India plans to spend around Rs15,000 crore on health-care schemes in its cities and towns, home to a third of its population, in the next four years, as the Union government expands the reach of an ambitious programme it laun-ched in 2005 in the villages.
The single largest budgetary allocation ever for health in cities will focus on slum dwellers, street children and the homeless. The government has talked about the proposed National Urban Health Mission, or NUHM, in the past but has finalized the funds for this only recently. Spending on health in urban India in the 2001-06 period, the 10th Plan, was just Rs750 crore.
NUHM will kick off nationwide in April and will cover 427 cities. It will employ a new category of health workers called urban social health activists or USHAs, on the lines of accredited social health activists under the National Rural Health Mission (NRHM).
NUHM will set aside between 7% and 10% of its budget for street children and the homeless. It will also roll out urban health centres—one for every 50,000 people—and recruit 100,000 USHAs.
The initiative comes at a time when “urban health is in an anarchic and chaotic state,” said K. Srinath Reddy, president of Public Health Foundation of India, a think-tank based in New Delhi. High levels of malnutrition, increased incidence of infectious diseases and poor access to health care, despite physical proximity of hospitals, marks the lives of the urban poor. About 100 million Indians will qualify as urban poor, a section that the United Nations Human Settlements Programme estimates could double by 2020.
Mortality of children under the age of five is nearly 73 for every 1,000 live births among the urban poor, against the average of almost 48 among all city-dwellers in India, according to advocacy group Urban Health Resource Centre, which bases its findings on data from the third National Family Health Survey. The centre, which is a technical consultant to the health ministry, found other worrying data as well from its analysis: malnutrition levels are the highest among urban poor at 54.2%—higher than 50.7% of rural areas—and more than three out of five children in urban slums do not receive all vaccinations in childhood.
Reddy said the urban poor had little access to primary health care. “There is a growing category of slum dwellers and rural migrant workers that end up going to secondary and tertiary health-care centres” even for minor ailments and ended up being a drag on efficiency of hospitals,” he said.
“We hope to start NUHM from 2 April and (already) have an in-principle approval from the Planning Commission for our proposed outlay of Rs15,000 crore for the 11th Plan,” said Pravir Krishn, a joint secretary with the health ministry, who has put the plan together. Of the Rs15,000 crore investment, half would come from budgetary sources with the remaining drawn from NRHM, which has not utilized all the money budgeted for it.
For the seven years between 2005 to 2012, the government plans to spend Rs63,000 crore on NRHM, with the last three Budgets allocating a cumulative Rs24,854 crore for the rural health mission.
The latest health initiative comes on the back of a massive hike in the provision for the sector under the 11th Plan, ending March 2012. It has projected an allocation of Rs1.24 trillion, or 8.7% of the plan outlay, up 171% from the Rs45,771 crore spent on the health sector in the 10th Plan. It had a 5.62% share then—the increase marking it as a thrust area for the government.
The 427 cities to be covered under NUHM have been identified on the basis of their slum population. “In the first year, 100 cities will be taken up. The target is to provide health facilities to 50 million slum dwellers,” said Krishn.
Slum dwellers were either “crowded out” because of the inadequacy of the public health delivery system or lacked finances or were plain “invisible” because of their illegal status, Krishn said.
NHRM has also envisaged a health insurance scheme, which will offer a cover of Rs50,000 for a premium of Rs750 to pay for hospitalization charges, surgical procedures and pre-existing diseases—a scheme that may have considerable overlap with ministry of labour and employment’s Rashtriya Swasthya Bima Yojana. “We will be coordinating with the labour ministry as well as issuing smart cards to avoid duplication of coverage,” said Krishn.
The challenge, Public Health Foundation’s Reddy said, wo-uld be to find sufficient public health workers to man both the urban and rural health missions. “Public health workers are in absolute shortage. One has to see how much will be delivered through public private partnerships, how much by the government machinery, at what cost and with what efficiency,” he said.