India has made good progress in achieving health outcomes over the last decades, but the urban poor have generally not benefitted. India is urbanizing rapidly, and the urban poor, estimated to number around 77.5 million, are one of the country's fastest-growing and most vulnerable population segments. They face harsh living conditions and have limited access to basic health care, resulting in a disproportionate burden of ill health. For example, the majority of urban poor women delivered their babies at home. Almost 60% of urban poor children below 1 year of age missed total immunization compared to the urban average of 42.4%. The under-five mortality rate among urban poor was 72.7 per 1,000 live births compared to the urban average of 51.9. Many are also migrant workers with informal status, which limits their access to basic public services and welfare programs.
The delivery of health services in urban areas is sub-optimal and fragmented. Past interventions have tended to be in the form of vertical programs focusing on particular diseases, rather than investments made to strengthen broader urban health systems. Urban primary health facilities are limited in number with weak referral linkages, underutilized, vary in norms and quality, and have limited scope of services, such as in community outreach and health promotion. The major proportion of curative primary care occurs at secondary and tertiary levels, leading to inefficiencies and overcrowding of these centers. Financial protection and prevention of further impoverishment of the poor and near-poor is a key concern, given that a major part of total health expenditures is paid out-of-pocket to private providers.
Private health providers dominate in urban areas. However, the large number of urban poor cannot afford these services, and the private health sector's contribution to primary health care has been minimal. The enabling environment for private sector engagement is limited in the health sector, due to inadequate regulatory mechanisms and management capacity. Moreover, health in the urban context is affected by multiple physical and social environmental factors and access to health services. For example, diarrhea a leading cause of death among children in India is clearly correlated with poor water, sanitation, and hygiene practices. More attention is therefore required to promote integrated urban planning and convergence across key sectors that affect urban health.
As a policy response, in May 2013, the Government of India launched the NUHM to strengthen health service delivery in urban areas. The NUHM builds on extensive stakeholder consultations and the successful experience of the National Rural Health Mission (NRHM), which started in 2005. The NUHM and the NRHM are sub-missions of the National Health Mission (NHM) under the Government's Twelfth Five Year Plan. As a core strategy, NUHM will enhance the public health system infrastructure by establishing a network of urban primary health centers (UPHCs) covering all cities with a population above 50,000. The UPHCs, linked with community outreach and referral services, will expand the access of the urban population to health services, and strengthen primary health care in urban areas. Given that urban health is a new priority for the Government of India, NUHM requires strong support at all levels to gain critical momentum and to effectively tackle evolving challenges unique to the urban context. In October 2014, the Government of India also introduced the Swachh Bharat Mission (Clean India Initiative) to provide universal access to sanitation facilities in urban areas. Ensuring coherence and convergence of the NUHM and Swachh Bharat Mission will be crucial to attain the desired health outcomes. Building on the health sector gains, the Government of India plans to progressively move towards universal health coverage (UHC) under the Twelfth Five Year Plan. Success of the NUHM will be critical to the UHC agenda in urban areas, as UPHCs are expected to facilitate referrals and insurance coverage for the urban poor.
|Project Rationale and Linkage to Country/Regional Strategy
||The program is in line with the priorities of the India country partnership strategy, 2013 2017, which seeks to reinforce India's efforts towards inclusive growth. The program is also aligned with the Midterm Review of Strategy 2020, which includes an increased focus on health sector operations and moving towards UHC. The results-based lending (RBL) modality is appropriate for the program because NUHM has (i) a well-defined program and an implementation framework and (ii) adequate systems in fiduciary management, safeguards, and M&E, as per the due diligence assessments. RBL will further strengthen NUHM's focus on and accountability to critical results, rather than focusing on inputs and transactions. The Government of India will take measures to improve NUHM systems further.