NATIONAL URBAN HEALTH MISSION

the current financial year. The District Health Society will function as the coordinating body at the district level for urban health also. Urban Heal...

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No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Annexure

NATIONAL URBAN HEALTH MISSION FRAMEWORK FOR IMPLEMENTATION

MINISTRY OF HEALTH AND FAMILY WELFARE GOVERNMENT OF INDIA OCTOBER 2012

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No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

TABLE OF CONTENTS S.No. Chapter

Page No.

1

Executive Summary

3

2

The Urban Health Context – A Situation Analysis

12

3

Key Public Health Challenges in Urban Areas

31

4

Defining the Poor in Urban Areas

37

5

NUHM- Goals, Objectives, Strategies and Outcomes

38

6

Convergent Action in Urban Areas

45

7

Institutional Arrangements for Implementation

57

8

Broad Norms for NUHM Interventions

79

9

Financial Resource Needs for NUHM

83

10

Planning Process of NUHM

86

11

Appraisal and Approval Process of NUHM

87

12

Role of the Non Governmental Sector in NUHM

89

13

Role of Regulation and Defining Standards

90

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No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

I - EXECUTIVE SUMMARY 1.1 As per Census 2001, 28.6 crore people live in urban areas. The urban population has increased to 37.7 crore in 2011. Urban growth has led to rapid increase in number of urban poor population, many of whom live in slums and other squatter settlements. 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) was expected to reach 7.66 crore by 2011, thus putting greater strain on the urban infrastructure which is already overstretched. As per the 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. While the Jawahar Lal Nehru Urban Renewal Mission is beginning to tackle the urban infrastructure issues, urban health issues need immediate attention, especially in the context of the urban poor. It also needs attention from a public health perspective. 1.2 As per Census 2011, population of India has crossed 121 crores with the urban population at 37.7 cores which is 31.16% of the total population. 1.3 Despite the supposed proximity of the urban poor to urban health facilities their access to them is severely restricted. This is on account of their being “crowded out” because of the inadequacy of the urban public health delivery system. Ineffective outreach and weak referral system also limits the access of urban poor to health care services. Social exclusion and lack of information and assistance at the secondary and tertiary hospitals makes them unfamiliar to the modern environment of hospitals, thus restricting their access. The lack of economic resources inhibits/ restricts their access to the available private facilities. Further, the lack of standards and norms for the urban health delivery system when contrasted with the rural network makes the urban poor more vulnerable and worse off than their rural counterpart. Many components of the National Rural Health Mission cover urban areas as well. These include funding support for the 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 Reproductive and Child Health Programme including support for Janani Suraksha Yojana in urban areas, strengthening of health infrastructure like District and Block level Hospitals, Maternity Centres under the National Rural Health Mission, etc. The only limitation has been the fact that norms for urban area primary health infrastructure were not part of the NRHM proposal, setting a limit to support for basic health infrastructure in urban areas, under the NRHM. Municipal Corporations,

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No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Municipalities, Notified Area Committees and Nagar (Town) Panchayats were not units of planning under NRHM, with their own distinctive normative framework. 1.4 The urban poor suffer from poor health status. As per NFHS III ( 2005-06) data under 5 Mortality Rate (U5MR) among the urban poor at 72.7, is significantly higher than the urban average of 51.9, More than 46% of urban poor children are underweight and almost 60% of urban poor children miss total immunization before completing 1 year. Poor environmental condition in the slums along with high population density makes them vulnerable to lung diseases like Asthma, Tuberculosis (TB) etc. Slums also have a high-incidence of vector borne diseases (VBDs) and cases of malaria among the urban poor are twice as high as other urbanites. 1.5 In order to effectively address the health concerns of the urban poor population, the Ministry proposes to launch a National Urban Health Mission (NUHM). The Mission Steering Group of the NRHM will be expanded to work as the apex body for NUHM also. Every Municipal Corporation, Municipality, Notified Area Committee, and Town Panchayat will become a unit of planning with its own approved broad norms for setting up of health facilities. The separate plans for Notified Area Committees, Town Panchayats and Municipalities will be part of the District Health Action Plan drawn up for NUHM. The Municipal Corporations will have a separate plan of action as per broad norms for urban areas. The existing structures and mechanisms of governance under NRHM will be suitably adapted to fulfill the needs of NUHM also. 1.6 The planning process as per broad approved norms for urban areas will be started in all Municipal Corporations, Municipalities, NACs and Town Panchayats in the current financial year. The District Health Society will function as the coordinating body at the district level for urban health also. Urban Health Mission will be implemented through the Health Department in the urban local bodies except the very large ones where in the view of the State Government this can be handed over to the Municipal Corporation or any other urban local body. In such cases, a society will be formed and registered in the concerned urban body for implementing urban health activities, which will receive funds from the State Health Society. SHS and the society formed in the designated urban local body will enter into a bipartite MOU regarding the implementation of NUHM and periodical reporting and review of the progress. 1.7 The treatment of seven metropolitan cities, viz., Mumbai, Newe Delhi, Chennai, Kolkata, Hyderabad, Bengaluru and Ahmedabad will be different. These cities are expected to manage the NUHM through their Municipal Corporations directly. Funds 4

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

will be transferred to them through the State Health Society on the basis of their PIPs approved by the GoI. 1.8 Planning process in urban areas will be more complex as in many cases capacity building for public health activities needs to be taken up in urban local bodies. Also, the possibility of seeking partnerships with the non-governmental sector needs to be explored very closely as urban areas have the advantage of large scale presence of non governmental providers of health care. The planning process will also have to undertake large scale community level activities. The identification and involvement of Non Governmental organizations in community processes will have to be developed in the preparatory planning process itself. The initiatives under the National Urban Health Mission will seek to strengthen the public health thrust in urban local bodies, besides providing for cost of health care for the urban poor. The focus of the National Urban Health Mission will clearly be on alleviating the distress and duress of the urban poor in seeking quality health services. 1.9 Thus during the Mission period all 779 cities with a population of above fifty thousand and all the district and state headquarters (irrespective of the population size) would be covered. This will be in partnership with the NRHM’s efforts so far to ensure that there is no duplication of services. Urban areas with population less than 50,000 will be covered through the health facilities established under the National Rural Health Mission (NRHM). 1.10

The NUHM would have high focus on:

1.10.1 1.10.2

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, and other temporary migrants. 1.10.3 Public health thrust on sanitation, clean drinking water, vector control, etc. 1.10.4 Strengthening public health capacity of urban local bodies. 1.11 The National Urban Health Mission therefore aims to address the health concerns of the urban poor through facilitating equitable access to available health facilities by rationalizing and strengthening of the existing capacity of health delivery for improving the health status of the urban poor. This will be done in a manner to ensure that well identified facilities are set up for each segment of target population, which can be accessed conveniently. Partnerships with all efforts made for community 5

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

buildings under various urban area programmes will be accessed to ensure full utilization of created infrastructure. Similarly, the communitisation process will draw heavily on the existing community organizations and self – help groups developed through other initiatives. 1.12 Acknowledging the diversity of the available facilities in the cities, flexible city specific models led by the urban local bodies would be needed. The NUHM will leverage the institutional structures of NRHM for administration and operationalisation of the Mission. It will also establish synergies with other programmes with similar objectives like JnNURM, SJSRY, and ICDS to optimize the outcomes. 1.13 The National Urban Health Mission will provide flexibility to the States to choose which model suits the needs and capacities of the states to best address the healthcare needs of the urban poor. Models will be decided through community led action. For strengthening the extant primary public health systems, NUHM based on the key characteristics of the existing urban health delivery system proposes a broad framework rationalizing the available manpower and resources, improving access through a communitised risk pooling mechanism and enhance participation of the community in planning and management of the health care service delivery by ensuring a community link volunteer (urban Accredited Social Health Activist-ASHA Link Workers from other programs like JnNURM, ICDS etc.) and establishment of Rogi Kalyan Samitis (RKS), ensuring effective participation of urban local bodies and their capacity building along with key stakeholders, and by making special provision for inclusion of the most vulnerable amongst the poor, development of e-enabled monitoring system. The quality of the services provided will be constantly monitored for improvement (IPHS/ Revised IPHS for Urban areas etc.). 1.14 All the services delivered under the urban health delivery system through the Urban-PHCs and Urban-CHCs will be universal in nature, whereas the outreach services will be targeted to the target groups (slum dwellers and other vulnerable groups). Unlike rural areas, Sub-centres will not be set up in the urban areas as distances and mode of transportation are much better here. Outreach services will be provided through the Female Health Workers (FHWs), essentially ANMs with an induction training of three to six months, who will be headquartered at the Urban PHCs. These ANMs will report at the U-PHC and then move to their respective areas for outreach services (including school health) on designated days. They will be provided mobility support for providing outreach services. On other days, they will conduct Immunization and ANC clinics etc. at the U-PHC itself. 6

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

1.15 Empowerment of community through awareness generation, whereby they are able to demand services from the Health System will be an important area of emphasis in the NUHM. An effort to ensure a change in the health seeking behavior of the community where they get into the habit of accessing the health facilities rather than expecting everything at their doorsteps will be made. Diagram: Urban Health Care Delivery Model

Urban Health Centre (One for about 50,000 population including 25-30000 slum population) Strengthened existing Public Health Care Facility for extending services FFFFF to unserved areas FFLthousand slum population)* Community Outreach Service (Outreach points in government/ public domain Empanelled private services provider) school health services

Referral

Public or empanelled Secondary/ Tertiary private Providers

-------------------Primary Level Health Care Facility -------------------Community Level

Urban Social Health Activist(200-500 HH)

* This may be adapted flexibly based on spatial situation of the city Mahila Arogya Samiitee (20-100HH)

1.16 The NUHM would encourage the effective participation of the community in planning and management of health care services. It would promote a community health volunteer - Urban Social Health Activist (ASHA) or Link Worker (LW) in urban poor settlements (one ASHA for 1000-2500 urban poor population covering about 200 to 500 households); ensure the participation by creation of community based institutions like Mahila Arogya Samiti (50-100 households) and Rogi Kalyan Samitis. However, the States will have the flexibility to take the work of motivating community from the Mahila Arogya Samitis (MAS) and in that case recruiting an ASHA may not be necessary. The performance-based incentives can be credited to the account of MAS in that case, which can be used to enhance the revolving fund or distributing some honorarium to the most active members. Existing women groups under the JnNURM 7

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

etc. and other like structures can be adopted for implementation of NUHM. Self-help groups of women made under programmes of urban development department etc. can also play the role of MAS. 1.17 NUHM would proactively reach out to urban poor settlements by way of regular outreach sessions and monthly health, sanitation and nutrition day. States would be encouraged to involve NGOs to facilitate communitization process, build the capacity of ASHA and MAS and carryout IEC/BCC activities. It mandates special attention for reaching out to other vulnerable sections like construction workers, rag pickers, sex workers, brick kiln workers, rickshaw pullers and street children. This could be done through the public healthcare systems or through PPP or other innovative models deemed suitable by the states. ANM will also be provided with mobility support to reach out the un-reached area and vulnerable population with outreach session. Communication facility in the form of Closed User Group (CUG) will be made available. 1.18 The NUHM would provide annual grant of Rs.5000 to the MAS every year. This amount can be used for conducting fortnightly/monthly meetings of MAS, sanitation and hygiene, meeting emergency health needs etc. To build the capacity of MAS quarterly orientation workshops on the subject of the Group organization, governance and management of the group, Leadership skills etc. would be organized in the first year, and thereafter once a year. 1.19 In case, ASHA is recruited, she will be required to organize orientation meetings of the MAS or else, this work can be handed over to NGOs also. 1.20 The National Urban Health Mission would leverage as far as possible the institutional structures of the NRHM at the National, State and District level for operationalisation of the NUHM. However, in order to provide dedicated focus to issues relating to Urban Health the institutional mechanism under the NRHM at various levels would be strengthened for NUHM implementation. 1.21 The National Urban Health Mission would promote the role of the urban local bodies in the planning and management of the urban health programmes. The NUHM would also incorporate and promote transparency and accountability by incorporating elements like health service delivery charter, health service guarantee, concurrent audit at the levels of funds release and utilization.

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No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

1.22 NUHM would aim to provide a system for convergence of all communicable and non-communicable disease programmes including HIV/AIDS through integrated planning at the City level. The objective would be to enhance the utilization of the system through the convergence mechanism, through provision of a common platform and availability of all services at one point (U-PHC) and through mechanisms of referrals. The existing IDSP structure would be leveraged for improved surveillance. The management, control and supervision systems however would vest within the respective divisions but urban component /funds within the programmes would be identified and all services will be sought to be converged /located at U-PHC level. Appropriate convergences and mechanisms for co-locations and strengthening would be sought with the existing systems of AYUSH at the time of operationalisation. NUHM will not provide for contractual staff of AYUSH as is the case with NRHM. 1.23 NUHM will specifically address the peculiarities of urban health needs, which constitutes non-communicable diseases (NCDs) as a major proportion of the burden of disease. The primary health care system being envisaged under NUHM will screen, diagnose and refer the cases of chronic diseases to the secondary and tertiary level through a system of referral. Hence, strengthening of healthcare facilities in secondary and tertiary care also needs substantial upgradation. 1.24 The effective implementation of the above strategies would require skilled manpower and technical support at all levels. Hence the National Urban Health Mission would ensure additional managerial and financial resources at all levels. 1.25 The urban areas need a thrust on enhancing public health capacity of urban local bodies. The NUHM will systematically work towards meeting the regulatory, reformatory, and developmental public health priorities of urban local bodies. It will promote convergent and community action in partnership with all other urban area initiatives. Vector control, environmental health, water, sanitation, housing, all require a public health thrust. NUHM will provide resources that enable communitization of such processes. It will provide resources that strengthen the capacity of urban local bodies to meet public health challenges.

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No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Urban Health Care Facilities

For every 2.5 lakh population (5 lakh for metros)

U-CHC Inpatient facility, 30 -50 bedded (100 bedded in metros) *Only for cities with a population of above 5 lakhs

U-PHC MO I/C

-

1

2nd MO (part time) - 1

For every 50,000 population

Nurse

-

3

LHV

-

1-2

Pharmacist

-

1

ANMs

-

3-5

Public Health Manager/ Mobilization Officer – 1

For every 10,000 population

200- 500 HHs (1000-2500 population)

50-100 HHs

Support Staff

-

3

M & E Unit

-

1

1 ANM Outreach sessions in area of every ANM on weekly basis

Community Health Volunteer (ASHA/ASHA/LW)

Mahila Arogya Samiti

(250-500 population) 10

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

States/ UTs wise Urban and Slum Population in India 2001

S. No.

Percentage of slum population to total

India/States/ UTs

Number of cities/ towns reporting slums

Total urban population

Population of cities/ towns reporting slums

Total Slum Population

1

2

3

4

5

Urban Population

Population of cities/ towns reporting slums

6

7

India

640

283,741,818

184,352,421

42,578,150

15.0

23.1

1

Andhra Pradesh

77

20,808,940

16,090,585

5,187,493

24.9

32.2

2

Assam

7

3,439,240

1,371,881

82,289

2.4

6

3

Bihar

23

8,681,800

4,814,512

531,481

6.1

11

4

Chattisgarh

12

4,185,747

2,604,933

817,908

19.5

31.4

5

Goa

2

670,577

175,536

14,482

2.2

8.3

6

Gujarat

41

18,930,250

12,697,360

1,866,797

9.9

14.7

7

Haryana

22

6,115,304

4,296,670

1,420,407

23.2

33.1

8

Jammu & Kashmir

5

2,516,638

1,446,148

268,513

10.7

18.6

9

Jharkhand

11

5,993,741

2,422,943

301,569

5

12.4

10

Karnataka

35

17,961,529

11,023,376

1,402,971

7.8

12.7

11

Kerala

13

8,266,925

3,196,622

64,556

0.8

2

12

Madhya Pradesh

43

15,967,145

9,599,007

2,417,091

15.5

25.2

13

Maharashtra

61

41,100,980

33,635,219

11,202,762

27.3

33.3

14

Meghalaya

1

454,111

132,867

86,304

19

65

15

Orissa

15

5,517,238

2,838,014

629,999

11.4

22.2

16

Punjab

27

8,262,511

5,660,268

1,159,561

14

20.5

17

Rajasthan

26

13,214,375

7,668,508

1,294,106

9.8

16.9

18

Tamil Nadu

63

27,483,998

14,337,225

2,866,893

10.4

20

19

Tripura

1

545,750

189,998

29,949

5.5

15.8

20

Uttar Pradesh

69

34,539,582

21,256,870

4,395,276

12.7

20.7

21

Uttarakhand

6

2,179,074

1,010,188

195,470

9

19.3

22

West Bengal

59

22,427,251

15,184,596

4,115,980

18.4

27.1

23

A&N Island

1

116,198

99,984

16,244

14

16.2

24

Chandigarh

1

808,515

808,515

107,125

13.2

13.2

25

Delhi

16

12,905,780

11,277,586

2,029,755

15.7

18

26

Pondicherry

3

648,619

513,010

73,169

11.3

14.3

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No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

2 - THE URBAN HEALTH CONTEXT – A SITUATION ANALYSIS Table 2.1: THE URBAN CONTEXT Census 2001 Projected figures

28.6 Crore in urban areas

430 towns with 1,00,000

4.26 Crore people in slums

and more population

35.7 Crore urban population in 46% population will be 2011

urban by 2030

43.2 Crore urban population in Growth 2021 7.66

of

urban

population is double of Crore

urban

slum rural population

population in 2011 Table 2.2: ANNUAL POPULATION GROWTH RATE

ALL INDIA URBAN INDIA MEGA CITIES SLUM POPULATION

2% 3% 4% 5-6%

Table 2.3: URBAN AREAS COVERED UNDER N.U.H.M TOWN PANCHAYATS NOTIFIED AREA COMMITTEES MUNICIPALITIES MUNICIPAL CORPORATIONS Table 2.4: CITIES COVERED UNDER N.U.H.M MEGA CITIES

7 – GREATER MUMBAI, KOLKATA, DELHI, CHENNAI, BENGALURU, HYDERABAD, AHMEDABAD 40

MILLION PLUS CITIES CITIES WITH POPULATION BETWEEN 110 LAKHS CITIES WITH POPULATION BETWEEN 50,000 TO 1 LAKH

552 604

* The number of cities has been estimated based upon projections using the Census 2001 data. 12

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Box 2.1: HEALTH CONDITION OF THE URBAN POOR ◙

U5MR of 72.7 against urban average of 51.9



46% under- weight children among urban poor – urban average – 32.8%

◙ 46.8% women with no education; urban average 19.3% ◙ 44.4% institutional deliveries; urban average – 67.5% ◙

71.4% anaemic among urban poor; urban average – 62.9%



18.5% urban poor have access to piped water supply; urban average – 50%



60% miss total immunization before completing one year.

◙ Poor environmental condition with high population density – lung diseases, TB, etc. ◙

Poor access to safe water and sanitation – water-borne diseases, diarrhea, dysentery



High incidence of vector borne diseases among urban poor

Table 2.5: Cause of Death in Rural & Urban Areas

Source: Report on Causes of Deaths in India (2001-2003), based on SRS, RGI, India 13

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Table 2.6: Age-wise causes of Death (%), Urban India 0-4 years ---

5-14 years ---

15-24 years 7.6

25-69 years 32.8

Cardiovascular Diseases Malignant and other neoplasms --3.8 5.3 11.3 COPD, Asthma and other respiratory diseases ------7.7 Tuberculosis ----8.1 7.7 Senility --------Diarrheal diseases 13.2 17.4 ----Unintentional injuries: Other 3.1 14.7 11.2 3.6 Symptoms signs and illdefined conditions 3.6 5.9 8.4 4.3 Digestive diseases 3.5 5.8 Respiratory infections 19.5 8.3 ----Perinatal Conditions 35.7 ------Other infectious and parasitic diseases 8.8 12.4 4.3 --Congenital anomalies 5.2 ------Nutritional deficiencies 3.1 ------Malaria 1.2 5.9 3.5 --Fever of Unknown origin 1.2 ------Motor Vehicle Accidents --4.4 11.8 3.7 Intentional self harm --3.2 13.1 --Maternal Conditions ----3.7 --Genito-Urinary diseases ------3.3 Diabetes Mellitus ------2.8 Source: Report on Causes of Deaths in India (2001-2003), based on SRS, RGI, India

70+ years 34.7 5.6 10.6 2.9 14.3 5 4.5 3.8 ----------------------2.8 3.4

Table 2.7: STATES WITH HIGHEST AND LOWEST RATES OF URBAN POVERTY HIGHEST RATES OF URBAN POVERTY BIHAR – 43.7% ORISSA – 37.6% MADHYA PRDESH-35.1% UTTAR PRADESH- 34.1%

LOWEST RATES OF URBAN POVERTY NAGALAND – 4.3% HIMACHAL PRADESH- 4.6% MIZORAM – 7.9% PUDUCHERRY – 9.9%

*Source; Expert group – Planning Commission- 2009.

