India : Strengthening Comprehensive Primary Health Care in Urban Areas Program under the Pradhan Mantri Ayushman Bharat Health Infrastructure Mission

Health / Health system development

Between 1990 and 2017, India has seen substantial improvements in basic health indicators: life expectancy increased by 8.9 years to 67.8 for men and by 9.8 years to 70.2 for women. Maternal deaths per 100,000 live births declined 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 (TB) declined by 29% and malaria incidence by 76%. Despite these achievements, India is facing a double burden of disease: persistent communicable and emerging infectious diseases, and rising NCDs. India accounts for 27% of TB and 4% of malaria cases in the world, and also has the third largest number of people living with HIV. India also faces the spread of vector-borne diseases such as dengue and chikungunya. For COVID-19, India has reported over 8.2 million confirmed cases, second largest after the United States as of 2 November 2020. Despite the countrywide lockdown for over 50 days from 25 March 2020 and increased testing capacity (over 1.16 million samples per day) to detect and isolate cases, COVID-19 cases are still increasing at an alarming rate. In addition, demographic transition due to increased life expectancy and changing lifestyles from rapid urbanization have led to a rise in NCDs. Cardiovascular diseases, respiratory diseases, and diabetes are major NCDs in India that kill around 4 million Indians annually, and most of these deaths are premature. This epidemiological transition leads to the incremental number of NCD patients with disabilities, which poses a heavy financial burden on not only the health system but also on affected households. Given the ongoing COVID-19 pandemic, those with underlying conditions, particularly NCDs, are also at increased risk of mortality during hospitalization.

In 2018, 461 million or one-third of the total Indian population were living in cities, which is the second largest urban population in the world. The urban population is growing rapidly, and by 2050 will reach 877 million-almost two-thirds of the total Indian population. Urban populations grew faster than most cities' capacity to provide basic social services for all. Despite the common perception of easier access to health services in urban areas due to the large presence of private sector providers, health indicators of the urban poor are often comparable to or worse than those of the rural population. Full immunization among children aged 12-23 months is 57.7% for the urban poor compared to 61.3% for rural population. Anemic children are 62.7% among the urban poor compared to 59.5% in rural population. Most urban poor women do not seek preventive health measures: among urban poor women aged 15-49 years, only 20% have undergone cervical examinations; 9.3% have undergone breast examinations; and 10.3% have had oral cavity examinations. The NCD burden is higher in urban areas, and the urban poor are particularly vulnerable to communicable and vector-borne diseases due to congested and poor living and health conditions. The risk of COVID-19 spread is 1.09 times higher in urban areas and 1.89 times higher in urban slums compared to rural areas based on the results of the first sero-survey conducted nationwide. More than one-third (35%) of all COVID-19 cases in India are concentrated in 20 cities or districts.

However, the large number of urban poor cannot access these services due to financial constraints or out-of-pocket expenditures when they do access these services. Drugs and diagnostics services make up 75% of out-of-pocket expenditures, which could be avoided if services were availed of in public health facilities. The national health insurance scheme for the poor and vulnerable, Pradhan Mantri Jan Arogya Yojana, significantly increased financial access to health services. However, it is limited to secondary and tertiary care, which treat more severe conditions that require specialized knowledge and more intensive health monitoring. The public sector is also far less expensive and caters to the more vulnerable population groups. In addition to costs of health services, especially from the private sector, the poor and vulnerable population's access to primary health care in urban areas is hampered by poor quality of available services, their poor health-seeking behaviors, lack of information and awareness of health care options, constraints such as working hours, mobility, and other physical and social barriers. Women's access to primary health care is inadequate due to lack of empowerment and financial barriers: 63% of married women cannot take decisions related to their own health; and only 57% of women in urban areas can freely visit a health facility alone. Further, limited availability of female doctors (17% of doctors) hinder women from seeking care.

