1. NATIONAL URBAN HEALTH MISSION

2. Frame work 1. Introduction 2. Objective and key strategies of urban health programme 3. Services delivery model 4. Institutional mechanisms at different levels 5. Role of urban local bodies 6. Public private partnership 7. Monitoring and evaluation plan 8. Sustainability 9. Funds for UH Programme 10. Operationalization of UHP 11. Salient features

3. Urban population in India  Urban population in India  31.2 % of total population  Approx 37.7 Crore (Census 2011) - increase from 26.1 Crore in Census 2001  Approx 7.5 Crore out of these live in urban slums  Rule of 2-3-4-5  Decadal growth rate: Total – 17.6%, Rural – 12.2%, Urban – 31.8%  UN projection: with current rate of urbanization, urban population will reach 46% by 2030

4. 2-3-4-5 phenomenon(3). Growth rate(%) country’s population2 Urban India3 mega cities4 slum populations5

5. Health conditions of urban poors  U5MR 72.7 vs urban average 51.9  46% underweight children vs urban average 32.8%  46.8% women with no education vs urban average 19.3%  44.4% institutional deliveries vs urban average 67.5%  71.4% anaemic among urban poor vs urban average 62.9%  18.5% urban poor with access to piped vs urban average 50%  60% miss total immunization before completing one year

6. ICDS coverage in urban slums Total 7,32,960 AWCs in 2005 in the country, only 62,407 are located in and serving the urban areas. Experiences of some of the NGOs as well as government run UH Programmes have shown that a focus on building community-provider linkages through community based volunteers can help to improve the community demand and usage of primary services. It further improves adoption of desired health-seeking behaviour and practices by the community.

7. Health Scenario in the Urban Slums Urban settlements are amongst the world’s most life threatening environments(8). Inevitably, challenging living conditions undermine the capacity of care takers to provide optimal care for the estimated 2 million children born each year among the urban poor population (based on fertility rate of 3 for a population of 67 million). Under-5, infant and neonatal mortality rates are considerably higher among the urban poor as compared to National and State averages(9). The urban poor neonate in India comes into the world with certain distinct disadvantages (10): – Almost 6 out of 10 are delivered at home in the slum environment – About 50 % are likely to be Low Birth Weight – Only 18% are breast fed immediately after being born.

9. Challenges of urban health care  Poor households not knowing where to go to meet health need  Weak and dysfunctional public system of outreach  Contaminated water, poor sanitation  Poor environmental health, poor housing  Unregistered practitioners first point of contact – use of irrational and unethical medical practice  Community organizations helpless in health matters

10. Challenges of urban health care  Weak public health planning capacity in urban local bodies  Large private sector but poor cannot access them  Problems of targeting the poor on the basis of BPL card  No convergence among wider determinants of health  No system of counselling and care for adolescents  No concerted campaigns for behaviour change  Problems of unauthorized settlements

11. Challenges of urban health care  Over congested secondary and tertiary facilities and under underutilized primary care facilities.  Problem of drug abuse and alcoholism  Many slums not having primary health care facility  High incidence of domestic violence  Multiplicity of urban local bodies, State government, etc. management of health needs of urban people  No norms for urban health facilities

12. Rates of urban poverty  Bihar – 44%  Orissa – 38%  Madhya Pradesh – 35%  Uttar Pradesh – 34%  Nagaland – 4.3%  Himachal Pradesh – 4.6%  Mizoram – 7.9%  Puduchery – 9.9%

13. Access to health care  Inadequate public health care delivery system  Severely restricted health care access (for urban poor)  lack of standards for urban health delivery system makes the urban poor more vulnerable  Poor environmental conditions – overcrowding, poor housing, poor water and electricity availability result in high incidence of communicable diseases, asthma etc.  Higher rates of traffic accidents, domestic violence, mental health cases, drugs, tobacco and alcohol abuse

14. Primary Health Infrastructure in the Urban Areas Grossly inadequate Only one UFWC/HP per 148,413 urban population in 2001 (based on a total of 1954 UFWCs & Health Posts for 285 million population). Though under India Population Project VIII (IPP-8) (1993 to 2002), 531 new facilities were constructed and 661 facilities were upgraded/renovated in Bangalore, Delhi, Hyderabad and Kolkata(6)

15. Water and Sanitation Services  Access to good quality water supply and sanitation facilities among the urban poor is very poor; about half of urban poor households do not receive water supply and about two-thirds do not have a toilet(13).