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Box 2.2: Findings of some studies regarding urban areas 

The estimated prevalence of coronary heart disease is around 3-4% in rural areas and 8-10% in urban areas among adults older than 20 years, representing a twofold rise in rural areas and a six fold rise in urban areas over the past four decades. [Responding to the threat of chronic diseases in India: K. Srinath Reddy, Bela Shah, Cherian Varghese, Ambumani Ramadoss, The Lancet, October 2005];



The age adjusted incidence rates in men vary from 44 per 100000 in rural Maharashtra to 121 per 100,000 in Delhi [National Cancer Registry Programme of ICMR];



Prevalence of diabetes in adults estimated to be 3.8% in rural areas and 11.8% in urban areas [ICMR – Recent surveys];



Prevalence of hypertension has been reported to range between 20-40% in urban adults and 12-17% among rural adults [Lancet 2005; Global burden of hypertension – Analysis of world wide data];



66.6 lakh cases of Asthma in urban areas in India in 2011 – to rise to 73.2 lakhs cases to 2016;



Dental caries more prevalent in urban areas;



Higher rates of traffic accidents in urban areas;



Higher rates of domestic violence in cities;



High incidence of mental health cases [Reddy and Chandra Shekhar 1998];



Drugs, Tobacco and alcohol abuse in urban areas

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Box 2.3: Current status of the private sector in India The private sector consists largely of sole practitioners or small nursing homes having 1-20 beds, serving an urban and semi-urban clientele and focused on curative care. A survey of the qualified provider markets in eight middle-ranging districts: Khammam (AP), Nadia (WB), Jalna (MH), Kozhikode (Kerala), Ujjain (MP), Udaipur (RJ), Vaishali (BH) and Varanasi (UP) showed (National Commission on Macro Economics and Health; 2005): 1. A highly skewed distribution of resources — 88% of towns have a facility compared to 24% in rural areas, with 90% of the facilities manned by sole practitioners. 2. The private sector has 75% of specialists and 85% of technology in their facilities. 3. The private sector account for 49% beds and an occupancy ratio of 44% whereas the occupancy rate is 62% in the public sector. 4. 75% of service delivery for dental health, mental health, orthopedics, vascular and cancer diseases and about 40% of communicable diseases and deliveries are provided by the private sector. An overview of the private sector: 1. Serious supply gaps and distributional inequities; 2. Need for uniform standards and treatment protocols; 3. Need for cost controls and quality assurance mechanisms; 4. Regulations to protect consumer interests and enforcement systems; 5. Supporting the NGO/charitable or the third sector, which has the capability to provide reasonable quality care at affordable rates and the potential to serve the poor in under-served areas if appropriately incentivized and supported. [[

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2.1

Expenditure on Health Care

2.1.1 As per consumer expenditure data, households spend 5-6% of their total expenditure and 11% of non-food consumption expenditure on health. Data also show an increasing growth rate of 14% per annum in household health spending. It may be noted that almost half the spending was just on outpatient care. 2.1.2 There are wide variations in household spending across states. While Kerala spends an average of Rs. 2548 ( 2004-05 current prices) per capita per annum, households in Bihar, one of the poorest and most backward state spent Rs. 1021 per capita per annum accounting for 90% of the total health expenditure in the state during the year 2004-05. 2.1.3 A survey of households conducted by the IIHMR, Jaipur (IIHMR 2000) showed that a married woman in the age group of 15-49 years spent an average of Rs 400 for RCH services (amounting to 10 days wage), with urban households spending Rs 604 and rural households about Rs 292. The study also showed that the reluctance of women for institutional deliveries and the persistently high proportion of domiciliary deliveries is driven by cost factors : delivery in a public hospital costs an average of Rs 601, private hospital about Rs 3593, while home only Rs 93. The major item of expenditure was also found to be drugs, which constituted 62%. 2.1.4 Drugs are one of the three cost drivers of the health care system. On the demand side, drugs and medicines form a substantial portion of the out-of-pocket (OOP) spending on health by households in India. Estimates from the National Sample Survey (NSS) for the year 1999-2000 suggest that about half of the total OOP expenditure is on drugs. In rural India, the share of drugs in the total OOP is estimated to account for nearly 83%, while in urban India, it is 77%. The share of drugs in the total inpatient treatment in rural and urban India is around 56% and 47%, respectively for the same period. 17

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2.2

The Urban Poor and the Private Health Sector

2.2.1 The burgeoning 80 million urban poor in India struggle for basic services like housing, water and sanitation. The links between these contextual forces and health outcomes is manifest not only in the striking differentials in health among urban poor and non-poor groups but in health indicators of the urban poor which are comparable to, and in many cases, worse off than, the poor living in rural areas of the country. Despite the presence of a vast public health network, in the absence of urban primary health care services, the private sector assumes prominence in the health seeking behaviour of this sub-population. One of the largest private healthcare sectors in the world, it encompasses a wide range of players. 2.2.2.

The private sector that the poor access may be thought of consisting of three wings:

2.2.2.1 the fully-organized-and-fully qualified; 2.2.2.2 the fully qualified private providers that operate in less than well to do neighborhoods where the slum population too go; and 2.2.2.3 the ‘less-than-fully-qualified’ practitioners in the slum.

2.2.3 The last group comprises practitioners who are either untrained or minimally trained in any system of medicine or trained in one system and practice another. It is estimated that these untrained, unlicensed practitioners in the country outnumber qualified medical doctors by at least 10:1. 2.2.4 Although a large majority of them operate in rural areas, urban areas too are witnessing increasing numbers of these untrained practitioners as we see in the report. [Health of the Urban Poor and Role of Private Practitioners: The Case of a Slum in Delhi – Nupur Barua, Jens Seeberg, Chandrakant S. Pandav, Centre for Community Medicine, AIIMS in collaboration with ICCIDD, New Delhi, 2009] 2.3

Public Sector Provisioning for health care in urban areas 18

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2.3.1 While the Constitution mandates the role of urban local bodies in the management of primary health care, there are a variety of models in the country today. Teams from the Ministry were sent to a diversity of States and urban situations to understand the management of health care in urban areas at present. The Table below captures the key findings. 2.4

City wise description of health care system Group

Cities

Type of Health Gaps and Constraints care System of the ULBs

A

IPP CITIES

Three tier structure comprising of UHP/ UFWC and Dispensary/ Maternity Homes/ and Tertiary / Super-speciality Hospitals.

Mumbai, Bengaluru, Hyderabad Delhi, Kolkatta, Chennai

Inequitable spatial distribution of facilities with multiple service providers Unsuitable timings and distance from urban poor areas, Overload on tertiary institutions and under utilized primary institutions primarily due to weak referral system.

Non integrated service delivery Community with focus mostly on RCH level volunteers. activities, very few lab facilities, Presence of vast shortage of medicines, drugs, network of equipment, limited capacity of health care professionals and private demotivation. providers /NGOs Charitable trusts

and Skewed priority to the tertiary sector by the ULBs, High turnover of medical professionals, issues of career progression, incentives and salaries, disconnect between doctors on deputation and

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Group

Cities

Type of Health Gaps and Constraints care System of the ULBs municipal doctors Limited community linkages and outreach Limited identification of the urban poor for health In many instances the first interface is with non-qualified medical practitioners

B

Surat, Thane, Ahemdabad

C

UHP/UFWCs, Dispensary / Maternity Homes / Tertiary Hospitals.

Agra

The Health care delivery infrastructure is better planned and managed due to personal initiative of the ULBs. However the aforesaid constraints remain.

UHP/UFWC / Dependent on State support for a few Maternity health activities in the cities Indore Homes Weak fiscal capacity of the ULBs to Patna Presence of plan for urban health. private Chengelpet Health low on priority of ULBs providers except in Madhyamgram Madhyamgram Few NGOs and , Poor availability of doctors and Charitable staff in facilities. Few found Bhuwaneshwar trusts relocated to secondary and tertiary facilities. Poor state of Udaipur, infrastructure in the facilities Jabalpur, Cuttack Guwahati Raipur

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Group

Cities

Type of Health Gaps and Constraints care System of the ULBs

D

Ranchi,

UFWC/ UHP

Non-existent urban local body

Large presence of Charitable Limited State level initiatives and NGOs

2.5

Central Assistance for primary health care [

2.5.1 The process of developing a health care delivery system in urban areas has not as yet received the desired attention. The Tenth Plan Document observes that ‘unlike the rural health services there have been no efforts to provide well-planned and organized primary, secondary and tertiary care services in geographically delineated urban areas. As a result, in many areas primary health facilities are not available; some of the existing institutions are underutilized while there is over-crowding in most of the secondary and tertiary centres’.1 2.5.2 The Government of India in the First Five Year Plan established 126 urban clinics of four types to strengthen the delivery of Family Welfare services in urban areas. In 1976 these were reorganized into three types by the Department with a staffing pattern as indicated in the table below; at present there are 1083 centres functioning in various states and UTs2. An amount of Rs. 520.40 crores has been proposed in the XIth Plan for sustaining the already ongoing activities and payments for heads like salary.

1

Planning Commission, Government of India ; Tenth Plan Document (2002-2007, Volume II)

2

MOHFW, GOI : Annual Report on Special Schemes, 1999-2000,

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Table 2.8: Types of Urban Family Welfare Centres (UFWC) Category

Number Popn. Covered UFWC Staffing Pattern (in ‘000)

Type I

326

10-25

ANM (1) / FP Field Worker Male (1)

Type II

125

25-50

FP Ext. Edu./LHV (1) in addition to the above

Type III

632

Above 50

MO – Preferable Female (1), ANM and Store Keeper cum Clerk (1)

TOTAL

1083

Source: MOHFW, GOI: Annual Report on Special Schemes, 2000 2.5.3 On the recommendations of the Krishnan Committee, under the Revamping scheme in 1983, the Government established four types of Urban Health Posts (UHP) in 10 States and Union Territories with a precondition of locating them in slums or in the vicinity of slums. The main functions of the UHPs are to provide outreach, primary health care, and family welfare and MCH services. The table below details the manpower along with the population coverage of health posts. At present there are 871 health posts in various states and UTs3, functioning not very satisfactorily. An amount of Rs. 438.44 crore has been proposed in the XIth Plan for sustaining the already ongoing activities and payments for heads like salary. Table 2.9: Types of Urban Health Posts (UHP)

3

Category

Number Population covered

Staffing Pattern

Type A

65

Less than 5000

ANM (1)

Type B

76

5,000 – 10,000

ANM (1), Multiple Worker – Male (1)

Type C

165

10,000 – 20,000

ANM (2), Multiple Worker – Male

MOHFW, GOI : Annual Report on Special Schemes, 1999-2000,

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Category

Number Population covered

Staffing Pattern

(2) Type D

TOTAL

Lady MO (1), PHN (1), ANM (3-4) 565

25,000 – 50,000

Multiple Worker – Male (3-4), Class-IV Women (1)

871

Source: MOHFW, GOI: Annual Report on Special Schemes, 2000 2.5.4 The Indian Institute of Population Studies (IIPS) undertook an evaluation of the functioning of UHP and UFWCs and came out with the following findings, as shown in box below: Box 2.4: IIPS evaluation of the UFWC and UHP scheme: Key findings4 • In terms of functioning, 497 (30%) UHPs and UFWCs were ranked good, 540 (35%) were average and 492(32%) as below average or poor. • Weak Referral Mechanism • Provision of only RCH services • Inadequate trained staff • In 30% of the facilities the sanctioned post of Medical Officer is vacant/ others mostly relocated. • Lack of equipments, medicines and other related supplies • Unequal distribution of facilities among states e.g. in Bihar one centre covers 1, 10,000 urban poor while in Rajasthan average population coverage is 5535. • Irregular and insufficient outreach activities by health workers 2.5.5 The implementation mechanism of most of the programmes except for the UFWC and UHP schemes of GOI is through the district institutional and planning mechanism. Therefore resources get disaggregated in terms of districts and not cities. 4

Indian Institute of Population Studies 2005; National Report on Evaluation of functioning of UHPs/UFWCs in India

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Implementation in cities thus appears to be fragmented and patchy. As such the absence of institutional/ planning mechanisms in cities therefore restricts institutionalized access of the urban poor to the programmes. 2.6

The India Population Project (IPP) V and VIII

2.6.1 Due to rapid growth of urban population, efforts were made in the metropolitan cities of Chennai, Bengaluru, Kolkata, Hyderabad, Delhi and Mumbai for improving the health care delivery in the urban areas through World Bank supported India Population Projects (IPP). Under the program 479 Urban Health Posts , 85 Maternity Homes and 244 Sub Centers were created, in Mumbai & Chennai as part of IPP V and in Delhi, Bengaluru, Hyderabad and Kolkata as part of IPP VIII. 2.6.2 These, to a limited extent, resulted in enhanced service delivery and also better capacity of urban local bodies to plan and manage the urban health programmes in these cities. They are presently however, facing shortage of manpower and resources. An examination of extended IPP VIII project in Khammam town of Andhra Pradesh has also identified management issues like lack of financial flexibility/ long term financial sustainability, and lack of need based management models as constraints which need to be redressed in any urban health initiative5. 2.7

Key characteristics of the extant situation

2.7.1 THE DIVERSITY OF THE URBAN SITUATION 2.7.1.1 The urban health situation in the cities is characterized by marked diversities in the organization of health delivery system in terms of provisioning of health care services, management, availability of private providers, finances etc. In cities like Mumbai, Kolkata, Chennai, Bengaluru, Ahmedabad, etc, it is primarily the urban local bodies (ULBs) in line with the mandate of the 74th Amendment, which are managing the primary health care services. However in many cities like Delhi, along with the urban local body i.e. the Municipal Corporation of Delhi (MCD), New Delhi Municipal Corporation (NDMC), Delhi Cantonment Board and other parastatal agencies along with the State Government jointly provide primary health care services. In cities like Patna, Ranchi, Agra, Bhopal, Meerut, Indore, Guwahati despite the presence of ULBs, 5

ECTA Working Papers 2000/31 ; Urban Primary Health Systems : Management Issues, September 2000

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the provision of primary health services still vests with the State Government through its district structures. Box 2.5: STUDY IN CONTRAST: BRIHAN MUMBAI MUNICIPAL CORPORATION AND MIRA BYANDAR MUNICIPAL CORPORATION IN MAHARASHTRA* The Brihan Mumbai Municipal Corporation (BMC), with a population of 1.19 crore (2001) and a slum population of about 60 lakh, is the largest Municipal Corporation in India, and a major provider of public health-care services at Mumbai. It has a network of teaching hospitals, Municipal General Hospitals and Maternity Homes across Mumbai. Apart from these there are Municipal Dispensaries and Health Posts to provide outpatient care services and promote public health activities in the city. However, Mira Byandar Corporation at the outskirts of Mumbai city and growing at a decadal growth rate of 196% from 1991-2001(from 1.75lakh to 5.20 lakh) with 40% slum population has only first tier structures, namely 7 Urban Health Posts and 2 PHCs( to be shortly transferred from the Zilla Parishad) , in the government system. However as informed there are approximately 1000 beds in the private sector in this city. On the one hand there is a BMC with a 900 crore health budget (9% of total BMC Budget of which 300 crore is on medical education), many times the health budget of a some of the smaller states, and on the other, there is another Corporation still struggling to emerge from the rural - urban continuum. While ADC heading the health division of BMC is a very senior civil servant, the Chief Health Officer of Mira Byandar Corporation is a recently regularized doctor with around three years experience in the Corporation. For the ADC of BMC, major health areas requiring policy attention apart from financial assistance from the Centre relate to guidelines for system improvement for health delivery esp. vis a vis issues of Town Planning, land ownership, governance, recruitment structures, reservation policies, migrants, instability of slums, high turnover of workforce in Corporations which often come in the way of providing health care to the poor along with the challenge of getting skilled human resources, which despite repeated advertisements still remain vacant in BMC. There are 8-9% vacancies in the municipal cadres of ANM. The chief concern of the Mira Byandar Corporation on the other hand is to 25

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construct a 200 bedded Hospital, as a Municipal Hospital offers high visibility and also because the poor find it difficult to access the private facility due to high cost of services and therefore are referred to Mumbai which is 40 km away. * Observations on field visit to cities in September 2007 for stakeholder consultation by officials of MoHFW 2.7.2 WEAK CAPACITY OF PRIMARY HEALTH CARE

URBAN

LOCAL

BODIES

TO

MANAGE

2.7.2.1 Two models of service delivery are seen to be prevalent in urban areas. In states like Uttar Pradesh, Bihar and Madhya Pradesh health care programmes are being planned and managed by the State government; the involvement of the urban local bodies is limited to the provisioning of public health initiatives like sanitation, conservancy, provision of potable water and fogging for malaria. In other states like Karnataka, West Bengal, Tamil Nadu and Gujarat the health care programmes are being primarily planned and managed by the urban local bodies. In some of the bigger Municipal bodies like Ahmedabad, Chennai, Surat, Delhi and Mumbai the Medical/Health officers are employed by the local body whereas in smaller bodies, health officers are mostly on deputation from the State health department. Though bigger corporations demonstrate higher capacity to manage their health programmes, there is still scope to further build their capacity. During consultations, officers of even large corporations like Mumbai mentioned that large numbers of urban poor remain underserved by health care. The situation in most cities also revealed that there was a lack of effective coordination among the departments that lead to inadequate focus on critical aspects of public health such as access to clean drinking water, environmental sanitation and nutrition. 2.7.2.2 Though bigger corporations demonstrate improved capacity to manage their heatlh programmes, there is still a need to build their capacity. The IPP VIII Project Completion Report (IPPCR) has also emphasized the capacity and commitment of political leadership as one of the critical factors for the efficacy of the health system. In Kolkata, strong political ownership by elected representatives has played a positive role in the smooth implementation of the project and sustainability of the reforms introduced. On the other hand, in Delhi, despite efforts by the project team, effective coordination between different 26

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agencies and levels could not develop a common understanding on improving service delivery and promoting initiatives crucial for sustainability. The experiences in Hyderabad and Bengaluru were mixed, but mostly driven by a few committed individuals. 2.7.2.3 The situation in most cities also revealed that there was a lack of effective coordination among the departments that lead to inadequate focus on critical aspects of public health such as access to clean drinking water, environmental sanitation and nutrition. 2.7.3 DATA INADEQUACY IN PLANNING 2.7.3.1 Urban population, unlike the rural population, is highly heterogeneous. Most published data does not capture the heterogeneity, as the Standard of Living Index does often not disaggregate it. It therefore masks the health condition of the urban poor. The informal or often illegal status of low income urban clusters results in public authorities not having any mandate to collect data on urban poor population. This often reflects in health planning not being based on community needs. It was seen that mental health, which was an observable problem of the urban slums, was not getting reflected in the city data profile. Most cities visited were found lacking in city-specific epidemiological data, inadequate information on the urban poor and illegal clusters, in-adequate information on existing health facilities esp. in the private sector. Data collection at the local /city level is therefore necessary to correctly comprehend the status of urban health and to assess the urban community needs for health care services. 2.7.4 MULTIPLICITY OF SERVICE PROVIDERS AND DYSFUNCTIONAL REFERRAL SYSTEMS 2.7.4.1 The multiplicity of service providers in the urban areas, with the ULBs and State Governments jointly provisioning even primary health care, has led to a dysfunctional referral system and a consequent overload on tertiary hospitals and underutilized primary health facilities. Even in states where ULBs manage primary health care with secondary and tertiary levels in the State domain, there are problems in referral management. Similar observations have also been made in IPP VIII completion report which states that multiplicity of agencies providing health services posed management and implementation problems in all project cities: In 27

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Delhi, there were coordination problems for health service among different agencies, such as Municipal Corporation of Delhi (MCD), New Delhi Municipal Corporation (NDMC), Delhi Cantonment Board, Delhi Jal Board (DJB), Delhi Government, and Employees State Insurance (ESI) Corporation. Similarly, in Hyderabad, coordination of the project with secondary and tertiary facilities under different managements constrained effective referral linkages. Bengaluru and Kolkata had fully dedicated maternity homes in adequate numbers that facilitated better follow-up care. However, even in these two places, linkages with district and tertiary hospitals, not under the control of the municipalities, remained weak. 2.7.5 WEAK COMMUNITY HEALTH CARE

CAPACITY

TO

DEMAND

AND

ACCESS

2.7.5.1 Heterogeneity among slum dwellers due to in-migration from different areas, instability of slums, varied cultures, fewer extended family connections, and more women engaged in work, has led to lesser willingness and fewer occasions to build urban slum community as a strong collective unit, which is seen as one of the major public health challenges in improving access. Even the migratory nature of the population poses a problem in delivery of services. Similar concerns have also been raised in the IPP VIII completion report which states lack of homogeneity among slum residents, coming from neighboring states/countries to the large metropolitan cities, made planning and implementation of social mobilization activities very challenging. 2.7.6 STRENGTHENING COMMUNITY UTILIZATION OF SERVICES

CAPACITY

INCREASES

2.7.6.1 The Urban Health programmes in Indore and Agra have demonstrated that the process of strengthening community capacity either through Link worker or a Community Based Organization (CBO) helps in improving the utilization of services. The IPP VIII project has also demonstrated that the use of female voluntary health workers viz. Link workers, Basti Sewikas etc. selected from the local community played an important role in extending outreach services to the door steps of the slums which helped in creating a demand base and ensuring people’s satisfaction. It was also observed that the collective

28

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community efforts played an important role in improving access to drinking water, sanitation, nutrition services and livelihood. 2.7.6.2 During the field visits there was consensus during all discussions that some form of community linkage mechanism and collective community effort was an important strategy for improving health of the urban poor. However, this strategy also had to be area specific as it would succeed in stable slums and not where slums were temporary structures under constant threat of demolition. 2.7.7 LARGE PRESENCE OF FOR PROFIT AND NOT FOR PROFIT PRIVATE PROVIDERS 2.7.7.1 The urban areas are characterized by presence of large number of for profit/not for profit private providers. These providers are frequently visited by the urban poor for meeting their health needs. The first interface for OPD services for the urban poor in many cities visited was the private sector, chiefly due to inadequacy of infrastructure of the public system and inconvenient working hours of the facilities. Partnership with private/charitable/NGOs can help in expanding services as was evident in Agra where NGO managed health care facilities were reaching out to large un-served areas. Even in Bengaluru, the management of health facilities had been handed over to NGOs. In several IPP VIII cities partnerships with profit/not for profit providers has helped in expanding the services. Kolkata had the distinction of implementing the programme through establishment of an effective partnership with private medical officer and specialists on a part time basis, fees sharing basis in different health facilities resulting in ensuring community participation and enhancing the scope of fund generation. Andhra Pradesh has completely outsourced service delivery in the newly created 191 Urban Health Posts in 73 towns to NGOs. The experimentation, it appears, has been quite satisfactory with reduced cost. 2.7.8 FOCUS ON RCH SERVICES AND INADEQUATE ATTENTION TO PUBLIC HEALTH 2.7.8.1 The existing health care service delivery mechanism is mostly focused on reproductive and child health services, while the recent outbreaks of Dengue and Chikungunya in urban areas and the poor health status of urban poor clearly articulate the need for a broad based public health programme focused on the urban poor. It stresses upon the need to effectively infuse public health focus along with curative services. The urban health programmes in Surat and 29

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Ahmedabad have been able to effectively integrate the two aspects. There is also need to integrate the implementation of the National programmes like National Vector Borne Disease Control Programme (NVBDCP), Revised National Tuberculosis Control Programme(RNTCP), Integrated Disease Surveillance Project ( IDSP), National Leprosy Elimination Programme (NLEP) , National Mental Health Programme (NMHP), National Deafness Control Programme (NDCP) , National Tobacco Control Programme (NTCP)and other Communicable and Non communicable diseases for providing an effective urban health platform for the urban poor. The urban poor suffer an equally high burden of ‘life style” associated diseases due to high intake of tobacco (both smoking and chewing) and alcohol. The limited income coupled with very high out-of-pocket expenditure on substance abuse creates a vicious cycle of poverty and disease. There is also the added burden of domestic violence and stress. Studies also indicate the need for early detection of hypertension in the urban poor, as it is a common cause of stroke and other cardio- neurological disorders. 2.7.8.2 The high incidence of communicable diseases emphasizes the need for strengthening the preventive and promotive aspects for improved health of urban poor. It also becomes critical that the outreach of services, which have an important bearing on health like safe drinking water, environmental sanitation, protection from pollutants, and nutrition services is improved. 2.7.9 LACK OF COMPREHENSIVE STRATEGY TO ENSURE EQUITABLE ACCESS TO THE MOST VULNERABLE SECTIONS 2.7.9.1 Though the urban health programmes have a mandate to provide outreach services as envisaged by the Krishnan Committee, at present very limited outreach activities were being undertaken by the ULBs. It is only the IPP cities, which were conducting some outreach activities as community Link workers were employed to strengthen demand and access. Limited outreach activities through provision of link volunteers under RCH were visible in Indore, Agra, Ahmedabad and Surat. 2.7.9.1 Another challenge facing the urban health programmes is inadequate methodology for identification of the most marginalized poor. None of the cities, except Thane, which had a scheme for rag pickers, had any operational strategy for the highly vulnerable section. 3 - KEY PUBLIC HEALTH CHALLENGES IN URBAN AREAS 30

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3.1

A list of key public health challenges in urban areas and possible responses from

the National Urban Health Mission is listed below: Table 3.1: Public Health Challenges & Possible Responses KEY PUBLIC HEALTH

POSSIBLE RESPONSES UNDER THE

CHALLENGES IN URBAN AREAS

NATIONAL URBAN HEALTH MISSION

1.

