usually floating in nature throng to cities insearch of employment. These mostly reside in temporary settlements on openlands, pavements, and desert these dwellings when they move back to villages.As such habitations are temporary in nature, city planners often overlook them,and these disadvantaged populations are thus deprived of basic service ofhealth, sanitation, etc.The NUHM has a special emphasis would on improving the reach of health careservices to these vulnerable among the urban poor, falling in the category ofdestitute, beggars, street children, construction workers, coolies, rickshawpullers, sex workers, street vendors and other such migrant workers. It is awelcome step that this support would be through city specific strategy with a capof 10% of the city budget.
  14. 14. EssentialsThere is need to conduct a mapping of such populations in cities since most ofsuch populations, such as street children, construction workers etc, have neverbeen part of any official surveys by the government.Most of such populations, especially street children, construction workers,beggars etc, are currently being covered by health services by NGOs, hencepartnerships with such NGOs in ensuring reach of NUHM programmes isessential.DesirablesThere is need for convergence of other programmes such as ICDS for streetchildren, SJSRY for construction workers, etc, with NUHM.Key strategy - 9Ensuring quality health care servicesIn India the quality of services provided to the population by both public andprivate sectors remains largely an unaddressed issue. The for-profit privatesector accounts for a substantial proportion of health care in India (50% ofinpatient care and 60-70% of outpatient care), but has received relatively lessattention from the policy makers as compared to the public sector. The privatesector health care delivery system in India has remained largely fragmented anduncontrolled, and there is a clear evidence of serious quality of care deficienciesin many practices. Problems range from inadequate and inappropriatetreatments, excessive use of higher technologies, and wasting of scarceresources, to serious problems of medical malpractice and negligence. Currentpolicies and processes for health care are inadequate or not responsive toensure health care services of acceptable quality and prevent negligence.NUHM aims to ensure quality health services by a) defining Indian Public HealthStandards (IPHS) suitably modified for urban areas wherever required b) definingparameters for empanelment/regulation/accreditation of non-governmentproviders, c) developing capacity of public and private providers for providingquality health care, d) encouraging the acceptance and enforcement of localpublic health acts d) ensuring citizen charters in facilities e) encouragingdevelopment of standard treatment protocols.EssentialsCurrent attempts at improving quality of health facilities such as IPHS for publichealth facilities and National Accreditation Board for Healthcare Providers(NABH) for private health facilities emphasize on physical standards, not onprocesses and outcomes. This could be done through development of standardtreatment guidelines, care protocols, integrated care pathways etc.
  15. 15. As is in the case of accreditation which is voluntary in nature, other aspects ofregulation such as licensing of practitioners (e.g. doctors, nurses etc) andregulation of health facilities should be made mandatory for all health facilities inurban areas.DesirablesImplementation of IPHS for urban public health services is a welcome step,however the foremost action would be introduction of legislation mechanisms forall public healthcare providers and personnel to conform to legislated minimalrequirements. These legislation mechanisms could include the elements of anyregulatory process include establishment of rules, its application to specificcases, detection or monitoring violations and imposition of penalties on violators.The reimbursement mechanisms for providers through urban insurance modelsshould be based on quality of services these providers render.ConclusionsIn the area of health, the Indian government (center and states) spends less than1 percent of GNP for health, compared to an average of around 3 percent for alldeveloping countries, and more than 5 percent for high-income countries. TheNational Common Minimum Program (NCMP) of the UPA government iscommitted to increasing total public expenditure on health to 2-3% of GDP. Thefiscal resources for government for increasing investments in health can comeonly through cuts in existing expenditures rather than increases in taxation as apercent of GNP (Sachs & Bajpai, 2001). The same holds true for a nation-wideprogram such as NUHM, where improved efficiencies through sound fiscalmanagement structures, local planning and governance structures, improvedmanagerial capacities especially at urban body levels, and involvement ofcitizens, could ensure increased resource availability and proper implementation.While the NUHM is a welcome introduction and its attempt to infuse funds intopractically defunct urban health services should be applauded. However, theemphasis is on PPP and Health insurance, rather than understanding andanalyzing the urban health system. If this is done, then the activities will differ.One needs to have a public health approach, wherein one develops a primaryhealth care system followed by a referral system.______________________________________ReferencesCensus of India (2001), Office of the Registrar General & Census Commissioner,Govt of India
  16. 16. Census of India (2001), Report of the Technical Group on Population ProjectionsConstituted by the National Commission on Population, May 2006National Commission of Population, 2000, Ministry of Health and Family Welfare,Govt of IndiaShekhar, C, and F, Ram (2005), National Report on Evaluation of Functioning ofUrban Health Posts/Urban Family Centers in India, International Institute ofPopulation Sciences (IIPS), MumbaiNandraj, S., A. Khot and S. Menon (1998), Data Base of Hospitals in Mumbai,unpublished, Centre for Enquiry into Health and Allied Themes (CEHAT),MumbaiCentre for Operation Research and Training (CORT) (2000). Rapid HouseholdSurvey RCH Phase-II1999, Greater Mumbai, CORT, VadodraNSS 60th round (2004), Morbidity, Health Care and the Condition of the Aged,National Sample Survey Organisation, Ministry of Statistics, Govt of IndiaNSS 52nd round (1995-96), Morbidity, Health Care and the Condition of the Aged,National Sample Survey Organisation, Ministry of Statistics, Govt of IndiaNSS 48th round (1986-87), Morbidity, Health Care and the Condition of the Aged,National Sample Survey Organisation, Ministry of Statistics, Govt of IndiaAgarwal S et al (2007), Urbanization, Urban Poverty and Health of the UrbanPoor: Status, Challenges and the Way Forward , Demography India Vol 36, No 1,pp. 121-134Yesudian, C.A.K. (1988). Utilisation of Health Services by Urban Poor- A Studyof Naigaum Maternity Home Health Post Area, Tata Institute of Social Sciences,BombayMohanty P K (2007), Municipal Finance in India: An Assessment, Dept ofEconomic Analysis and Policy, Reserve Bank of India, MumbaiMOHFW (2008), Draft Urban Health Mission, Urban Health Division, Govt ofIndiaVoluntary Health Association of India (VHAI) (1997), Report of the IndependentCommission on Health in India. VHAI, New DelhiGovernment of India (1988), Directory of Hospitals, Govt of India, New Delhi
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