DR SURAJ CHAWLA,DEPTT. OF COMMUNITY MEDICINE PGIMS, ROHTAK
Contents• Introduction• NUHM – High Focus Areas – Goals – Coverage – Core strategies• Institutional Framework• Urban Health Delivery System – Urban Social Health Activist (USHA) – Mahila Arogya Samitee (MAS) – Primary Urban Health Centre
Contents• Community Risk Pooling• Community Health Insurance• IT enabled services (ITES) and e-governance• Monitoring & Evaluation• References
Introduction• There has been a progressive rise of urbanization in the country over the last decade. Provisional Census 2011 data showed that 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 United nations projections, if urbanization continues at the present rate, then 46% of the total population will be in urban regions of India by 2030.
Introduction• This urbanization brings with it influx of migrants, rapid growth of populations, expansion of the city boundaries and a concomitant 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.
Introduction• There are more than 2 million births annually among the urban poor and the health indicators in this group are poor. 56% deliveries among the urban poor take place at home.• Under 5 Mortality at 72.7 among urban poor is significantly higher than the urban average of 51.9.• In addition, several health indicators among the urban poor are significantly worse than their rural counterparts.• 60% urban poor children do not receive complete immunization compared to 58% in rural areas.
Introduction• 47.1 % urban poor children <3 are under-weight as compared to 45% of the children in rural areas and 59% of the woman (15-49 age group) are anemic as compared to 57% in rural India.• The invisibility of the urban poor has contributed to their systemic exclusion from the public health care system.• Lack of economic resources restricting their access to private facilities, Illegal status, poor environmental condition, overcrowding and environmental pollution has further contributed to their poor health status.
Introduction• 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.• The 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.
Introduction• Recognizing the seriousness of the problem, urban health will be 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 deprivationsThe United Nations Human Settlements Programme (UN-Habitat) defines a slum household as one that lacks one ormore of the following:• Access to safe water• Access to improved sanitation• Security of tenure• Durability of housing• Sufficient living area
Slums: Census 2011 DefinitionConsist of all clusters of 20-25 households or more with thefollowing criteria:• Roof materials 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
NUHM would have high focus on:• Urban poor population living in listed and unlisted slums.• All the other vulnerable population such as homeless, rag- pickers, street children, rickshaw pullers, construction and brick kiln workers, sex workers, any other temporary migrants.• Public health thrust on sanitation, clean drinking water and vector control.• Strengthening public health capacity of urban local bodies (ULBs).
GOALS• To address the health concerns by facilitating equitable access to available health facilities by rationalizing and strengthening the capacity of the existing health care delivery system.• Partnership with all efforts made for accessing community buildings under various health programmes to ensure full utilization of created infrastructure.• Similarly, the communitization process draw heavily on the existing community organizations and self-help groups developed through other initiatives.
GOALS• It aims to synergize the mission with the existing progammes such as Jawahar Lal Nehru National Urban Renewal Mission (JNNURM), Swarn Jayanti Shahri Rozgar Yojana (SJSRY) and ICDS which have similar objectives to NUHM.
Coverage• The NUHM will be launched in 779 cities/towns (772 cities/towns + 7 metros), having a population of 50,000 or more including all district headquarters.• Towns having less than 50,000 population will be covered under healthcare infrastructure/ system created under NRHM.• Seven mega cities (Mumbai, New Delhi, Kolkata, Chennai, Bengaluru, Hyderabad, Ahmedabad) will be treated differently – their municipal corporations will implement NUHM.• In other cities, District Health Societies will be responsible for NUHM implemetation.
Coverage• Flexibility will be given to states to hand over management of NUHM to cities/towns where sufficient capacity exists with Urban Local Bodies.• In the 12th Plan period NUHM and NRHM will be separate programmes which may be merged in the 13th Plan period or later.
Budget Allocation• The budget allocation for NUHM in the 12th Plan period is envisaged to be approximately Rs 30,000 Crores.• States contribution of the total amount released will be 25% (NRHM – 85:15).• It is also proposed that, in the XII Plan, 25% state contribution may be shared between states and the Urban Local Bodies (ULBs).• For calculation purpose it is assumed that state share would be 15% and ULBs share 10%.