Poor households not knowing where to

The biggest challenge is to connect every

go to meet health need

household to health facilities. The role of the slum level Community Worker ( like the Honorary Health Worker in Kolkata slums) is a possible intervention. The Community Worker becomes the first point of contact for any health need. She has the authority to connect households to health facilities. A health facility or health personnel is responsible for a certain number of households.

2.

Weak and dysfunctional public system

A

detailed

review of

the

existing

of outreach

arrangements to identify the causes for dysfunctional/functional systems. The investments under NUHM could be to provide a responsive public system – service guarantees well defined and well recognized by all.

3.

Contaminated water, poor sanitation.

Work towards a possible public health

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bill that sets standards for provision of basic

entitlements

like

water

and

sanitation facilities. Provide resources to communities to ensure action at their end to prevent contamination/ maintain cleanliness.

Work with urban local

bodies to increase access to functional toilets. 4.

Poor environmental health, poor

Work with urban local bodies to set

housing

standards for environmental sanitation, set up systems of waste disposal, basic housing systems, etc. Work towards a rights and entitlement based approach though a public health bill.

5.

Unregistered practitioners first point of

Develop systems of accrediting private

contact – use of irrational and unethical

not fully qualified practitioners if they

medical practice

do basic specially designed courses for them, which gives them some level of acceptable work

competence.

under

the

Make

supervision

them of

government doctors. Special thrust on rational drug use and ethical practice. Making local practitioners do more of preventive and promotive health. 6.

Community organizations helpless in

Establish

vibrant

community

health matters

organizations at slum level, under the umbrella of the urban local body, wherever feasible. Co-opt community 32

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leaders like members of Self Help Groups, women’s groups, etc. Provide untied

grants

to

local

community

organizations to carry out community led action for public health. JNURM is providing the hardware but in the absence of effective community action, the hardware will be of little sustainable use. Community led action for public health

encompassing

determinants

of

all

health,

the is

wider needed.

(nutrition, water, sanitation, education, housing, women’s empowerment, skill development, etc. ). 7.

Weak public health planning capacity

Re-orient existing staff of urban local

in urban local bodies

bodies

to understand public health

challenges better. 8.

Large private sector but poor cannot

Develop systems of accrediting private

access them

practitioners for public health goals. These could be for a range of services. Need for transparency in developing protocols,

and

costs.

Community

organizations to exercise key role in rollout

of

such

partnerships.

Non

Governmental Organizations to build capacity in community organizations to handle such partnerships. 9.

Problems of targeting the poor on the

Many urban poor households do not 33

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basis of BPL card

have BPL card. How to reach every poor household

and

provide

special

entitlements at public costs to them for secondary and tertiary care. It will not be possible to provide free cancer treatment for all. Naturally there is a need for identifying the poor. NUHM to develop criteria for such identification on the basis of a wider understanding of poverty

as

not

only

income

or

nutritional poverty. 10. No convergence among wider

Creating

determinants of health

common

institutional

arrangements to ensure that the same community umbrella

of

responsible determinants

organization, urban for –

under

local all

water,

body,

the

the is

wider

sanitation,

nutrition, health care, education, skill development, housing, etc. 11. No system of counseling and care for

Adolescents face multiple problems in

adolescents

urban areas. Need to mobilize local youth for community led public health action. Need to attend to special needs of adolescent girls to make them cope with physiological changes.

12. Over congested secondary and tertiary

Need to generate awareness through

facilities and under underutilized

MAS and community workers in every

primary care facilities.

slum so that people know clearly where 34

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the household has to be sent. Need based referrals are the only way of decongesting. 13. Problem of drug abuse and alcoholism

Urban life is demanding and leads to living with stress of all kinds. Problems of drugs and alcoholism, tobacco use, etc.

need

strong

public

health

interventions. 14. Many slums not having primary health care facility

Creating

new

infrastructure

public using

health

community

buildings, mobile medical units based on fixed schedules where infrastructure cannot be created. 15. High incidence of domestic violence

Need for Counselors in Bastis to help in many behavior change and gender relation issues.

16. Multiplicity of urban local bodies, State

Need for clarity of responsibilities for

government, etc. management of health

urban health. Setting up of an over-

needs of urban people

arching urban local body level health mission for convergent action.

17. No norms for urban health facilities.

Need to develop clear norms for primary health care service guarantees for urban areas.

18. No concerted campaigns for behavior

Need

change

for

concerted

campaigns

for

behavior change to enforce public health thrust. Problem of malaria, dengue, Chikanguniya

in

urban

areas.

Counseling services for well-being of 35

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households. 19. Problems of unauthorized settlements

Developing health care facilities in the framework of law for such areas.

4 – DEFINING THE POOR IN URBAN AREAS 4.1

Targeting is a difficult process in informal economies. Income data is unreliable.

Mere targeting by slum residence is also faulty as there are many slums that are not even notified. Targeting is needed, especially for secondary and tertiary care to all. It can be provided free only to those who cannot afford it otherwise. Primary health care through Urban PHCs will be universally available to all citizens residing in urban areas. Outreach services will be provided on a targeted basis for the slum and other vulnerable population. 4.2

How to define the urban poor? Considering that urban areas have a constant

stream of migration, the process of issuing BPL cards does not keep pace with the migration of poor people from rural to urban areas, in search of a livelihood. As a consequence, many poor households are also not necessarily in slums. This means that mere spatial targeting will also not suffice. 4.3

This calls for a household survey through community organizations/ NGOs

under the supervision of urban local bodies, to define the urban poor. This necessarily has to be through a communitized process and must also take note the vulnerability of the households in terms of the assets that it possesses. There will be a need to get away from mere income poverty or mere calorie based poverty line. The urban poor will have to be defined and selected based on a household survey through community validation and transparency. It has to take note of vulnerability in the context of urban life. It will also have to take note of assets possessed and state of access to basic public services.

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4.4

The NUHM will make use of surveys of urban poor done under various

government programmes. However, it will subject all such listings to a household survey and a public disclosure of names of households before the Mahila Arogya Samiti (MAS) or Ward level ULB unit.

5 - NUHM – GOALS, OBJECTIVES, STRATEGIES, OUTCOMES 5.1

GOAL

The National Urban Health Mission would aim to improve the health status of the urban population in general, but particularly of the poor and other disadvantaged sections, by facilitating equitable access to quality health care through a revamped public health system, partnerships, community based mechanism with the active involvement of the urban local bodies. 5.2

CORE STRATEGIES

The exigencies of the situation as detailed in the aforesaid chapters merit the consideration of the strategies given below. These strategies may be implemented mainly by strengthening the existing public health systems. In some big cities where credible private sector or other public sector exists, partnerships may be developed with them through (i) public private partnerships i.e. with private service providers or with NGOs/faith based organizations, and (ii) through public-public partnerships, i.e. partnership with Railways hospitals, ESIC, Public sector companies hospitals etc. An optimal mix of these strategies can be included in the existing planning and implementation framework of the state to augment the urban health care system. The decision as to which is the best mix for the state may be taken by the state in the best interests of the urban poor. In case of partnerships, clear guidelines as defined later should be in place with monitoring by the state. 5.2.1 Improving the efficiency of public health system in the cities by strengthening, revamping and rationalizing existing government primary urban health structure and designated referral facilities

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5.2.1.1 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 into an “Urban Primary Health Centre” with outreach and referral facilities, to be functional for every 50,000 population on an average. However, depending on the spatial distribution of the slum population, the population covered by a U-PHC may vary from 50000 for cities with sparse slum population to 75,000 for highly concentrated slums. The U-PHC may cater to a slum population between 25000-30000 (covering approximately 50,000 urban population, including slums), providing preventive, promotive and non-domiciliary curative care (including consultation, basic lab diagnosis and dispensing). 5.2.1.2 The NUHM would improve the efficiency of the existing system by making provision for a need based contractual human resource, equipments and drugs. Provision of Rogi Kalyan Samiti is also being made for promoting local action. To further strengthen the delivery of specialised OPD care, the cities, if need arises, can utilize the services of specialist on weekly basis. 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. 5.2.1.3 The eligibility criterion for resource support under the Mission however would be rationalization of the existing public health care facilities and human resources in addition to mapping of unlisted slums and clusters. 5.2.1.4 The existing UHP/ UFWCs are already being supported through planned grant. With the launching of NUHM, all of these existing programmes/schemes will automatically cease to exist. Hence all the existing staff in this scheme (Urban Health Posts, Urban Family Welfare Centers) should be rationalized. 5.2.1.5 Based on GIS mapping, the cities would identify existing public sector health facilities to act as referral points for different types of healthcare services like maternal health, child health, diabetes, trauma care, orthopaedic complications, dental surgeries, mental health, critical illness, deafness control, cancer management, tobacco counseling / cessation, critical illness, surgical cases 38

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etc. NUHM would provide strengthening support as per the city PIP subject to approval at appropriate levels. 5.2.2 Promotion of access to improved health care at household level through community based groups : Mahila Arogya Samitis 5.2.2.1 The ‘Mahila Bachat Gat’ scheme in Maharashtra and urban health initiatives in Indore and Agra have demonstrated the efficacy of women led thrift/self help groups in meeting urgent cash needs in times of health emergency and also empowering them to demand improved health services. 5.2.2.2 In view of the visible usefulness of such women led community/ self help groups; it is proposed to promote such community based groups for enhanced community participation and empowerment in conjunction with the community structures created under the Swarna Jayanti Shahari Rojgar Yojana (SJSRY), a scheme of the Ministry of Urban Development which seeks to provide employment to the urban poor. Under the Urban Self Employment Programme (USEP) of the scheme there are provisions for Development of Women and Children in Urban Areas (DWCUA) groups of at least 10 urban poor women and Thrift Credit Groups (TCG), which may be set up by groups of women. There is also provision for informal association of women living in mohalla, slums etc to form Neighborhood Groups (NHGs) under SJSRY who may later federate towards a more formal Neighborhood Committee (NHC). Such existing structures under SJSRY may also federate into Mahila Arogya Samiti, (MAS) a community based federated group of around 50-100 households, depending upon the size and concentration of the slum population, with flexibility for state level adjustments, and be responsible for health and hygiene behavior change promotion and facilitating community risk pooling mechanism in their coverage area. The urban Accredited Social Health Activist (ASHA) , detailed in the following pages, may provide the leadership to the Mahila Arogya Samiti. Each of the MAS may have a committee of 5-20 members with an elected Chairperson/ Secretary and other elected representative like Treasurer. The mobilization of the MAS may also be facilitated by a contracted agency/NGO, working along with the ASHA responsible for the area.

5.2.3 Strengthening public health through innovative preventive and promotive action 39

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5.2.3.1 Urban Poor face greater environmental health risks due to poor sanitation, lack of safe drinking water, poor drainage, high density of population etc. There is a significant correlation between morbidity due to diarrhea, acute respiratory infections and household hygiene behavior, environmental sanitation, and safe water availability. Thus strengthening preventive and promotive action for improved health and nutrition and prevention of diseases will be a major focus of the Mission. The Mission would also provide a framework for pro-active partnership with NGOs/civil society groups for strengthening the preventive and promotive actions at the community level. The ASHA, in coordination with the members of the MAS would promote proactive community action in partnership with the urban local bodies for improved water and environmental sanitation, nutrition and other aspects having a bearing on health. 5.2.3.2 The urban areas, due to presence of multiple health service providers, presence and access to technology and relatively higher awareness and demand of health services in the community, provide with opportunities to develop innovative strategies. Hence NUHM provides for some untied funds at all levels for developing need based innovative strategies for improved service delivery and public health action. 5.2.4 Increased access to health care through creation of revolving fund 5.2.4.1 As substantiated by various studies (" Morbidity and Treatment of Ailments" NSS Report Number- 441(52/25.0/1) based on 52nd round) the urban poor incur high out-of- pocket expenditure often leading to indebtedness and impoverishment. To mitigate this risk, it is proposed to encourage Mahila Arogya Samitis to “save for a rainy day” for meeting urgent health needs. 5.2.5 IT enabled services (ITES) and e- governance for improving access improved surveillance and monitoring 5.2.5.1 Various studies (Conditions of Urban Slums, 2002, NSSO Report Number 486(58/0.21/1) based on 58th round) have shown that the informal status and migratory nature of majority of the urban poor, compromises their entitlement and access to health services. It also poses a challenge in tracking and provisioning for their health care.

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5.2.5.2 Studies have also highlighted that the private providers, which the majority of the 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. 5.2.5.3 The availability of ITES in the urban areas makes it a useful tool for effective tracking, monitoring and timely intervention for the urban poor. The NUHM would provide software and hardware support for developing web based HMIS for quick transfer of data and required action. Mobile telephony will be used for data gathering and follow ups. 5.2.5.4 The States would also be encouraged to develop strategies for affecting an urban disease surveillance system and a plan for rapid response in times of disasters and outbreaks. It is envisioned that the GIS system envisioned would be integrated into a disease surveillance and reporting system on a regular basis. This system would also be synchronized with the IDSP surveillance system. 5.2.6 Capacity building of stakeholders 5.2.6.1 It was observed that except for a few, provisioning of primary health care was low on priority for most of the urban local bodies with many Counselors showing a clear proclivity for development of tertiary facilities. This skewed prioritization appears to have clearly affected the primary health delivery system in the urban local bodies, also adversely affecting skill sets of the workforce and limiting technical and managerial capacities to manage health. NUHM thus proposes to build managerial, technical and public health competencies among ULBs/ Medical and Paramedical staff/ Private Providers/ Community level structures and functionaries of other related departments. 5.2.7 Prioritizing the most vulnerable amongst the poor 5.2.7.1

It is seen that a fraction of the urban poor who normally do not reside in slum, but in temporary settlements or are homeless, comprise the most disadvantaged section. Under the NUHM special emphasis would be on improving the reach of health care services to these vulnerable groups among the urban poor, falling in the category of destitute, beggars, street children, construction workers, coolies, 41

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rickshaw pullers, sex workers, street vendors and other such migrant workers. Outreach services would target these segments consciously, irrespective of their formal status of residentship etc. 5.2.8 Ensuring quality health care services 5.2.8.1 NUHM would aim to ensure quality health services by a) defining Indian Public Health Standards suitably modified for urban areas wherever required b) defining parameters for empanelment/regulation/accreditation of nongovernment providers, c) developing capacity of public and private providers for providing quality health care, d) encouraging the acceptance and enforcement of local public health acts d) ensuring citizen charters in facilities e) encouraging development of standard treatment protocols. 5.3

OUTCOMES

The NUHM would strive to put in place a sustainable urban health delivery system for addressing the health concerns of the urban poor. The NUHM proposes to measure results at different levels with a long term as well as intermediate term view. 5.3.1 Process/ Throughput level indicators: 5.3.1.1 Number cities/population where Mission has been initiated 5.3.1.2 Number of City operationalised

specific

urban

health

plans

developed

5.3.1.3 Number of U-PHCs with outreach made operational 5.3.1.4 Number of Cities/population with all slums and facilities mapped 5.3.1.5 Number of Slum/ Cluster level Health and Sanitation Day 5.3.1.6 Number of MAS formed 5.3.1.7 Number of U-PHCs with Programme Managers 5.3.1.8 Number of ASHAs trained and functioning 5.3.2 Output level indicators: 5.3.2.1 Increase in OPD attendance 42

and

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5.3.2.2 Increase in BPL referrals from U-PHCs/ referral availed 5.3.2.3 Increase in institutional deliveries as percentage of total deliveries 5.3.2.4 Increase in complete immunization among children < 12 months 5.3.2.5 Increase in case detection for malaria through blood examination 5.3.2.6 Increase in case detection of TB through identification of chest symptomatic 5.3.2.7 Increase in referral for sputum microscopy examination for TB 5.3.2.8 Increase in number of cases screened and treated for dental ailments 5.3.2.8 Increase in ANC check-up of pregnant women 5.3.2.10 Increased Tetanus toxoid (2nd dose) coverage among pregnant women 5.3.2.11 Strengthened civil registration system to achieve 100% registration of births and deaths 5.3.3 Impact level focus on urban poor: 5.3.3.1 Reduce IMR by 40 % (in urban areas) – National Urban IMR down to 20 per 1000 live births by 2017 5.3.3.1.1

40% reduction in U5MR and IMR

5.3.3.1.2

Achieve universal immunization in all urban areas.

5.3.3.2 Reduce MMR by 50 %

5.3.3.3

5.3.3.2.1

50% reduction in MMR (among urban population of the state/country)

5.3.3.2.2

100% ANC coverage (in urban areas)

Achieve universal access to reproductive health including 100% institutional delivery

5.3.3.4 Achieve replacement level fertility (TFR 2.1) 5.3.3.5 Achieve all targets of Disease Control Programmes

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6 – CONVERGENT ACTION IN URBAN AREAS 6.0.1 The NRHM provides scope for innovations at the district level. These have resulted in development of need based innovative strategies resulting in expansion of services and greater access of those services especially by the poorest communities. 6.0.2 Some of the innovations coming out under NRHM are very encouraging and paving way for many more similar initiatives. The use of radio technology for capacity building of ASHAs (in Assam), promotion of high end diagnostic services in medical colleges and establishment of regional diagnostic centers through public private partnerships (PPP) and promoting easy availability of generic drugs in shops through PPPs are some of such innovations. 6.0.3 The urban areas, due to presence of multiple health service providers, access to technology and relatively higher awareness and demand of health services in the community, provide the opportunities to develop innovative strategies. Hence NUHM provides for some untied funds at all levels for carrying out these activities. Some of the areas of innovation are listed below. This list is illustrative and not exhaustive. 6.1

SUGGESTED SLUM LEVEL INNOVATIONS 6.1.1

Community monitoring

6.1.2

Creating mentoring groups/support structures for MAS/ASHA through NGO/CBOs

6.1.3

“Healthy Mother”, “Healthy Infant” competitions

[

6.2

6.3

SUGGESTED U-PHC LEVEL INNOVATIONS 6.2.1

Involving private practitioners for special drives on immunization, diabetes, etc.

6.2.2

Involving schools for public health action like “slum cleaning (safai abhiyan)”, health promotion, etc.

6.2.3

Special programs for adolescent health

SUGGESTED CITY LEVEL INNOVATIONS 44

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6.4

6.3.1

Innovations with ICT (Information and Communication Technology) like ‘sms’ based health promotion, touch screen kiosks, PDAs for outreach workers.

6.3.2

“Help-lines” for general health advise / medical emergencies

6.3.3

Review/monitoring of quality, regularity of services through NGOs

6.3.4

Identification and management/rehabilitation of malnourished children (with special focus on girl child) and Nutrition Resource Centres

6.3.5

Special Strategies for addressing anaemia among women and girls

6.3.6

Special strategies for addressing anemia, malnutrition and neonatal mortality

SUGGESTED STATE LEVEL INNOVATIONS 6.4.1

Operations/Action research/special studies 6.4.2 Resource Centres/Units at State or city levels for urban health data, program lessons, and other information

6.5

6.4.3

Empanelment of hospitals/doctors for defined specialised services

6.4.4

Innovations for addressing adverse sex ratio

SUGGESTED NATIONAL LEVEL INNOVATIONS 6.5.1 Human Resource development, training, capacity building, Resource Centres/Units for urban health data, program lessons, & other information and additional support to national health programmes at all levels e.g. 6.5.1.1

Maternal/infant death audit

6.5.1.2

Disease outbreaks in case of natural disasters like floods

6.5.1.3

Mass injury/trauma cases because of fire in slums, riots, etc.

