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8/14/2019 URBAN HEALTH PROBLEMS & NUHM
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URBAN HEALTH PROBLEMS
&
URBAN HEALTH MISSION
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Urbanization: Trends and
Patterns Movement of people from rural to urban areas
with population growth equating to urbanmigration
A double edged sword On one hand- Provides people with varied opportunities
and scope for economic development
On the other- Exposes community to new threats
Unplanned urban growth is associated with Environmental degradation
Population demands that go beyond the environmentalservice capacity, such as drinking water, sanitation, andwaste disposal and treatment
3
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Urbanization: Trends and
Patterns-2 286 million people in India live in urban areas (around 28% ofthe population)* The proportion of urban population in India is increasing
consistently over the years
From 11% in 1901 to 26% in 1991 and 28% in 2001
Estimated to increase to 357 million in 2011 and to 432 millionin 2021*
After independence
3 times growth - Total population 5 times growth - Urban population*
* Census of India 20014
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Urbanization: Trends and
Patterns-3 4.26 crore people live in slums
A large number of slums are not notified*- around
50%
Urban growth has led to rapid increase in the numberof urban poor
In-migration and a floating population has worsenedthe situation
5* NSSO Report No. 486
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Factors Affecting Health in
Slums* Economic conditions
Social conditions
Living environment
Access and use of public health care services
Hidden/Unlisted slums
Rapid mobility
6* Agarwal S, Satyavada A, Kaushik S, Kumar R. Urbanization, Urban Poverty and Health of theUrban Poor: Status Challen es and the Wa Forward. Demo ra h India. 200 6 1 : 121-1
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Migration-causes
Increased family size-limited agricultural property
-Land use Pattern
-Irrigation facilities
Better income prospects
Better educational facilities
Better Life style
Basic amenities health, transport,water, electricity. Victims of natural/manmade calamities-Refugees
7
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Migration-consequences
Overcrowding
Mushrooming of slums
Unemployment
Poverty
Physical & mental stress
Family structure-Nuclear families-Single males
8
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Urban Vs Rural health
Is urban health better than rural health?
Almost all health indicators are better for urban when comparedto rural
When the urban slums are taken many are worser than rural !!!
9
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Growth of Slums
28
46
61.8
Sour ce: Annu al Report 2006-07, MoHUPA
The Urban ettingSlum Populat ion as %age of total urban pop ulat ion is given in parenthesis
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Source: Regis t rar General of India
12.65
19.86
23.43
20.0719.44
9.70
15.20
17.24
12.82
11.65
1.95
4.666.19
7.25 7.89
The Urban etting
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Marriage & Fertility Indicators of
Urban Poor in India: NFHS 3
12
Indicators Urban
Poor
Urban
Non
poor
Overall
Urban
Overall
Rural
All
India
Urban
Poor
NFHS 2
Women age 20-24 married by age 18
years (%) 51.5 21.2 28.1 52.5 44.5 63.9
Women age 20-24 who became
mothers before age 18 (%)25.9 8.3 12.3 26.3 21.7 39.0
Total fertility rate (children per
woman)2.8 1.8 2.1 3.0 2.7 3.8
Higher order births (3+ births) (%) 28.6 11.4 16.3 28.1 25.1 29.5
Birth Interval (median number of
months between current and
previous birth)
29.0 33.0 32.0 30.8 31.1 31.0
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Maternal Health Indicators of Urban
Poor in India: NFHS 3
13
Indicators UrbanPoor
UrbanNon
PoorOverall
UrbanOverall
RuralAll
IndiaUrban
PoorNFHS 2
Mothers who had at least 3 antenatal
care visits (%) 54.3 83.1 74.7 43.7 52.0 49.6Mothers who consumed IFA for 90
days or more (%) 18.5 41.8 34.8 18.8 23.1 47.0Mothers who received tetanus toxoid
vaccines (minimum of 2) (%) 75.8 90.7 86.4 72.6 76.3 70.0Mothers who received complete
ANC (%) 11.0 29.5 23.7 10.2 15.0 19.7Births in health facilities (%) 44.0 78.5 67.4 28.9 38.6 43.5Births assisted by a doctor/nurse
/LHV/ANM/other health personnel (%) 50.7 84.2 73.4 37.4 46.6 53.3Women age 15-49 with anaemia (%) 58.8 48.5 50.9 57.4 55.3 54.7
The statistics for urban poormuch lesser than urban
non-poor and comparable torural population
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Child Survival Indicators of Urban
Poor in India: NFHS 3
14
Indicators UrbanPoor UrbanNon
PoorOverallUrban OverallRural AllIndia UrbanPoor