Core Strategies• Improving the efficiency of public health system in the cities by strengthening, revamping and rationalizing urban primary health structure• Promotion of access to improved health care at household level through community based groups: Mahila Arogya Samitees (MAS)• Strengthening public health through preventive and promotive action• Increased access to health care through community risk pooling and health insurance models
Core Strategies• IT enabled services (ITES) and e-governance for improving access improved surveillance and monitoring• Capacity building of stakeholders• Prioritizing the most vulnerable amongst the poor• Ensuring quality health care services
Institutional Framework• The NRHM and NUHM will be two major sub Missions of a larger National Health Mission.• The Mission steering group of NRHM will become Mission steering group of National Health Mission.• The National Programme Coordination Committee of NRHM will now become NPCC of National Health Mission.• The additional secretary and Mission Director of NRHM will become MD National Health Mission, under whom both the sub Missions will work.
Institutional Framework• The Mission Steering Group under the Union Health Minister the Empowered Programme Committee under the Secretary (H&FW), and the NPCC under the Mission Director would be strengthened by incorporating additional government and non government and urban stakeholders , professionals and urban health experts.• The National Urban Health Mission will provide flexibility to the States to choose the model which suits the needs and capacities of the states to best address the healthcare needs of the urban poor.
Institutional Framework• The states will be free to choose from Non Governmental partnerships for public health goals, Public Private Partnership (PPP), strengthening the extant primary public health systems, an optimal mix of these or to propose other innovative models best suitable to their state needs.• The State Health Mission under the Chief Minister, the State Health Society under the Chief Secretary and the State Mission Directorate would also be similarly strengthened.
Institutional Framework• Every Municipal corporation, Municipality, Notified Area Committee, and Town Panchayat will become a unit of planning with its own approved broad norms for setting of health facilities. Their separate plans will be the part of the DHAP drawn up for NRHM.• The district plan will now be called integrated DHAP covering urban and rural population.• The municipal corporation will have separate plan of action as per broad norms for urban areas.
Urban Health Delivery System
Urban Social Health Activist (USHA)• An Urban Social Health Activist (USHA) will be posted for every 200-500 households and provide the leadership and promote the Mahila Arogya Samitee.• The USHA on the lines of ASHA, would preferably be a woman resident of the slum– married/widow/ divorced, preferably in the age group of 25 to 45 years.• She would be chosen through a rigorous community driven process involving ULB counsellors, community groups, self- help groups, Anganwadis and ANMs.
Urban Social Health Activist (USHA)• The USHA would actually be the nerve centres for delivering outreach services in the vicinity of the door steps of the beneficiaries.• The USHA may be preferably co-located with the Anganwadi Centres located in the slums for optimization of health outcomes.
Mahila Arogya Samitee (MAS)• The NUHM proposes the creation of Mahila Arogya Samitee (MAS) a community based federated group of around 20 to 100 households, depending upon the size and concentration of the slum population, with flexibility for state level adjustments.• MAS - acts as community based peer education group, involved in community monitoring and referral.
Mahila Arogya Samitee (MAS)• The MAS will have 5-20 members with an an elected Chairperson and a Treasurer, supported by an USHA.• This group would focus on health and hygiene behaviour change promotion, facilitating access to identified facilities and risk pooling.• The MAS will be provided an annual united grant of Rs 5000 per year.
Primary Urban Health Centre• The situational analysis has clearly revealed that most of the existing primary health facilities, namely the Urban Health Posts (UHPs) /Urban Family Welfare Centres (UFWC)/ Dispensaries are functioning sub- optimally due to problems of infrastructure, human resources, referrals, diagnostics, case load, spatial distribution, and inconvenient working hours.• The NUHM therefore proposes to strengthen and revamp the existing facilities in to a "Primary Urban Health Centre" with outreach and referral facilities, to be functional for every 50,000 population on an average.
