Govt plans Rs 7,000 cr urban health scheme, will use RWAs to handle Covid shock to cities

With about 10 cities accounting for half the 10 lakh-odd cases reported in India, the govt is looking to fast track a plan that mitigates the Covid crisis.

Workers install a cloth partition at the Covid-19 hospital in the Nehru Science Centre in Mumbai | Bloomberg

New Delhi: Stunned by the onslaught of the novel coronavirus disease (Covid-19) in cities, the health ministry is putting together an ambitious Rs 7,000 crore plan for urban health and wellness centres (HWCs), with a pivotal role envisaged for Resident Welfare Associations (RWA) in the public health framework.

About 10 cities account for half of the 10 lakh-odd cases that have been reported in the country so far.

While the scheme itself is a direct fallout of the pandemic, the unique feature of RWA participation is a direct lift-off from the way the associations have been roped in for everything, from compliance in masks and social gathering restrictions to access control for auxiliary domestic staff in colonies and apartments.

Each urban HWC will cater to a population of 15,000-20,000 with five Accredited Social Health Activists (ASHAs) and Auxilliary Nurse Midwives (ANMs) each apart from doctors, nurses and paramedics. These are different from both the HWCs being set up under Ayushman Bharat, many of which are refurbished sub-centres and primary health centres. They also differ from urban primary health centres that were planned under the 2013 National Urban Health Mission but never quite took form due to the change in government a year later.

RWAs to bridge urban folk and health workers

The urban health and wellness centres will perform public health functions, pave the way for better community engagement through ASHAs, ANMs and RWAs. They will also have specialists attending on a rotational basis on fixed days so that the centres function as polyclinics too.

“The plan to rope in RWAs came from the way they have played a crucial role in the Covid strategy — they are vigilant, they know the community and have some amount of influence over them. The bottomline is that people in highrises and posh colonies will never allow ASHAs and ANMs to enter and have the conversation that they need to have to go about their work. RWAs would have that access. ASHAs and ANMs would perform that function in urban slums,” explained a senior government official.

ASHAs and ANMs are frontline health workers that were envisioned as the cogs of the National Health Mission in their knowledge and access to the community, but that model never quite took off in urban areas.

Under the proposal being drawn by the health ministry, every urban primary health centre (PHC) that is supposed to cater to a population of 50,000, will have two urban HWCs under it.

India currently has 4,581 urban PHCs, which is about half of what was originally planned. Each of these have two ASHAs and ANMs. Of the total 80,000 posts sanctioned for ASHAs in urban areas, 62,000 are in place, while all 17,000 sanctioned posts of ANMs are currently full.

For the first phase, 10,000 urban health centres are being planned under the Atmanirbhar scheme, which envisages investment in “grassroots” health institutions in urban and rural areas.

“As per our initial calculations, each urban health and wellness centre will cost Rs 70 lakh per year including establishment costs, salaries etc. Among the other things that are planned in the social sector arm of the self sufficiency plan are pathological laboratories and infectious disease wings in district hospitals.

Urban health workers missing, cities fold under viral load

In the initial days of the pandemic, when coronavirus was still a problem only in Wuhan and even later when the first countrywide lockdown was announced, one of the primary concerns in the corridors of power had been the lack of health infrastructure in rural areas. Given the mass return of migrants to their hometowns, administrations were worried about whether the spread of the disease in more remote locations could be handled at all.

That is partly what triggered Prime Minister Narendra Modi’s diktat: “Jo jahan hain, wahi rahiye (stay where you are)” in his 24 March address to the nation, say top sources in the government.

However as the pandemic progressed, it was the cities that started buckling. Delhi, Mumbai, Pune, Chennai, Bengaluru, Ahmedabad, Kolkata, Hyderabad, Guwahati and Thane — these cities accounted for an overwhelming number of cases, leading to the health ministry realising they had very few urban health workers to conduct contact-tracing operations at the scale that was needed. As the situation became desperate, the police in many states performed the public health messaging and community engagement functions, leading to allegations of police brutality.

To mitigate all of this, the government intends to fast track the plan for urban health centres, sources said.

National Urban Health Mission fails to take off

Over the last four months, the health ministry, which kept sending teams to the worst-hit states, received this consistent feedback — that there was a lack of community health workers in urban areas, government officials say.

In 2013, the Union cabinet had passed a proposal for the National Urban Health Mission (NUHM) for urban areas as a sub mission under the National Health Mission. It would replicate and modify the highly successful National Rural Health Mission that brought primary care to the rural areas through a three-tiered mechanism of sub centres, primary health centres and community health centres.

Th NUHM envisaged one Urban Primary Health Centre (U-PHC) for every 50,000-60,000 population, one Urban Community Health Centre (U-CHC) for five to six U-PHCs in big cities, one ANM for a population of 10,000 and one ASHA for 200-500 households. To be implemented in 779 cities across the country and reaching an estimated 8 crore people, the targets for NUHM were reduction in maternal and infant mortality rates, access to reproductive health care and most crucially in the present context, convergence of all health related interventions.

The scheme was never officially called off but it was never completely implemented either after 2014 when the first Modi government came to power, resulting in gaps in the establishment of UPHCs.

It was mostly states which took the initiative while the Centre moved on to the ambitious health insurance programme, Ayushman Bharat, that was first mooted in 2016 but took off in 2018.