Maharashtra is the second most urbanised state in India, with a high internal migration to large cities. It has the highest number of slums in the country.The increased urbanization in Maharashtra has also brought about increase in urban poverty. Though it is one of the richest states in the country (In 2004-05 current prices, Maharashtra’s GSDP of Rs 371,877 crore was 12 percent of the gross domestic product of India), it has the largest urban poor population (27% of urban population) among all states. This growth of urban poverty has almost doubled in the last 2-3 decades; from 24% to 45% between 1977 and 2000 (State Planning Commission, 2005). Urbanization of poverty was much faster in Maharashtra than in India.
The Gini coefficient ratio of consumption expenditure in urban Maharashtra is higher than the all India average and across 35 states/union territories of India, at 0.371 in urban areas is the eight highest . Religion wise incidence of poverty indicates that scheduled castes and scheduled tribes among Hindus, and Muslims in urban areas have a greater share of poor compared to their share in population.
Accompanying the rapid rate of urbanization and urban poverty has been the rapid growth of the population living in slums. Slums are characterized by poor-quality and overcrowded shelters, lack of public services and infrastructure such as piped water, sanitation facilities, garbage collection, drainage and roads, as well as insecure land tenure. The high cost of land tenure, and lack of affordable housing has seen most urban poor residing in illegal slums such as unrecognized squatter-settlements, pavements and urban fringes.
According to NSSO 52nd round around 63.5 % of the slums are un-notified in Maharashtra. In un-notified slums these public services and infrastructure are either non-existent or inadequately available. Lack of income resulting in inadequate diet reduces slum-dwellers’ resistance to disease, especially because they live in the constant presence of pathogenic micro-organisms.
Maharashtra has the largest number of urban health posts in India; however, a considerable number are not functional. Facilities are deficient and there is shortage of staff, equipment and drugs. Services are not uniform across cities.
- The urban health infrastructure needs to be revamped, with attention given to financing of urban health posts. The role of urban social health activist (USHA) is crucial to ensure universal access to services by the poor.
- There is need for a comprehensive referral system and increased inter-departmental and inter-sectoral co-ordination.
Universal access to health care in urban areas:
There is a clear need to combine various existing resources (including all public resources) in urban areas – including Municipal Corporation hospitals, State government hospitals, Medical college hospitals, Railway hospitals etc. There is a definite case to harness large scale ESI facilities and resources, and pool these in the UAHC system. Provision in urban areas would be by a combination of strengthened and integrated public hospitals, combined with ESI facilities and regulated trust and private providers. The concept of Urban Primary Health Care – as per the Krishnan commission needs to be actively explored.
Basic amenities to unrecognized slums and vulnerable populations– Along with improved provision of health services there is requirement of basic amenities such as access to clean drinking water, disposal of waste, drainage etc, for maintaining and improving one’s health. There is an inherent contradiction in not providing basic health, ICDS, drinking water, drainage and other services to unrecognized slums since the need would be greatest here. Policies and strategies need to be devised to ensure that the health services and basic amenities reach to those at the highest risk. In the urban context, these would include those living in unlisted slums, pavement dwellers, construction workers etc.A point of concern is the health of vulnerable populations such as street children, pavement dwellers, construction workers etc. These populations due to the harsh environments in which they live and work subject them to numerous health issues. The lack of identity due to lack of ration cards, BPL cards etc, makes it difficult or in most cases impossible for these populations to access government –supported schemes such as free or subsidized healthcare in public facilities, access to free PDS rations etc.
Re-classification of urban poor- While there has been some attempt over the past two decades to identify the poor in rural areas, even though very inadequately, in the urban areas, no serious attention has been given to the tasks of identifying the poor correctly. There is need for proper principles for identifying the urban poor unlike the current process of providing BPL cards which majorly looks only into the income aspects and its provision is highly influenced by corruption. These principles should be based on three filters, namely; social vulnerability, occupational categories, and place of residence (shelterless/dwellers of unauthorized slums/dwellers of authorized slums and residents of resettlement colonies). The proper identification of the urban poor is essential since the identification could be used to target government-supported subsidies in health, food and nutrition.By linking health services to supporting documentary proof , a system of exclusion rather than inclusion of the marginalized is followed.Eg. The Maharashtra state Health Insurance scheme for the poor( Rajeev Gandhi Jeevandayi Arogya Yojna) is only for Ration card holders . This is despite a state Govt. GR that ration card is for Ration thro the PDS only.
