National Urban Health Mission

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. The Destitute…. Homeless Rag-pickers Street children Rickshaw pullers Construction and brick and lime kiln workers Sex workers Other temporary migrants.

21. 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.

22. 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

23. 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.

24. Institutional framework…

25. 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

26. Aadhaar card…. Block No. 05, 1 st floor Housefed Complex, Beltola Basistha Road Dispur , Guwahati Assam-781006 Ph no. 0361-222 1819 UIDAI: Unique Identification Authority of India

27. Urban Health Delivery System

28. 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

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. 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

35. 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.

36. 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.

37. 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.

38. Community Health risk pooling

39. 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

40. Community Health Insurance

41. 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.

42. 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