NATIONAL URBAN HEALTH MISSION

DR SUBRAHAM PANY

Department of Community Medicine.Institute Of Medical Sciences & SUM Hospital.

INTRODUCTION

The NUHM as a sub-mission of National Health Mission (NHM) has been approved by the Cabinet on 1st May 2013.

Census of India defines urban areas as:1.all areas with a municipality, corporation or notified area

committee. 2.place satisfying the following three criteria simultaneously. A minimum population of 5,000At least 75% of male working population engaged in non agricultural pursuits

A density of population of at least 400 per sq. km.

URBANIZATION AND

PUBLIC HEALTH

BACKGROUND There has been a considerable rise of urbanization in the country over the last decade.

At present, rural population in India is 68.84% (down from 72.19% in 2001 Census) as against 31.16% urban population.

From census 2001 to census 2011 Urban population has increased from 28.6 to 37.7 crore.

2-3-4-5 SYNDROME…???All-India population growing at 2 %, urban population at 2.75 %, large cities at 4 % and slums at 5-6 %.

As Per UN Projections, If Urbanization Continues At The Present Rate, Then 46% Of The Total Population Will Be In

Urban Regions Of India By 2030.

URBANIZATION IN INDIA 1951 - 2026Ur

ban

Popu

latio

n (in

m

illion

)

Percentage to total population

Urban growth has led to rapid increase in number of urban poor population.

Many of whom live in urban slums and other squatter settlements.

Despite the supposed proximity of the urban poor to urban health facilities their access to them is severely restricted.Overcrowding of patientsIneffective in outreach and referral system Lack of standard and norms for urban health

care delivery system, Lack of information & assistance to access

modern health care facilities, Lack of economic resources.

PROBLEM STATEMENT…More than 2 million births annually amongst urban

poor; around 56% deliveries of them taking place at home.

U - 5 Mortality at 72.7% among urban poor is significantly higher than the urban average of 51.9%.

60% urban poor children do not receive complete immunization compared to 58% in rural areas.

About 47.1 % urban poor (<3 children) are under-weight as compared to 45% of the children in rural areas.

About 59% of the woman (15 - 49 age group) are anemic as compared to 57% in rural India.

Despite availability of govt & private hospitals the urban poor prefers home delivers. Social exclusionLack of information and assistanceExpensive private healthcare facilitiesPerceived unfriendly treatment at government hospitals, Emotionally securer environment at homeNon-availability of caretakers for other siblings in the event

of hospitalization

• Poor environmental condition in the slums along with high population density makes the urban poor vulnerable to Systemic diseases. • Slums have high density of vector born diseases (VBDs)

A HIGHLIGHT ON ENVIRONMENTAL CONDITION

•According to National commission on Macro environment & Health report on Urban health of India

Cases of CHD will continue to riseLoad of diabetes cases will rise from 2.6

crores in 2000 to 4.6 crores by 2015.

01/05/2023 14

Vulnerable groups

MOREOVER….“Crowded out” because of the inadequacy of the urban public health delivery system.

Ineffective outreach and weak referral systemLack of standards and norms for the urban health delivery system.

Norms for urban area primary health infrastructure were not part of the NRHM proposal……

……..limiting the basic health infrastructure in urban areas, under the NRHM.

INVENTORY MISMATCH…..Further, no systematic investments and efforts have

been made to improve health care in urban areas.There has been a history of underinvestment with a

project based approach instead of comprehensive strategy.

Public Health Network in urban areas is inadequate and functions sub optimally with a lack ofManpower, Equipments, Drugs, Weak referral system and In-adequate attention to public health.

SO…….HERE WE ARE….Recognizing the

seriousness of the problem, urban health was taken up as a thrust area for the 12th Five Year Plan.

The National Urban Health Mission (NUHM) was launched as a separate mission for urban areas with focus on slums and other urban poor.

THE NUHM WOULD HAVE HIGH FOCUS ON:

Urban Poor Population living in listed and unlisted slumsAll other vulnerable population such as

Homeless, Rag-pickers

Street children Rickshaw pullers

Construction and brick and lime kiln workers Sex workers

Other temporary migrants.Public health thrust on sanitation, clean drinking water,

vector control, etc.Strengthening public health capacity of urban local

bodies.