6.5.1.4

Epidemiological surveys/research

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6.6

IMPROVING SANITATION AND WATER SERVICES

6.6.1 It is important to focus on infra-structural facilities in terms of access to safe and adequate water supplies and sanitation facilities for combating various infectious diseases in children residing in urban slums. 6.6.2 Studies have shown that non-availability of piped water and absence of flush toilets are associated with increased incidence of infant deaths from diarrhea. Hence, it is vital to expand availability of water and sanitation facilities to the urban population to effectively address mortality and morbidity associated with diarrhea. 6.7 ADDRESSING COMMUNITY BEHAVIOURS PERTINENT TO THE CAUSATION OF CHILDHOOD ILLNESSES IN URBAN SLUMS 6.7.1 Appropriate hygiene behaviors can play a critical role in minimizing the frequency of infectious diseases, and can possibly reduce the risk of malnutrition in children. In India and in developing regions it is recognized that if community water supply and sanitation programs are undertaken in isolation, without action to integrate these with promotion and education on hygiene and sanitation within the community (particularly the home and its immediate surroundings), the health benefits from these programs will not commensurate with the investment made. Evidence shows hand washing could prevent more than one million deaths a year from diarrheal diseases 6. Therefore, improvement of water supplies needs to be integrated with other interventions, such as sanitation and health education, which focus on better environmental hygiene and personal cleanliness. 6.7.2 Health seeking behavior: Behavior promotion strategies addressing community beliefs focusing on environment-related issues such as hand washing, feeding practices, health seeking and appropriate prenatal and new born care are paramount7.

6

Curtis V, Cairncross S. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. The Lancet Infectious Dis 2003; 3: 275-281. 7 Determinants of Childhood Mortality and Morbidity in Urban Slums in India; Shally Awasthi, Siddharth Agarwal, Indian Paediatrics, Vol 40, December17, 2003

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6.8 COMMUNITY PARTICIPATION IN PREVENTION AND TREATMENT OF CHILDHOOD ILLNESSES 6.8.1 There is an urgent need to empower communities to take control of their health by strengthening their participation in identifying their own maternal and child health needs and identifying measures to address them. 6.8.2 This can be achieved by training basti level women groups which could serve as a platform for counseling and behavior promotion focusing on health education about environment-related issues. These women groups could also strengthen linkage with service providers, thereby increasing utilization of services, coverage of left outs and dropouts and improved referrals. 6.9

FOCUS ON ALL ASPECTS OF PUBLIC HEALTH

6.9.1 The existing health care service delivery mechanism is mostly focused on reproductive and child health (RCH) services, while the recent outbreaks of Dengue and Chikungunya in urban areas and the poor health status of urban poor clearly articulate the need for a broad based public health programme focused on the urban poor. It stresses upon the need to effectively infuse public health focus along with curative services. 6.9.2 The situation in most cities also reveals that there is a lack of effective coordination among the departments that leads to inadequate focus on critical aspects of public health such as access to clean drinking water, environmental sanitation and nutrition.

6.10 Inter and Intra Sectoral Coordination NUHM will promote both inter sectoral as well as intra sectoral convergence to avoid duplication of resources and efforts. The convergent actions can be grouped as:

Convergence with the National Disease Control Programmes



Convergence with other departments of Ministry of Health and Family Welfare



Convergence with other Ministries

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6.10.1 CONVERGENCE PROGRAMMES

WITH

NATIONAL

DISEASE

CONTROL

6.10.1.1 NUHM would aim to provide a system for convergence of all communicable and non communicable disease programmes at the city level through integrated planning - both annual and prospective, sharing of funds and human resources and joint monitoring and evaluation. 6.10.1.2 NUHM would bring all the disease control programs like RNTCP, IDSP, NVBDCP, NPCB etc. under the umbrella of City Health Plan so that preventive, promotive and curative aspects are well integrated at all levels. 6.10.1.3 The objective of convergence would be optimal utilization of resources and ensuring availability of all services at one point (U-PHC) thereby, enhancing their utilization by the urban population. The existing IDSP structure would be leveraged for improved surveillance.

6.10.2 CONVERGENCE WITH OTHER DEPARTMENTS OF MOHFW 6.10.2.1 DEPARTMENT OF AYUSH 6.10.2.1.1 NUHM would also strive to revitalize local health traditions and mainstream AYUSH to strengthen the Public Health System at all levels. The following areas for convergence with the Department of AYUSH have been identified:(i)

Co-location of an existing AYUSH dispensary in Urban PHCs/CHCs, wherever feasible, so as to provide clear choices to people to avail services under one system or other.

(ii)

AYUSH drugs to be regularly supplied by the state government.

(iii)

AYUSH doctor posted would essentially practice his own system. However he may additionally provide basic emergency services in absence of allopathic doctor and participate in national health programmes.

(iv)

Specialized AYUSH treatment facilities like Panchkarma, Ksharsutra to be made available by AYUSH department in Urban PHCs/CHCs.

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(v)

Department of AYUSH to support Govt. AYUSH hospitals and dispensaries at the district /sub district level.

(vi)

Life style clinics of AYUSH for preventive and promotive health care to be established at the District Hospitals.

(vii)

AYUSH doctors engaged at the Urban PHCs/CHCs would be given adequate training on current diagnostic techniques, emergency medicine, IUCD insertions and treatment approaches on a regular basis.

6.10.2.1.2 However, no provision of funds will be made separately for mainstreaming of AYUSH activities under NUHM. Funds and manpower available with the AYUSH departments of the Central/ State Govt. will be utilized. 6.10.2.2

DEPARTMENT OF AIDS CONTROL:

6.10.2.2.1 Convergence between NUHM and NACP will help in early detection, effective surveillance and timely intervention by means of: (i)

Universal HIV screening will be made an integral part of ANC checkup. The health and nutrition days would be utilized for rapid blood tests and positive cases would be referred to ICTCs for confirmation.

(ii)

Counselors, ANMs and ASHA/Link workers at the U-PHC would be trained for counseling on RTI, PPTCT, ANC, nutrition and spacing between births. The training for RTI and PPTCT counseling will be provided by the respective State AIDS Control Society.

(iii)

Testing kits to be made available at the Urban PHCs/CHCs by NACO.

(iv)

Distribution of condoms and IEC materials for promoting safe sexual practices will be done at the Urban PHCs.

(v)

All HIV positive patients will be tested for T.B. and vice-versa.

6.10.2.3 DEPARTMENT OF HEALTH RESEARCH: 6.10.2.3.1 Convergence of NUHM with the Department of Health Research (DHR) will help to bring modern health technology to people by: (i)

Encouraging innovations related to diagnostics, treatment methods and vaccines; 49

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(ii)

Translating the innovations into products/ processes by facilitating evaluation/ testing in synergy with other departments of MOHFW and

(iii)

Introducing these innovations into public health service

6.10.2.3.2 For promoting innovations some funds will be provided to the states every year under a separate budget head. 6.10.3 CONVERGENCE WITH SCHEMES OF OTHER MINISTRIES

6.10.3.1 MINISTRY OF URBAN DEVELOPMENT AND MINISTRY OF HOUSING AND URBAN POVERTY ALLEVIATION 6.10.3.1.1 Convergence with Jawaharlal Nehru National Urban Renewal Mission (JnNURM): 6.10.3.1.1.1 Basic Services to the Urban Poor (BSUP), which is a sub mission of JnNURM mandates the provision of health services to the urban poor via a seven point charter, namely security of land tenure, affordable shelter, water, sanitation, education, health and social security. 6.10.3.1.1.2 Under the Sub- Mission on Basic Services to the Urban Poor (BSUP), convergence would be sought through the following: (i)

City will be the unit of planning for health and allied activities.

(ii)

The City Health plan would also be shared for prioritization of actions at the City level. Similarly the City Development Plans (CDPs) of JnNURM cities (Basic Services component) would also be taken into account for avoiding duplication of efforts and resources.

(iii)

Under JnNURM at the city level as part of the City development plans GIS based physical mapping of the slums is being undertaken. The City level planning process would also leverage the GIS based mapping wherever completed.

(iv)

The community level institutions such as MAS may also be utilized by the implementation mechanism of JnNURM. 50

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6.10.3.1.1.3 The guidelines for the Integrated Housing and Slum Development Programmes (IHSDP) include the following under the admissible components: (i)

The community centers being created under IHSDP will be used as sites for conducting fixed outreach session.

(ii)

Under the admissible components of IHSDP Community primary health care center buildings can be provided. This mechanism can be used for establishing new urban primary health centres for un-served urban poor population.

6.10.3.1.1.4 Under the BSUP and IHSDP mandatory reforms at the urban local body level are proposed. The same can be reinforced by NUHM also for strengthening the role of urban local bodies in cities where the BSUP and IHSDP are being implemented. Identification of slums and updating of the lists can also be made part of the mandatory reforms. 6.10.3.1.2

Convergence with Rajiv Awas Yojana (RAY):

6.10.3.1.2.1 Rajiv Awas Yojana aims at creating a slum free India by bringing existing slums within the formal system and enabling them to avail the same level of basic amenities as the rest of the town. 6.10.3.1.2.2

Convergence of RAY and NUHM would be sought through the following: (i)

The City Health Plans under NUHM can be incorporated into the slum free city and state plans of action under RAY.

(ii)

GIS based physical mapping of the slums and the spatial representation of the socio-economic profile of slums (Slum MIS) is being undertaken under RAY. This will also be useful for development of city health plans.

6.10.3.1.3 Convergence with Swarn Jayanti Shahri Rozgar Yojana (SJSRY): The community level structures being proposed under NUHM can be strengthened by effectively aligning them with the SJSRY structures.

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(i) (ii)

(iii)

(iv)

Community organizer for about 2000 identified families under SJSRY can be co-opted as ASHA. Neighborhood Groups which are informal associations of woman living in mohalla or slum or neighborhood representing 10 to 40 urban poor or slum families and Development of Women and Children in Urban Areas (DWCUA) Groups under SJSRY may be federated into Mahila Arogya Samitis (MAS). Neighborhood Committee (NHC) is a more formal association of women from the above neighborhood groups. Representatives from other sectoral programmes in the community like ICDS supervisor, school teacher, ANM etc. are also its members. These may be coterminous with the MAS. Alternatively, State/District can choose to make them function as MAS. Project officer in-charge of the project responsible for managing community level structures may be involved in planning and identification of urban poor.

6.10.3.1.4 Convergence with North Eastern Region Urban Development Programme (NERUDP): 6.10.3.1.4.1 Ministry of Housing & Urban Poverty Alleviation has project proposals for the North Eastern States in the following identified areas: (i) (ii) (iii)

Housing projects (predominantly for the urban poor) Poverty alleviation projects Slum improvement/up gradation projects

Funds under this provision are non-lapsable and unspent balances under this provision in a financial year are pooled up in the non-lapsable central fund meant for these States, and are governed by the Department of Development of North Eastern Region (DoNER). Hence, in the north eastern states, NUHM can develop synergy and mobilize funds from this programme.

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6.10.3.2

MINISTRY OF WOMEN AND CHILD DEVELOPMENT (i)

MAS/ASHA in coordination with the ANM to organize Community Health and Nutrition day in close coordination with the Anganwadi worker (AWW) on lines of NRHM.

(ii)

MAS/ ASHA to support AWW/ANM in updating the cluster/ slum level health register.

(iii)

Outreach session also to be organized in the Anganwadi centers located in slums or nearby.

(iv)

Organization level health education activities at the AW Centre.

(v)

AWW and MAS to work as a team for promoting health and nutrition related activities.

6.10.3.3 MINISTRY OF HUMAN RESOURCE DEVELOPMENT 6.10.3.3.1

Convergence with School Health Programme:

6.10.3.3.1.1 School Health Programme helps in advocating healthy behavioral practices and imparting awareness about preventive and curative health measures to the school going children. This awareness further percolates to households and families of the students. Therefore School Health Programme in cities can help the National Urban Health Mission to achieve its goals and objectives by reaching out to a large section of the community in a cost effective manner. 6.10.3.3.1.2 In urban areas, the scheme would cover Government or private schools located in slums (U-PHC catchment) or government schools near slums which slum children attend. The major components of School Health Programme are: (i)

Health Education (H.E.) Activities, creating awareness about hygiene, prevention of Vector Borne Disease Nutrition/Balanced Diet, Oral Rehydration etc.

(ii)

Medical examination of primary school children for eye ailment, nutrition, and others

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(iii)

Treatment of minor ailments such as de-worming, anaemia, skin diseases at school itself

(iv)

Special In-patient care at identified hospitals and referral services

(v)

Control of communicable diseases through Immunization

(vi)

Training of teachers for early identification of symptoms

(vii)

To advise children and school health authorities regarding importance of safe drinking water and good environmental sanitation etc.

6.10.3.3.2

Convergence with Adolescent Reproductive and Sexual Health (ARSH):

6.10.3.3.2.1 Under ARSH, once a week adolescent clinic will be organized at the Urban PHC. During this teen clinic health education and counseling will be provided to the adolescent girls for promoting menstrual hygiene, prevention of anaemia, prevention of RTIs/STIs, counseling for sexual problems etc. 6.10.3.4

MINISTRY OF MINORITY AFFAIRS

6.10.3.4.1

Convergence with Multi Sectoral Development Programme (MsDP):

6.10.3.4.1.1 Under this scheme, 90 minority districts have been identified throughout the country which are relatively backward and are falling behind the national average in terms of socio-economic and basic amenities indicators. The programme aims at improving the socio-economic parameters of basic amenities for improving the quality of life of the people residing in rural and semi-urban areas. 6.10.3.4.1.2 District specific plans are prepared for provision of better infrastructure for school and secondary education, sanitation, pucca housing, drinking water and electricity supply, besides beneficiary oriented schemes for creating income generating activities. In addition, creation of basic health infrastructure and ICDS centres is also eligible for inclusion in the plan. 6.10.3.4.1.3 So, in the towns covered under MsDP, NUHM can leverage the health infrastructure and Anganwadi centres created under this programme for provision of health care services to the urban poor population.

6.10.3.5

OTHER AREAS OF SYNERGY 54

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6.10.3.5.1 MEMBER SCHEME (MPLADS):

OF

PARLIAMENT

LOCAL

AREA

DEVELOPMENT

All members of parliament (MPs), members of legislative assemblies (MLAs) and municipal councilors (MCs) receive area development fund which can be mobilized for creation of health facilities in underserved urban areas and also for procurement of equipments, Mobile Medical Units and ambulances etc. 6.10.3.5.2

CORPORATE SOCIAL RESPONSIBILITY (CSR):

Around 2 percent of the total profit of all corporate sector companies is earmarked for social development under CSR. This fund can also be mobilized for health sector through efforts of MOHFW and the State Govts. Department of Public Enterprise (DPE) for public sector and Ministry of Corporate Affairs for the private sector can emerge as important players.

7 - INSTITUTIONAL ARRANGEMENTS FOR IMPLEMENTATION 7.1 The National Urban Health Mission would leverage the institutional structures of the NRHM at the National, State and District level for operationalisation of the NUHM. However in order to provide dedicated focus to issues relating to Urban Health the institutional mechanism under the NRHM at various levels would be strengthened for NUHM implementation. 7.2 At the central level, the Mission Steering Group under the Union Health Minister, the Empowered Programme Committee under the Secretary (H&FW), and the National Programme Coordination Committee under the Mission Director will be responsible for providing overall guidance and taking important decisions. 7.3 For effective implementation and monitoring of NUHM, a National Programme Management Unit (NPMU) will be set up at the central level. The NPMU will also be expected to provide technical assistance to the Urban Health Division of the Ministry. 7.4 At the state level, for improving the Program Management under NUHM, a State Program Management Unit (SPMU) will be set up, which would essentially be an extension of the NRHM SPMU, with a separate Urban Health Cell, reporting to the State Mission Director. The staff at the SPMU- Urban Health Cell may be as proposed below:

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(i)

State Urban Health Program Manager

(ii)

State Urban Health MIS Manager

(iii)

State Urban Health Finance Manager

(iv)

State Urban Health Consultant ( M&E and Community Participation)

7.5 In addition to the above, at the City level the States may either decide to constitute a separate City Urban Health Missions/ City Urban Health Societies or use the existing structure of the District Health Society / Mission under NRHM with additional stakeholder members. 7.6 At the city level, the management of NUHM activities may be coordinated by a City level Urban Health Committee headed by the District Magistrate/ Additional District Magistrate/Sub Division Magistrate based on whether the city is a district headquarters or a sub-division headquarter. This would help ensure better coordination with municipal departments like sanitation, water, waste management, especially in times of response to disease outbreaks/epidemics in the city. 7.7 Further for enhancing the Program Management, a City Program Management Unit (CPMU) may be established. The staff at the City PMU level may be as proposed below: (i)

Urban Health Data Manager.

(ii)

Urban Health Accounts Manager

(iii)

Consultant (Epidemiologist)

7.8 The National Urban Health Mission would promote participation of the urban local bodies in the planning and management of the urban health programmes. 7.9 For the seven mega cities, namely Delhi, Mumbai, Kolkata, Chennai, Bengaluru, Hyderabad and Ahmedabad, the NUHM may be implemented through the respective ULBs. For the remaining cities, health department would be the primary implementation agency for NUHM. However, for cities/towns where capacity exists with the ULBs, the states may decide to hand over the management of the NUHM to them.

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7.10 A generic institutional model for a National / State/District/City level Urban Health Mission and Society is illustrated, notwithstanding the flexibilities provided to the states. FIGURE 7.1 DIAGRAM: INSTITUTIONAL MODEL

7.11 The National Urban Health service delivery model would make a concerted effort to rationalize and strengthen the existing public health care system in urban areas 57

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and promote effective engagement with the non-governmental sector (profit/not for profit) for expanding reach to urban poor, along with strengthening the participation of the community in planning and management of the health care service delivery. 7.12 The diagram below describes the components of the proposed urban health service delivery model. Diagram: Urban Health Care Delivery Model

Urban Primary Health Centre (One for about 50,000 population-25-30 thousand slum population)* Strengthened existing Public Health Care Facility for extending services to unserved areas

Referral

Public or empanelled Secondary/ Tertiary private Providers

-------------------Primary Level Health Care Facility --------------------

Community Outreach Service (Outreach points in government/ public domain/ Empanelled private services provider) school health services

Community Level

Urban Social Health Activist(200-500 HH)

* This may be adapted flexibly based on spatial situation of the city Mahila Arogya Samiitee (20-100HH)

7.13 The urban health delivery model would basically comprise of an Urban Primary Health Centre for provision of primary health care with outreach and referral linkages as elucidated below: 7.14 7.14.1

COMMUNITY LEVEL Urban Accredited Social Health Activist (ASHA)

7.14.1.1 Each slum/community would have one frontline community worker called ASHAASHA on the lines of ASHA under NRHM, covering about 1000-2,500 beneficiaries, between 200-500 households based on spatial consideration, preferably colocated at the Anganwadi Centre functional at the slum level, for delivery of services at 58

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the door steps. She would remain in charge of each area and serve as an effective demand–generating link between the health facility (Urban Primary Health Centre) and the urban slum populations. ASHA would maintain interpersonal communication with the beneficiary families and individuals to promote the desired health seeking behavior. They will be responsible to the Mahila Arogya Samitis (community groups) for which they are designated. 7.14.1.2 Wherever possible the existing community workers under other schemes like JnNURM, SJSRY etc. may be co-opted under NUHM. ASHAASHA 7.14.1.3 The ASHA would be a woman resident of the slum, preferably in the age group of 25 to 45 years. The ASHA should also be literate with formal education up to class tenth, which may be relaxed only if no suitable person with this qualification is available. ASHAASHA would be chosen through a rigorous community driven process involving ULB Counselors, community groups, self-help groups, Anganwadis, ANMs. A team of five facilitators may be identified in each U-PHC catchment area with the help of an NGO, through a consultative process, for facilitating the selection of the ASHA. The facilitators would preferably be from local NGOs; community based groups, Anganwadi or Civil Society Institutions. In case none of these is available in the area, the officers of other Departments at the slum level/local school teachers may be taken as facilitators. The selection process for ASHA in NRHM may be suitably modified to the urban context as per the local condition and adopted for selection of the urban ASHAs. 7.14.1.4 The ASHA would help the ANM in delivering outreach services in the vicinity of the doorsteps of the beneficiaries. Preferably some suitable identified place for ASHA may be arranged in the slums which may be AWW centres, clubs, community premises set up under the JnNURM, Sub Health Posts set up in IPP cities, municipal premises etc, or even her own residence. 7.14.1.5 An ASHA mentoring system on the lines of NRHM may be put in place involving dedicated community level volunteers/professionals preferably through the local NGO at the U-PHC level, for supporting and coordinating the activities of the ASHA. The states may also consider the option of 1 Community Organizer for 10 ASHAs for more effective coordination and mentoring, preferably located at the mentoring NGO. The Community organizer along with the ANM may be designated as the mentoring and management team at the slum level for the ASHAs.

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7.14.1.6

Essential services to be rendered by the ASHA may be as follows:

(i)

Active promoter of good health practices and enjoying community support.

(ii)

Facilitate awareness on essential RCH services, sexuality, gender equality, age at marriage/pregnancy; motivation on contraception adoption, medical termination of pregnancy, sterilization, spacing methods. Early registration of pregnancies, pregnancy care, clean and safe delivery, nutritional care during pregnancy, identification of danger signs during pregnancy; counseling on immunization, ANC, PNC etc. act as a depot holder for essential provisions like Oral Re-hydration Therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine, Oral Pills & Condoms, etc.; identification of target beneficiaries and support the ANM in conducting regular monthly outreach sessions and tracking service coverage.

(iii)

Facilitate access to health related services available at the Anganwadi/Primary Urban Health Centres/ULBs, and other services being provided by the ULB/State/ Central Government.

(iv)

Formation and promotion of Mahila Arogya Samitis in her community.

(v)

Arrange escort/accompany pregnant women and children requiring treatment to the nearest Urban Primary Health Centre, secondary/tertiary level health care facility.

