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. Devadasan2

Background

There has been a progressive rise of urbanization in the country over the last
decade. As per the Census 2001, there were 285 million populations living in
urban areas. The decadal growth of population in rural and urban areas during
the last decade (1991-2001) was 17.9% and 31.2% respectively. The urban
population in the country, which is 28 percent in 2001, is expected to increase to
33 percent by 2026. According to the population projections report (Office of the
Registrar General and Census Commissioner, 2006), out of the total population
increase of 371 million during 2001-2026 in the country, the share of increase in
urban population is expected to be 182 million. This unprecedented growth in
population poses challenges for the city governments in providing basic services
in urban areas. Existing health and basic services like drinking water, housing,
electricity, drainage, sewerage etc, are not accessible to most of urban poor
populations living in slum or slum-like conditions.

The increase in poverty in cities and towns has lead to urbanization of rural
poverty. For example, for states of Maharashtra and Karnataka while the
percentage of rural population below poverty line stand at 29.6 and 20.8
respectively, the similar figures for percentage of urban population stand at 32.2
and 32.6 respectively (Planning Commission estimates based on NSSO 61st
round)
There exist multiple issues which limit the reach of basic provisions of health and
basic services to all in urban areas. These issues range across lack of
government priorities in urban health, inadequate public health infrastructure in
urban areas, varying socio-economic, environment and infrastructural conditions
among vulnerable and non-vulnerable slums, increase usage of private health
services by urban poor, and lack of social security mechanisms. Around 21 % of
the 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, street
children, etc.

This paper attempts to discuss the proposed National Urban Health Mission
(NUHM). While doing this the paper also makes attempts to provide comments
on the various strategies of the NUHM while suggesting essential and desirable

1
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 India

2
Faculty, Institute of Public Health, Bangalore
services for improving access and quality of healthcare services to urban poor
populations.

Summary of National Urban Health Mission3

Problem statement

NUHM 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 existing
infrastructure which is deficient. It recognizes the inaccessibility of the health care
facilities in the urban areas due to the following reasons; overcrowding of
patients, ineffective in outreach and referral system and lack of standard and
norms for urban health care delivery system, social exclusion, lack of information
and assistance to access the modern health care facilities and lack of economic
resources.

They suffer from poor health status, as per NFHS-III the under five mortality rate
among urban poor at 72.7 is higher than the urban average of 51.9. More that
50% children are underweight, and almost 60% of the children miss total
immunization before completing 1 year. Poor environmental condition coupled
with high population density makes them vulnerable to diarrhoeal diseases,
malaria, lung diseases such as asthma, tuberculosis etc.

Coverage

In phase I, the mission aims to cover 430 cities with more than one lakh
population across the country. It proposes to cover district head quarters with
less than one lakh population during phase II. On a priority basis the mission
would cover a list of 100 cities during the first year. Same norms will be applied
to all the cities, irrespective of the population. It intends to cover the urban poor
population living in listed and unlisted slums, all the other vulnerable population
such as homeless, rag-pickers, street children, rickshaw pullers, construction and
brick and lime kiln workers, sex workers, any other temporary migrants.

The Government of India will allocate approximately Rs. 8600 crores from the
Central Government for a period of 4 years (2008-2012) to the NUHM.

Goal of NUHM

It aims to address the health concerns by facilitating equitable access available

health facilities by rationalizing and strengthening the capacity of the existing
health care delivery system. It proposes to address gaps with the support of non
governmental organizations.

3
MOHFW, Draft Urban Health Mission, Urban Health Division, Govt of India, 2008
It aims to evolve a model out of diverse facilities available. It hopes to synergize
the mission with the existing progammes such as JNNURM, SJSRY and ICDS
which 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 Cards

