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Urban Health And Universal Health

Coverage The Indian Context

By: Sonalini Khetrapal, Health Specialist
Disclaimer: The views expressed in this paper/presentation are the views of the author and do
not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board
of Governors, or the governments they represent. ADB does not guarantee the accuracy of
the data included in this paper and accepts no responsibility for any consequence of their use.
Terminology used may not necessarily be consistent with ADB official terms.
SDG 3.8
Achieve universal
health coverage,
including financial risk
protection, access to
quality essential
health-care services
and access to safe,
effective, quality and
affordable essential
medicines and
vaccines for all
Moving towards UHC
To move towards filling more of the larger cube from prepaid and pooled funds

Increase the proportion of a population

that can access essential quality health
Decrease the proportion of the population
that spends a large amount of household
income on health

Pre-paid and pooled funds

Taxes funding budgets for direct provision
Taxes subsidizing people into
national health insurance systems
Compulsory contributions (mostly from
Formal sector workers
Voluntary contributions
Health Inequity in India

In India, individuals with the greatest need for health care have
the greatest difficulty in accessing health services

Despite being the fourth largest economy in the world, India is

near the bottom of the U.N. Human Development Index and
healthcare inequities contribute greatly to Indias low standing

Types of inequities that exists in India Income, Education,

Gender, Region, Religion and caste, Occupation
Inequalities in under five mortality

India Poor Rich No Education Rural Urban Girls Boys

Published studies on health
inequalities between 1990 and
2016 by country of lead author
Conceptual model for understanding
challenges to equity in health care
Framework for
Health Inequalities in Urban Poor

Health Risks

Urban Poor

Source: Elsey et al. Public Health Risks in Urban Slums: Findings of the Qualitative Healthy Kitchens Healthy Cities Study in
Kathmandu, Nepal
Rural-Urban transition
As the world becomes increasingly urban, the center of gravity is moving to South Asia
Region accounts for 5 of the worlds 12 biggest urban mega cities - Mumbai, Delhi,
Kolkata, Dhaka and Karachi
45% of the population lived in urban areas in 2010, this figure is projected to increase
to 56% in 2030 and to 64% urban in 2050
46 %

United Nations projections

31 %
28 % Percent

for 2030
population living in
Urban area

377 Million
286 Million

2001 2011 2030

Source: Gupta et al. Urban growth and governance in South Asia; Census of India 2011.
Slums in India: the urban poor
17% of urban India lives in slums (13.7

Rapid unplanned urbanization can not

cope with the growth-2% National; 4% City;
6% Slum

Urban sector contributes 60% of GDP

Informal sectors contribution to non

agricultural GDP is 45%
Factors for Increased Vulnerability
Inadequate Infrastructure: The speed of urbanization has outpaced the
ability of governments to build essential infrastructure, causing unsafe
water, poor sanitation, traffic injuries, etc

Income disparity: A Large percentage live in overcrowded and life-

threatening conditions

Air pollution: WHO estimates that 1.5 billion urban dwellers face levels of
outdoor air pollution that are above the maximum recommended limits

Limited health access: Insurance Coverage is low

The extent to which [the countrys] health
system can provide for this large and growing
city-based population will determine the
countrys success in achieving universal health
coverage and improved national health
National Urban Health Mission
ADB Support
National Urban Health Mission
Approved on May 1, 2013 as a sub-mission of the National
Health Mission to strengthen the primary health care system in
cities & towns

People living in listed, unlisted slums and

other low income neighborhoods

Other vulnerable population such as

homeless, rag-pickers, street children,
Cities/ towns District
rickshaw pullers, and other temporary Headquarter towns
with population
migrants above 50,000
with population
between 30 50,000
Creation of new facilities
Rationalization and strengthening existing urban primary health structures

Deployment of MOs, Paramedical Staff at U-PHCs / U-CHCs, Engagement of ANMs

Selection of ASHAs and Formation of MAS

Involvement of ULBs in planning, implementation and monitoring of the program

Convergence with all National Health Programs and other Ministries

Capacity building of ULBs/ Medical and Paramedical staff/ASHA, MAS

Use of ICT For better service delivery, improved surveillance and monitoring
NUHM and ADBs Health Support in India
ADB and the GoI have signed a $300 million loan to support NUHM
Funds will be disbursed over subject to - more births in health facilities,
increased immunization rates, establishment of Primary health care,
implement Quality Assurance, innovation & partnerships, etc.
Capacity building technical assistance of $2 million, financed by the Japan
Fund for Poverty Reduction
Significant capacity building and mechanisms for learning and innovation
are also in-built to enhance NUHM systems, management capacity, and
implementation processes
Loan from ADBs Ordinary Capital Resources has a 20-year term & an
interest rate in accordance with ADBs LIBOR-based lending facility
ADB Organized Field visits during
Urban Health and UHC meeting in Manila (2017)

ADB facilitated the Government of India Team from

Urban Health to visit the field and share experiences with
the Philippines health sector team.

The India team visited PhilHealth - to learn and

exchanges experiences in comparison to India's RSBY

Visited urban and semi urban health centers to review

the health system - To study challenges and strengthens
in delivery of services
Progress of NUHM
NUHM Progress
Planning and Mapping Human Resources & Infrastructure
About 2/3rd staff is already in position
81% Cities completed Mapping of Urban
80% (54344) ASHAs engaged
Health facilities

Amongst existing U-PHCs, 91% are

Cities completed Mapping of operationalized and amongst 461
87% Urban Slums
newly approved, 30 are functional and
remaining 343 under construction
Cities completed Vulnerability
49% Mapping 26 Urban CHCs are also under
construction and 7 would be soon
NUHM - Financial Progress
NUHM in India since inception (2013-14, 2015-16 and 2016-17)
Overall Utilization is 52%
Rs. in crore

Total Releases Proportionate State Total Expenditure

Total expenditure is based on audited Expenditure from 2013-14 to 2015-16 and for F.Y. 2016-17 is
updated till 4th quarter (provisional)
Rashtriya Swasthya Bima Yojna
Voluntary Health Insurance Scheme for Below Poverty Line
(BPL) workers in the unorganised sector and their families
It is based on Public Private Partnerships model
RSBY became operational from 1st April 2008
Implementing Agency
Central Government: Ministry of Health and Family Welfare
State Government: State Nodal Agency
Based on cashless transactions through smart cards
Total benefit of up to INR 30,000 per family
NUHM and RSBY through same lens


Connect NUHM and RSBY

Primarily Moving from vertical approach
Centrally towards to integrated one
Sponsored UHC More cost effective & efficient
Easy to monitor and evaluate
Targeted Engagement
of Private
for Poor Sector
Thank You