(vi)

Reinforcement of community action for immunization, prevention of water borne and other communicable diseases like TB (DOTS), Malaria, Chikungunya and Japanese Encephalitis.

(vii)

Carrying out preventive and promotive health activities with AWW/ Mahila Arogya Samiti.

(viii) Maintenance of necessary information and records about births & deaths, immunization, antenatal services in her assigned locality as also about any unusual health problem or disease outbreak in the slum and share it with the ANM in charge of the area. In return for the services rendered, she would receive a performance based incentive. For this purpose a revolving fund would be kept with the ANM at the U-PHC (in the PHC account), which would be replenished from time to time, based on UC/SOE. The 60

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following performance based incentive package is suggested subject to modifications by the State. TABLE 7.4: ASHA INCENTIVE CHART *

Proposed Activities 1

Organization of outreach sessions

2

Organization of monthly meeting of MAS

3

Attend monthly meeting at U-PHC

4

Organize Health & Nutrition day in collaboration with AWW

5

Organize community meeting for strengthening preventive and promotive aspects

6

Provide support to Baseline survey and filling up of family Health Register

7

Maintain records as per the desired norms like Household Registers, Meeting Minutes, Outreach Camps registers

8

Additional Immunization incentives for achieving complete immunization in among the children in her area of responsibility:

9.

Incentives/compensation in built in national schemes for ASHA under JSY, RNTCP, NVBDCP, Sterilization, Home Based Newborn Care etc. and any other National programme

* This list is indicative but not exhaustive. 7.14.1.8 During the field visits it was observed that provision of a photo identity card to the community volunteers greatly boosts their self esteem. The states/cities can also explore the option of providing ASHAs with Photo ID card. 7.14.1.9 The Urban Local Body would provide the leadership to the selection process of ASHA. The following process may be adopted: (i)

The ASHA will be selected through a community driven process led by the Urban Local Body. To facilitate the selection process the District/ City 61

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level Mission would constitute a City Level ASHA Selection Committee headed by the member of the urban local body. The CMO/CDMO; DPOICDS; and PO of JnNURM; DUDA; SJSRY would be the members. The District/ City level health mission can also decide to induct more members from the NGO/ Civil society based on the local need. The City Level ASHA Selection Committee would approve the names of the ASHA proposed by the PUHC level facilitation committee. The selection committee would also provide all the guidelines for the selection of ASHA. The City Level ASHA Selection Committee would also be responsible for Constitution of health facility/unit level ASHA selection committees. It will monitor and provide all necessary support to carry out the ASHA selection process including approval of the list of selected ASHAs/LWs.

7.14.2

(ii)

The Catchment area of the U-PHC would form the unit for selection process. At the unit level a ASHA Facilitation Committee for proposing the name of the ASHA to the City level Selection Committee would be constituted. The U-PHC level committee would also monitor the whole process and ensure that the selection process is as per the approved selection process.

(iii)

The Urban Local Body if appropriate may also involve local NGOs working in urban areas in the selection process of the ASHA. As the situation varies from city to city flexibility would be provided for need based adoption of above process.

Mahila Arogya Samiti (MAS) –

7.14.2.1 MAS acts as community group, involved in community awareness, interpersonal communication, community based monitoring and linkages with the services and referral. The MAS may cover around 50- 100 households (HHs) with an elected Chairperson and a Treasurer, supported by an ASHA. This group would focus on preventive and promotive health care, facilitating access to identified facilities and management of revolving fund. The following process may be adopted for constitution of the MAS

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7.14.2.2

Constitution of Mahila Arogya Samiti:

To expand the base of health promotion efforts at the community level and to build sustainable community processes, each ASHA will promote organized collective efforts through a group of socially committed females from the community itself. Present or past experiences of collective efforts in the slums towards fulfillment of any objective will be explored. Women’s/ SHG groups wherever present would be encouraged to expand their scope of work to address health challenges in the community. 7.14.2.3

Process of promotion of Mahila Arogya Samiti:

7.14.2.3.1 Constitution of a team at slum level: The ASHA with support of NGO field functionary(if any), AWW and ANM will constitute a team 7.14.2.3.2 Meetings with slum women: The team (ASHA and others) conduct a series of meetings with women from the slum to understand the health conditions and to sensitize the women to work towards improving the health of the men, women and children in the slum It is generally observed that the initial meetings have a large number of slum women attending mainly due to curiosity or with expectations to get some benefits (monetary). 7.14.2.3.3 Identification of active and committed women: At least a gap of 1-2 weeks is given between women to reflect, discuss with others and determine their commitment to serve their slum community. Generally towards the 3rd or 4th meeting, the numbers of women attending falls and only interested women come for the meeting. Active, interested and committed women will be identified and over a period of time, encouraged to work collectively on community issues to form the base of the Mahila Arogya Samiti. It may be borne in mind that each community responds differently and takes its own time to crystallize, and interventions would have to be designed, keeping in alignment with the community 7.14.2.3.4 Suggested group size: The suggested norm for one group is 10-12 members over 50-100 families. The numbers will vary depending on the size of the slum (e.g. in case of a small slum with 50 families, the Committee will be promoted over 50 families) and also the factors within the slum (e.g. different communities within a small area).

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7.14.2.3.5 Promotion of MAS: The active women (10-12) identified then meet and decide to work collectively as a group. They nominate office bearers, formulate rules and regulations for the group and record proceedings of the meetings and start functioning as a group. 7.14.2.4

Desired characteristics of members of Mahila Arogya Samiti:

7.14.2.4.1 Membership in the Women’s Health Committee may be guided by the objectives and expected roles of this group. The membership in the group would be a natural process, guided by the team of ASHA and others. Therefore the following should not be seen as eligibility criteria. However the common features emerging in this scene would be – 7.14.2.4.2. Woman with a desire to contribute to ‘well-being of the community’ and with a sense of social commitment and leadership skills. 7.14.2.4.3 Woman’s age is not being kept as a barrier as the role of the woman in the house and the community is either as a target beneficiary or as an influencing force. 7.14.2.4.4 If a group is being formed over a number of pockets of different communities, membership from all such pockets shall be ensured. 7.14.2.4.5 If the slum has a presence or history of collective efforts (as a self help group, DWCUA group, Neighborhood Group under SJSRY, thrift and credit group), women involved in these efforts should be encouraged. 7.14.2.4.6 ASHA may be a member of this group, if the group desires so. She should be conscious of her dual role in this context, and consciously encourage leadership. 7.14.2.5

Outreach session: ANM

7.14.2.5.1 Responsible for providing preventive and promotive healthcare services at the household level through regular visits and outreach sessions. (i) Each ANM will organize a minimum of one routine outreach session in her area every month. ii) special outreach Medical/Health Camps (for slum and vulnerable population) – Once in a week the ANMs covering slum/vulnerable populations would organize one special outreach Medical/Health Camp in partnership with other health professionals (doctors/pharmacist/technicians/nurses – government or private). It will include screening and follow-up, basic lab investigations (using portable /disposable kits), drug dispensing, and counseling. 64

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7.14.2.5.2 For improving the routine outreach services in the field ANMs would be provided with mobility support of Rs. 500 per month, apart from a provision of Rs.30,000 per ANM for the 12th Plan period, which may be used to supplement the mobility support. 4-5 ANMs will be posted in each U-PHC depending upon the population. 7.14.2.5.3 Outreach sessions will be planned to reach out to the vulnerable sections like slum population, rag pickers, sex workers, brick kiln workers, street children and rickshaw pullers. 7.14.2.5.4 The outreach sessions (both routine and special outreach) could be organized at designated locations mentioned in the aforesaid paras in coordination with ASHA and MAS members. 7.15 URBAN PRIMARY HEALTH CENTRE

7.15.1 Functional for a urban population of around approximately 50,000-60,000, the UPHC may be located preferably within a slum or near a slum within half a kilometer radius, catering to a slum population of approximately 25,000-30,000, with provision for OPD from 12 noon to 8 pm in the evening. The cities, based upon the local situation may establish a U-PHC for 75,000 for areas with very high density and can also establish one for around 5,000-10,000, slum population for isolated slum clusters. 7.15.2 At the U-PHC level services provided will include OPD (consultation), basic lab diagnosis, drug /contraceptive dispensing, apart from distribution of health education material and counseling for all communicable and non communicable diseases. In order to ensure access to the urban slum population at convenient timings, the U-PHC may provide services from 12 noon to 8 pm in the evening. It will not include in-patient care. 7.15.3 It will be staffed by two doctors, one regular and one on a part time basis. Apart from that there will be 3 staff nurses, 1 pharmacist, 1 lab technician, 1-2 LHV and 4-5 ANMs (depending upon the population covered), apart from clerical and support staff and one Programme Manager for supporting community mobilization, behavior change communication, capacity building efforts and strengthening referrals. 7.15.4 To further strengthen the delivery of services cities can also engage the services of specialist doctors to provide services periodically at U-PHC based on needs on reimbursement basis. U-PHC can also serve as collection centre for diagnostic tests in partnership with empanelled private diagnostic centres. 65

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7.15.5 The option of co-locating the AYUSH centre with U-PHC may also be explored, thus enabling the placement of AYUSH doctor and other AYUSH paramedic staff in the U-PHC. 7.15.6 The situation analysis showed that at present there are various types of primary health care facilities (UHP/UFWC/ Dispensary) with different service guarantee and human resource norms. There has been no reorganization/expansion of these schemes for a long period. With the launching of NUHM, all of these existing programmes/schemes will automatically cease to exist. The existing infrastructure available under these schemes would be rationalized and aligned with the new IPHS. 7.15.7 Under NUHM a uniform health care service deliver mechanism with IPHS norms will be developed and the states are encouraged to adopt these norms for UPHCs. 7.15.8 Maximum effort would be made to strengthen the already existing public health care infrastructure in urban areas. Existing SDH/CHC etc. would be upgraded and strengthened. 7.15.9 Where there are no government health facilities, new public health facilities would be established. All the U-PHCs would be set up in Govt. buildings. Partnership with other government facilities like Railways, Army, ESIC and Public Sector Units could also be explored for strengthening the delivery of services. 7.15.10 The government facilities strengthened as U-PHC will also be provided annual financial support in the form grants to Rogi Kalyan Samiti/ Hospital Management Committee Fund of Rs. 2,50,000 per U-PHC per year. 7.15.11 The recurrent cost support provided to U-PHCs of Rs.20 lakh per year, would include cost of all staff in the U-PHC (staff norms as per Annex-IV – Financing Pattern of U-PHC). 7.15.12 The posts of ANMs and LHVs are supported separately (not included in the Rs.20 lakh per year recurrent cost support) and these may be contractual posts to begin with, but eventually need to be absorbed into the system, and liability of these posts would be on the central government.

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7.16

REFERRAL UNIT:

7.16.1 Urban Community Health Centre (U-CHC) may be set up as a satellite hospital for every 4-5 U-PHCs. The U-CHC would cater to a population of 2,50,000. It would provide in patient services and would be a 30-50 bedded facility. U-CHCs would be set up in cities with a population of above 5 lakhs, wherever required. These facilities would be in addition to the existing facilities (SDH/DH) to cater to the urban population in the locality. 7.16.2 For the metro cities, the U-CHCs may be established for every 5 lakh population with 100 beds. 7.16.3 For setting up the U-CHCs the Central Govt. would provide only a one time capital cost, and the recurrent costs including the salary of the staff would be borne by the respective state governments. 7.16.4 The U-CHC would provide medical care, minor surgical facilities and facilities for institutional delivery. 7.17

REFERRAL LINKAGES:

7.17.1 Existing hospitals, including ULB maternity homes, state government hospitals and medical colleges, apart from private hospitals will be empanelled /accredited to act as referral points for different types of healthcare services like maternal health, child health, diabetes, trauma care, orthopedic complications, dental surgeries, mental health, critical illness, deafness control, cancer management, tobacco counseling / cessation, critical illness, surgical cases etc. 7.17.2 There might be different and multiple facilities for the different healthcare services, depending upon type of hospitals available in the city. 7.17.3 Collaboration with District Hospitals/ Area Hospitals/ Sub District hospitals and local Medical Colleges may be promoted for strengthening the training support and supplement human resource at the U-PHC level. 7.17.4 Public Health laboratories will also be strengthened under NUHM for early detection and management of disease outbreaks in urban concentrations. 7.17.5 Wherever public sector coverage is inadequate, reputed private sector institutions may be considered. The empanelled/accredited facilities would be reimbursed for the services provided as per the pre-decided rates, negotiated with them at the time of empanelling/accrediting them and indicated in the city level urban health 67

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PIPs subject to approval at the appropriate level. This will not only ensure flexibility to adapt to different conditions in different cities but also increase the range of options for the beneficiaries. 7.18

SCHOOL HEALTH SERVICES

7.18.1 Schools can serve as nodal points for advocating healthy behavioral practices and imparting awareness about preventive and curative health measures. This awareness percolates to households and families of the students. It also ensures creation of aware students who will be parents in the near future. Therefore School Health Programme in cities can help the National Urban Health Mission to achieve its goals and objectives by reaching out to a large section of the community in a cost effective manner. 7.18.2 Over one fifth of our population comprises of children, aged 5-14 i.e., the age group covering primary and secondary education. About 80% of these children are enrolled in schools. Of those enrolled 65-85% are regularly attending school, for an average of 200 days in a year. In urban areas, most of children who are attending government run primary and secondary schools are coming from disadvantaged sections of the urban population. Thus the bulk of the school age children are in schools on majority of days in a year and are very easy to reach. There are around 6.25 crore slum population in India (Census 2001). There will be approximately 1 crore urban poor children going to schools from slums. 7.18.3 The school health programmes can gainfully adopt specially designed modules in order to disseminate information relating to 'health' and 'family life'. This is expected to be the most cost-effective intervention as it improves the level of awareness, not only of the extended family, but the future generation as well. 7.18.4 In urban areas, the scheme would cover Government or private schools located in slums (U-PHC catchment) or government schools near slums which slum children attend. 7.18.5 School health programmes may consist of three related components; school health services, school environment and health education. It aims at screening of all primary school children for common ailments which include anaemia, worm infections, night blindness, iodine deficiency diseases (goitre), ear discharge, scabies, pyoderma, vision defects and dental problems. 68

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7.18.6 COMPONENTS OF THE SCHOOL HEALTH PROGRAMME

(i)

Health Education (H.E.) Activities, creating awareness about hygiene, prevention of Vector Borne Disease etc

(ii)

Medical examination of primary school children for eye ailment, nutrition, and others

(iii)

Treatment of minor ailments such as de-worming, skin diseases at school itself

(iv)

Special In-patient care at identified hospitals and referral services

(v)

Control of communicable diseases through Immunization

(vi)

Training of teachers for early identification of symptoms

7.18.7 Partnership with NGOs for health education activities, liasioning with other schools and monitoring the referral services could be done. Referral services have to be emphasized because without a good functioning referral system school health services cannot be successful in their objectives. The two way referral system, school-health worker-medical officer at health centre/school health clinic-specialist shall be established and be working. Teachers may be trained and equipped for recognition of sickness/danger signals, for giving first aid/on the spot treatment and for referring the children needing further care. For this purpose training programmes have to be designed, ideally jointly with health functionaries (of appropriate levels) for present teachers and suitable changes made in the training curricula for future teachers. 7.18.8 The states are implementing their existing school health programmes and the scheme can be integrated with the School Health Programme under NUHM. The state can take a lead in streamlining implementation of the programme with appropriate budget allocation. 7.19

IMPROVING ACCESS TO VULNERABLE SECTION OF URBAN POOR

7.19.1 To target special interventions on the vulnerable groups in the cities, mapping of the vulnerable groups (one time) would be undertaken. The vulnerable sections would 69

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include the rag pickers, destitute, beggars, street children, construction workers, coolies, rickshaw pullers, sex workers, street vendors and other such migrant workers. It is also envisaged that dedicated drug distribution centres be opened for the identified concentration of vulnerable groups, through NGO/CSOs, which will have provisions for emergency OTC drugs and contraceptives. Special attention would be paid to organizing outreach sessions for these vulnerable communities. For targeted IEC/BCC interventions, the details of which will be as per the city PIP, the provision is Rs.5 per capita for the target urban vulnerable population (in line with the provision for IEC/BCC under NRHM). This will also include community mobilization, identification of recently settled urban poor families and support through NGO/CSO. The details of this mobilization strategy will be as per the city PIP.

TABLE 17.1:

Services**

Indicative Service Norms by levels of Service Delivery *

Levels of service delivery Community (Outreach)

First point of Referral Centre service delivery (U- U- CHC (Specialist PHC) services)

A. Essential Health Services A1. Maternal Registration, ANC, identification of ANC, PNC, initial danger signs, referral for management of health complicated institutional delivery, follow-up delivery cases and referral, of Counseling and behavior management regular maternal promotion health conditions, referral of complicated cases

A2. Family Counseling, distribution of OCP/CC, referral for sterilization, welfare follow-up of contraceptive related complications

70

Delivery (normal and complicated), management of complicated Gynae/ maternal health condition, hospitalization and surgical interventions, including blood transfusion.

Distribution of Sterilization OCP/CC, IUD operations, fertility insertion, referral treatment for sterilization, management of

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Services**

Levels of service delivery Community (Outreach)

First point of Referral Centre service delivery (U- U- CHC (Specialist PHC) services) contraceptive related complications

A3. Child Immunization, identification of health and danger signs, referral, follow-up, distribution of ORS, paediatric nutrition cotrimoxazole post-natal visits/counseling for newborn care

Diagnosis and treatment of childhood illnesses, referral of acute cases/ chronic illness

A4. RTI/STI referral, community level follow(including up for ensuring adherence to treatment regime of cases HIV/AIDS) undergoing treatment

Symptomatic Diagnosis and primary treatment and referral of complicated cases

Management of complicated cases, hospitalization (if needed)

A5. Nutrition Height/weight measurement, Hb deficiency testing, distribution of therapeutic doses of IFA, promotion of iodized disorders salt, nutrition supplements to identified children and pregnant/ lactating women

Diagnosis and treatment of seriously deficient patients, referral of acute deficiency cases

Management of acute deficiency cases, hospitalization

Promotion of breast feeding, complementary feeding for prevention of under-nutrition A6. Vector- Slide collection, borne RDKs, DDT diseases

testing

Management of complicated paediatric/neonatal cases, hospitalization, surgical interventions, blood Identification and transfusion referral of neonatal sickness

Treatment and rehabilitation of severe undernutrition

using Diagnosis and Management of treatment, referral terminally ill cases, of terminally ill hospitalization cases 71

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Services**

Levels of service delivery Community (Outreach)

First point of Referral Centre service delivery (U- U- CHC (Specialist PHC) services)

Counseling for practices for vector control and protection A7. Mental Health

Initial screening and Psychiatric and neurological referral services, including hospitalization, if needed

A7.1 Health

Diagnosis referral

Oral

and Management of complicated cases, hospitalization (if needed)

A7.2 Hearing Impairment/ Deafness

Management of complicated cases, hospitalization (if needed)

A8. Chest Symptomatic search and referral, infections ensuring adherence to DOTs, other (TB/ treatment Asthma)

Diagnosis and Management of treatment, referral complicated cases of complicated cases

A9. Cardio- BP measurement, symptomatic Diagnosis and vascular search and referral, follow-up of treatment and referral during diseases under-treatment patients specialist visits,

Management of emergency cases, hospitalization and surgical interventions (if needed)

Blood/urine sugar test (using Diagnosis and disposable kit), symptomatic treatment, referral of complicated search and referral, cases

Management of complicated cases, hospitalization (if needed)

A10. Diabetes

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Services**

Levels of service delivery Community (Outreach)

A11. Cancer

First point of Referral Centre service delivery (U- U- CHC (Specialist PHC) services)

Symptomatic search and referral, Identification and follow-up of under-treatment referral, follow-up of under-treatment patients patients

A12. Trauma First aid and referral care (burns & injuries)

First aid , emergency resuscitation, documentation for MLC (if applicable) and referral

A13. Other --- not applicable --surgical interventions

Identification referral

Diagnosis, treatment, hospitalization (if and when needed) Case management and hospitalization, physiotherapy and rehabilitation

and Hospitalization and surgical interventions

B. Other support services B1. IEC/BCC

IPC, Health Camps/fairs, Distribution of Distribution of performing arts, wall/poster health education health education writing, events (in schools, material material women’s groups)

B2. Counseling

Individual and counseling –

group/family Patient/attendant counseling

B3. Personal IEC on hygiene, community --- not applicable --& Social mobilization for cleanliness drives, Hygiene disinfection of water sources, etc.

*Norms adapted from NCMH Report ** Services based on situational analysis

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Patient/attendant counseling --- not applicable ---

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TABLE 7.2: 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

(iii)

Basic Infrastructure a. Consultation room, Dressing and treatment room, Medicine room b. Medical equipments and instruments

(iv)

Basic Staff

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TABLE 7.3: PROPOSED HUMAN RESOURCE AT URBAN PHC #

Staff Category

Number 2 (1 regular and 1 part time)

1

Medical Officer

2

Staff Nurse

3

3

Pharmacist

1

4

Lab Technician

1

5

Public Health Mobilisor

6

LHV

Manager/

Community

1

1-2 Depending upon number of ANMs

7

ANMs

4-5 * Depending upon the population

8

Secretarial Staff including for account keeping and MIS

2

9

Support staff

1

TABLE 7.4: INDICATIVE NORMS FOR OPERATIONALISATION OF URBAN CHC As the partnership for the referral unit would be need based, empanelment criteria can be developed based upon the norms prescribed by the IPHS for hospitals. Some of the suggested criteria can be

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a. Accessibility i. The Hospital/ Nursing home to be easily accessible for the served population. ii. Willingness to provide services at the rates negotiated b. Facilities : i. As per IPHS norm for Hospitals locally adapted as per need ii. Round the clock availability of services c. Availability of Specialties services for which the partnership is being entered. Some of them may be: 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 xiii. Any other based on epidemiological profile of the City d. Diagnostic facilities: As per the requirement. Some of it can be: i. Fully equipped laboratory for biochemistry, microbiology and hematology

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ii. X- Ray machine with minimum capacity of 60 MA iii. Ultra-Sonography iv. Any other based on epidemiological profile of the City

8 - BROAD NORMS FOR NUHM INTERVENTIONS Activity

Norm

1.