Model

Three-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 providers

It aims to provide community level care with the support of USHA and MAS. In
urban poor settlements, promote position of one USHA for 1000-2500 population
covering about 200 to 500 households and ensure community participation
through community-based institutions, through one MAS for 20-100 households
and Rogi Kalyan Samitees. These mechanisms will make sure community
participates 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 for
meeting health emergencies. MAS would decide the lending norm and rate of
interest, 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 earning
income from interest on small loans and interest on saving. The premium for
health insurance would be paid from the fund.
The mission would promote an urban health insurance model for hospitalization.
Premium would be subsided through the mission. The insurance would be
implemented through risk pooling with the partnership of center, state, Urban
Local Bodies (ULB) and communities. Under this scheme a Smart
Card/Individual or Family Health Suraksha card will be given to a family for five
for a premium of Rs.600. Additional cost is expected to be contributed by state or
Urban Local Bodies or Beneficiaries. The insurance project aims to cover both
the urban below poverty line groups as well as the above poverty line groups.
The collected pooled premiums will be paid to IRDA approved Insurance
Company/TPA; but the subsidy for slum populations will be provided by the
Mission. The benefit package includes coverage for hospitalization. surgery, and
ambulatory surgery expenses. Pre existing condition/diseases including maternal
and child hood illnesses would also be covered, with minimum exclusions.

Services will be accessed from the accredited empanelled providers from both
public and private sect\ors. There will be a mobliser or an administrator, maybe
part of the insurer who will be responsible for implementation. IRDA approved
insurance company will be assigned the job. The premiums will be self financed
for APL populations while the BPL populations will be provided subsidy from the
center.

NUHM will follow similar system to NRHM and use health missions at city and
state level for operationalization. It proposes to strengthen the role of urban local
bodies. For the purpose of promoting transparency and accountability it propose
to incorporate elements such as health service delivery charter, health service
guarantee and concurrent audit; audit at the level of funds released and utilized.

It proposes the convergence of both the communicable and non communicable

disease progammes at the city level through integrated planning. The existing
IDSP structure would be leveraged for improved surveillance.

It proposes to promote decentralized governance by vesting the powers to the

urban heath centers for converge of all the programmes at the urban health
center level.

It recognizes the need for additional human and financial resource and it
purposes to ensure that it would be taken care. Over 800 crores has been
allocated and function as 100% centrally sponsored programme during the first
year and it expects the state and the local bodies would contribute and own the
programmes initiated by the mission.

Comments on the proposed strategies

Key strategy - 1
Improving the efficiency of public health system in the cities by strengthening,
revamping and rationalizing urban primary health structure
The availability of healthcare services in urban areas is currently inadequate. An
evaluation study conducted by Shekhar and Ram (2005) indicated that the lower
socio-economic population pockets of urban areas tend to have higher unmet
need for healthcare. In spite of having better health-care services, there are
studies that show people residing in Mumbai are not having proper access to
health-care services as 32 per cent of the reported ailments remained untreated
(Nandraj et al, 1998). The main reasons mentioned for not utilizing services of
public sector at Mumbai were inconvenient location and timing for not utilizing
services 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 decreased
to 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 public
institutions were 382 cases out of 1000 in 2004 (NSSO 60th round) while the
corresponding figures have been 431 in 1995-96 (NSSO 52nd round) and 603 in
1986-87 (NSSO 42nd round).

The Constitution (74th Amendment) Act, 1992 has mandated grassroots level
democracy in urban areas by assigning the task of preparation and
implementation of plans for economic development and social justice to elected
Municipal councils and wards committees, including public health facilities. A
comparison of per capita spending on core services (these include public health
services) by the Metropolitan MCs in terms of the Zakaria Committee norms
indicates that the level of under-spending on an average works out to be about
76 percent (Mohanty et al, 2007). According to MOHFW (2008), financially and
administratively stronger municipal bodies, such as Ahmedabad, Chennai, Surat,
Delhi, Mumbai, Thane, etc, were found to be more efficient in managing
healthcare facilities.

The NUHM proposes to strengthen and revamp the existing urban health post
facilities into a “Primary Urban Health Centre” (PUHC) with outreach and referral
facilities, to be functional for every 50,000 population on an average. Depending
on the spatial distribution of the slum population, the NUHM cites that the
population covered by a PUHC may vary from 5000 for cities with sparse slum
population to 75,000 for highly concentrated slums. The PUHC may cater to a
slum population between 20000-30000, with provision for evening OPD,
providing preventive, promotive and non-domiciliary curative care (including
consultation, basic lab diagnosis and dispensing). The mission intends to use
GIS maps for establishing referral mechanisms.

Essentials

For increasing demand of service towards the urban public health services
various sectors must work together, such as health, housing, education,
sanitation etc. There is also need to support public health infrastructure, such as
adequate and capable workforce, supplies, equipments, drugs etc.

