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National Urban Health

Mission
RAKESH PATIDAR
There has been a considerable rise of urbanization in the country over
the last decade.

Census 2011 data showed, for the first time since Independence, the
absolute increase in population was more in urban areas that in rural
areas.

As per Census 2001, 28.6 crore people live in urban areas. The urban
population has increased to 37.7 crore in 2011

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

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.

Cont.
With urbanization:
Influx of migrants,
Rapid growth of populations,
Expansion of the city boundaries
Parallel rise in slum populations and urban poverty.

Of the 370 million urban dwellers, over 100 million are
estimated to live in slums and face multiple health
challenges on the fronts of
Sanitation,
Communicable and
Non communicable diseases
All-India population growing at 2 per cent, urban
population at 2.75 per cent, large cities at 4 per cent and
slums at 5-6 per cent.
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.

In addition, several health indicators among the urban poor are
significantly worse than their rural counterparts.

Social exclusion
Lack of information and assistance
Expensive private healthcare facilities
Perceived unfriendly treatment at government hospitals,
Emotionally securer environment at home
Non-availability of caretakers for other siblings in the
event of hospitalization
Crowded out because of the inadequacy of the
urban public health delivery system.

Ineffective outreach and weak referral system

Lack 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.
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 of
Manpower,
Equipments,
Drugs,
Weak referral system and
In-adequate attention to public health.

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)
will be launched as a
separate mission for
urban areas with focus on
slums and other urban
poor.

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 defination
Consists 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..
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 & CBOs.

Planning process to undertake large scale community level
activities

The NUHM would have high focus on:

Urban Poor Population living in listed and unlisted slums
All 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.
Mission would aim to improve the health status of the
urban poor particularly the slum dwellers and other
disadvantaged sections, by facilitating

Equitable access to quality health care through a
revamped public health system

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 progammes
having similar objectives to NUHM.
All 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 to ensure that there is no duplication of
services.
Cont.
Seven mega cities will be treated differently their
municipal corporations will implement NUHM.

In other cities, District Health Societies will be responsible
for NUHM implemetation.

Flexibility- given to states

In the 12th Plan period NUHM and NRHM will be separate
programmes

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




The budget allocation in the 12th Plan period is
envisaged to be approximately Rs 30,000 Crores.

States contribution will be 25% (NRHM 85:15).

In the 12th Plan, 25% state contribution shared between
states and the Urban Local Bodies (ULBs).

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

Core strategies
Improving the efficiency of public health
Promotion of access to improved health care at household
level
Strengthening public health through preventive and
promotive action
Increased access to health care through community risk
pooling and health insurance models
IT enabled services (ITES) and e-governance
Capacity building of stakeholders
Prioritizing the most vulnerable amongst the poor
Ensuring quality health care services




The NUHM institutional structures.. at the National,
State and District level for operation.

The Mission Steering Group under the Union Health
Minister....
...The EPC under the Secretary (H&FW)...
...The NPCC under the Mission Director

At the State level, the State Health Mission under the
Chief Minister
The 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 DHS /
Mission

The Mission provides flexibility to the
states to choose the best suited model
Cont
Every ULB will become will become a unit of planning
with its own approved broad norms for setting of health
facilities.

These separate plans will be part of DHAP drawn for
NRHM

District plan will now be called Integrated DHAP
covering both Urban and Rural population

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

All the services delivered under the mission will be based
on identification of the target groups.

Through distribution of Family/ Individual Health
Suraksha Cards

Provision of primary health care in Urban health delivery
mode is basically through:

USHA (At community Level)
Primary Urban Health Centre
Referral Units

Urban & Rural health care delivery
50,000 pop
District Hospital
BLOCK
Municipality
DISTRICT
CENTRE
STATE
80,000-1.2 lakh pop
ASHA
SHC
ANMs
PHC UPHC
ANM
USHA 200-500 HH; 1000-2500 popl
10,000 popl
Slum
UCHC
CHC/
FRU
3000-5000 pop
1 village=1500 pop
20,000-30,000 pop
5 Lakh pop
Urban Social Health Activist(USHA)
An USHA will be posted for every 200-500 households

Maintain IPC with the families and the Mahila Arogya Samities
(MAS) for which they are earmarked.

The USHA , preferably be a woman resident of the slum-
married/widowed/ divorced

Preferably in the age group of 25 to 45 years.

Should be literate with formal education up to class eight
subjected to relaxation.

Chosen through a rigorous community driven process involving
ULB Counsellors, community groups, self help groups,
Anganwadis, ANMs.
Cont.
The USHA would be delivering outreach services in
the vicinity of the door steps of the beneficiaries.
Suitable place for USHA may be arranged in the
slums for optimization of health outcomes.
Role of NGOs.