16. Current provisions  Many components of NRHM cover urban areas as well:  Urban Health and Family Welfare Centres and Urban Health Posts  Funding of National Health Programmes like TB, immunization, malaria, etc.,  Urban health component of the RCH Programmes including support for Janani Suraksha Yojana  Strengthening of health infrastructure like District and Block level Hospitals, Maternity Centres under the National Rural Health Mission, etc.

17. Cities to be covered under NUHM  Coverage: All 779 cities with a population of above fifty thousand and all the district and state headquarters (irrespective of the population size)  Urban areas with population <50,000 will be covered through the health facilities established under NRHM  Mega cities - 7  Million-plus cities (more than 10 lakhs) – 40

18. National Urban Health Mission  The NUHM would focus on:  Urban Poor living in listed and unlisted slums  Vulnerable population such as homeless, rag-pickers, street children, rickshaw pullers, construction and brick and lime kiln workers, sex workers, and other temporary migrants.  Public health thrust on sanitation, clean drinking water, vector control, etc.  Strengthening public health capacity of urban local bodies.

19. Principles  Rationalizing and strengthening of the existing capacity of health delivery and full utilization of existing infrastructure  Utilize the diversity of the available facilities in the cities, flexible city specific models led by the urban local bodies  Communitization process to be built over existing community organizations and self – help groups developed through other initiatives.

20. Key Strategies  Improving access to FW and MCH services through renovation/up- gradation and re-organization of existing facilities  Strengthening of existing urban health infrastructure at 1 st and 2 nd tier  Improve quality of FW at all levels of health functionaries  Appropriately & optimally involve NGOs and the private sector  Increasing demand by IEC activities and enhancing communities participation  Convergence of efforts among multiple stakeholders, including the private sector to improve the health conditions of the urban poor  Effective linkages between communities and health delivery systems.  Strengthening Monitoring and Evaluation mechanisms

21. Urban Health Care Delivery Model

22. Urban Health Care Delivery  Health services delivered under the urban health delivery system through the Urban-PHCs and Urban- CHCs will be universal in nature  Outreach services will be targeted to specific groups (slum dwellers and other vulnerable groups)  Sub-centres will not be set up  1 FHW (ANM) for 10,000 population; Outreach sessions in area of every ANM on weekly basis  FHW to be stationed at PHC; Mobility support for outreach activities  School Health Programmes

23. Urban PHC  MO In-charge - 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

24. Urban CHC  For 2,50,000 population (5,00,000 for metros)  Inpatient facility, 30 -50 bedded (100 bedded in metros)  Only for cities with a population of above 5 lakhs  Renovation of existing referral facility or up- gradation of first tier facility shall essentially be the first choice  Support for local contractual arrangements for part time Specialist/ Medical Officer.

25. Second tier(Zonal Hospital) – Renovation of existing referral facility or up-gradation of first tier facility shall essentially be the first choice – Support for need based additional add on lab/indoor facilities. – Equipment & furniture for services from the referral centres – Need based drugs & supplies (over and above the supplies being made under other programmes/schemes) – The strengthening of 2nd tier facilities shall be in line with the CHC norms proposed under NRHM.

26. Urban Health Care Delivery  Promote role of urban local bodies in the planning and management of urban health care  One ASHA for 1000-2500 population  States to have flexibility of motivating Mahila Arogya Samiti (MAS) for getting the work done  One MAS for 50-100 households  Annual grant of Rs. 5000 to the MAS  NGOs may also be given this responsibility

27. Roles & responsibilities of ASHA Identify target beneficiaries and support ANM in conducting outreach sessions Promote formation of Women’s Health Groups Provide information to the community Facilitate access to health and related services Accompany pregnant women and children requiring treatment/ admission Facilitate development of a comprehensive health plan Facilitate construction of community/ household toilets Act as depot holder Maintain necessary information and records.

28. Women’s Health Committee  Process of promotion of Women’s Health Committee Women’s Health Committee 15 members for about 250-350 families encouraged to work collectively on community issues potential community leaders and target women

29. Roles of the Mahila Arogya Samiti Support ASHA in tracking and monitoring coverage of key interventions Facilitate group counseling sessions Support outreach camps by ensuring presence of target group The conveners or other designated representatives of the group along with the respective Link Volunteer will attend meetings held at the UHC and provide feedback on service delivery. Collect, manage and utilize a Community Health Fund for meeting health emergencies in the slum and for sustaining health promotion efforts. Maintain BCC and IEC materials at a safe and easily accessible place in the community.

30.  IPHS/ Revised IPHS for Urban areas etc  Quality of the services provided will be constantly monitored for improvement  Strengthen IDSP  Convergence with AYUSH practitioners