This is just an overview of the mission

1. National Urban Health
Mission
Presenter
Dr Utpal Sharma
Post Graduate Student
Moderator
Dr Jutika Ojah
Professor
Department of Community Medicine
Gauhati Medical College

2. 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.
 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.

3. 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

4. 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.

5. 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.

6. Tolerant attitude….why???
 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

7. 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.

8. 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.

9. 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)
will be launched as a
separate mission for
urban areas with focus
on slums and other
urban poor.

10. 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

11. 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.

12. Slums…..

13. 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

14. 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.

15. 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.

16. Coverage
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.

17. 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.

18. Budget allocation
 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%.

19. 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

20. Institutional framework
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.

21. 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

22. 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.

23. Institutional framework…

24. Urban Health Delivery
System
 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

25. Urban Health Delivery
System

26. Urban & Rural health care
delivery
CENTRE
STATE
DISTRICT
District Hospital
Municipality
BLOCK
80,000-1.2 lakh pop
20,000-30,000 pop
3000-5000 pop
CHC/
FRU
UCHC
PHC
SHC
ANMs
UPHC
ANM
5 Lakh pop
50,000 pop
10,000 popl
Slum
1 village=1500 pop
ASHA
USHA
200-500 HH; 1000-2500 popl

27. 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 slummarried/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.

28. 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.

29. 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.

30. Urban Primary Health Center
 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.

31. 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.

32. 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

33. Referral unit
 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.

34. 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.

35. Community Risk Pooling
 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.

36. Community Health risk
pooling

37. 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

38. Community Health Insurance

39. 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.

40. 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

41. 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.

42. Thank you