There is weak coordination among various service providers such as State

Health Department, Municipal Corporation Health Bodies, ICDS, NGOs, private
hospitals etc, for providing services to the urban poor. There is little coordination
between these agencies and often service areas of different agencies overlap
while there are large areas where there are no services (Agarwal, 2007). There is
need for improving coordination and synergies through partnerships models and
resource pooling mechanisms for working in a complementary manner.

The lack of an organized referral system from primary healthcare level to tertiary
level care results in overcrowding of public hospitals with minor ailments and
under-utilization of dispensaries where the latter should actually be treated
(Yesudian, 1988). This means that for effective and efficient delivery of urban
delivery services, there is need for referral protocols and service delivery
linkages at all levels of care for all kinds of ailments.

And finally it appears that the NUHM will promote PPP to ensure the availability
of PUHC. This means that the private practitioners should be exhorted to not limit
their services to curative care. They should also provide promotive and
preventive care as well as out reach services. This is an important requirement
for empanelment. Also the NUHM managers should ensure that the care
provided is accessible 24x7, affordable and acceptable to the people. Medicines
and diagnostics should be available and the staff attitudes should be patient
centred.

Desirables

The 12th Schedule introduced in the Constitution by 74th Amendment Act

envisages that functions like ‘safeguarding the interests of weaker sections of
society, including the handicapped and the mentally retarded’, ‘slum
improvement and upgradation’ and ‘urban poverty alleviation’ belong to the
legitimate functional domain of urban local bodies. However, there are no
commensurate resources with these institutions to discharge these functions. In
Mumbai, there are 16 Ward Committees in place, however, all are not into good
work and many are ridden with corruption. Some of these committees have no
NGO representation or the nominated have no social backing or are not really
aware of citizens’ grievances and cannot see eye to eye with Councillors.
Moreover, with no right to vote and with no financial powers, these nominated
members find that their hands are tied. For efficient civic administration, apart
from an enlightened citizenry, there has to be a suitable local government
structure.

Key Strategy – 2
Partnership with non government providers for filling up of the health
delivery gaps

According to an estimate by the Independent Commission on Health in India,

more than 7000 NGOs are working in the field of healthcare. The Directory of
Hospitals 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 were
not-for-profit and 42% of all beds were in this sector. Not-for-profit organizations
that are presently delivering curative services range from faith-based to
community-based organizations working at the primary and secondary levels,
and also a few at the tertiary level. In addition, big business groups have also
established hospitals as trusts or societies, which qualify them for tax
exemptions. At the other end of the spectrum we have trust hospitals located
mostly in urban centres providing secondary or tertiary care. Many charitable
institutions venture into providing specialized services for communicable
diseases 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 Health
Posts (UHPs) are not able to cover the entire urban population. As per the Task
Force Report (NRHM, 2005), there were only 1954 UFWCs/Health Posts
available for catering to the population of about 285 million in the country. There
are only 1083 Urban Family Welfare Centers and 871 Health Posts functioning in
the country. However, only 10 states and union territories have presence of the
urban 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-medical
manpower. The NUHM proposes to leverage the existing non government
providers to improve access to curative care. It is seen that in many cities non
government agencies/ civil society groups are playing a significant role in
community mobilization. The NUHM thus also proposes to forge partnership with
this sector to promote active community participation and ownership.

There are a number of initiatives in the country with regard to Public Private
Partnerships (PPPs) initiatives for urban health services. These include covering
a wide range of services for contracting the management of the Urban Health
Centers to NGOs, contracting in private practitioners/specialists for public sector
facilities, providing outreach services, contracting delivery of health services in
un-served areas to NGOs, social franchising/social marketing, community health
insurance/health vouchers, partnership with corporate sector and formation of
community based organizations under the MNGO/SNGO scheme.

Essentials
A prerequisite for building partnerships is that there should be free and fair
competition in the selection of partners (Baru & Nundy, 2008).

There is need to create institutional structures and mechanisms for ensuring

accountability by both public and private non-profit partners.

Where there is a weak managerial capacity at State and/or Municipal levels, it

needs to be strengthened to ensure that such partnerships are well-managed,
are of acceptable quality, and expand access to under-served groups and to
services not available in the public sector.

