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India: Strengthening Comprehensive Primary Health Care in Urban Areas

Sovereign (Public) Project | 53121-001 Status: Proposed

India is one of the fast-growing large economies. Its growth averaged over 7% between 2015 and 2019 which has been fueled by strong expansion of services and industrial manufacturing sectors as well as robust food supply and agricultural production. Over the past three decades, India has seen substantial improvement in key health indicators. Between 1990 and 2017, life expectancy increased by 8.9 years to 67.8 for men and 9.8 years to 70.2 for women. The number of maternal deaths per 100,000 live births reduced from 408 to 160 in the same period. The greatest achievement has been the reduction of under-five mortality from 111 to 42 deaths per 1,000 live births. Tuberculosis incidence reduced by 29%, and Malaria incidence reduced by 76%, too.

Project Details

Project Officer
Chin, Brian South Asia Department Request for information
Country
  • India
Sector
  • Health
 
Project Name Strengthening Comprehensive Primary Health Care in Urban Areas
Project Number 53121-001
Country India
Project Status Proposed
Project Type / Modality of Assistance Loan
Technical Assistance
Source of Funding / Amount
Loan: Strengthening Comprehensive Primary Health Care in Urban Areas
Ordinary capital resources US$ 500.00 million
TA: Strengthening Comprehensive Primary Health Care in Urban Areas
Technical Assistance Special Fund US$ 2.00 million
Strategic Agendas Inclusive economic growth
Drivers of Change Gender Equity and Mainstreaming
Governance and capacity development
Knowledge solutions
Partnerships
Private sector development
Sector / Subsector

Health / Health system development

Gender Equity and Mainstreaming Gender equity
Description

India is one of the fast-growing large economies. Its growth averaged over 7% between 2015 and 2019 which has been fueled by strong expansion of services and industrial manufacturing sectors as well as robust food supply and agricultural production. Over the past three decades, India has seen substantial improvement in key health indicators. Between 1990 and 2017, life expectancy increased by 8.9 years to 67.8 for men and 9.8 years to 70.2 for women. The number of maternal deaths per 100,000 live births reduced from 408 to 160 in the same period. The greatest achievement has been the reduction of under-five mortality from 111 to 42 deaths per 1,000 live births. Tuberculosis incidence reduced by 29%, and Malaria incidence reduced by 76%, too.

Despite these achievements, India is facing double burden of disease: persistent communicable and emerging infectious diseases; and rising noncommunicable diseases (NCDs). India accounts for 27% and 4% of global tuberculosis malaria cases. It also has the third largest number of people living with HIV in the world. India reported 106,749 confirmed cases of coronavirus disease (COVID-19) as of 20 May 2020. Despite the country being under lock-down for over 50 days and increased testing capacity (over 100,000 samples per day), COVID-19 cases are still increasing at an alarming rate. India also faces the spread of dengue and chikungunya, both transmitted by the Aedes mosquito. The annual number of new dengue cases is estimated at more than 30 million, while the number of suspected and confirmed chikungunya cases is over 65,000 and have increased by 390% over the last 3 years. The advent of rapid urbanization and changing lifestyles and environment has led to a rise in NCD. Cardiovascular diseases, respiratory diseases, and diabetes kill around 4 million Indians annually, and most of these deaths are premature, occurring among Indians aged 30 70 years.