SLUMS: THE FIVE DEPRIVATIONS

The United Nations Human Settlements Programme (UN-Habitat) defines a slum household as one that lacks one or more of the following:

Access to safe water

Access to improved sanitation

Security of tenure

Durability of housing

Sufficient living area

SLUMS: CENSUS 2011 DEFINITIONConsists of all cluster of 20-25 households or more with the following criteria:

Roof material using any material other than concrete.

Potable water source not available within the premises of the house.

Latrines not available within the premises of the house.

Absence of drainage or open drainage.

Slums

WHAT WE ARE UP TO…???

The NUHM therefore aims to address the health concerns of the urban poor.

Facilitating equitable access to available health facilities

Strengthening of the existing capacity of health delivery

The existing gaps to be filled up through partnership with NGOs & Local bodies.

Planning process to undertake large scale community level activities.

GOALSFacilitation of:

Equitable access to quality health care.Partnerships with NGOs Community based risk pooling and insurance mechanism with the active involvement of the urban local bodies.

Synergizing the mission with the existing programmes having similar objectives to NUHM.

TARGETS UNDER NUHM IMR: 30/1000 live births by 2015MMR: 1/1000 live births by 2015MALARIA: 50% reduction in mortality by 2015KALA AZAR: 100% reduction in mortality & elimination by

2015FILARIASIS: >80% coverage of by Mass drug administration

with DECDENGUE: 50% reduction in mortality by 2015.CHIKUNGUNYA: control of outbreaks & morbidity.T.B: 85% cure rate to be achieved through DOTS.LEPROSY: reduction in prevalence to less than 1 per 10,000

population.

COVERAGEAll 779 cities with >50,000 population. All the district and state headquarters

(irrespective of the population size). Urban areas with < 50,000 population

to be covered by NRHM.So far many tentative measures have

been initiated to ensure that there is no duplication of services.

CONT….In cities, District Health Societies will be responsible for NUHM implementation.

Flexibility - given to statesIn the 12th Plan period NUHM and NRHM will be separate programmes……

…….may be merged in the 13th Plan period or later.

BUDGET ALLOCATION

Budget allocation in the 12th Plan period is approximately Rs.30,000 Crores.

The Centre-State funding pattern will be 75:25 for all the states. 25% state contribution shared between states and the Urban Local Bodies.

For calculation, it is assumed that state share would be 15% and ULBs share 10% approximately.

CORE STRATEGIESImproving the efficiency of public healthPromotion of access to improved health care at household levelStrengthening public health through preventive and promotive actionIncreased access to health care through community risk pooling and

health insurance modelsIT enabled services and e-governanceCapacity building of stakeholdersPrioritizing the most vulnerable amongst the poorEnsuring quality health care services.

INSTITUTIONAL FRAMEWORKThe NUHM institutional structures….. at the

National, State and District level for operation.The Mission Steering Group under the Union Health

Minister.At the State level, the State Health Mission under

the Chief MinisterThe State Health Society under the Chief

Secretary and... The State Mission Directorate.

CONT…

At the City level, the States may either decide to constitute a separate.. City Urban Health Missions/ Societies or....Use the existing structure of the National health Mission.

The Mission provides flexibility to the states to choose the best suited model

CONT…

Every ULB will become a unit of planning with its own approved broad norms for setting of health facilities.

These separate plans can be part drawn from NRHM

Municipal corporations will have separate plan of action as per broad norms for urban areas.

For every2.5 lakh population (5lakh for metros)

U-CHCInpatient facility, 30 - 50 bedded(100 bedded in metros)*Only for cities with a population of above 5 lakh

U-PHCMO I/C - 12nd MO (part time) - 1Nurse - 3LHV - 1Pharmacist - 1ANMs - 3-5Public Health Manager/ Mobilization Officer – 1Support Staff - 3M & E Unit - 1

For every 50,000population

For every 10,000population

200- 500 HHs(1000-2500 population)

50-100 HHs(250-500 population)

1 ANMOutreach sessions in area of every ANM on weekly basis

Community HealthVolunteer (USHA / LHW)

Mahila Arogya Samiti

URBAN HEALTH DELIVERY SYSTEMAll the services delivered under the mission will be based on identification of the target groups.

Provision of primary health care in Urban health delivery mode is basically through:U-ASHA (At community Level) - USHAUrban Primary Health CentreReferral Units

URBAN & RURAL HEALTH CARE DELIVERY

50,000 pop

District Hospital

BLOCKMunicipalit

y

DISTRICT

CENTRE

STATE

80,000-1.2 lakh pop

ASHA

SHCANMs

PHC UPHC

ANM

USHA 200-500 HH; 1000-2500 popl

10,000 popl

Slum

UCHCCHC/FRU

3000-5000 pop

1 village=1500 pop

20,000-30,000 pop

5 Lakh pop

URBAN ASHA - USHAPreferably in the age group of 25 to 45 years.Should be literate with formal education up to class eight.