Mapping of all urban health Norms will have to be developed to classify the facilities/ poor households poor households. GIS Mapping of all health care facilities-public and private and slumslisted and unlisted would be done to study the population distribution and morbidity pattern (GIS maps prepared under various urban schemes would be taken wherever available). Data base to be generated involving the Community Workers, CBOs and NGOs. Cost will vary in mega cities, million plus cities, and other categories of cities and towns.

2.

Preparation of specific plans

3.

Female Health Worker (FHW)

One FHW/ANM will be provided in urban areas for a population of 10-12 thousand. As health sub-centres are not proposed under NUHM, FHWs will be based in U-PHC. They will be provided mobility support for outreach services.

4.

Community Worker/Link Worker for every 200-500 slum/vulnerable households (1000-2500 slum/vulnerable population)

Community Worker/ASHA/ASHA/LW preferably a woman should be a local resident and at least Class 10 pass. To be paid performance based incentives. Main tasks to be generating awareness in the community, coordinating with community groups/MAS for preventive and promotive actions for health and health determinants, and linking

slum/city Based on the detailed GIS mapping and household surveys and after intensive discussion at all levels, Slum/City level plans to be drawn up. Cost of planning will vary as per the population.

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households to health facilities (government or private accredited). 5.

Capacity building, performance Basic training modules for Community based payments, drug kit for Workers to be developed based on the ASHA Community Worker training modules. 4 weeks induction training followed by 10-15 days refresher training in various aspects of public health and community mobilization. Compensation for training.

6.

Community Organization (Mahila Arogya Samiti) for 50100 households in slums/other vulnerable population (250-500 slum/vulnerable population).

7.

Training and Capacity Building Through NGOs. To ensure greater role in of Mahila Arogya Samitis management of savings and community mobilization. Quarterly orientation workshops/meetings will be organized for the MAS members.

8.

One Urban Primary Centre for every population

Community Organization in homogeneous setting with 10-12 members, will receive grant of Rs. 5000 per year. Major responsibility of community mobilization and awareness/demand generation addressing health and health determinants.

Health U-PHC as nodal point. To function under 50,000 government with well defined service guarantees and provisions for human resources, infrastructure, equipment, etc. Indian Public Health Standards will be developed for U-PHC as per the recommendations of the Shiv Lal Committee. U-PHC to operate preferably from 12 noon to 8 pm.

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9.

One Urban Community Health Centre for every 2.5-3 lakhs population (every 5 –6 U-PHCs) in cities above 5 lakh population

U-CHC to function as in-patient and first referral level for the urban population, reducing the workload of sub-district/district or medical college hospital in the city (which take the load of the entire area and only of the city). To function under government with well defined service guarantees and provisions for human resources, infrastructure, equipment, etc. Indian Public Health Standards will be developed for U-CHC. The central assistance would provide only for one-time grant of Rs.5 crores and the recurrent cost would be borne by the state.

10.

11.

Establishment of U-CHCs to be decided by the concerned State Government on the basis of actual need. Training and Capacity NGOs to be involved in training and capacity Development of Ward level development of Ward level Standing Standing Committee on health Committees of health. under Urban Local Body Untied grants to Rogi Kalyan Each U-PHC to get Rs. 2.5 Lakh and each USamiti CHC to get Rs.5 lakhs as untied grant every year for local public health action and for its maintenance and upkeep. The District Health Society may re-appropriate the overall amount amongst various health institutions by +25%, depending on need and utilization levels. For calculation of resource envelop of a district, allocation will be done on normative basis for the health facilities.

12.

Resources for outreach services Outreach services at slum level will be as per fixed schedule in urban provided by the ANM. Buildings (community slums by ANMs halls etc) constructed under the schemes of the Department of UD, HUPA and other government departments may be utilized as fixed points for providing periodic outreach services. 79

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13.

Involvement of NGOs in U-PHC NGOs will be utilized for community area mobilization, capacity building, and other preventive and promotive activities for health and health determinants.

14.

Hiring of NGOs/Private Services of NGOs and private providers may be providers for U-PHC services hired to bridge the gaps in health care delivery as per actual need. For this the accreditation process and deliverables to be clearly defined.

15.

Enhancing planning capacity in Provision for need based additional human urban local bodies resources in public health, management of health system, finance, MIS, planning , etc.

16.

Referral Transport and Mobile MMUs and Referral Transport System provided Medical Units in the district under NRHM will also be used to cover urban areas.

17.

Setting up of City Level society

In the metropolitan cities and other cities where the State government decides to hand over the management of urban health system to municipal corporations, city level health society will be set up.

18.

Behavior Change Communication

IEC and BCC have a very important role especially in urban areas where the influence of media and advertizing needs to be countered effectively, especially against use of junk food, aerated drinks, tobacco and alchohol consumption, etc. Provision of Rs. 5 per capita for IEC/BCC. Interpersonal communication through LWs/ASHAs to play a major role in promoting behavior change.

19.

MIS for health in urban areas

As per need.

20.

Management programme

21.

Interventions

cost

for

for Up to 6 percent of the resource envelope for recurrent cost. A capital grant of Rs.5 lakhs per Program Management Unit (PMU) would be provided separately. making As per norms of IDSP. 80

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surveillance system effective 22.

Special interventions for As per specific proposals and preferably vulnerable groups like sex through NGOs. workers, street children, migrant labor, etc.

23.

Strengthening Secondary and As per need. tertiary care hospitals

24.

Community Monitoring

25.

Urban Areas having less than Urban Areas having less than 50,000 population 50,000 population will be covered by the health care delivery system supported by the National Rural Health Mission.

26.

Building ownership Divisional Officer

As per need.

of

Sub In the cities/towns other than State/district headquarters, a committee headed by the subdivisional officer will be constituted by the District Magistrate in consultation with the Chief Medical Officer. This committee will ensure effective coordination and implementation of NUHM activities in the cities/towns in the jurisdiction of the subdivision. Similar arrangement with Additional District Magistrate (ADM)/Sub Divisional Officer may also be put in place for district headquarter towns/cities.

9 - FINANCIAL RESOURCE NEEDS FOR NUHM 9.1

The National Urban Health Mission would initiate planning activities in 2011-12.

The sharing arrangement for NUHM will be 100% by centre in XI Plan, and 85-15 in the XII Plan (75-25 for the seven metro cities).

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TABLE 9.1: POPULATION ESTIMATES FOR NUHM:

ASSUMPTIONS

UNDERLYING

Population

FINANCIAL

Numbers

1.

Urban Population 2001 ( Census 2001)

28.61 crores

2. 3.

Urban population 2011 (Census 2011) Urban population residing in cities with a population of above 50 thousand Projected Urban slum population 2011 (in cities above 50 thousand population – estimated 25% of urban population + 10% additional estimated vulnerable population) No. of metro cities No. of cities with population above 1 million (10 lakh) as per projections (taking into account urban population [email protected] 3% p.a) Cities with population between 1 - 10 lakh Cities with population between 50,000 - 1 lakh Total Number of U-PHCs to be strengthened (@ 1 U-PHC for 50,000 population) Total Number of U-CHCs (@ 1 U-CHC for 5UPHCs, i.e. 2.5 lakhs population Total no. of ANMs required in the U-PHCs (@ 4 ANM per U- PHC) Total Number of ASHAs /LWs required (@ 1 ASHA for 2000 slum population) Total Number of Mahila Arogya Samitis (@ 1 MAS for 100 HHs in slum areas)

37.71 crores 22.13 crores

4.

5. 6.

7. 8. 9. 10. 11. 12. 13.

7.75 crores

7 27

353 392 4,425 344 23,688 38,720 1,54,882

9.2 ESTIMATED FUNDS REQUIRED FOR NATIONAL URBAN HEALTH MISSION

9.2.1 It is estimated that the proposed NUHM would need a total of Rs.22,507 crores (approximately) from 2012-13 to 2016-17, of which Rs.16,955 crores (approximately) is

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No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

envisaged to be the central government share. Year wise financial requirement, by central and state share, is shown below. Year 2012-13 2013-14 2014-15 2015-16

GOI 2,325.61 3,782.74 3,957.74 3,949.20

2016-17 Total

2,939.77 16,955.07

States 762.13 1,239.42 1,296.35 1,293.20

Total 3,087.74 5,022.17 5,254.09 5,242.40

Remarks GOI 75%, state 25% in all states except northeastern states where the ratio is GOI 90%, state 10%

961.04 3,900.82 5,552.14 22,507.21

9.2.2 As per the above table, the financial requirement for the central government in the XII Plan period is estimated to be Rs. 16,955 crores (central share). 9.3

MANAGEMENT COSTS

9.3.1 It is imperative that management capacities be built at each level. To attain the outcomes, the NUHM would provide management costs up to 6% of the total annual plan approved for a State/City (similar to NRHM norms of 6% for management costs). The services of experts and other functionaries may have to be hired on contractual basis to carry out the activities under the Mission. The Mission would also need to be vested with authority to strengthen management structures without creating any new permanent posts. 9.4

NORMS FOR RELEASE OF FUNDS TO THE STATE GOVERNMENTS

9.4.1 In order to ensure that the state specific focus is retained in planning and management of NUHM the urban population and health infrastructure would be given appropriate weight-age for release of the funds to the States. However, actual release

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would depend upon the actual State Level PIP based on respective city and district level PIPs subject to approval by the NPCC at the Central level.

9.5

SUSTAINABILITY

9.5.1 The NUHM would strive to ensure the sustainability of the Mission through state and ULB contribution, promotion of community structures like the Mahila Arogya Samitis and facility based Rogi Kalyan Samitis on the lines of NRHM. 9.5.2 The Rogi Kalyan Samiti would also be encouraged to pool funds, on the lines of NRHM, from other sources like donations/ MP or MLA/ULB etc contributions for broad-basing the community health fund.

10 - PLANNING PROCESS OF NUHM 10.1

City specific planning is extremely essential as the health structure in cities

varied considerably. However in order to optimize the utilization of central, state, municipal, and private health assets and manpower, it was essential that a City Health and Sanitation Planning Committee in the urban areas works under the umbrella of the District Health Mission and the District Health Society whose primary role would be to integrate health service delivery to the urban poor in the urban areas. 10.2

The planning process would involve identification, mapping and vulnerability

assessment of slums, assessment and mapping of the existing health care services, stakeholder consultations, mapping of referrals in each area, rationalization of manpower, mapping and accrediting the private sector, ensuring private sector participation and also ensure effective convergence with departments likes ICDS and JnNURM. 10.3

Household surveys through the Mahila Arogya Samiti and the ASHA/Link

Worker are needed to understand the poverty of households and the challenges of

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public health in urban slums. The Mahila Arogya Samiti will be the basic unit of planning and community action.

11 - APPRAISAL AND APPROVAL PROCESS OF NUHM 11.1

The NRHM has developed a transparent mechanism for appraisal of state PIPs

and subsequent release of funds. The NUHM will also follow norms as has been developed under NRHM for programme appraisal and fund release. 11.2

Each City would develop a CPIP, which would be consolidated at the State level

as State Programme Implementation Plan (SPIP) incorporating additonalities at the State level. 11.3

The CPIP would be a reflection of the comprehensive resources available to the

City under the various ongoing national health/state/ULB programmes and also other sources of funds including State Health Systems projects, State Partnership Projects, Finance Commission awards, projects / schemes funded through Global Funds and/or Global Partnerships in the health sector and projects / schemes being (or proposed to be) funded outside the State budget as an illustrative but not an exhaustive list. Clear delineation of funds allocated under RCH, NRHM Flexipool, RNTCP, NVBDCP, IDD, NLEP, NMHP, NPCB, NACP, UFWC, UHP etc would have to be enunciated in the PIP. 11.4

The National Programme Coordination Committee (NRHM) headed by the

Mission Director would undertake the appraisal of the proposals received and also recommend for funding. 11.5

With the launching of NUHM, all of these existing programmes/schemes

(supporting

the

various

types

of

primary

healthcare

facilities

like

UHP/UFWC/Dispensary) will automatically cease to exist. The existing infrastructure available under these schemes would be rationalized and aligned with the new IPHS.

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11.6

The City /State PIP would also clearly articulate the funds required for the urban

component of the various National programmes and the funds would be released by the Programme Divisions. 17.7

The NUHM similar to the NRHM would also try to provide a platform for

integrating all the programmes for urban areas as is being done under the NRHM. Till the time this process is put in place and institutionalized the fund flow mechanism under the NRHM would be adopted. E-banking systems would be put in place for facilitating this. 17.8

Given the current absorptive capacities in the States as also the structures for

managing accountability at various levels, it is likely that the demand for resources will be less in the initial years. The actual need year to year will depend on the pace at which States push reforms in order to remove the constraints on expenditure and its effective utilization. Efforts would be made to kick-start the Mission with the desired pace by capacity building workshops to increase the absorptive capacity of the states. Annual financial demands would be accordingly made. A flexible pool of resource envelope would be indicated to the states with provision for inter component variability in activity heads/costs in view of extant urban situation/city specific conditions.

12 - ROLE OF THE NON-GOVERNMENTAL SECTOR IN NUHM 12.1

Transparent partnerships with non-governmental providers for health care

services 12.1.1 Recognizing that government health facilities do not have adequate reach in urban slums leading to low demand and poor utilization, involving NGOs in outreach and referral in the urban poor settings may be a viable option. Many state governments have also contracted private hospitals to provide outreach activities (using the private partner’s facilities and staff) in un-served areas and also provide referral support. There is a considerable existing capacity among private providers (NGOs, medical 86

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practitioners and other agencies), which should be explored, fruitfully exploited and operationalised. 12.1.2 Potential private partners should be identified and tapped optimally to improve the quality and standard of health among the urban poor, by capitalizing on the skills of potential partners, encouraging pooling of resources, and supplementing the investment burden on the Government of India’s resources deployed in the health sector. Appropriate mechanisms for partnering (or entering into agreement) with the private sector needs to be considered, including accreditation methods (for ensuring quality), memorandum of understanding, reporting and monitoring systems etc. 12.2

Role of NGOs in strengthening health services for the poor

12.2.1 The presence of active NGOs in several cities presents a unique and powerful opportunity to extend the reach of health services through various ways of outreach and enhancing utilization by raising community demand for the existing services. The support of the NGOs would be encouraged and supported to get suitably involved in the planning and implementation of the urban health projects. They may support in undertaking situational analysis, identification and mapping of slums, identification & capacity building of Link Volunteers and IEC/BCC activities.

13 - ROLE OF REGULATION AND DEFINING STANDARDS 13.1

The IPHS standards for U-PHC and U-CHC will be developed and shared with

the States. 13.2

The Quality Assurance activities would mainly involve formation of an

overarching Quality Assurance Committee (QAC) at state and city levels and one or more Quality Assurance Teams (QAT), composed of renowned specialists and senior technicians.

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13.3

The Quality Assurance teams would be responsible for recommending

accreditation of clinics/ hospitals/ nursing homes/ diagnostic centers and pharmacies for empanelment for outreach services/ U-PHCs/ referral centers. 13.4

These

teams

would

also

undertake

periodic

medical

audits

of

selected/empanelled health facilities, either by themselves, or through external auditors, in consultation with the Quality Assurance Committee. 13.5

For this purpose, it is proposed to allocate a lump sum amount of Rs. 50 lacs per

year per metro city, Rs. 20 lacs per city with 10 lac+ population, Rs. 10 lacs per other city with 1 lac+ population, and Rs. 1 lac for cities less than 1 lac population (but above 50,000 population). 13.6

These funds would also include provision for orientation and training of

QAC/QAT. 13.7

But these provisions do not include funds for certification of government

hospitals. 13.8

In addition a Health Service Charter will be displayed at the facility level. It is

envisaged that such public display of information would empower the community for demanding services. The different institutional mechanism like Rogi Kalyan Samiti/ Mahila Arogya Samiti would ensure that the service guarantee at each level is met. 13.9

In order to identify discrepancies and take corrective actions the practice of

Concurrent audit may be introduced right from the inception stage. All the funds/ untied grants would be audited on a quarterly basis and report of which would be made public. This process would also facilitate timely submission of utilization certificates and Audit Reports to ensure financial health of the Mission. 13.10 A grievance redressal mechanism would be put in place in which a committee, comprising of members from government and reputed community members would be constituted which will help resolve the problems and complaints.

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Annexure – II The list of proposed 779 cities and towns including 7 metros

State

City

Andaman Nic

Port Blair

Total (ANC)

Population

1

State

City

Population

99,984

Andhra Pr.

Suryapet

94,585

99,984

Andhra Pr.

Chilakaluripet

91,656

Andhra Pr.

Hyderabad

57,42,036

Andhra Pr.

Miryalaguda

91,359

Andhra Pr.

Vishakhapatnam

13,45,938

Andhra Pr.

Tadpatri

86,843

Andhra Pr.

Vijayawada

10,39,518

Andhra Pr.

Kavali

85,616

Andhra Pr.

Warangal

5,79,216

Andhra Pr.

Jagtial

85,521

Andhra Pr.

Guntur

5,14,461

Andhra Pr.

Anakapalle

85,486

Andhra Pr.

Rajahmundry

4,13,616

Andhra Pr.

Yemmiganur

76,411

Andhra Pr.

Nellore

4,04,775

Andhra Pr.

Palacole

76,308

Andhra Pr.

Kakinada

3,76,861

Andhra Pr.

Kadiri

76,252

Andhra Pr.

Kurnool

3,42,973

Andhra Pr.

Nirmal

75,254

Andhra Pr.

Tirupati

3,03,521

Andhra Pr.

Tanuku

72,970

Andhra Pr.

Nizamabad

2,88,722

Andhra Pr.

Rayachoti

72,297

Andhra Pr.

Cuddapah

2,62,506

Andhra Pr.

Bodhan

71,520

Andhra Pr.

Anantapur

2,43,143

Andhra Pr.

Srikalahasti

70,854

Andhra Pr.

Ramagundam

2,37,686

Andhra Pr.

Palwancha

69,088

Andhra Pr.

Karimanagar

2,18,302

Andhra Pr.

Gudur

68,782

Andhra Pr.

Eluru

2,15,804

Andhra Pr.

Bapatla

68,397

Andhra Pr.

Khammam

1,98,620

Andhra Pr.

Bellampalle

66,792

Andhra Pr.

Vizianagaram

1,95,801

Andhra Pr.

Mandamarri

66,596

Andhra Pr.

Machilipatnam

1,79,353

Andhra Pr.

Sircilla

65,314

Andhra Pr.

Chirala

1,66,294

Andhra Pr.

Kamareddy

64,496

Andhra Pr.

Adoni

1,62,458

Andhra Pr.

Siddipet

61,809

Andhra Pr.

Nandyal

1,57,120

Andhra Pr.

Kagaznagar

59,734

Andhra Pr.

Ongole

1,53,829

Andhra Pr.

Narasapur

58,604

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State

City

Andhra Pr.

Tenali

Andhra Pr.

Population

State

City

1,53,756

Andhra Pr.

Sattenapalle

51,404

Chittoor

1,52,654

Andhra Pr.

Bhongir

50,407

Andhra Pr.

Proddatur

1,50,309

Andhra Pr.

Tuni

50,368

Andhra Pr.

Bhimavaram

1,42,064

Andhra Pr.

Nuzvid

50,354

Andhra Pr.

Mahbubnagar

1,39,662

Andhra Pr.

Kandukur

50,326

Andhra Pr.

Adilabad

1,29,403

Andhra Pr.

Wanaparthy

50,114

Andhra Pr.

Hindupur

1,25,074

Andhra Pr.

Pithapuram

50,103

Andhra Pr.

Mancherial

1,18,195

Total (AP)

Andhra Pr.

Srikakulam

1,17,320

Arunachal Pr

Andhra Pr.

Guntakal

1,17,103

Total (Ar.P)

Andhra Pr.

Gudivada

1,13,054

Assam

Guwahati

8,18,809

Andhra Pr.

Nalgonda

1,11,380

Assam

Silchar

1,84,105

Andhra Pr.

Madanapalle

1,07,449

Assam

Jorhat

1,37,814

Andhra Pr.

Kothagudem

1,05,266

Assam

Dibrugarh

1,37,661

Andhra Pr.

Dharmavaram

1,03,357

Assam

Nagaon

1,23,265

Andhra Pr.

Tadepalligudem

1,02,622

Assam

Tinsukia

1,08,123

Andhra Pr.

Narasaraopet

95,349

Assam

Tezpur

1,05,377

Andhra Pr.

Bobbili

50,096

Assam

Bongaigaon

75,928

Andhra Pr.

Markapur

58,462

Assam

Dhubri

64,168

Andhra Pr.

Tandur

57,941

Assam

Lakhimpur North

54,285

Andhra Pr.

Ponnur

57,640

Assam

Sibsagar

53,854

Andhra Pr.

Sangareddy

57,113

Assam

Karimganj

52,613

Andhra Pr.

Rayadurg

54,125

Assam

Diphu

52,310

Andhra Pr.

Koratla

54,012

Assam

Lumding

50,570

Andhra Pr.

Samalkot

53,602

Total (Assam)

Andhra Pr.

Gadwal

53,560

Bihar

Jehanabad

81,503

Andhra Pr.

Vinukonda

52,519

Bihar

Aurangabad

79,393

90

Population

83 Itanagar

1,86,42,704 35,022

1

14

35,022

20,18,882

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Andhra Pr.