Project Rationale and Linkage to Country/Regional Strategy

PHC is critical element in addressing the existing and emerging health issues in urban areas in India. However, availability of services at PHC level continues to be a challenge mainly due to limited availability of drugs and diagnostics, high level of vacant positions, absenteeism of key human resource personnel, lack of specialty staff, and also limited or poor-quality infrastructure. Data shows that because of limited availability of drugs and diagnostics at public health facilities, a majority of the out-of-pocket expenditure, as much as 75%, is attributable to this. Further, an audit survey of selected health facilities across 29 states revealed that key equipment and drugs as per the essential list were not available in several of the PHC facilities. In terms of availability of human resources only 71% of medical officers, 50% of specialist, 67% of staff nurse, 79% of auxiliary nurse midwives and 75% of pharmacists are currently in position at urban PHCs. Demand side interventions and outreach services also face persisting challenges with high attrition of accredited social health activist workers and limited operationalization of Mahila Arogya Samitis (MAS). Exacerbating the situation is the poor health seeking behavior of the urban poor which is largely influenced by morbidity pattern, income level, overcrowding, personal and cultural practices, beliefs, and attitude toward healthcare providers. Women are also particularly vulnerable due to lack of empowerment and financial barriers to accessing health care: (i) 63% of the married women do not have decision making powers in matters related to their own health; and (ii) only 57% of women in urban areas have the freedom to visit a health facility alone. Further, the difficulty in accessing care from a female doctor might limit the willingness of women to seek care, with one study estimating that only 17% of doctors in India are women.

The National Health Policy (2017) recommended strengthening the delivery of PHC through the establishment of _Health and Wellness Centres_ (HWCs) as the platform to deliver comprehensive PHC (CPHC) and called for a commitment of two-thirds of the health budget to primary health care. For primary health care to be comprehensive, it needs to span preventive, promotive, curative, rehabilitative and palliative aspects of care. These include reproductive, maternal, neonatal and child health services; adolescent care services; management of national communicable disease programs; general outpatient services and minor ailments; screening, prevention, control and management of NCDs; common ophthalmic, ear, nose, and throat problems; basic oral health; elderly and palliative care services; emergency medical services including burns and trauma; and screening and basic management of mental health ailments. In February 2018, the government announced that 150,000 HWCs would be created by transforming existing sub-centers and primary health centers to deliver CPHC and declared this as one of two components of Ayushman Bharat or _Healthy India_ national initiative. The NHM, now in its 15 years of implementation, has supported states to create several platforms for the delivery of health care and priority public health programs, and expanded infrastructure and human resources for health towards strengthening primary and secondary care. While the delivery of CPHC through HWCs builds on existing systems, it will need change management and systems design at various levels, to reach its full potential. HWCs will be an essential component of the Indian health system towards achieving universal health coverage. A well functionating HWC requires several critical elements including (i) strong institutional capacity is key for urban health at central, state, municipal levels; (ii) expanded availability of services; (iii) well maintained infrastructure; (iv) availability of critical inputs to care such as human resources, equipment, diagnostics, and medicine; (v) improved quality of care including increased accountability, accreditation, and enforcement for quality assurance; (vi) effective referral mechanisms to establish continuum of care; (vii) detailed and updated patient record maintained through family health folders and health cards; (viii) effective community outreach resulting in increased health seeking behavior; and (ix) use of robust IT systems for data analysis and decision support.

Impact Impact the RBL Program is Aligned with
Outcome Equitable access to quality comprehensive primary health care services in urban areas improved in 12 states
Outputs Provision for comprehensive primary health care in urban areas strengthened
Geographical Location Nation-wide
Safeguard Categories
Environment B
Involuntary Resettlement C
Indigenous Peoples C
Summary of Environmental and Social Aspects
Environmental Aspects
Involuntary Resettlement
Indigenous Peoples
Stakeholder Communication, Participation, and Consultation
During Project Design
During Project Implementation
Business Opportunities
Consulting Services NA
Procurement NA
Responsible ADB Officer Chin, Brian
Responsible ADB Department South Asia Department
Responsible ADB Division Human and Social Development Division, SARD
Executing Agencies
Ministry of Health and Family Welfare
150 A Nirman Bhawan
New Delhi - 110 011
India
Timetable
Concept Clearance 22 Jun 2020
Fact Finding 10 Aug 2020 to 14 Aug 2020
MRM 14 Sep 2020
Approval -
Last Review Mission -
Last PDS Update 24 Jun 2020

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