Inadequacy of Primary Health Infrastructure-One of the reasons for such poor health indicators among urban poor is the inadequate primary health infrastructure in urban areas of Maharashtra State. The problem is compounded by many posts remaining vacant for long periods of time.
Many of the primary studies conducted in slum areas of Maharashtra point out to the affect on health status of slum dwellers in Maharashtra due to lack of primary healthcare in slum pockets of urban cities.A major reason for the lack of public health infrastructure in Maharashtra State is declining trend of government contribution to the overall health expenditure.Though it is the mandate for municipal corporations is that one-third of their budget should be devoted to public health and medical relief, only about 17% of BMC’s core budget is devoted to health – Rs. 8 billion being revenue health expenditure and Rs. 1.75 billion being capital health expenditure in 2004-05 .
Coordination of urban health issues in cities– Building Co-ordination among Pubic and Private Urban Health Stakeholders: There are multiple urban health stakeholders including Health and Family Welfare Department, ICDS, ULBs, DUDA, NGOs, CBOs, donor agencies, professional bodies (IMA, IAP), formal and informal private practitioners, corporate sector, charitable organizations, employee state insurance and local resources such as schools. These stakeholders operate in isolation with little coordination. They can benefit greatly by sharing resources, information and expertise and avoiding duplication of efforts. This co-ordination can be brought about by the Mumbai Public Health department (MPHD) by creating a data base of various stakeholders and securing their active participation in policy.
Compulsory Accreditation of Public and Private Hospitals: The MPHD should create an independent agency for accreditation of hospitals in the city.
Close monitoring of free beds in trust hospital
NUHM Budget, utilization and implementation.- The resources that NUHM brings should add on to the existing commitment / resources of Urban self Governments. BMC budget should not be decreased due to NUHM budget. In fact NUHM should be additional to BMC budget. NUHM should carefully ensure access to health services to all with state taking larger responsibility. The Project Implementation Plans should be made public on the web so as to seek opinions and suggestion that would only enrich the Mission. Infrastructural development is one aspect but sustainable human resource development and availability is more important and needs more accountability on that front. Mapping and accordingly provision of services at various levels ( not piggy bagging on existing infrastructure) to prevent overcrowded tertiary level institution as the resources and expertise is concentrated. Sound responsive health information system should be in place for education and better management of health care need. Complete commitment for transparency and participation of people at various level. Convergence with other related departments like WCD, Social justice, etc. for better reach to the vulnerable and marginalised segments including children.
The Rs. 5,000 community health fund is extremely inadequate and in the absence of an SOP , it will lead to adhocism, biased decisions, corruption, local level dynamics which will not be healthy for the community .
Patients rights should be integrated in public health service delivery – capacities of Public health personnel needs to be built on this.
Social health security to the urban poor-
The poor coverage of any health insurance programme (currently only about 10% of the population are covered through any form of health security) and inadequacy of public healthcare system has made India a country where out-of-pocket expenditure for seeking healthcare constitutes to 72.0% of total expenditure on healthcare. Such a high level of spending on healthcare drastically affects the economic status of households. Various studies have pointed to the linkage between healthcare utilization and poverty levels in the country.
The source of financing healthcare is an important indicator which points to the impoverishment among households due to healthcare costs. Majority of the financing mechanisms are through household income/savings and borrowings (See Table below). This trend affects the poor and vulnerable much more since they lack access to formal banking or loans and are forced to borrow loans from moneylenders at exorbitant rates ( 3-5 % per month), as compared to rich or middle class who can access personal or loans from employer for financing their healthcare expenses.
