National Urban Health Mission

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. 5/15/2015 1

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 5/15/2015 3

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. 5/15/2015 4

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. 5/15/2015 5

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 Urban Population (in million) 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)

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 5/15/2015 7

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. 5/15/2015 8

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 5/15/2015 9

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. 5/15/2015 10

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. 5/15/2015 11

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 5/15/2015 13

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) 5/15/2015 14

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. 5/15/2015 15

16. 5/15/2015 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. 5/15/2015 17

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. 5/15/2015 18

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. 5/15/2015 19

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. 5/15/2015 20

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 5/15/2015 21

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. 5/15/2015 22 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 5/15/2015 23

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. 5/15/2015 24

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. 5/15/2015 25

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. 5/15/2015 26

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%. 5/15/2015 27

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 5/15/2015 28

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. 5/15/2015 29

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 5/15/2015 30

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. 5/15/2015 31

32. Institutional framework… 5/15/2015 32

33. For every 2.5 lakh population (5 lakh for metros) 5/15/2015 33 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 5/15/2015 34

35. Urban Health Delivery System 5/15/2015 35

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 5/15/2015 36

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. 5/15/2015 37

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. 5/15/2015 38

39. Essential services to be rendered by the ASHA Active promoter of good health practices Facilitate awareness on essential RCH services act as a depot holder for essential provisions Facilitate access to health related services Formation and promotion of MAS. Arrange escort/accompany pregnant women and children requiring treatment to the nearest Urban Primary Health Centre, secondary/tertiary level health care facility. Reinforcement of community action for immunization etc. Carrying out preventive and promotive health activities Maintenance of necessary information and records. 5/15/2015 39

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. 5/15/2015 40

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. 5/15/2015 41

42. For improving the routine outreach services ANMs would be provided with mobility support of Rs. 500 per month. 5/15/2015 42

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. 43

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 5/15/2015 44

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 5/15/2015 45

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. 5/15/2015 46

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 5/15/2015 47

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 5/15/2015 48

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. 5/15/2015 49

50. Service Norms by levels of Service Delivery 5/15/2015 50

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. 5/15/2015 51

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 5/15/2015 52

53. References National Urban Health Mission Framework For Implementation Ministry Of Health And Family Welfare Government Of India ;May 2013 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 Urban Health Division, Ministry of Family Welfare, Government of India. National Urban Health Mission(2008-2009):Jul 2008 Annual Report,2006-07:towards better Health in Underserved Urban Settlements, Urban Health Resource Centre 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 The Technical Group On Population Projections. Population Projections For India And States 2001-2026.May 2006:8. 5/15/2015 53

54. Thank you 5/15/2015 54