A proposed USHA mentoring system.
Support and coordinating the activities of the USHA.
Community Organiser for 10 USHA
The Community organizer along with ANM be
Mentoring and Management team at the slum level for the
USHAs.
Mahila Arogya Samitee (MAS)
A community based federated group of around 20 to 100 households

Acts as community based peer education group, involves in community
monitoring and referral.

Each of the MAS may have 5-20 members with an elected Chairperson
and Treasurer, supported by USHA.

The mobilization of the MAS facilitated by NGO, working along with the
USHA

The group focuses on:
Health and hygiene behaviour change promotion
Facilitating access to identified facilities
Community risk pooling.

The MAS will be provide with an annual untied grant of Rs 5000.
Functional for a population of around 50,000
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 UHC for 75,000 for densely populated areas or. and
One UHC for around 5000-10,000 for isolated slum clusters.

Facilities provided are:
Preventive
Promotive and
Non-domicilliary curative care including consultation
Basic lab diagnosis and dispensing.
Cont.
It will ordinarily not include in-patient care.

Co-locating the AYUSH centre with UHC

Making way for placement of AYUSH doctor and other
AYUSH paramedic staff in the UHC.

NUHM will not provide for contractual staff of AYUSH as
is the case with NRHM.
For a non-functional government health facility, required
staff may be posted from:
Medical institutes or state government (on deputation)
or....
......Contractual appointments from the private market.
Human Resource at UPHC
Sl
no.
Staff Category Number
1 Medical Officer 2* (1 regular and 1
part time)
2 Staff Nurse 3
3 Pharmacist 1
4 Lab Technician 1
5 Public Health Manager/ Community Mobilisor 1
6 LHV 1
7 AMNs 4-5** Depending upon
population
8 Secretarial Staff including for account
keeping and MIS
2
9 Support staff 1

Existing hospitals in the area, will be empanelled /accredited

For empanelled government facilities, RKS /HMS will be funded,
which will be utilized for providing cash-less services.

Referral services will be cash-free for the beneficiary
.financed by community health insurance or voucher scheme
as per the PIP developed for the city.

Collaboration with local Medical Colleges for strengthening the
training support and supplement HR at the PUHC level.
Referral unit
Urban Community Health Centre (U-CHC) are proposed to be
set up as a satellite hospital for every 4-5 U-PHCs.

Cater to a population of 2,50,000.

Provide in patient services and a 30-50 bedded facility.

The U-CHCs would be set up in cities with a population of
above 5 lakhs, wherever required.

They will be in addition to the existing facilities (SDH/DH) to
cater to the urban population in the locality.

For the metro cities, the U-CHCs may be established for
every 5 lakh population with 100 beds.

The U-CHC would provide medical care, minor surgical
facilities and facilities for institutional delivery.
The NUHM would promote Community Health risk pooling and
health insurance ..
.as measures for protecting the poor form
improvising effect of out of pocket expenses.

The members of MAS would be encouraged to save money on
monthly basis for meeting the health emergencies.

The group members would themselves decide the norms and rate
of interest.

The Mission would provide seed money of Rs 5000 to the group.

The Mission also proposes incentives to the group on the basis of
the targets achieved for strengthening the savings.
Community Health Insurance
To ensure access of identified families to quality medical care for
hospitalisation/surgery

Beneficiaries
Identified urban poor families, for a maximum of five members
Smart Card: Individual/Family Health Suraksha Cards to be proof of eligibility
and to avoid duplication

Implementing Agency: Preferably ULBs, state for smaller cities

Premium Financing
Up to a maximum of Rs.600 per family as subsidy by the central govt.
Additional cost, if any, may be contributed by state/ULB/beneficiary

Benefits
Coverage for hospitalisation/surgical procedures
Coverage of surgical care on a day care basis
Pre-existing conditions: Diseases, including maternal and childhood
conditions and illness, to be covered, subject to minimal exclusion

The Monitoring and evaluation framework would be
based on triangulation of information.

The three components would be
Community Based Monitoring
A web based Urban HMIS 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 and
End line evaluation would be conducted in each city.
Cont.
The Urban Health Society along with the Urban Health Mission would
regularly monitor the progress and provide feedback.

Similarly the State level Society and Mission would also monitor the
progress.

The Health Service Guaranteed would be translated Charter and be
displayed at the facility level.

Making available all the information to the community through
appropriate .
Wall journals and circulars
Guidelines. to empower the community to enforce accountability.

The RTI would be a major instrument in ensuring accountability.

The practice of Concurrent audit may be introduced right from the
inception stage.

All the funds/ untied grants would be audited on a monthly basis and
report of which would be made public
References
1. National Urban Health Mission Framework For Implementation Ministry Of
Health And Family Welfare Government Of India ;May 2013

2. National Urban Health Mission; Meeting the Health Challenges of the urban
Population especially the Urban Poors(With special focus on Urban Slums);
Urban Health Division, Ministry of Family Welfare, Government of India
2008-2012

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

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

5. 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

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

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