Amalapuram

Bihar

Population

State

City

51,444

Bihar

Lakhisarai

77,875

Jamui

66,797

Bihar

Mokameh

56,615

Bihar

Madhubani

66,340

Bihar

Gopalganj

54,449

Bihar

Patna

16,97,976

Bihar

Supaul

54,085

Bihar

Gaya

3,94,945

Total (Bihar)

Bihar

Bhagalpur

3,50,133

Chandigarh

Bihar

Muzzafarpur

3,05,525

Total (Chd)

Bihar

Darbhanga

2,67,348

Chhattisgarh

Durg-Bhilai

9,27,864

Bihar

Arrah

2,03,380

Chhattisgarh

Raipur

7,00,113

Bihar

Purnia

1,97,211

Chhattisgarh

Bilaspur

3,35,293

Bihar

Katihar

1,90,873

Chhattisgarh

Korba

3,15,690

Bihar

Munger

1,88,050

Chhattisgarh

Rajnandgaon

1,43,770

Bihar

Chapra

1,79,190

Chhattisgarh

Raigarh

1,15,908

Bihar

Sasaram

1,31,172

Chhattisgarh

Chirmiri

93,373

Bihar

Saharsa

1,25,167

Chhattisgarh

Ambikapur

90,967

Bihar

Hajipur

1,19,412

Chhattisgarh

Dhamtari

82,111

Bihar

Dehri

1,19,057

Chhattisgarh

Dalli-Rajhara

57,058

Bihar

Bettiah

1,16,670

Chhattisgarh

Bhatapara

50,118

Bihar

Siwan

1,09,919

Total (Chgr)

Bihar

Motihari

1,08,428

Delhi

Bihar

Begusarai

1,07,623

Total (Delhi)

Bihar

Jamalpur

96,983

Goa

Mormugao

Bihar

Bagaha

91,467

Goa

Panaji

99,677

Bihar

Sitamarhi

87,279

Goa

Margao

94,383

Bihar

Kishanganj

85,590

Total (Goa)

Bihar

Buxar

83,168

Gujarat

Ahmadabad

45,25,013

Bihar

Nawada

81,891

Gujarat

Surat

28,11,614

91

Population

34 Chandigarh

60,98,373 8,08,515

1

11 Delhi

8,08,515

29,12,265 1,28,77,470

1

1,28,77,470 1,04,758

3

2,98,818

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Bihar

Samastipur

Bihar

Araria

Gujarat

Population

State

City

61,998

Gujarat

Vadodara

14,91,045

60,861

Gujarat

Rajkot

10,03,015

Jamnagar

5,56,956

Gujarat

Dhoraji

80,811

Gujarat

Bhavnagar

5,17,708

Gujarat

Mahuva

80,726

Gujarat

Junagadh

2,52,108

Gujarat

Savarkundla

73,774

Gujarat

Navsari

2,32,411

Gujarat

Visnagar

73,488

Gujarat

Wadhwan

2,19,585

Gujarat

Vapi

71,406

Gujarat

Anand

2,18,486

Gujarat

Dhrangadhra

70,663

Gujarat

Porbandar

1,97,382

Gujarat

Anjar

68,343

Gujarat

Nadiad

1,96,793

Gujarat

Keshod

63,257

Gujarat

Gandhinagar

1,95,985

Gujarat

Dholka

61,569

Gujarat

Morvi

1,78,055

Gujarat

Kadi

60,026

Gujarat

Bharuch

1,76,364

Gujarat

Sidhpur

58,194

Gujarat

Veraval

1,58,032

Gujarat

Bilimora

57,564

Gujarat

Gandhidham

1,51,693

Gujarat

Borsad

56,548

Gujarat

Valsad

1,45,592

Gujarat

Himatnagar

56,464

Gujarat

Mahesana

1,41,453

Gujarat

Mangrol

56,320

Gujarat

Bhuj

1,36,429

Gujarat

Upleta

55,438

Gujarat

Godhra

1,31,172

Gujarat

Dabhoi

54,952

Gujarat

Palanpur

1,22,300

Gujarat

Bardoli

51,946

Gujarat

Patan

1,13,749

Gujarat

Palitana

51,944

Gujarat

Anklesvar

1,12,643

Gujarat

Una

51,261

Gujarat

Dohad

1,12,026

Gujarat

Modasa

54,135

Gujarat

Kalol

1,12,013

Gujarat

Unjha

53,876

Gujarat

Jetpur Navagadh

1,04,312

Gujarat

Viramgam

53,094

Gujarat

Botad

1,00,194

Gujarat

Petlad

51,147

Gujarat

Gondal

97,506

Total (Guj)

92

Population

56

1,62,50,463

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Gujarat

Amreli

Gujarat

State

City

95,307

Haryana

Faridabad

Khambhat

93,194

Haryana

Panipat

3,54,148

Gujarat

Deesa

83,382

Haryana

Ambala

3,07,595

Haryana

Yamunanagar

3,06,740

J&K

Baramula

71,896

Haryana

Rohtak

2,94,577

J&K

Sopore

59,624

Haryana

Hisar

2,63,186

J&K

Kathua

51,034

Haryana

Gurgaon

2,28,820

Total (JK)

Haryana

Sonipat

2,25,074

Jharkhand

Jamshedpur

11,04,713

Haryana

Karnal

2,21,236

Jharkhand

Dhanbad

10,65,327

Haryana

Bhiwani

1,69,531

Jharkhand

Ranchi

8,63,495

Haryana

Sirsa

1,60,735

Jharkhand

Bokaro

4,97,780

Haryana

Panchkula

1,40,925

Jharkhand

Phusro

1,74,402

Haryana

Jind

1,35,855

Jharkhand

Hazaribag

1,35,473

Haryana

Bahadurgarh

1,31,925

Jharkhand

Deoghar

1,12,525

Haryana

Thanesar

1,22,319

Jharkhand

Ramgarh

1,10,496

Haryana

Kaithal

1,17,285

Jharkhand

Chirkunda

1,06,227

Haryana

Palwal

1,00,722

Jharkhand

Giridih

1,05,634

Haryana

Rewari

1,00,684

Jharkhand

Saunda

85,075

Haryana

Hansi

75,747

Jharkhand

Sahibganj

80,154

Haryana

Narnaul

62,077

Jharkhand

Daltonganj

71,422

Haryana

Fatehabad

59,917

Jharkhand

Jhumri Tilaiya

69,503

Haryana

Mandi Dabwali

53,811

Jharkhand

Chaibasa

63,648

Haryana

Tohana

51,519

Jharkhand

Chakradharpur

55,228

Haryana

Narwana

50,435

Total (Jhar)

Total (Har) Himachal Pr Total (HP)

Population

24 Shimla 1

Population 10,55,938

7

16

19,67,122

47,01,102

47,90,801

Karnataka

Bengaluru

1,44,975

Karnataka

Mysore

7,99,228

1,44,975

Karnataka

Hubli-Dharwad

7,86,195

93

57,01,446

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

J&K

Srinagar

J&K

Jammu

J&K

Population

State

City

9,88,210

Karnataka

Mangalore

5,39,387

6,12,163

Karnataka

Belgaum

5,06,480

Anantnag

97,896

Karnataka

Gulbarga

4,30,265

J&K

Udhampur

86,299

Karnataka

Devangere

3,64,523

Karnataka

Bellary

3,16,766

Karnataka

Channapatna

63,577

Karnataka

Shimoga

2,74,352

Karnataka

Sindhnur

61,262

Karnataka

Bijapur

2,53,891

Karnataka

Chamarajanagar

60,558

Karnataka

Tumkur

2,48,929

Karnataka

Yadgir

58,811

Karnataka

Raichur

2,07,421

Karnataka

Basavakalyan

58,785

Karnataka

Bidar

1,74,257

Karnataka

Nipani

58,081

Karnataka

Hospet

1,64,240

Karnataka

Jamkhandi

57,883

Karnataka

Bhadravati

1,60,662

Karnataka

Koppal

56,160

Karnataka

Robertson Pet

1,57,084

Karnataka

Haveri

55,913

Karnataka

Gadag Betigeri

1,54,982

Karnataka

Chik Ballapur

54,968

Karnataka

Hassan

1,33,262

Karnataka

Dandeli

53,290

Karnataka

Mandya

1,31,179

Karnataka

Kollegal

52,607

Karnataka

Udupi

1,27,124

Karnataka

Ilkal

51,920

Karnataka

Chitradurga

1,25,170

Karnataka

Sagar

50,131

Karnataka

Kolar

1,13,907

Karnataka

Sira

50,088

Karnataka

Gangawati

1,01,392

Total (Ka)

Karnataka

Chikmagalur

1,01,251

Kerala

Kochi

Karnataka

Bagalkot

90,988

Kerala

Thiruvananthapuram

8,89,635

Karnataka

Ranibennur

89,618

Kerala

Kozhikode

8,80,247

Karnataka

Harihar

87,744

Kerala

Kannur

4,98,207

Karnataka

Ramnagaram

79,394

Kerala

Kollam

3,80,091

Karnataka

Karwar

75,038

Kerala

Thrissur

3,30,122

Karnataka

Dod Ballapur

71,606

Kerala

Palakkad

1,97,369

94

Population

50

1,37,46,611 13,55,972

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Karnataka

Rabkavi-Banhatti

Karnataka

State

City

70,248

Kerala

Kottayam

1,72,878

Gokak

67,170

Kerala

Malappuram

1,70,409

Karnataka

Shahabad

66,550

Kerala

Cherthala

1,41,558

Karnataka

Chintamani

65,493

Kerala

Guruvayoor

1,38,681

Karnataka

Sirsi

65,335

Kerala

Kanhangad

1,29,367

Kerala

Vadakara

1,24,083

Madhya Pr

Bhind

1,53,752

Kerala

Kodungallur

94,883

Madhya Pr

Chhindwara

1,53,552

Kerala

Ponnani

87,495

Madhya Pr

Morena

1,50,959

Kerala

Kasargod

75,968

Madhya Pr

Shivpuri

1,46,892

Kerala

Neyyattinkara

69,467

Madhya Pr

Guna

1,37,175

Kerala

Quilandy

68,982

Madhya Pr

Damoh

1,27,967

Kerala

Payyannur

68,734

Madhya Pr

Vidisha

1,25,453

Kerala

Kayamkulam

68,585

Madhya Pr

Mandsaur

1,17,555

Kerala

Taliparamba

67,507

Madhya Pr

Mhow

1,12,887

Kerala

Thiruvalla

56,837

Madhya Pr

Neemuch

1,12,852

Kerala

Nedumangad

56,138

Madhya Pr

Chhatarpur

1,09,078

Kerala

Tirur

53,654

Madhya Pr

Itarsi

1,07,831

Kerala

Changanassery

51,967

Madhya Pr

Khargone

1,03,448

Kerala

Kunnamkulam

51,592

Madhya Pr

Hoshangabad

97,424

62,80,428

Madhya Pr

Nagda

96,579

Total (Keral)

Population

26

Population

Madhya Pr

Indore

15,16,918

Madhya Pr

Sarni

95,012

Madhya Pr

Bhopal

14,58,416

Madhya Pr

Chikhri Parasia

93,037

Madhya Pr

Jabalpur

10,98,000

Madhya Pr

Sehore

92,518

Madhya Pr

Gwalior

8,65,548

Madhya Pr

Burhar-Dhanpuri

91,975

Madhya Pr

Ujjain

4,31,162

Madhya Pr

Seoni

89,801

Madhya Pr

Sagar

3,08,922

Madhya Pr

Betul

83,722

Madhya Pr

Dewas

2,31,672

Madhya Pr

Datia

82,755

95

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Madhya Pr

Satna

Madhya Pr

State

City

2,29,307

Madhya Pr

Shahdol

78,624

Burhanpur

1,93,725

Madhya Pr

Balaghat

75,997

Madhya Pr

Katni

1,87,029

Madhya Pr

Dhar

75,374

Madhya Pr

Singrauli

1,85,190

Madhya Pr

Tikamgarh

68,426

Madhya Pr

Rewa

1,83,274

Madhya Pr

Pithampur

68,080

Madhya Pr

Khandwa

1,72,242

Madhya Pr

Basoda

64,937

Madhya Pr

Harda

64,497

Maharashtra

Ichalkaranji

2,85,860

Madhya Pr

Mandla

60,542

Maharashtra

Parbhani

2,59,329

Madhya Pr

Bina-Etawa

58,401

Maharashtra

Jalna

2,35,795

Madhya Pr

Sheopur

58,342

Maharashtra

Bhusawal

1,87,564

Madhya Pr

Shajapur

57,818

Maharashtra

Nalasopara

1,84,538

Madhya Pr

Ashoknagar

57,705

Maharashtra

Vasai

1,74,396

Madhya Pr

Dabra

56,672

Maharashtra

Yavatmal

1,39,835

Madhya Pr

Narsimhapur

56,203

Maharashtra

Bid

1,38,196

Madhya Pr

Panna

52,057

Maharashtra

Kamptee

1,36,491

1,04,97,304

Maharashtra

Gondiya

1,20,902

1,64,34,386

Maharashtra

Virar

1,18,928

Total (MP)

Population

50

Population

Maharashtra

Mumbai

Maharashtra

Pune

37,60,636

Maharashtra

Wardha

1,11,118

Maharashtra

Nagpur

21,29,500

Maharashtra

Satara

1,08,048

Maharashtra

Nashik

11,52,326

Maharashtra

Achalpur

1,07,316

Maharashtra

Aurangabad

8,92,483

Maharashtra

Barshi

1,04,785

Maharashtra

Solapur

8,72,478

Maharashtra

Panvel

1,04,058

Maharashtra

Bhiwandi

6,21,427

Maharashtra

Nandurbar

94,368

Maharashtra

Amravati

5,49,510

Maharashtra

Hingaghat

92,342

Maharashtra

Kolhapur

5,05,541

Maharashtra

Udgir

91,933

Maharashtra

Sangli

4,47,774

Maharashtra

Amalner

91,490

Maharashtra

Nanded-Waghala

4,30,733

Maharashtra

Pandharpur

91,379

96

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Maharashtra

Malegaon

Maharashtra

Population

State

City

4,09,403

Maharashtra

Chalisgaon

91,110

Akola

4,00,520

Maharashtra

Ballarpur

89,995

Maharashtra

Jalgaon

3,68,618

Maharashtra

Shrirampur

88,761

Maharashtra

Ahmadnagar

3,47,549

Maharashtra

Khamgaon

88,687

Maharashtra

Dhule

3,41,755

Maharashtra

Parli

88,537

Maharashtra

Latur

2,99,985

Maharashtra

Bhandara

85,213

Maharashtra

Chandrapur

2,89,450

Maharashtra

Navi Mumbai

81,855

Maharashtra

Akot

80,726

Manipur

Imphal

Maharashtra

Osmanabad

80,625

Total (Mani)

Maharashtra

Malkapur

79,003

Meghalaya

Shillong

Maharashtra

Manmad

72,401

Meghalaya

Tura

Maharashtra

Ratnagiri

70,383

Total (Megha)

Maharashtra

Ambejogai

69,478

Mizoram

Maharashtra

Hingoli

69,432

Total (Mizo)

Maharashtra

Pusad

67,166

Nagaland

Dimapur

98,096

Maharashtra

Buldana

62,972

Nagaland

Kohima

77,030

Maharashtra

Washim

62,956

Total (Naga)

Maharashtra

Sangamner

61,958

Odhisa

Bhubaneswar

6,58,220

Maharashtra

Shirpur-Warwade

61,694

Odhisa

Cuttack

5,87,182

Maharashtra

Chopda

60,865

Odhisa

Raurkela

4,84,874

Maharashtra

Karanja

60,158

Odhisa

Brahmapur

3,07,792

Maharashtra

Kopargaon

59,970

Odhisa

Sambalpur

2,26,469

Maharashtra

Khopoli

58,664

Odhisa

Puri

1,57,837

Maharashtra

Uran Islampur

58,330

Odhisa

Baleshwar

1,56,430

Maharashtra

Basmath

57,365

Odhisa

Baripada

1,00,651

Maharashtra

Bhadravati

56,903

Odhisa

Bhadrak

92,515

Maharashtra

Karad

56,161

Odhisa

Balangir

85,261

97

Population

2,50,234 1

2,50,234 2,67,662 58,978

2 Aizwal

3,26,640 2,28,280

1

2

2,28,280

1,75,126

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Maharashtra

Lonavala

Maharashtra

State

City

55,652

Odhisa

Brajarajnagar

76,959

Wani

52,834

Odhisa

Jeypur

76,625

Maharashtra

Palghar

52,677

Odhisa

Jharsuguda

76,100

Maharashtra

Shegaon

52,423

Odhisa

Paradip

73,625

Maharashtra

Baramati

51,334

Odhisa

Bargarh

63,678

Maharashtra

Anjangaon

51,170

Odhisa

Bhawanipatna

60,787

Maharashtra

Phaltan

50,800

Odhisa

Sunabeda

58,884

3,55,21,003

Odhisa

Jatani

57,957

Total (Maha)

Population

73

Population

Odhisa

Rayagada

57,759

Punjab

Sangrur

77,989

Odhisa

Dhenkanal

57,677

Punjab

Mansa

72,627

Odhisa

Barbil

52,627

Punjab

Malout

70,765

Odhisa

Kendujhar

51,845

Punjab

Gurdaspur

68,441

36,21,754

Punjab

Fazilka

67,427

5,05,959

Punjab

Nabha

62,000

74,438

Punjab

Gobindgarh

60,677

5,80,397

Punjab

Jagraon

60,080

Total (Odisa)

22

Pondicherry

Pondicherry

Pondicherry

Karaikal

Total (Pondi)

2

Punjab

Ludhiana

13,98,467

Punjab

Sunam

56,251

Punjab

Amritsar

10,16,079

Punjab

Tarn-Taran

55,787

Punjab

Jalandhar

7,54,608

Total (Punjb)

Punjab

Patiala

3,23,884

Rajasthan

Jaipur

Punjab

Bathinda

2,17,256

Rajasthan

Jodhpur

8,60,818

Punjab

Pathankot

1,68,485

Rajasthan

Kota

7,03,150

Punjab

Firozpur

1,53,153

Rajasthan

Bikaner

5,29,690

Punjab

Hoshiarpur

1,49,668

Rajasthan

Ajmer

4,90,520

Punjab

Batala

1,47,872

Rajasthan

Udaipur

3,89,438

Punjab

Moga

1,35,279

Rajasthan

Bhilwara

2,80,128

Punjab

Abohar

1,24,339

Rajasthan

Alwar

2,66,203

98

30

61,06,685 23,22,575

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Punjab

Mohali

Punjab

Population

State

City

1,23,484

Rajasthan

Ganganagar

2,22,858

Malerkotla

1,07,009

Rajasthan

Bharatpur

2,05,235

Punjab

Khanna

1,03,099

Rajasthan

Pali

1,87,641

Punjab

Phagwara

1,02,253

Rajasthan

Sikar

1,85,925

Punjab

Barnala

96,624

Rajasthan

Tonk

1,35,689

Punjab

Kapurthala

85,686

Rajasthan

Hanumangarh

1,29,556

Punjab

Muktsar

83,655

Rajasthan

Beawar

1,25,981

Punjab

Rajpura

82,956

Rajasthan

Kishangarh

1,25,695

Punjab

Kot Kapura

80,785

Rajasthan

Gangapur City

1,05,396

Rajasthan

Sawai Madhopur

1,01,997

Tamil Nadu

Chennai

65,60,242

Rajasthan

Churu

1,01,874

Tamil Nadu

Coimbatore

14,61,139

Rajasthan

Jhunjhunun

1,00,485

Tamil Nadu

Madurai

12,03,095

Rajasthan

Bundi

88,871

Tamil Nadu

Tirichirappalli

8,66,354

Rajasthan

Banswara

87,308

Tamil Nadu

Salem

7,51,438

Rajasthan

Hindaun

84,861

Tamil Nadu

Tiruppur

5,50,826

Rajasthan

Sujangarh

83,846

Tamil Nadu

Tirunelveli

4,33,352

Rajasthan

Barmer

83,591

Tamil Nadu

Erode

3,89,906

Rajasthan

Sardarshahar

81,394

Tamil Nadu

Vellore

3,86,746

Rajasthan

Baran

78,665

Tamil Nadu

Thoothukkudi

2,43,415

Rajasthan

Fatehpur

78,462

Tamil Nadu

Thanjavur

2,15,314

Rajasthan

Karauli

66,239

Tamil Nadu

Dindigul

1,96,955

Rajasthan

Ratangarh

63,486

Tamil Nadu

Kancheepuram

1,88,733

Rajasthan

Balotra

61,813

Tamil Nadu

Kumbakonam

1,60,767

Rajasthan

Dausa

61,601

Tamil Nadu

Cuddalore

1,58,634

Rajasthan

Suratgarh

58,119

Tamil Nadu

Karur

1,53,365

Rajasthan

Jaisalmer

57,537

Tamil Nadu

Neyveli

1,38,035

Rajasthan

Ladnu

57,070

Tamil Nadu

Tiruvannamalai

1,30,567

99

Population

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Rajasthan

Nawalgarh

Rajasthan

State

City

56,491

Tamil Nadu

Pollachi

1,28,458

Rajsamand

55,687

Tamil Nadu

Pudukkottai

1,26,824

Rajasthan

Nimbahera

53,327

Tamil Nadu

Karaikkudi

1,25,717

Rajasthan

Rajgarh

51,640

Tamil Nadu

Rajapalayam

1,22,307

Rajasthan

Chomu

50,708

Tamil Nadu

Bhavani

1,04,646

Rajasthan

Kuchaman City

50,587

Tamil Nadu

Vaniyambadi

1,03,950

Rajasthan

Bari

50,474

Tamil Nadu

Coonoor

1,01,490

94,12,413

Tamil Nadu

Gudiyatham

1,00,115

29,354

Tamil Nadu

Ambur

99,624

29,354

Tamil Nadu

Viluppuram

95,455

Total (Raj) Sikkim

Population

46 Gangtok

Total (Sikkm)