To address the large gaps in urban primary health care, especially for the poor and vulnerable populations, the government launched the National Urban Health Mission (NUHM) in 2013, as a sub-mission of the National Health Mission (NHM). By 2019, NUHM had established over 4,500 functional urban primary health centers (UPHCs) across India, significantly improving urban population's access to maternal and child health care and implemented key mechanisms for urban health system governance and management. UPHCs have also played a crucial role in the COVID-19 response through surveillance, contact tracing, and test referrals. Overall, primary health care in India prioritizes a narrow range of services such as reproductive and child health services and selected communicable diseases. Currently, even a well-functioning primary health center provides a limited range of services that caters to less than 15% of all morbidities for which people seek health care. For other morbidities, people resort to local private care providers, distant and crowded district hospitals, or government medical college hospitals. Investment in primary health care is cost-effective and can reduce overall health costs. The public sector has also collaborated with the private sector in selected aspects of primary health care delivery such as contracting-in of specialist services, mobile medical units for improved outreach, biomedical waste management, etc. More recently, to further strengthen private sector engagement, some states have contracted out entire management and service provision of primary health service centers to the private sector, usually nonprofit entities. The UPHCs need further improvement in infrastructure, human resources, and availability of diagnostics and drugs. Outreach services also face challenges from high attrition of community health workers, inadequate community organizations, unreached pockets of vulnerable populations, and poor health-seeking behavior of the urban poor. Gaps in the health system become even more apparent during the pandemic, where significantly underfunded and patchy public health systems, coupled with large variations in quality and service delivery across states, pose challenges for India's disease containment strategy.

Impact the RBL Program is Aligned with

Equitable access to quality comprehensive primary health care services in urban areas improved in 13 states

Comprehensive primary health care services in urban areas strengthened

Support for improved health-seeking behavior increased

Health systems strengthened

1a. 3,596: Cumulative for 13 States

1b.

(i) cervical cancer: 2,849

(ii) breast cancer: 3,626

(iii) oral cancer: 3,625

(iv) diabetes: 3,629

(v) hypertension: 3,629

1c. Medicines available as per the guidelines in 3,630 HWCs (cumulative for 13 states)

1d. Consultations are being held with IDSP division to fix baseline and to obtain progress on timely reporting of notifiable diseases either manually or Integrated Health Information Portal (IHIP).

1e. Specialist services are being provided through part time specialists in facilities and through teleconsultation in the HWCs.

This indicator is not captured in the HWC portal or HMIS. Hence the data being obtained from the 13 states as of 31st March 2022 to establish the baseline (1,531 urban HWCs offering at least 3 specialist services) and thereafter the achievement shall be provided later.

2a. HWCs are providing outreach activities. The States are conducting health promotion activities as per health calendar however, the baseline as well as the source of data is currently being obtained from the States.

2b. as of June 2022:

(i) ASHA: Total trained in Universal Screening of NCD:

In Position= 37,972

Trained in NCD=34,194

Percentage: 90%

(ii) MPW trained in NCD (Total F+M):

Female position=11,062

Male position=1,201

Female trained=10,023

Male trained=689

Total In Position=12,263

Total Trained=10,712

Percentage: 87%

Percentage of MPW Female trained-93.5%

Percentage of women frontline workers (ASHA+MPW- Female) trained-91.75%

2c. 1356 urban HWCs out of 3596 operational urban HWCs (37.7%) have been integrated with Mera Aspatal application.

3a. Structure is being reworked. Under process.

3b. Revision of NUHM framework is currently under process. Relevant gender responsive issues/indicators shall be prepared for inclusion. CPHC guidelines revision is yet to be initiated.

3c. Detailed roadmaps for CPHC are yet to be developed for states. Plan for implementing CPHC in urban areas in all states/UTs being included in the two year Project Implementation Plans (PIPs) for 2022-24

3d. Innovations under NUHM being implemented by states/UTs. 5 innovations received from 4 (out of the 13) States.

3e. Over 90% of UPHCs in one state assessed for Kayakalp; 54% of UPHC-HWCs in the 13 states completed self- and peer assessments for Kayakalp

3f. Sex disaggregated data in analytical reports wherever available is being utilized. For example, sex disaggregated data of OPD is being used by States for improving the utilization of urban health facilities (UPHC-HWCs) of women which is an important indicator in key deliverables of State Programme Implementation Plan (SPIP)

3g. Development of Institutional capacity development plans shall be initiated soon.

3h. Not yet due

3i. Not yet due