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National Urban Health Mission

Presenter Dr Narasimha BC

Post Graduate Student

Department of Community MedicineBangalore Medical College & Research Institute.

INTRODUCTION

Census of India defines urban areas as a) all areas with a municipality, corporation, cantonment board or

notified area committee etc b) place satisfying the following three criteria simultaneously:

i) a minimum population of 5,000;

ii) at least 75% of male working population engaged in non agricultural pursuits

iii) a density of population of at least 400 per sq km. (1000 per sq. mile)

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Urbanization and Public Health

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Background  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.

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

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2-3-4-5 syndrome…??? 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.

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 - 2026

Urb

an P

opul

ation

(in

mill

ion)

Percentage to total population

India has been urbanizing rapidly in recent decades. It is estimated that the urban population will nearly double to reach 534 million by 2026.(NFHS,05-06)

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

Many of whom live in urban slums and other squatter settlements

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• As per Census 2001, 4.26 crore people lived in slums spread over 640 towns/ cities having population of fifty thousand or above.

• In the cities with population one lakh and above, the 3.73 crore slum population (in 2001) is reached to 7.66 (in 2011) thus putting greater strain on the urban infrastructure which is already overstretched.

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• Despite the supposed proximity of the urban poor to urban health facilities their access to them is severely restricted.

• overcrowding of patients- inadequacy of the urban public health delivery system.- ineffective in outreach and referral system - lack of standard and norms for urban health care delivery

system, - social exclusion, - lack of information and assistance to access the modern health

care facilities - lack of economic resources.- lack of standards and norms for the urban health delivery system

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• This situation is further worsened by the fact that a large number of urban poor are living in slums that have an illegal status.

• Compromises the slum dweller to basic services.

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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.

Child Health among Urban Poor

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• Despite availability of govt & pvt hospitals the urban poor prefers home delivers.

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

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• Poor environmental condition in the slums along with high population density makes the urban poor vulnerable to lung diseases.

• Slums have high density of vector born diseases (VBDs)

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• According to National commission on Macro environment & Health report– Cases of CHD will continue to rise– Load of diabetes cases will rise from 2.6 crores in

2000 to 4.6 crores by 2015. • Heterogeneity among slum dwellers • The traditional temporary migration of

pregnant women for delivery results in their missing out on services at either the residences.

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Vulnerable groups

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Moreover….“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.

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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 of Manpower,

Equipments,

Drugs,

Weak referral system and

In-adequate attention to public health.

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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.

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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.

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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 waterAccess to improved sanitationSecurity of tenureDurability of housingSufficient living area

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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

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What we are upto…???

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

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Goals 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.

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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 to ensure that there is no duplication of services.

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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 implementation.

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.

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Budget allocation

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

The Centre-State funding pattern will be 75:25 for all the states. (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%.

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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

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Institutional frameworkThe 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.

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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

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Cont…

Every ULB 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.

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Institutional framework…

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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 lakhU-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 (ASHA/LW)

Mahila Arogya Samiti

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Urban Health Delivery System

All 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) Urban Primary Health Centre Referral Units

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Urban Health Delivery System

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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

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Urban ASHA Covering about 1000 - 2,500 beneficiaries, btw 200-500

households. Delivery of services at the door steps. Maintain IPC with the families and the Mahila Arogya

Samities (MAS) for which they are designated. Preferably in the age group of 25 to 45 years. Should be literate with formal education up to class eight

subjected to relaxation. Preferably be a woman resident of the

slum-married/widowed/ divorced Chosen through a rigorous community driven process

involving ULB Counsellors, community groups, self help groups, Anganwadis, ANMs.

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Cont….

The U ASHA would help ANM in delivering outreach services in the vicinity of the door steps of the beneficiaries.

Suitable place for U ASHA 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.

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Essential services to be rendered by the ASHA

1. Active promoter of good health practices2. Facilitate awareness on essential RCH services3. act as a depot holder for essential provisions4. Facilitate access to health related services5. Formation and promotion of MAS.6. Arrange escort/accompany pregnant women and

children requiring treatment to the nearest Urban Primary Health Centre, secondary/tertiary level health care facility.

7. Reinforcement of community action for immunization etc.

8. Carrying out preventive and promotive health activities9. Maintenance of necessary information and records.

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Mahila Arogya Samitee (MAS)

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

Cover around 50- 100 households (HHs)

Each of the MAS may have 10-12 members with an elected Chairperson and Treasurer, supported by ASHA.

Group would focus on preventive and promotive health care, facilitating access to identified facilities

The MAS will be provide with an annual untied grant of Rs 5000.

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Outreach session: ANM

• Responsible for providing preventive and promotive healthcare services at the household level through regular visits and 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.

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• For improving the routine outreach services ANMs would be provided with mobility support of Rs. 500 per month.

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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 or…. and One U-PHC for around 5000-10,000 for isolated slum

clusters.

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INDICATIVE NORMS FOR OPERATIONALISATION OF URBAN PHC

(i) Accessibilitya. Preferably located near the slum to be servedb. Accessed by slum dwellers

(ii) Servicesa. Medical care: OPD services: From 12 noon to 8 pmb. Services as prescribed under RCH IIc. National Health Programmesd. Collection and reporting of vital events and IDSPe. Referral Servicesf. Basic Laboratory Servicesg. Counseling servicesh. Services for Non Communicable Diseasesi. Social Mobilization and Community level activities

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Human Resource at UPHCSl no.

Staff Category Number

1 Medical Officer 2* (1 regular and 1part 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 accountkeeping and MIS

2

9 Support staff 1

10 Programme Manager 1

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Referral unit Satellite hospital for every 4-5 U-PHCs to cater to a

population of 2,50,000.

Provide in patient services and would be 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.

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INDICATIVE NORMS FOR OPERATIONALISATION OF URBAN CHC

a. Accessibilityi. The Hospital/ Nursing home to be easily accessible for the

served population.ii. Willingness to provide services at the rates negotiatediii. 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 hematologyii. X- Ray machine with minimum capacity of 60 MAiii. Ultra-Sonography

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Availability of Specialties servicesi. Obstetrics and Gynaecologyii. Paediatricsiii. General Surgeryiv. Ophthalmologyv. ENTvi. Orthopaedicsvii. Dermatologyviii. CVDix. Endocrinology (Diabetes, Thyroid)x. Mental Healthxi. General Medicinexii. Dental

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Referral linkages Existing hospitals in the area, will be empanelled /accredited

to act as referral points for different types of healthcare services

Collaboration with local Medical Colleges for strengthening the training support and supplement HR at the PUHC level.

Wherever public sector coverage is inadequate, reputed private sector institutions may be considered.

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Service Norms by levels of Service Delivery

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Monitoring & Evaluation 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.

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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

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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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Thank you