The Third Tier of Government Can Bolster Urban Health

Context: A greater role for local bodies can boost urban healthcare but administrative challenges need to be addressed.

Case studies:

• Argentina’s Plan Nacer, where city governments receive funds from the national health ministry based on population coverage.
  • The probability of low birth weight, a key health outcome, fell by 23% in Argentina.
• In 1996, Kerala granted autonomy to local governments to develop and implement expenditure plans based on local needs.
  • Accompanied by training and the transfer of 35-40% of the state government’s development budget.

Issues with the urban healthcare system in India:

• Less focus on urban health: Union government expenditure on urban areas was ?850 crore in 2019-20, compared to nearly Rs 30,000 crore for rural.
• Lack of primary health infrastructure: Against a norm-based target of 9,072 urban primary health centres (UPHCs), only 5,190 are operational.
  • Absence of urban sub-centres (SCs): Most states do not have urban sub-centres (SCs), people’s first point of access for healthcare services. There are only 3,000 urban SCs compared to over 150,000 in rural areas.
• ‘Over-hospitalization’: Urban areas suffer from ‘over-hospitalization’ of basic care.

Government initiatives to improve urban healthcare:

• Budgetary provisions: The 2021-22 budget provides Rs 5,000 crore for urban primary health through urban local bodies (ULBs).
• Grants from 15^th Finance Commission (FC): Nearly 40% of 15th FC’s health grants—worth Rs 70,000 crore over a five-year period (2021-22 to 2025-26)—are for urban areas. 

Need of decentralized healthcare through ULBs: over state government-led model.

• Will lead to better understanding of needs: Municipalities are best placed to understand the needs of the population in their wards and they are closer to the communities they serve.
• ULBs are more responsive: To the demands of citizens, given their greater direct accountability and accessibility.

Way forward:

• Improvise the technical and managerial capacity of ULBs: To utilize the grants effectively, by establishing a state-level project management units (PMUs) to assist ULBs.
  • Ensure sustained support to ULBs: Building and running a health system requires capacities in governance, contracting, procurement, monitoring, and evaluation.
• Bring adequate clarity on roles of ULBs: Healthcare is not explicitly mentioned in the 12th Schedule (contains the powers, authority, and responsibilities of Municipalities), only public health is.
  • Eighteen categories of functions—listed in 12th Schedule of Article 243W—could be devolved to municipalities at the state’s discretion.