NFHS 2Children completely immunized (% 39.9 65.4 57.6 38.6 43.5 40.3Children under 5 years breastfed within
one hour of birth (%) 27.3 31.5 30.3 22.4 24.5 17.7Children age 0-5 months exclusively
breastfed (%) 44.7 38.6 40.7 48.6 46.4 44.3Children age 6-9 months receiving solid or
semi-solid food and breast milk (%) 56.2 66.1 63.1 54.7 56.7 52.7Children who are stunted (%) 54.2 33.2 39.6 50.7 48.0 52.5Children who are underweight (%) 47.1 26.2 32.7 45.6 42.5 48.0Children with anaemia (%) 71.4 59.0 63.0 71.5 69.5 79.0Neonatal Mortality 34.9 25.5 28.7 42.5 39.0 45.5Infant Mortality 54.6 35.5 41.7 62.1 57.0 69.8Under-5 Mortality 72.7 41.8 51.9 81.9 74.3 102.0
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Poor Child Health among Urban Poor
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Family Planning Indicators of Urban
Poor in India: NFHS 3
17
Indicators UrbanPoor
UrbanNon
PoorOverall
UrbanOverall
RuralAll
IndiaUrban
poorNFHS 2
Any modern method (%)
48.7 58.0
55.8
45.3
48.5
43.0
Spacing method (%) 7.6 19.8 16.9 7.2 10.1 4.6Permanent sterilization method rate
(%) 41.1 38.2 38.9 38.1 38.3 38.4Total unmet need (%) 14.1 8.3 10.0 14.6 13.2 16.7Unmet need for spacing (%) 5.7 4.1 4.5 6.9 6.2 8.5Unmet need for limiting (%) 8.4 4.2 5.2 7.2 6.6 8.2
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Environmental Conditions, Infectious
Diseases and access to Health Care in
Urban Poor : NFHS 3
18
Indicators UrbanPoor
UrbanNon
PoorOverall
UrbanOverall
RuralAll
IndiaUrban
poorNFHS 2
Households with access to piped water supply
at home (%) 18.5 62.2 50.7 11.8 24.5 13.2Households accessing public tap / hand pump
for drinking water (%) 72.4 30.7 41.6 69.3 42.0 72.4Household using a sanitary facility for the
disposal of excreta (flush / pit toilet) (%) 47.2 95.9 83.2 26.0 44.7 40.5Prevalence of medically treated TB (per
100,000 persons) 461 258 307 469 418 535
Women (age 15-49) who have heard of AIDS
63.4 89.1
83.2
50.0
60.9
42.1
Prevalence of HIV among adult population
(age 15-49) 0.47 0.31 0.35 0.25 0.28 naChildren under age six living in enumeration
areas covered by an AWC (%) 53.3 49.1 50.4 91.6 81.1 naWomen who had at least one contact with a
health worker in the last three months (%)10.1 5.8 6.8 14.2 11.8 16.7
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Double Burden of Diseases
Overcrowding and related health issues
Rapid growth of urban centers has led tosubstandard housing on marginal land and
overcrowding Outbreaks of diseases transmitted through
respiratory and faeco-oral route due to increased
population density
It exacerbates health risks related to insufficient andpoor water supply and poor sanitation systems
Lack of privacy leading to depression, anxiety,
stress etc 19
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Double Burden of Diseases
Air pollution and its consequences
Due to increase in the numbers of motorized vehiclesand industries in the cities of the developing world
Problems of noise and air pollution Air pollution can affect our health in many ways with
both short-term and long-term effects
Short-term air pollution can aggravate medical
conditions like asthma and emphysema Long-term health effects can include chronic
respiratory disease, lung cancer, heart disease, andeven damage to other vital organs
20
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Double Burden of Diseases
Water and sanitation problems
Due to increasing urbanization coupled withexisting un-sustainability factors and
conventional urban water management Nealy 1.1 billion people worldwide who do not
have access to clean drinking water and 2.6billion people i.e. over 400 million people, lack
even a simple improved latrine Can lead to increased episodes of diarrhea and
economic burden
21
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Double Burden of Diseases
Upsurge of Non-communicable diseases
The rising trends of non-communicable diseasesare a consequence of the demographic and
dietary transition Decreases in activity combined with access to
processed food high in calories and low innutrition have played a key role
Urbanization is an example of social change thathas a remarkable effect on diet in thedeveloping world
22
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Double Burden of Diseases
Traditional staples are often more expensive in urbanareas than in rural areas, whereas processed foods areless expensive
This favors the consumption of new processed foods
This places the urban population at increasedrisk of NCDs
In India, chronic diseases are estimated to account for53% of all deaths and 44% of disability-adjusted life-years (DALYs) lost in 2005
23
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Health challenges in urban India(Cont..)Inadequate public health infrastructure in urban slums
Health programs- The scheme on Urban Family Welfare Centers (UFWCs) 1950.