In certain cases, the existence of NGOs in areas of implementation is not known

to the government authorities, as was seen in case of RNTCP implementation
(Rangana S, et al). There is need for process for mapping of health services
provided by various NGOs in various urban areas before initiating a dialogue and
partnership between NGOs and government machinery.

Desirables

In their regulatory and stewardship role, governments need to evolve standard

protocols of care and establish mechanisms of quality control. There ought to be
legislation governing the entry of any private player or a specific public-private
interaction through licensing and registration.

There should also be recourse for consumers of such PPP health facilities for
complaint and redressals mechanisms, through consumer protection laws.

Key strategy – 3
Promotion of access to improved health care at household level through
community based groups: Mahila Arogya Samitees

Urban slum communities lack a sense of strong collective and cohesive unit due
to the heterogeneity among slum dwellers. This lack of collectivity in urban slums
comes in their way for mechanisms for collective demand for government health
services.

The NUHM proposes the creation of Mahila Arogya Samitee (MAS) a community
based federated group of around 20 to 100 households, depending upon the size
and concentration of the slum population, with flexibility for state level
adjustments, and be responsible for health and hygiene behaviour change
promotion and facilitating community risk pooling mechanism in their coverage
area. The Urban Social Health Activist (USHA) will provide the leadership and
promote the Mahila Arogya Samitee. The USHA on the lines of ASHA, would
preferably 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 a
rigorous community driven process involving ULB Counsellors, community
groups, self-help groups, Anganwadis, ANMs. A team of five facilitators may be
identified in each UHC catchment area with the help of an NGO, through a
consultative process, for facilitating the selection of the USHA. The facilitators
would preferably be women from local NGOs; community based groups,
Anganwadis or Civil Society Institutions. In case none of these is available in the
area, the officers of other Departments at the slum level/local school teachers
may be taken as facilitators. The USHA would actually be the nerve centres for
delivering outreach services in the vicinity of the door steps of the beneficiaries.

Essentials

Maintaining such a close-to-client (CTC) system for USHA and MAS is not an
easy task. Along with National leadership, it is vital that it is coupled with capacity
and accountability at local level (WHO, 2001).

There is need to avoid political appointments for such community-level workers

positions, as is being currently seen in the appointment of Anganwadi
Supervisors in urban areas.

Desirables

Community-programs should look at communities and community members as

resources with a sense of being partners having ownership of the process, rather
than 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 up
program 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 – 4
Strengthening public health through preventive and promotive action

The focus of urban healthcare has been primarily on family welfare services with
greater focus on family planning. Most of the focus of the municipal corporations
has been on curative care, while primary and preventive care was neglected. It
was 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 areas
reflects 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 health
and nutrition and prevention of diseases. The Mission would also provide a
framework for pro active partnership with NGOs/civil society groups for
strengthening the preventive and promotive actions at the community level. The
USHA, in coordination with the members of the MAS would promote proactive
community action in partnership with the urban local bodies for improved water
and environmental sanitation, nutrition and other aspects having a bearing on
health.

Essentials
The Sub-Mission to the Basic Services to Urban Poor (BSUP), Jawaharlal Nehru
National Urban Renewal Mission (JNNURM) and other related schemes of the
Ministry aim to provide for improving water, sanitation, drainage, housing and
roads in urban slum localities. These services will go a long way into improving
the environmental conditions of the slum populations.

Existing community groups as being formed under SJSRY for promoting

livelihoods could be linked to MAS and utilized for promoting health in slum
communities.

Desirables

Budgetary allocations for Municipal Public Health Budgets and NUHM should
have 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 Teaching
Hospitals.

Key Strategy – 5
Increased access to health care through risk pooling and community health
insurance models

