The National Urban Health Mission (NUHM) aims to provide accessible and affordable health care to the urban poor population in India. It will focus on improving health indicators among slum populations and expanding coverage to all towns with a population over 50,000. Key strategies include establishing Urban Health Centers, promoting community-based groups like Mahila Arogya Samitees, implementing health insurance programs, and using information technology to strengthen surveillance. The NUHM will be implemented through municipal corporations and district health societies with the goal of synergizing with other health programs to comprehensively address urban health issues.

1. DR SURAJ CHAWLA,
DEPTT. OF COMMUNITY MEDICINE
PGIMS, ROHTAK

2. 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

3. Contents
• Community Risk Pooling
• Community Health Insurance
• IT enabled services (ITES) and e-governance
• Monitoring & Evaluation
• References

5. 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.

6. Introduction

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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

13. Slums: Census 2011 Definition
Consist of all clusters of 20-25 households or more with the
following 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

14. 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).

15. 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.

16. 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.

17. 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.

18. 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.

19. 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%.

20. 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

21. 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

22. 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.

23. 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.

24. 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.

25. 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.

26. Institutional Framework

27. Urban Health Delivery System

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. Human Resource at PUHC

35. 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.

36. 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.

37. 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.

38. Community health risk pooling

39. Community health Insurance
To ensure access of identified families to quality medical care for
hospitalization/surgery
Beneficiaries
• 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 schemes
Implementing Agency:
• Preferably ULBs, possibly 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

40. Community health Insurance

41. 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.

42. 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.

43. 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

44. 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.

45. 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

46. Thank You