Urban Revamping Scheme (1983)-
India Population Project (IPP) VIII (19932003) Nationwide RCH I (19972003) Project.
Current status- 1,083 Urban Family Welfare Centers (UFWCs)
871 Urban Health Posts(UHP) - many of which are run byhospitals.
It means 1UFWC/UHP per 148,413 urban population.
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Urban Health Programmes of the
Government:
The scheme on Urban Family Welfare Centers (UFWCs) has been functioningsince 1950 to provide family welfare services in urban areas through existinghealth institutions and newly established clinics.
The urban Revamping Scheme (1983), where the Health posts have been
established to provide outreach services, Primary health care, MCH andFamily welfare services in urban slums. Health posts and post-partum centersin urban areas have by and large become hospital based programs which donot cater effectively to slum populations.
The World Bank assisted the Nation wide RCH I Project, wherein sub-projects
were implemented in seven cities, which included local capacity building foroptimizing the use of available resources, strengthening infrastructure andimplementing innovative approaches.
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National Urban Health Mission
Goal :to improve the health status of the urban poor particularlythe slum dwellers and other disadvantaged sections, byfacilitating equitable access to quality health care through an
effective public health system, partnerships, community basedrisk pooling and insurance mechanism with the activeinvolvement of the urban local bodies.
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Scope, Coverage and Duration of the
Mission The Mission would be covering 430 cities, i.e. all cities with
population one lakh and above and all the state capitals inPhase I.
In the first year 100 cities would be accorded priority forinitiating the mission.
All District Head- Quarter towns with population less than onelakh will be covered under Phase II of the Mission if NRHM
does not cover it in the interim. The cities with population less than one lakh would be covered
under NRHM and norms of service delivery as proposed underthe NUHM would be made applicable in such cities.
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Scope, Coverage and Duration of the
Mission For targeting the urban poor the NUHM would focus on the people
living in listed and unlisted slums.
The following definition a combination of the description (a) used by
Census 2001 and (b) `National Slum Policy (Draft) to be used for
identification of Slums.
Any compact habitation of at least 300 people or about 60-70
households of poorly built congested tenaments, unhygienic
environments, usually without adequate infrastructure and lacking in
proper sanitary and drinking water facilities in these townsirrespective of the fact as to whether such slums have been notified or
not as Slum by State/Local Government and Union Territory (UT)
administration under any Act, recognized or not, are legal or not,
would be covered under NUHM.
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Scope, Coverage and Duration of the
Mission The duration of the Mission would be for the remaining period of the 11th
Plan (2008-2012).
While the initial focus would be on the urban slums it is envisioned that asthe capacity at city level grows the scope may be broadened based on Mid-
Term Appraisal to cover the entire urban poor population.
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Core Strategies: (i) Improving the efficiency ofpublic health system in the cities by strengthening,
revamping and rationalizing urban primary health structure
Provision for a need based contractual human resource,equipments and drugs & provision of RKS.
The provision of health care delivery with the help of outreach
sessions in the slums. On the basis of the GIS map the referrals would also be clearly
defined and communicated to the community.
Rationalization of the existing public health care facilities and
human resources
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(ii) Partnership with non-government providers
for filling up of the health delivery gaps:
A large number of urban slum clusters do not have physicalaccess to public health facilities whereas there are nongovernment providers being accessed by the urban poor.
Specialized care, diagnostics and referral transport isprominently available in the non government sector.
To leverage the existing non government providers to improveaccess to curative care.
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(iii) Promotion of access to improved health care
at household level through community based groups
: Mahila Arogya Samittees In view of the usefulness of such women led community/ self
help groups; it is proposed to promote MAS for enhancedcommunity participation and empowerment
The USHA may provide the leadership and promote the MAS. The USHA may be preferably co-located with the Anganwadi
Centres located in the slums for optimisation of healthoutcomes.
Each of the MAS may have 5-20 members with an elected
Chairperson/ Secretary and other representative like Treasurer. The mobilization of the MAS may also be facilitated by a
contracted agency/NGO, working along with the USHA.
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(iv) Strengthening public health
through preventive and promotive
action A major focus of the Mission.
Urban Poor face greater environmental health risks due to poorsanitation, lack of safe drinking water, poor drainage, high densityof population etc. the urban local bodies for improved water and
environmental sanitation, nutrition and Resources for public health action would be provided as per city
specific need.
(v) Increased access to health care through risk pooling
and community health insurance models NUHM also proposes to promote Community based Health
Insurance models to meet costs arising out of hospitalization andcritical illnesses.
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(vi) Capacity building of
stakeholders
NUHM proposes to build managerial, technical and public healthcompetencies among the health care providers and the ULBsthrough capacity building, monetary and non monetaryincentives, and managerial support.