According to WHO, private health expenditure in India accounts for 80% of the
total health expenditure in the country (WHO, 2004), and most of this expenditure
flows directly from households to the for-profit private healthcare sector. With
only 10% of the total population have some sort of health security most people
have to rely on out-of-pocket expenses for paying health expenses. The lack of
financial resources makes many people forgo medical treatment. According to
NSSO 60th round, around 6-8% of the population did not seek care due to
financial reasons. Among those who sought care, around 24% of hospitalized
cases get impoverished each year (Peters et al, 2002). According to World
Development Report (2004), medical care remains the third most cause of
impoverishment in the country and each year an additional 3.7% of the
population is impoverished due to medical causes (van Doorslaer, 2006). A
recent study by Dev and Ravi (2008), shows that the total poverty ratio in India
increases from 28 to 36 percent (for year 2004-05) if private expenditures on
education and health are included.
In recent years, community health insurance (CHI) has emerged as a possible
means of: (1) improving access to health care among the poor; and (2) protecting
the poor from indebtedness and impoverishment resulting from medical
expenditures (Devadasan et al 2004). As per ILO estimates (2007) there are 75
such schemes in the country covering around 7,000,000 populations. The Task
Force on Exploring New Health Financing Mechanisms (MOHFW, 2005) has
suggested community health insurance as a means of mobilizing community
resources 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 be
developed. While the private insurance companies may be encouraged to bring
in innovative insurance products, the Mission would strive to set up a risk pooling
system where the Centre, States and the local community would be partners.
This would be done by resource sharing, facility empanelment and regulation of
adherence to quality standards, establishing standard treatment protocols and
costs, apart from encouraging various premium financing mechanisms. NUHM
encourages setting up of Mahila Arogya Samities (MAS), to act as the unit of
user group as well as for designing and managing a need-based and affordable
health insurance scheme.

Essentials

The Ministry of Labour has recently announced the Rastriya Swasthya Bima
Yojana (RSBY) to cover the unorganised sector BPL populations. In such
context, there is no need to announce a separate health insurance scheme for
BPL populations in urban areas under NUHM. Apart from other benefits, the
RSBY covers transport expenses and also for pre and post-hospitalization
expenses. The urban health insurance model in NUHM does not provide these
expenses.

In the urban health insurance model the premium is proposed to be fixed by

ULB/district/state through a tendering process involving insurance companies. As
seen in the experience of community health insurance schemes under NRHM,
most state governments do not have the inherent capacity to develop such
schemes and neither do they have capacity to negotiate with private insurance
providers for pro-poor benefit package.

Unlike RSBY, the insurance model aims to cover above-poverty populations

through self-financed mechanisms. In the urban areas, both the schemes could
be merged to cover the entire populations.

Desirables
The smart card being provided to BPL families under the insurance scheme of
the NUHM could also be linked to use of free OPD services in public healthcare
facilities.

The insurance model and smart card could be linked to other state-specific
schemes, such as Jeevandai Yojana4 for provision of high-risk but expensive
health services.

Key strategy – 6
IT enabled services (ITES) and e- governance for improving access
improved surveillance and monitoring

In 1983, Indian Journal of Public Health commented in the editorial on the need
for HMIS in India, “A good health service superstructure can be built only on a
solid base provided by the reliable health statistics collected through a well
organised infrastructure”. The lack of awareness by health policy-makers and
programme managers of the strategic importance and practical usefulness of
health information for planning and management results in a low demand for
information. In the paper, “Evaluation of Health Management Information System
(HMIS) in India” (Bodavala, 2005), the existing HMIS system in the country has
structural, procedural, technological and human resource related issues. There is
lack of proper maintenance of medical records by Municipal Corporation health
facilities and private doctors result in poor tracking of epidemiological diseases in
all cities. There is no proper system with the regard of notification of non-
communicable diseases and the interaction between various levels (including
private 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 the
integration of GIS into a system of reporting alerts and incidence of diseases on
a regular basis and will be synchronized with the IDSP surveillance system.

Essentials

It is imperative that the private health sector which is currently accessed by a

majority of urban populations be linked to the HMIS system.

Desirables

Civil Society initiatives such as Online Complaint Management Systems (OCMS)

developed by Praja Foundation in Mumbai, which aims at monitoring the
progress of complaints’ complaints in a holistic manner, could be utilized for an
effective 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, kidney
and cancer to below poverty line or economically backward patients, residing in Maharashtra.
Community-based monitoring structures through linkages with community
organisations, NGOs etc, could improve the governance mechanisms of
programme implementation.

Key strategy – 7
Capacity building of stakeholders

Professional management of urban local bodies is an important reform that is

needed to improve civic service delivery in the country. The ULBs, especially the
smaller ones, have limited capacity to develop public-private partnerships and
need to be assisted by specialized state agencies.

NUHM proposes to build managerial, technical and public health competencies

among the health care providers and the ULBs through capacity building,
monetary and non monetary incentives, and managerial support.

