India: Supporting National Urban Health Mission

Sovereign Project | 47354-003

Summary

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.

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Project Name Supporting National Urban Health Mission
Project Number 47354-003
Country India
Project Status Approved
Project Type / Modality of Assistance Loan
Technical Assistance
Source of Funding / Amount
Loan 3257-IND: Supporting National Urban Health Mission
Ordinary capital resources US$ 300.00 million
TA 8899-IND: Strengthening Capacity of the National Urban Health Mission
Japan Fund for Poverty Reduction US$ 2.00 million
Strategic Agendas Inclusive economic growth
Drivers of Change Governance and capacity development
Knowledge solutions
Partnerships
Private sector development
Sector / Subsector Health - Health system development
Gender Equity and Mainstreaming Gender equity
Description

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.
Impact Improved health status of the urban population, particularly the poor and vulnerable, across India
Project Outcome
Description of Outcome Increased access to equitable and quality urban health system
Progress Toward Outcome
Implementation Progress
Description of Project Outputs

3. Capacity for planning, management, and innovation and knowledge sharing strengthened

2. Quality of urban health services improved

1. Urban primary health care delivery system strengthened

Status of Implementation Progress (Outputs, Activities, and Issues)
Geographical Location
Safeguard Categories
Environment B
Involuntary Resettlement C
Indigenous Peoples C
Summary of Environmental and Social Aspects
Environmental Aspects

An assessment is expected to ensure that the upgrading of urban primary health centers do not result in any adverse environmental impact.

[Potential environmental impacts of the program will not be significant or irreversible during the site specific activities, including construction and operations of the PHCs. The mitigation measures can be built into the program safeguard system. The program's initial categorization of environmental impacts is Category B.]

Involuntary Resettlement

An assessment is expected to ensure that the upgrading of urban primary health centers do not result in any adverse impact on involuntary resettlement or indigenous people.

[The program's initial categorization of social impacts is Category C. No adverse social impacts are expected or will be supported under the program.]

Indigenous Peoples

An assessment is expected to ensure that the upgrading of urban primary health centers do not result in any adverse impact on involuntary resettlement or indigenous people.

[The program's initial categorization of social impacts is Category C. No adverse social impacts are expected or will be supported under the program.]

Stakeholder Communication, Participation, and Consultation
During Project Design The development of National Urban Health Mission (NUHM) and Framework for Implementation by the Ministry of Health and Family Welfare involved extensive consultations across all levels of Government and civil society. The NUHM Technical Resource Group (TRG) further guided on key issues of reaching vulnerable sections of the society, main strategies and institutional design of NUHM, and organization of urban health service delivery and governance based on series of consultations with experts and a range of vulnerable urban poor groups and field visits to 30 cities. The ADB team also conducted stakeholder consultations and detailed field assessment of NUHM implementation in West Bengal, Madya Pradesh, and Tamil Nadu, which gave important insights into NUHM implementation challenges and capacity building requirements.
During Project Implementation For stakeholder participation, the NUHM emphasizes community participation and processes, reaching of vulnerable groups, and capacity building of stakeholders (urban local bodies, health workers, private providers, community structures, and functionaries of other related departments) in managerial, technical, and public health competencies
Business Opportunities
Consulting Services A total of 63 person-months, including 15 person-months of international and 48 person-months of national consultant are provided under the PPTA.
Procurement The procurement scope under the NUHM will include renovation of existing public health centers, construction of new public health centers, procurement of medicines, consumables, medical equipment, and ICT equipment and other office and laboratory facilities, engagement of consulting services for project and financial management, medical consultants, community workers, and NGOs. Procurement will be undertaken following the country procurement systems as spelt out in the General Financial Rules, 2005 (GFR) of the GOI and its amendments and the State Financial Rules/ Procurement Law/ Procurement Policy developed by the States within the frame work of the national GFR.
Responsible ADB Officer Hayman K. Win
Responsible ADB Department South Asia Department
Responsible ADB Division Human and Social Development Division, SARD
Executing Agencies
Ministry of Health and Family Welfare150 A Nirman Bhawan
New Delhi - 110 011
India
Timetable
Concept Clearance 25 Aug 2014
Fact Finding 18 Sep 2014 to 24 Sep 2014
MRM 11 Dec 2014
Approval 28 May 2015
Last Review Mission -
Last PDS Update 15 Apr 2015

Loan 3257-IND

Milestones
Approval Signing Date Effectivity Date Closing
Original Revised Actual
28 May 2015 28 Jul 2015 - 30 Sep 2018 - -
Financing Plan Loan Utilization
Total (Amount in US$ million) Date ADB Others Net Percentage
Project Cost 1,954.90 Cumulative Contract Awards
ADB 300.00 28 May 2015 0.00 0.00 0%
Counterpart 1,654.90 Cumulative Disbursements
Cofinancing 0.00 28 May 2015 0.00 0.00 0%

TA 8899-IND

Milestones
Approval Signing Date Effectivity Date Closing
Original Revised Actual
28 May 2015 30 Jul 2015 30 Jul 2015 30 Jun 2018 - -
Financing Plan/TA Utilization Cumulative Disbursements
ADB Cofinancing Counterpart Total Date Amount
Gov Beneficiaries Project Sponsor Others
0.00 2,000,000.00 0.00 0.00 0.00 0.00 2,000,000.00 28 May 2015 0.00

Evaluation Documents

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