1

Population

Tamil Nadu

Valparai

95,107

Tamil Nadu

Virudhachalam

60,164

Tamil Nadu

Udhagamandalam

93,987

Tamil Nadu

Puliyankudi

60,080

Tamil Nadu

Nagapattinam

93,148

Tamil Nadu

Udumalaipettai

59,668

Tamil Nadu

Kovilpatti

87,450

Tamil Nadu

Kambam

58,891

Tamil Nadu

Tiruchendur

87,101

Tamil Nadu

Ambasamudram

58,485

Tamil Nadu

Theni Allinagaram

85,498

Tamil Nadu

Attur

57,519

Tamil Nadu

Hosur

84,934

Tamil Nadu

Thiruvarur

56,341

Tamil Nadu

Mayiladuthurai

84,505

Tamil Nadu

Panruti

55,346

Tamil Nadu

Tirupathur

84,435

Tamil Nadu

Gobichettipalayam

55,158

Tamil Nadu

Aruppukkottai

84,029

Tamil Nadu

Mettur

53,633

Tamil Nadu

Tiruchengode

80,187

Tamil Nadu

Sankarankoil

53,606

Tamil Nadu

Arakonam

78,686

Tamil Nadu

Namakkal

53,055

Tamil Nadu

Mettupalayam

74,145

Total (TN)

Tamil Nadu

Bodinayakanur

73,410

Tripura

Tamil Nadu

Srivilliputhur

73,183

Total (Tripu)

Tamil Nadu

Chidambaram

67,795

Uttar Pradesh

Kanpur

27,15,555

Tamil Nadu

Tindivanam

67,737

Uttar Pradesh

Lucknow

22,45,509

100

68 Agartala

1,80,76,941 1,89,998

1

1,89,998

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Tamil Nadu

Palani

Tamil Nadu

Population

State

City

67,231

Uttar Pradesh

Agra

13,31,339

Pattukkottai

65,533

Uttar Pradesh

Varanasi

12,03,961

Tamil Nadu

Devarshola

65,001

Uttar Pradesh

Meerut

11,61,716

Tamil Nadu

Dharapuram

64,984

Uttar Pradesh

Ghaziabad

9,68,256

Tamil Nadu

Krishnagiri

64,587

Uttar Pradesh

Bareilly

7,48,353

Tamil Nadu

Dharmapuri

64,496

Uttar Pradesh

Aligarh

6,69,087

Tamil Nadu

Tenkasi

63,432

Uttar Pradesh

Moradabad

6,41,583

Tamil Nadu

Chengalpattu

62,582

Uttar Pradesh

Gorakhpur

6,22,701

Tamil Nadu

Ramanathapuram

62,050

Uttar Pradesh

Jhansi

4,60,278

Tamil Nadu

Mannargudi

61,478

Uttar Pradesh

Saharanpur

4,55,754

Tamil Nadu

Arani

60,815

Uttar Pradesh

Firozabad

4,32,866

Uttar Pradesh

Muzaffarnagar

3,31,668

Uttar Pradesh

Gonda

1,20,301

Uttar Pradesh

Mathura

3,23,315

Uttar Pradesh

Mughalsarai

1,16,308

Uttar Pradesh

Shahjahanpur

3,21,885

Uttar Pradesh

Hardoi

1,12,486

Uttar Pradesh

Noida

3,05,058

Uttar Pradesh

Lalitpur

1,11,892

Uttar Pradesh

Rampur

2,81,494

Uttar Pradesh

Basti

1,07,601

Uttar Pradesh

Farukha-Fatehgarh

2,42,997

Uttar Pradesh

Etah

1,07,110

Uttar Pradesh

Maunath Bhanjan

2,12,657

Uttar Pradesh

Mainpuri

1,04,851

Uttar Pradesh

Hapur

2,11,983

Uttar Pradesh

Allahabad

1,04,229

Uttar Pradesh

Etawah

2,10,453

Uttar Pradesh

Deoria

1,04,227

Uttar Pradesh

Faizabad

2,08,162

Uttar Pradesh

Chandausi

1,03,749

Uttar Pradesh

Mirzapur

2,05,053

Uttar Pradesh

Ghazipur

1,03,298

Uttar Pradesh

Sambhal

1,82,478

Uttar Pradesh

Ballia

1,01,465

Uttar Pradesh

Bulandshahar

1,76,425

Uttar Pradesh

Sultanpur

1,00,065

Uttar Pradesh

Rae Bareli

1,69,333

Uttar Pradesh

Khurja

98,610

Uttar Pradesh

Bharaich

1,68,323

Uttar Pradesh

Behta Hajipur

94,298

Uttar Pradesh

Amroha

1,65,129

Uttar Pradesh

Azamgarh

93,521

101

Population

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Uttar Pradesh

Jaunpur

Uttar Pradesh

Population

State

City

1,60,055

Uttar Pradesh

Barabanki

92,687

Fatehpur

1,52,078

Uttar Pradesh

Kasganj

92,541

Uttar Pradesh

Sitapur

1,51,908

Uttar Pradesh

Bijnor

90,471

Uttar Pradesh

Badaun

1,48,029

Uttar Pradesh

Shamli

90,055

Uttar Pradesh

Unnao

1,44,662

Uttar Pradesh

Shikohabad

88,161

Uttar Pradesh

Modinagar

1,39,929

Uttar Pradesh

Baraut

85,708

Uttar Pradesh

Banda

1,39,436

Uttar Pradesh

Tanda

83,467

Uttar Pradesh

Orai

1,39,318

Uttar Pradesh

Deoband

81,641

Uttar Pradesh

Hathras

1,26,355

Uttar Pradesh

Najibabad

79,025

Uttar Pradesh

Pilibhit

1,24,245

Uttar Pradesh

Mubarakpur

78,789

Uttar Pradesh

Lakhimpur

1,21,486

Uttar Pradesh

Mahoba

78,782

Uttar Pradesh

Loni

1,20,945

Uttar Pradesh

Bhadohi

74,522

Uttar Pradesh

Muradnagar

74,151

Uttar Pradesh

Obra

51,014

Uttar Pradesh

Kairana

73,011

Uttar Pradesh

Mauranipur

50,882

Uttar Pradesh

Balrampur

72,501

Uttar Pradesh

Konch

50,844

Uttar Pradesh

Bela Pratapgarh

71,999

Uttar Pradesh

Chhibramau

50,268

Uttar Pradesh

Kannauj

71,727

Uttar Pradesh

Laharpur

50,092

Uttar Pradesh

Nagina

71,350

Uttar Pradesh

Jalaun

50,057

Uttar Pradesh

Gangaghat

70,803

Total (UP)

Uttar Pradesh

Sikandrabad

69,867

Uttarakhand

Dehradun

5,30,263

Uttar Pradesh

Mawana

69,191

Uttarakhand

Hardwar

2,20,767

Uttar Pradesh

Chandpur

68,287

Uttarakhand

Haldwani

1,58,896

Uttar Pradesh

Pilkhuwa

66,907

Uttarakhand

Roorkee

1,15,278

Uttar Pradesh

Renukoot

66,597

Uttarakhand

Kashipur

92,967

Uttar Pradesh

Auraiya

64,740

Uttarakhand

Rudrapur

88,676

Uttar Pradesh

Faridpur

61,139

Total (UK)

Uttar Pradesh

Khatauli

58,622

West Bengal

102

Population

103

6 Kolkata

2,37,83,938

12,06,847 1,32,05,697

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Uttar Pradesh

Baheri

Uttar Pradesh

Population

State

City

58,492

West Bengal

Asansol

Dadri

57,416

West Bengal

Durgapur

4,93,405

Uttar Pradesh

Vrindavan

56,692

West Bengal

Siliguri

4,72,374

Uttar Pradesh

Rath

55,950

West Bengal

Barddhaman

2,85,602

Uttar Pradesh

Kiratpur

55,769

West Bengal

Kharagpur

2,72,865

Uttar Pradesh

Tundla

54,576

West Bengal

Habra

2,39,209

Uttar Pradesh

Gangoh

53,913

West Bengal

English Bazar

2,24,415

Uttar Pradesh

Gola Gokarannath

53,842

West Bengal

Raiganj

1,75,047

Uttar Pradesh

Hasanpur

53,326

West Bengal

Haldia

1,70,673

Uttar Pradesh

Tilhar

52,911

West Bengal

Baharampur

1,70,322

Uttar Pradesh

Sherkot

52,880

West Bengal

Medinipur

1,49,769

Uttar Pradesh

Jahangirabad

51,394

West Bengal

Krishnanagar

1,48,709

Uttar Pradesh

Ujhani

51,051

West Bengal

Ranaghat

1,45,285

West Bengal

Balurghat

1,43,321

Total (WB)

West Bengal

Santipur

1,38,235

West Bengal

Bankura

1,28,781

West Bengal

Birnagar

1,15,127

West Bengal

Alipurduar

1,14,035

West Bengal

Puruliya

1,13,806

West Bengal

Basirhat

1,13,159

West Bengal

Darjiling

1,08,830

West Bengal

Koch Bihar

1,03,008

West Bengal

Bangaon

1,02,163

West Bengal

Chakdaha

1,01,320

West Bengal

Jalpaiguri

1,00,348

West Bengal

Contai

77,513

West Bengal

Katwa

77,255

103

Population 10,67,369

42

1,95,79,529

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

State

City

Population

State

West Bengal

Jangipur

74,458

West Bengal

Dhulian

72,850

West Bengal

Bolpur

65,693

West Bengal

Bishnupur

61,947

West Bengal

Suri

61,806

West Bengal

Kalna

59,155

West Bengal

Gobardanga

57,878

West Bengal

Arambag

56,140

West Bengal

Gangarampur

53,533

West Bengal

Jhargram

53,145

West Bengal

Islampur

52,738

West Bengal

Ghatal

51,582

West Bengal

Rampurhat

50,613

West Bengal

Kandi

50,349

104

City

Population

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Annexure –II Assumptions and justification for physical norms and costs

A. Capital (non-Recurrent) Costs:

Components

Units

1. Planning & Mapping 2. Program Management

No capital cost for GIS mapping etc. State PMU 35 No. of states and UTs City PMU

3. Training & Capacity Building 4. Strengthening Health Services (a) Outreach

No capital cost

(b) U-PHC

upgradation of existing

ANM (bike)

new U-PHC

No. of Units

Justification of physical units

779 Cities with population above 50 thousand (projected for 2011)

23,689 @ 1 ANM per 10,000 urban population, and 10% additional for non-metro cities 746 33% of required PHCs in metros (assumed) and 10% of required PHCs in other cities (assumed) 3,679 Remaining 67% of required PHCs in metros 105

Rates (Rs.)

Justification of costs

Rs. 5 lacs Lump-sum for rent, furniture, computers, stationery, etc. Rs. 5 lacs Lump-sum for rent, furniture, computers, stationery, etc.

Rs. 30,000 Cost of Scooty/moped, based on approximate market cost [Dropped]. This amount to be used for mobility support for outreach Rs. 10 lacs NRHM norm for PHC upgradation

Rs. 75 lacs NRHM norm for new PHC (based on IPHS defined constructed

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Components

Units

No. of Units

Justification of Rates Justification of costs physical units (Rs.) and 90% of area) required PHCs in other cities Total U-PHC 4,425 @ 1 U-PHC per --- --50,000 pop (c) Referral U-CHC 344 @ 1 U-CHC per Rs. 5 As per NRHM norms 2.5 lakh crores population in 66 cities with more than 5 lakhs population; and in 7 metros it is taken per 5 lakh population Strengthening No capital cost on one-time grants to District Hospitals, is that is DH covered under a separate program. (d) Assistance to Govt. Med 150 Approximate no. Rs. 5 lakhs Lump-sum for training Med Coll Coll of govt. med. or research support to Colleges (as per the city where the MCI website) medical college is located (e) IEC/BCC No capital cost The assumption of 746 U-PHCs takes into account 632 Type-III UFWC covering 50,000 population each and some of 565 Type-D UHPs that might be covering 50,000 population (Type-D UHPs cover 25,000 to 50,000 population). Other types of health facilities cover less than 50,000 population and hence have not been accounted for. 5. Regulation & Quality Assurance 6. Community Processes No capital cost 7. Innovative Actions & PPP 8. Monitoring & Evaluation

B. Recurrent Costs: 106

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Components

Units

1. Planning & Mapping

Metros

10lac+ cities

2. Program Management

No. of Units (per year)

Justification of physical units

7 As per projection for 2011, based on 2001 census 27

Rates (per year)

Justification of costs

Rs. 15 lacs

Lump-sum estimate (two-thirds of NRHM norm for district planning)

Rs. 10 lacs

Lump-sum estimate (half of NRHM norm for district planning)

other cities

353

Rs. 5 lacs

Half of large cities (10lac+ population)

cities <1lac

392

Rs. 2 lacs

One-fifth of large cities

Lumpsum

---

6% of NUHM budget

Similar to NRHM norm for program management costs

Rs. 5 lacs

Approximate workshop cost in metros (based on experience under NRHM)

27

Rs. 3 lacs

Approximate workshop cost in large cities (based on experience under NRHM)

other cities

353

Rs. 1 lac

Approximate workshop cost at district headquarter level (based on experience under NRHM)

cities <1lac

392

Rs. 50,000 Approximate workshop cost at block level (based on experience under NRHM)

---

3. Training & Capacity Building (a) ULBs

Metros

10lac+ cities

7 As per projection for 2011, based on 2001 census

107

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Components

Units

(b) Govt. Health staff8

ANM/ Nurse/ Paramed ic

MO Speciali sts (c) ASHA & CBOs

MAS

ASHA

No. of Units (per year)

Justification of physical units

Rates (per year)

Justification of costs

55,960 @ 500 per metro, 200 per 10lac+ city, 100 per 1-10lac city, and 30 per city with 1lac-50 thousand population)

Rs. 5,000

Approximate training costs under NRHM (as reflected by state PIPs)

27,980 Half of the estimated no. of ANMs

Rs. 10,000 Twice that of approximate training costs under NRHM (as Rs. 10,000 reflected by state PIPs)

5,596 One-tenth of the estimated no. of ANMs 1,54,882 Per 100 slum households (per 500 slum population) 38,720 Per 400 slum households (per 2000 slum population)

Rs. 10,000 Similar to training norm for ASHA under NRHM Rs. 10,000 Similar to training norm for ASHA under NRHM

The training load of government health staff is almost 2½ times the number of new ANMs, 3 times the number of doctors in the proposed UPHCs and 2 times the number of specialists in the proposed new UCHCs. The higher training load accommodates existing staff in various urban health facilities and hospitals and also for re-training/orientation (2-3 times during the 12th Plan period) 4. Strengthening Health Services (a) Outreach (25% Slum population + 10% vulnerable population)

Outreach sessions per ANM in slums9

8,291 As slum/vulnerable population is assumed as 35% of total urban population, the number of ANMs serving slum/vulnerable population is taken as 35% of total

9

Rs. 10,000 Similar to norm for Village Health & Nutrition Day (VHND) under NRHM

These are special outreach sessions in slums, where the ANMs can rope in services of govt or private doctors, pharmacists, lab technicians to organize a more comprehensive health camp in the slums.

108

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Components

Units

No. of Units (per year)

Justification of physical units

Rates (per year)

Justification of costs

ANMs.

(b) U-PHC

(c) Referral

ANM10 (rec. cost)

23,689 One per 10,000 urban population, with 10% additional numbers for nonmetro cities.

Rs. 6,800

Rs. 500 per month in first 2 years and Rs. 600 per month thereafter

ANM (salary cost)

23,689

Rs.1.5 lakhs

Rs.12,500 per month

LHV

4,425 One LHV per UPHC

Rs.1.8 lakhs

Rs.15,000 per month

U-PHC

4,425 One per 50,000 population

Rs. 20 lacs

Operating and maintenance cost, exclusive of ANM/LHV salary and medicines cost. (Details in Annex IV)

untied grants to U-PHC

4,425 One per 50,000 population

Rs. 2.5 lacs

50% more than current untied grants norm for PHCs under NRHM

Drugs & Consuma bles per U-PHC

4,425 One per 50,000 population

Rs.12.5 lakhs per year

Rs.25 per capita per year. As, states are spending around Rs.20 per capita on medicines (as per state budgets), this is short by Rs.25 per capita to meet the WHO norm of Rs.45 per capita (US$ 1 per capita norm).

Rs. 5 lacs

Equal to current untied grants to hospitals (district/sub-division level) under NRHM

U-CHC (untied grants)

344 One U-CHC per 2.5 lakhs urban population for cities above 5 lakhs population. In metro cities, one U-CHC

10

This is for routine outreach that ANMs would undertake (for the entire population and not only for slum population) for ANC/PNC, immunization, etc.

109

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Components

Units

No. of Units (per year)

Justification of physical units

Rates (per year)

Justification of costs

Rs.5 per capita

Half of NRHM norm of Rs.10 per capita for IEC/BCC (based on NCMH estimates)

Rs.50 lacs

Lump-sum grants for constituting, training and operationalising a Quality Assurance Committee and conducting medical audits at city level

per 5 lakh population (d) Med College support

No recurrent costs

(e) IEC/BCC

Urban Populati on

5. Regulation & Quality Assurance

Metros

6. Community Processes

10lac+ cities

7 As per projection for 2011, based on 2001 27 census

Rs.20 lacs

1 lac+ cities

353

Rs.10 lacs

cities <1 lac

392

Rs.1 lac

MAS

ASHA

7. Innovative

22.13 Projected population crores for 2011 for cities with population more than 50,000 (based on 2001 census)

1,54,882 Per 100 slum households (per 500 slum population)

38,720 Per 400 slum households (per 2000 slum population)

Rs.5,000

Matching grants – half of untied grants to Village Health & Sanitation Committee (VHSC) under NRHM (other half to be contributed by MAS members)

Rs.24,000

Maximum Rs.2000 per month per ASHA (similar to estimates for remuneration of ASHA under NRHM)

NGO support per slum pop

7.74 Slum population crores estimated as 30% of urban population + additional 10% vulnerable population

Rs.20 per capita

Estimate for community level activities, converted to per capita from norms for FNGOs under MNGO scheme (under RCH-II)

Populati

22.13 Projected population

Rs.10 per

Similar to norm for

110

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Components

Units

actions/PPP

on

No. of Units (per year)

Justification of physical units

crores for 2011 for cities with population more than 50,000 (based on 2001 census)

Rates (per year)

Justification of costs

capita

M&E and research studies under NRHM

8. Monitoring & Evaluation (a) Health Survey/Con. Eval

metros Other cities

(b) Research Grant

(d) Community Audits

11 12

Rs.20 lacs

772 Non-metro cities above 50,000 population

Rs.10 lacs

High Focus states11

11

Rs.30 lacs

Metro cities

7

Rs.30 lacs

NE12 & UTs

14

Rs.10 lacs

Other states

12

Rs.20 lacs

metros

7

Rs.10 lacs

Other cities (e) CRM/3rdparty Evaluation

7

States/ UTs

772 Non-metro cities above 50,000 population 35

Rs.1 lac

Rs.5 lacs

8 EAG states and J&K, HP, Assam 7 smaller NE states (minus Assam)

111

Lump-sum grants

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Annexure –III

Financing pattern of U-PHCs The broad financing pattern of U-PHCs at present and as per revised norms would be as follows: Annual funds requirement for Urban Primary Health Centers Sl. No.

Item

AS PER EXISTING NORMS

AS PER REVISED NORMS

Difference between current

&

suggested norms (Rs.) for one SC

A

Capital/Nonrecurring

1

PHC building

2

Staff Quarters

3

Equipment (As per IPHS Standards) Furniture (As per IPHS Standards) Sub-total

4

B

Recurring

1

Staff

Norms

Cost (Rs.)

Norms

Costs (Rs)

4000 sft @ Rs.600/ sft. 2 1 for MO @ 1200 sft

24,00,000

3000 sft @ Rs.1000/ sft.

30,00,000

7,20,000

1200 sft for MO and 800 sq ft for nurses X 3 , and 600 sq ft for class IV staff @ Rs.1000/sft

42,00,000

1 kit each per district

41,500

31,61,500

1,00,000

lumpsum

2,00,000

lumpsum

75,00,000

Medical Officer

1

3,15,225

1+1(AYUSH)

5,40,000

25,000, 20,000

Pharmacist

1

1,53,720

(on contract) 1

1,92,000

16,000

Staff Nurse

1

1,53,720

5,76,000

16,000

112

3

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Health Worker (F)/ANM

1

1,36,260

Health Educator

1

1,53,720

0

Health Assistant (Male)

1

1,71,180

0

Health Assistant (F)/LHV Public Health Nurse practitioner

1

1,71,180

0

-

UDC/Computer clerk LDC

1

(on contract)

-

1,18,800

1

-

1

91,330

1

1,08,000

9,000

Laboratory Technician

1

1,18,800

1

1,20,000

10,000

Driver

1

79,806

0

-

Class IV

4

2,77,320

(on contract)

-

15

19,41,061

9

Sub-total salaries 2

3 4

-

for

Drugs ( As per IPHS norms and standards) Travel Allowance

Under RCH

For contractual Class IV.

None

9,025

Rs.75/ visit -

Pharmacist

3,00,000

12 visits/mth X 2 persons Rs.3500 +

28,800 60,000

Rs.1500/mth.

5

Telephone

None

-

Rs.1000/ mth

6

For hiring transport in emergency.

None

-

Rs.300/case 80 cases

7

Other expenses

no norms

-

Rs.2000/mth

Sub-total

15,36,000

19,50,086

113

12,000 X

24,000

24,000 19,84,800

No. L 1907/1/2008-UH Government of India Ministry of Health & Family Welfare Department of Health & Family Welfare

Apart from this, additional contractual staff in the form of Public Health Manager (@ Rs.25,000 pm) and IEC/BCC (@ Rs. 20,000 pm) coordinator, will be required. This will cost additional Rs.5,40,000 per year, taking the total Recurrent Cost projected for U-PHC to Rs.17,66,470. This is rounded off to Rs.20 lakhs per U-PHC per year. Note: The provision of ANM (@ approx. 3 ANMs per U-PHC + 1 LHV per U-PHC), and that for medicines, consumables and blood products (@ Rs.25 per capita per year) has been shown separately as a different budget head, and therefore not included in the UPHC cost estimates.

114