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National Urban Health

Dr. Vijay B. Lambole
Asso. Professor


Department of Pharmacology
SNLPCP, Umrakh,
❑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

❑ 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

❑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

❑ 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
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.
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.
Tolerant attitude….why???
❑ Social exclusion
❑ Lack of information and assistance
❑ Expensive private healthcare facilities
❑ Perceived unfriendly treatment at government

❑ 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
……..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 of
❑ Manpower,
❑ 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)
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 toimproved sanitation
➢Security of tenure
➢Durability of housing
➢Sufficient living area
Slums: Census 2011 defination
❑Consists of all cluster of 20-25households 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 thehouse.
➢Absence of drainage or open drainage.
What we are
❑ 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
❑ Urban Poor Population living in listed and unlisted
❑ 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
❑ 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

➢ …..with the active involvement of the urban local

➢ 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

❑ Seven mega cities will be treated differently — their
municipal corporations will implement NUHM.

❑ In other cities, District Health Societies will be
responsible for NUHMimplemetation.

❑ 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.
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%.
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
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 MissionDirectorate.

❑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 /

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

❑ 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

❑ 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…
Urban Health Delivery
❑ 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 Health Delivery
Urban & Rural health care

District Hospital

CHC/ 5 Lakh pop
80,000-1.2 lakhpop FRU UCHC


20,000-30,000 pop PHC UPHC

SHC ANM 10,000 popl
3000-5000pop ANMs

1 village=1500 pop ASHA USHA 200-500 HH; 1000-2500popl
Urban Social Health
❑ 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.

❑ The USHA would be delivering outreach services
in the vicinity of the door steps of the
❑ 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

❑ 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.
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.

❑ 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 AYUSHas
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
Human Resource at UPHC
Sl 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
8 Secretarial Staff including foraccount 2
keeping and MIS
9 Support staff 1
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

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

❑ 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/surgicalprocedures
➢ 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
Community Health Insurance
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.

❑ 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
❑ 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 andcirculars
➢ 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
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.
Thank you