Preferably be a woman resident of the slum – married / widowed / divorced

Chosen through a community driven process involving ULB Counsellors, community groups, self help groups, Anganwadis, ANMs.

Essential services to be rendered by the USHA

1. Active promoter of good health practices.2. Facilitate awareness on essential RCH services.3. act as a depot holder for essential provisions.4. Facilitate access to health related services.5. Formation and promotion of MAS.6. Arrange escort / accompany pregnant women & children

requiring treatment to Urban PHC / secondary / tertiary health care.

7. Reinforcement of community action for immunization.8. Carrying out preventive and promotive health activities.9. Maintenance of necessary information and records.

MAHILA AROGYA SAMITEE (MAS)

Community group, involved in community awareness, community based monitoring and linkages with the services and referral.

Cover around 50- 100 households.Each of the MAS may have 10-12 members with an elected Chairperson and Treasurer, supported by USHA. Group would focus on preventive and promotive health care, facilitating access to identified facilitiesThe MAS will be provided with an annual untied grant of Rs. 5000.

OUTREACH SESSION: ANM•Responsible for providing preventive & promotive

healthcare services at the household level through regular visits & outreach sessions.• Each ANM will organize a minimum of one routine

outreach session in her area every month.• special outreach sessions – Once in a week.• include screening and follow-up, basic lab

investigations, drug dispensing, and counselling.• For improving the routine outreach services ANMs would

be provided with mobility support of Rs. 500 per month.

URBAN PRIMARY HEALTH CENTER

Functional for a population of around 50,000-60,000.

Located preferably within a slum or a half km radius, Catering a population of approximately 20000-

30000, With provision for evening OPD also.

Flexibility- One U-PHC for 75,000 for densely populated areas

orOne U-PHC for around 5000-10,000 for isolated slum

clusters.

HUMAN RESOURCE AT UPHCSl no.

Staff Category Number

1 Medical Officer 2 (1 regular and 1part time)

2 Staff Nurse 33 Pharmacist 14 Lab Technician 15 Public Health Manager/ Community

Mobiliser1

6 LHV 17 ANMs 4 / 5 Depending upon

population8 Secretarial Staff including for account

Keeping.2

9 Support staff 110 Programme Manager 1

INDICATIVE NORMS FOR OPERATIONALISATION OF URBAN CHC

a. Accessibilityi. The Hospital/ Nursing home to be

easily accessible.ii. Round the clock availability of

services.b. Diagnostic facilities: As per the requirement. Some of it can be:

i. Fully equipped laboratory for biochemistry, microbiology and haematology

ii. X- Ray machine iii. Ultra - Sonography

AVAILABILITY OF SPECIALTIES SERVICES

i. Obstetrics and Gynaecology

ii. Paediatricsiii. General Surgeryiv. Ophthalmologyv. ENTvi. Orthopaedics

vii. Dermatologyviii. CVDix. Endocrinologyx. Mental Healthxi. General Medicinexii. Dental

MONITORING & EVALUATIONThe monitoring components would be:

Community Based Monitoring A web based Urban monitoring for reporting and

feedback External evaluations

To ensure evaluation of the urban health programme three surveys namely:Baseline at the beginning of the programme, Mid line or concurrent evaluation andEnd line evaluation would be conducted in each

city.

REFERENCES & BIBLIOGRAPHY National Urban Health Mission Framework For Implementation Ministry Of

Health And Family Welfare Government Of India ;May 2013 National Urban Health Mission; Meeting the Health Challenges of the urban

Population especially the Urban Poor(With special focus on Urban Slums); Urban Health Division, Ministry of Family Welfare, Government of India 2008-2012

Urban Health Division, Ministry of Family Welfare, Government of India. National Urban Health Mission(2008-2009):Jul 2008

Annual Report,2006-07:towards better Health in Underserved Urban Settlements, Urban Health Resource Centre

Urban Health Division, Ministry of Health & Family Welfare, Government of India; Health of the Urban Poor in India Key Results from the National Family Health Survey, 2005 – 06

The Technical Group On Population Projections. Population Projections For India And States 2001-2026.May 2006:8.

Thank you !