Percentage Distribution of Total Household Expenditure on Inpatient and Outpatient care by source of finance in urban areas of Maharashtra 2004
Source of Finance (%)
|Household Income/Savings||Borrowings||Friends & Relatives||Others (Sale of assets)|
Source: NSSO 60th round unit level data
According to NCEUS (2007), the informal sector constituted 86 percent of the total workers in 2004-05. The NCEUS Report also points to the fact that around about 79 percent of this informal group lived on less than Rs 20 per day for consumption. Only about 0.4 percent of this informal group was receiving social security benefits like provident fund, and this proportion had not changed since 1999-2000.
The informal sector comprising about 70 percent of the urban workforce (NCEUS, 2007), accounts for an astounding 68 percent of total employment in Mumbai, have no legal protection of their jobs or their working conditions or social security and live in abject poverty. Incidence of poverty among unorganized workers at 20.5 percent is almost double as compared to their counterparts in organized sector which stood at 11.3 percent
Poverty Ratios of Workers by Industry and Sector, 2004-05
|Sector||Unorganized Sector||Organized Sector||Unorganized worker in Organized Sector||Unorganized Worker||Organized Worker||All workers|
Source: NCEUS, 2007
Health Care Financing
The challenge lies in creating an organized system of healthcare provision. This would involve strengthening primary healthcare services and allocating more resources to it. Setting up an appropriate referral system is critical for rationalizing resource use at secondary and tertiary levels.A major breakthrough will be needed in designing innovative financing mechanisms that, apart from rationalizing use of resources, also helps in raising new resources. User charges are regressive and promote inequity. In urban areas, with a larger workforce in the organized sector, it is easier to organize resources in a collectivized way, and people can contribute on the basis of capacity to pay, through some form of social insurance.
To support this reorganization, regulation of the health sector is most essential. Minimum quality standards of good practice have to be evolved. Standard treatment protocols have to be put in place and an accreditation system needs to be created. The best route to this is self-regulation and ethics in medical practice. Thus the onus lies on the medical profession to bring about this change, which will benefit not only the patient but also the professional.
All resources invested in urban healthcare deal primarily with curative services. Public health measures are grossly inadequate, resulting in poor hygiene and environmental health. Filth, pollution, epidemics, and unsanitary living conditions cause preventable health problems, leading to avoidable medical care expenditures.
A declining public healthcare system adds to the problems, especially for the poor. The decline is due to falling investments and declining expenditures in public health spending, largely a post-SAP phenomena. For instance Mumbai’s health budget, which was close to 30% of the municipal budget in the eighties, has declined to less than 15% presently.. Within the public health system there is pressure for privatization because of accumulating debt burdens. The private health sector is expanding rapidly and the corporate sector is also getting increasingly involved in providing healthcare. This has raised the cost of healthcare substantially. Even in public health institutions user charges have been raised substantially. This makes access to healthcare more difficult not only for the poor but also for the middle classes.. The private health sector is plagued by large-scale malpractice, unnecessary interventions and negligence, which has made private health care more risky and hence more unaffordable. The complete lack of ethics and self-regulation within the profession makes matters worse and has affected the status of the medical profession.
In Mumbai, there is an increasing tendency to directly access specialty services, and primary care is ignored. Even public health services give inadequate resources for primary care. For instance dispensaries and health posts in the BMC health budget get only 6% of the allocations. Dispensaries average 80 patients per day, which is a reasonable number, and shows that there is need to expand the dispensary infrastructure (surveys show that only 10-15% of OPD care is dealt with by the public system). Demand surveys show that people prefer public services provided they become more accessible. Setting up an appropriate referral system is critical for rationalizing resource use at secondary and tertiary levels.
Public health measures and environmental health issues need immediate attention and increased investments because they cause a large proportion of the ill health. In the long run such investments are more cost-effective.
Small-scale insurance schemes suggested by NUHM as a financing option cannot solve problems of health care financing. Tax-based provision, with modified social insurance for the organized sector (reformed versions of CGHS, ESI) and social security with tax-based subsidy for the unorganized sector should be the direction forward.Occupation-based group insurance strategies will play an important role in achieving universal coverage of health services.
