In the past, governments have focused on rural health, exactly. This is evident in the costs under the National Health Mission (NHM), India’s primary public health and health care delivery vehicle. Central government spending on urban areas ₹850 crore in 2019-20 compared to almost 2015 ₹30,000 crore for rural areas. However, with the rapid urban population growth, the lack of government primary and preventive health infrastructure in urban India remains a challenge. Contrary to the standard-based target of 9,072 urban primary health centers (UPHCs), only 5,190 are operational. Furthermore, most states do not have urban sub-centers (SCs), making health services the first priority of the people. There are only over 3,000 urban SCs out of over 150,000 in rural areas.
As a result, four-thirds of the population receive primary health care at private facilities in urban areas, compared to two-thirds in rural areas. Urban areas also suffer from ‘over-hospitalization’ of primary care, which is ideally done in clinics. Furthermore, UPHCs, like their rural counterparts, are not suited to urban high-density settings and their specific epidemiological challenges. Kovid pointed out the need to focus on urban prevention and promotional health.
The government has shown political and economic will to solve this problem. 2021-22 provides the budget ₹5,000 crore for urban primary health care through Urban Local Bodies (ULBs) ₹1,000 crore NUHM budget. These allocations came from the 15th Finance Commission (FC) funds for primary health care for our third tier government. About 40% of the allocated health funds of the 15th FC are worth ₹70,000 crore over a five-year period (2021-22 to 2025-26) – for urban areas. Most of this money will be used to build urban health and care centers (HWCs).
But, why ULBs? Why not continue with the state government-led model? There are two reasons. First, municipalities are best placed to understand the needs of the population in their wards. They are close to the communities in which they work. Second, they are more responsive to the demands of citizens, due to their direct accountability and accessibility.
Experiences from Argentina and Brazil, as well as close home in Kerala, show that decentralization of health care is beneficial to ULBs. For example, Argentina’s plan is to receive funding from city governments based on Nazar-population coverage from the Ministry of National Health — which has had a positive impact. Low birth weight and health outcome decreased by 23% in Argentina.
FC grants to ULBs provide an opportunity to change urban health. However, two factors need attention. First, most municipal organizations do not have the technical and administrative capacity to utilize grants. Building and running a health care system requires competencies in governance, contracting, procurement, monitoring and evaluation. These are complex tasks that require constant support.
Part of the solution to that capacity challenge is to set up state level project management units (PMUs) to assist ULBs on technical and administrative matters. The PMU is responsible for facilitating design elements, developing and implementing contracts, and setting up a monitoring framework. Second, the law and governance framework on health distribution from state governments to ULBs is unclear. The 74th Amendment increased the autonomy of municipal governments. The functions of the eighteen categories listed in the 12th Schedule of Article 243W are assigned to the municipalities at the discretion of the State. One of them is public health. Municipalities can implement public health schemes if state governments agree. However, almost three decades after that amendment, most ULBs have had a limited role in health. The main reason is that state governments do not distribute that performance, lack of adequate role clarity in various health-related agencies, the poor financial condition of many ULBs and the low priority given to health. Furthermore, health care is not explicitly stated in the 12th Schedule; Public health only. Depending on the large inflow of funds from FC grants, state governments may be able to delegate greater powers to ULBs for health. It should be in line with HWCs’ comprehensive primary health care vision with a broader concept of public health. Otherwise, the money will sit idly by with ULBs due to lack of legislative clarity and lack of administrative capacity to implement it.
The Kerala experience offers lessons. In 1996, Kerala granted autonomy to local governments to develop and implement spending plans based on local needs. In addition, 35-40% of the training and state government development budget has been transferred to local governments.
As the total population of urban India is expected to grow by more than half by 2050, a strong health system is needed to ensure the well-being, resilience and productivity of the people. The Central Government has shown a determination to improve urban health through the Third Tier Government of India. Building ULB capacity, and fixing nuts and bolts of governance, financing and service-delivery is now important.
These are the personal opinions of the authors.
Nina Badgaiyan and Anurag Kumar are senior consultants and health economists in the field of health and nutrition, respectively, at the Nithi Aayog.