Essentials

Training Needs Assessment to be conducted at all managerial levels of public

healthcare providers and ULBs and suitable training curriculum needs to be
developed to enable those that are in-charge for effective administration and
implementation of programme. Training institutions such as All India Local Self-
Government (AIILSG) could be utilized for this purpose.

Desirables
Training of civil society members, community organisations and citizen
organizations regarding public health is also needed.

Key strategy - 8
Prioritizing the most vulnerable amongst the poor

Various population groups which are usually floating in nature throng to cities in
search of employment. These mostly reside in temporary settlements on open
lands, 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 of
health, sanitation, etc.

The NUHM has a special emphasis would on improving the reach of health care
services to these vulnerable among the urban poor, falling in the category of
destitute, beggars, street children, construction workers, coolies, rickshaw
pullers, sex workers, street vendors and other such migrant workers. It is a
welcome step that this support would be through city specific strategy with a cap
of 10% of the city budget.
Essentials

There is need to conduct a mapping of such populations in cities since most of

such populations, such as street children, construction workers etc, have never
been 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, hence
partnerships with such NGOs in ensuring reach of NUHM programmes is
essential.

Desirables

There is need for convergence of other programmes such as ICDS for street
children, SJSRY for construction workers, etc, with NUHM.

Key strategy - 9
Ensuring quality health care services

In India the quality of services provided to the population by both public and
private sectors remains largely an unaddressed issue. The for-profit private
sector accounts for a substantial proportion of health care in India (50% of
inpatient care and 60-70% of outpatient care), but has received relatively less
attention from the policy makers as compared to the public sector. The private
sector health care delivery system in India has remained largely fragmented and
uncontrolled, and there is a clear evidence of serious quality of care deficiencies
in many practices. Problems range from inadequate and inappropriate
treatments, excessive use of higher technologies, and wasting of scarce
resources, to serious problems of medical malpractice and negligence. Current
policies and processes for health care are inadequate or not responsive to
ensure health care services of acceptable quality and prevent negligence.

NUHM aims to ensure quality health services by a) defining Indian Public Health
Standards (IPHS) suitably modified for urban areas wherever required b) defining
parameters for empanelment/regulation/accreditation of non-government
providers, c) developing capacity of public and private providers for providing
quality health care, d) encouraging the acceptance and enforcement of local
public health acts d) ensuring citizen charters in facilities e) encouraging
development of standard treatment protocols.

Essentials
Current attempts at improving quality of health facilities such as IPHS for public
health facilities and National Accreditation Board for Healthcare Providers
(NABH) for private health facilities emphasize on physical standards, not on
processes and outcomes. This could be done through development of standard
treatment guidelines, care protocols, integrated care pathways etc.
As is in the case of accreditation which is voluntary in nature, other aspects of
regulation such as licensing of practitioners (e.g. doctors, nurses etc) and
regulation of health facilities should be made mandatory for all health facilities in
urban areas.

Desirables

Implementation of IPHS for urban public health services is a welcome step,

however the foremost action would be introduction of legislation mechanisms for
all public healthcare providers and personnel to conform to legislated minimal
requirements. These legislation mechanisms could include the elements of any
regulatory process include establishment of rules, its application to specific
cases, detection or monitoring violations and imposition of penalties on violators.
The reimbursement mechanisms for providers through urban insurance models
should be based on quality of services these providers render.

Conclusions

In the area of health, the Indian government (center and states) spends less than
1 percent of GNP for health, compared to an average of around 3 percent for all
developing countries, and more than 5 percent for high-income countries. The
National Common Minimum Program (NCMP) of the UPA government is
committed to increasing total public expenditure on health to 2-3% of GDP. The
fiscal resources for government for increasing investments in health can come
only through cuts in existing expenditures rather than increases in taxation as a
percent of GNP (Sachs & Bajpai, 2001). The same holds true for a nation-wide
program such as NUHM, where improved efficiencies through sound fiscal
management structures, local planning and governance structures, improved
managerial capacities especially at urban body levels, and involvement of
citizens, could ensure increased resource availability and proper implementation.

While the NUHM is a welcome introduction and its attempt to infuse funds into
practically defunct urban health services should be applauded. However, the
emphasis is on PPP and Health insurance, rather than understanding and
analyzing 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 primary
health care system followed by a referral system.
______________________________________
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