National Urban Health Mission

1. National Urban Health Mission
Presenter
Dr Narasimha BC
Post Graduate Student
Department of Community Medicine
Bangalore Medical College & Research Institute.
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2. 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)

3. Urbanization and Public Health
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4. 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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5. 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.
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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 - 2026
UrbanPopulation(inmillion)
Percentagetototalpopulation
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)

7.  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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8. • 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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9. • 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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10. • 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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11. 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.
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12. Child Health among Urban Poor

13. • 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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14. • 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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15. • 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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16. 5/29/2015 16
Vulnerable
groups

17. 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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18. 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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19. 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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20. 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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21. 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
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22. 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.
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Slums

23. 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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24. 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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25. Coverage
All 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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26. 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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27. 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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28. 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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29. 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.
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30. 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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31. 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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32. Institutional framework…
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33. For every
2.5 lakh population (5
lakh for metros)
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U-CHC
Inpatient facility, 30 -50 bedded
(100 bedded in metros)
*Only for cities with a population of above 5 lakh
U-PHC
MO I/C - 1
2nd MO (part time) - 1
Nurse - 3
LHV - 1
Pharmacist - 1
ANMs - 3-5
Public Health Manager/ Mobilization Officer – 1
Support Staff - 3
M & E Unit - 1
For every 50,000
population
For every 10,000
population
200- 500 HHs
(1000-2500 population)
50-100 HHs
(250-500 population)
1 ANM
Outreach sessions in area of every ANM
on weekly basis
Community Health
Volunteer (ASHA/LW)
Mahila Arogya Samiti

34. 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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35. Urban Health Delivery
System
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36. 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
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37. 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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38. 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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39. Essential services to be rendered by the ASHA
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 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 activities
9. Maintenance of necessary information and records.
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40. 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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41. 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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42. • For improving the routine outreach services
ANMs would be provided with mobility
support of Rs. 500 per month.
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43. 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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44. INDICATIVE NORMS FOR OPERATIONALISATION
OF URBAN PHC
(i) Accessibility
a. Preferably located near the slum to be served
b. Accessed by slum dwellers
(ii) Services
a. Medical care: OPD services: From 12 noon to 8 pm
b. Services as prescribed under RCH II
c. National Health Programmes
d. Collection and reporting of vital events and IDSP
e. Referral Services
f. Basic Laboratory Services
g. Counseling services
h. Services for Non Communicable Diseases
i. Social Mobilization and Community level activities
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45. 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
10 Programme Manager 1
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46. 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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47. INDICATIVE NORMS FOR OPERATIONALISATION
OF URBAN CHC
a. Accessibility
i. The Hospital/ Nursing home to be easily accessible for
the served population.
ii. Willingness to provide services at the rates negotiated
iii. 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 hematology
ii. X- Ray machine with minimum capacity of 60 MA
iii. Ultra-Sonography
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48. Availability of Specialties services
i. Obstetrics and Gynaecology
ii. Paediatrics
iii. General Surgery
iv. Ophthalmology
v. ENT
vi. Orthopaedics
vii. Dermatology
viii. CVD
ix. Endocrinology (Diabetes, Thyroid)
x. Mental Health
xi. General Medicine
xii. Dental
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49. 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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50. Service Norms by levels of Service Delivery
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51. 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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52. 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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53. 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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54. Thank you
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