NUHM puts great emphasis on public-private partnership for financing. However, no definite guidelines have been laid down for regulation of the private sector. Regulation, especially rationality of care, is important if NUHM is looking to PPP in order to solve the issue of financing.The funds allotted for NUHM are not adequate for the purpose of carrying out the planned activities. One way out of this could be to allot funds on a performance-based fashion, for cities that have a comprehensive plan in place.
Regulation of the health sector and quality standards in medical practice needs priority attention, under an accreditation system. While NRHM has evolved this for the public health system, the private sector is completely unregulated. Regulation can become a route for reining in the private health sector under a public domain through a financing mechanism based on pooled resources. NUHM falls into the trap of selective and targeted approach, which, history tells us does not work. Anything designed separately for the poor never does. Health financing for universal access and equity requires cross subsidy and hence can only work if everyone is part of the health scheme, and all resources for healthcare are pooled. NUHM requires a fresh strategic thinking.
Community Based Monitoring in the Urban Context:
There are some experiences from different urban areas in Maharashtra such as Mumbai, Pune and Nagpur which demonstrate the potential and possible strategies for community mobilisation on health issues, linked with improving community interface with public health services. These experiences need to be analysed with the help of the civil society organisations which have been involved in these initiatives, and the lessons could be used as an input for designing strategies for community action for health in context of NUHM in Maharashtra and even other states.
Concept of CBM as like in NRHM should also included in the NUHM and Budget provisions made proportionately.
If existing health centers and hospitals are not enough as per the population, then new hospitals and UHC need to be constructed, staffed and equipped under the NUHM. Otherwise whatever existing services will be renamed and shown under the NUHM.
With this background, some major forms of Community action for Health in context of NUHM which could be considered may be as follows:
- Organising campaigns for widespread awareness of Health entitlements and programmes, emphasizing outreach services and availability of free services at various levels in the public health system.
- Forming and orienting Urban locality based health committees, which would definitely include women but may not be exclusively limited to women .
- Forming participatory Hospital development committees / RKS for urban hospitals and Urban PHCs, with representation from all Locality based health committees which are served by the particular facility. Regular meetings of these HDCs / RKS would help resolve various issues pointed out by community representatives.
- Regular (say once in six months) collection by Locality based health committees of community feedback on experiences of public health services. This should include both group discussions and interviews of individual beneficiaries like women who have undergone deliveries in recent months, mothers of infants, patients with chronic illnesses etc.
- Periodic participatory dialogue events (Jan Samvads) at Health facility level, involving Health committee members, Health officials and providers and local elected representatives. Information on community feedback along with suggestions for improvement in quality and increasing coverage of services would be presented by Health committee members. Such dialogues at Urban PHC level may also cover the quality and coverage of outreach programmes in various localities like immunization, ANC etc.
- Integration of these community accountability and participation activities with community oversight and involvement regarding ICDS and drinking water services, which need to be dealt with in a combined manner. There is now emerging experience of Community based monitoring of ICDS services in slum localities of Nagpur and Mumbai cities which could be taken into account while developing such approaches.
- Formation of city / town level monitoring and planning committees which would include representatives of locality based health committees, CBOs and NGOs working on community health issues, elected representatives and urban Health officials. These committees would discuss broader issues and suggestions relevant to improving delivery of services in the town / city including infrastructure, staffing, medicine and supplies, budgetary allocations, implementation of various programmes etc.
An integrated approach to implementing such community action for health in urban areas may be initiated on a pilot basis in some cities / towns in each state in the coming year as part of the NUHM framework. Ensuring effective development of such a range of activities would require active facilitation during first few years, which may be done by civil society organisations with demonstrated experience of community mobilization on health issues and community based health activities in localities of various cities / towns.
Submission arising out of meeting NUHM delegates on Dec 15th 2013
By -Jan Swasthya Abhiyan (JSA) is the Indian circle of the People’s Health Movement, a worldwide movement to establish health and equitable development as top priorities through comprehensive primary health care and action on the social determinants of health. The Jan Swasthya Abhiyan coalition consists of several hundred organisations as well as a large number of individuals that have endorsed the Indian People’s Health Charter adopted in the year 2000..We are the Mumbai- Chapter of Jan Swasthya Abhiyan
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