(vii) Prioritizing the most vulnerable amongst the poor
Under the NUHM special emphasis would be on improving the
reach of health care services to the vulnerable among the urbanpoor, falling in the category of destitute, beggars, streetchildren, construction workers, coolies, rickshaw pullers, sexworkers, street vendors and other such migrant workers.
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Community Level
Urban Social Health Activist (USHA)
Each slum would have a well defined grass root level area covering 1000-2,500beneficiaries, 200-500 households
USHA would remain in charge of each area and serve as an effective anddemandgenerating link between the health facility and the urban slum
populations. The USHA would preferably be a woman resident of the slum
married/widowed/ divorced, preferably in the age group of 25 to 45 years withformal education up to class eight, chosen through a community drivenprocess involving ULB Counsellors, SHGs, Anganwadi, ANMs.
The states may also consider of Community Organiser for 10 USHA for moreeffective coordination and mentoring, preferably located at the mentoringNGO. He along with the ANM may be designated as the mentoring andmanagement team at the slum level for the USHAs.
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Mahila Arogya Samiti (MAS)
Act as community based peer education group, involved incommunity monitoring and referral. The MAS may consist of20-100 households (HH) with an elected Chairperson and aTreasurer, supported by an USHA.
ANMProviding preventive and promotive healthcare servicesat the household level through regular visits and outreachsessions. Four ANMs will be posted in each UHC.
Outreach Medical Camps Once in a month the MO would
accompany the ANMs to the outreach sessions. It will includeOPD (consultation), basic lab investigations (usingmobile/disposable kits), and drug dispensing, apart fromcounselling..
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Primary Urban Health Centre
Functional for a population of around approximately50,000, the PUHC may be located preferably within aslum or a half km radius, catering to a slum population of
approximately 20000-30000, with provision for eveningOPD also.
The cities, based upon the local situation may establish aUHC for 75,000 for areas with very high density and canalso establish one for around 5000-10,000, slumpopulation for isolated slum clusters.
It act as first point for curative healthcare.
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Community Risk Pooling and Health
Insurance
NUHM recognizes that state/city specific, community oriented,innovative and flexible insurance policies need to be developed.
The private insurance companies may be encouraged to bring ininnovative insurance products.
A risk pooling system where the Centre, States and the localcommunity would be partners may be set.
This would be done by resource sharing, facility empanelmentand regulation of adherence to quality standards, establishing
standard treatment protocols and costs, apart from encouragingvarious premium financing mechanisms.
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Community Risk Pooling Mechanism
NUHM encourages setting up of MAS, to act as the unit of user groupas well as for designing and managing a need-based and affordablehealth insurance scheme.
The sources of funds for the savings account created by the MAS will
primarily include the savings by the women constituting the MAS, theone-time Seed Money, and annual Performance Grant provided underNUHM.
The money may be spent on the members familys unforeseen healthexpenditure needs and other activities like group meetings,
mobilisation for health camps, etc. The members of the MAS would be encouraged to pool an agreed
amount (say Rs.10- 20 or more - per family, per month). The amountwill be deposited in a savings bank account, managed by the MAS.
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Community Risk Pooling under NUHM
Mahila Arogya
Samiti(MAS)
Slum Women
Seed Money and
Performance Grant
Interest on savings
Interest on loans
Smallloans
Savings
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Budgetary Provisions and
Norms The NUHM would commence as a 100% centrally sponsored Scheme in the firstyear of its implementation during the XIth Plan period.
However, for the sustainability of the Mission from the second year, onward thesharing mechanism between the Central Government State/Urban local bodywould be as follows:
Funds / Resource required *
An estimated allocation of approximately Rs.8600 crores from the CentralGovernment for a period of 4 years (2008-2012) to the NUHM at the central, stateand city level may be required to enable adequate focus on urban health.
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Monitoring and Evaluation
Mechanism
The M&E framework would make use of the IT enabled services for informationcollection and its quick transfer. An appropriate programme based on the needwould be developed.
The NUHM would provide support for developing web based HMIS component
by making provision for developing need based software, provision forhardware procurement, software development, installation, training andmaintenance at PUHC/ City/ State / National level
The Monitoring and evaluation framework would be based on triangulisation ofinformation. The three components would be
(a) Community Based Monitoring
(b) A web based Urban HMIS for reporting and feedback
(c) external evaluations.
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Take Home Messages-4
The possible solutions can be
Ensuring adequate and reliable health related data
Inter-sectoral co-ordination
Sharing of successful experiences and bestpractice models
Application of PURA models
Reducing the financial burden of health care throughimproved financing techniques
Strengthening public private partnerships
Strengthening public health care facilities
51
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A lot of possibilities are
there in slums.So we cant ignore it.