Primary Urban Health Centre• The PUHC may cater to a slum population between 20000- 30000, with provision for evening OPD, providing preventive, promotive and non-domiciliary curative care (including consultation, basic lab diagnosis and dispensing)• However, depending on the spatial distribution of the slum population, the population covered by a PUHC may vary from 5000 for cities with sparse slum population to 75,000 for highly concentrated slums.• The NUHM would improve the efficiency of the existing system by making provision for a need based contractual human resource, equipments and drugs.
Human Resource at PUHC
Rogi Kalyan Samiti and Referrals• Rogi Kalyan Samiti will be made for promoting local action.• The provision of health care delivery with the help of outreach sessions in the slums would also strengthen the delivery of health care services.• On the basis of the GIS map the referrals would also be clearly defined and communicated to the community thus facilitating their easy access.
Rogi Kalyan Samiti and Referrals• Creation of Sub Centers has not been proposed. Outreach services will be provided through Female Health Workers (FHWs)/ANMs headquartered at the U-PHCs, utilizing community halls, AWC, etc., as fixed points for these services.• Secondary and Tertiary level care and referral services will be provided through public or empanelled private providers.
Community health risk pooling• The NUHM would promote Community health risk pooling and health insurance as measures for protecting the poor from impoverishing effect of out of pocket expenditure.• To promote community risk pooling mechanism the members of the MAS would be encouraged to save money on monthly basis for meeting the health emergencies.• The group members themselves would decide the lending norms and rate of interest.• The NUHM would provide seed money of Rs. 5000 to the MAS .• The NUHM also proposes incentives to the group on the basis of the targets achieved for strengthening the savings.
Community health risk pooling
Community health InsuranceTo ensure access of identified families to quality medical care forhospitalization/surgeryBeneficiaries• Identified urban poor families, for a maximum of five members• Smart Card/Individual or Family Health Suraksha Cards to be proof of eligibility and to avoid duplication with similar schemesImplementing Agency:• Preferably ULBs, possibly state for smaller citiesPremium 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
Community health Insurance
IT enabled services (ITES) and e-governance• Studies have highlighted that the private providers, which provide the majority of them urban poor access for OPD services, remain outside the public disease surveillance network.• This leads to compromised reporting of diseases and outbreaks in urban slums thereby adversely affecting timely intervention by the public authorities.• The availability of ITES in the urban areas makes it a useful tool for effective tracking, monitoring and timely intervention for the urban poor.
IT enabled services (ITES) and e-governance• The NUHM would provide software and hardware support for developing web based HMIS for quick transfer of data and required action.• GIS system would be integrated into a system of reporting alerts and incidence of diseases on a regular basis.• This system would also be synchronized with the IDSP surveillance system.
Monitoring & Evaluation• The Monitoring and evaluation framework would be based on triangulisation of information.• The three components would be (a) Community Based Monitoring (b) A web based Urban HMIS for reporting and feedback and (c) external evaluations
Monitoring & Evaluation• The District/ City Urban Health Society along with the District/ City Urban Health Mission would regularly monitor the progress and provide feedback.• Similarly the State level Society and Mission would also monitor the progress.• The practice of Concurrent audit will 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.
References• Draft NUHM Document - Urban Health Resource Centre Available from: www.uhrc.in/downloads/Reports/NUHM-Draft.pdf• National Urban Health Mission - Ministry of Health and Family Welfare Available from: mohfw.nic.in/NRHM/Documents/Urban.../UH_Framework_Final.pdf• http://articles.timesofindia.indiatimes.com/keyword/nuhm• http://www.thehindu.com/news/national/article3775214.ece• http://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(12)61313-0/fulltext• http://www.igovernment.in/site/national-urban-health-mis• http://www.indianexpress.com/news/unified-national-health-mission-for- all-says-pm/988836/0sion-take-soon• http://articles.timesofindia.indiatimes.com/2012-08- 08/india/33099834_1_high-level-expert-group-public-health-universal- health-insurance-coverage/2• http://news.outlookindia.com/items.aspx?artid=768082