urban health problems & nuhm

8/14/2019 URBAN HEALTH PROBLEMS & NUHM

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URBAN HEALTH PROBLEMS

&

URBAN HEALTH MISSION


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Urbanization: Trends and

Patterns Movement of people from rural to urban areas

with population growth equating to urbanmigration

A double edged sword On one hand- Provides people with varied opportunities

and scope for economic development

On the other- Exposes community to new threats

Unplanned urban growth is associated with Environmental degradation

Population demands that go beyond the environmentalservice capacity, such as drinking water, sanitation, andwaste disposal and treatment

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Patterns-2 286 million people in India live in urban areas (around 28% ofthe population)* The proportion of urban population in India is increasing

consistently over the years

From 11% in 1901 to 26% in 1991 and 28% in 2001

Estimated to increase to 357 million in 2011 and to 432 millionin 2021*

After independence

3 times growth - Total population 5 times growth - Urban population*

* Census of India 20014


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Patterns-3 4.26 crore people live in slums

A large number of slums are not notified*- around

50%

Urban growth has led to rapid increase in the numberof urban poor

In-migration and a floating population has worsenedthe situation

5* NSSO Report No. 486


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Factors Affecting Health in

Slums* Economic conditions

Social conditions

Living environment

Access and use of public health care services

Hidden/Unlisted slums

Rapid mobility

6* Agarwal S, Satyavada A, Kaushik S, Kumar R. Urbanization, Urban Poverty and Health of theUrban Poor: Status Challen es and the Wa Forward. Demo ra h India. 200 6 1 : 121-1


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Migration-causes

Increased family size-limited agricultural property

-Land use Pattern

-Irrigation facilities

Better income prospects

Better educational facilities

Better Life style

Basic amenities health, transport,water, electricity. Victims of natural/manmade calamities-Refugees

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Migration-consequences

Overcrowding

Mushrooming of slums

Unemployment

Poverty

Physical & mental stress

Family structure-Nuclear families-Single males

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Urban Vs Rural health

Is urban health better than rural health?

Almost all health indicators are better for urban when comparedto rural

When the urban slums are taken many are worser than rural !!!

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Growth of Slums

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61.8

Sour ce: Annu al Report 2006-07, MoHUPA

The Urban ettingSlum Populat ion as %age of total urban pop ulat ion is given in parenthesis


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Source: Regis t rar General of India

12.65

19.86

23.43

20.0719.44

9.70

15.20

17.24

12.82

11.65

1.95

4.666.19

7.25 7.89

The Urban etting


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Marriage & Fertility Indicators of

Urban Poor in India: NFHS 3

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Indicators Urban

Poor

Urban

Non

poor

Overall

Urban

Overall

Rural

All

India

Urban

Poor

NFHS 2

Women age 20-24 married by age 18

years (%) 51.5 21.2 28.1 52.5 44.5 63.9

Women age 20-24 who became

mothers before age 18 (%)25.9 8.3 12.3 26.3 21.7 39.0

Total fertility rate (children per

woman)2.8 1.8 2.1 3.0 2.7 3.8

Higher order births (3+ births) (%) 28.6 11.4 16.3 28.1 25.1 29.5

Birth Interval (median number of

months between current and

previous birth)

29.0 33.0 32.0 30.8 31.1 31.0


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Maternal Health Indicators of Urban

Poor in India: NFHS 3

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Indicators UrbanPoor

UrbanNon

PoorOverall

UrbanOverall

RuralAll

IndiaUrban

PoorNFHS 2

Mothers who had at least 3 antenatal

care visits (%) 54.3 83.1 74.7 43.7 52.0 49.6Mothers who consumed IFA for 90

days or more (%) 18.5 41.8 34.8 18.8 23.1 47.0Mothers who received tetanus toxoid

vaccines (minimum of 2) (%) 75.8 90.7 86.4 72.6 76.3 70.0Mothers who received complete

ANC (%) 11.0 29.5 23.7 10.2 15.0 19.7Births in health facilities (%) 44.0 78.5 67.4 28.9 38.6 43.5Births assisted by a doctor/nurse

/LHV/ANM/other health personnel (%) 50.7 84.2 73.4 37.4 46.6 53.3Women age 15-49 with anaemia (%) 58.8 48.5 50.9 57.4 55.3 54.7

The statistics for urban poormuch lesser than urban

non-poor and comparable torural population


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Child Survival Indicators of Urban


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Indicators UrbanPoor UrbanNon

PoorOverallUrban OverallRural AllIndia UrbanPoor

NFHS 2Children completely immunized (% 39.9 65.4 57.6 38.6 43.5 40.3Children under 5 years breastfed within

one hour of birth (%) 27.3 31.5 30.3 22.4 24.5 17.7Children age 0-5 months exclusively

breastfed (%) 44.7 38.6 40.7 48.6 46.4 44.3Children age 6-9 months receiving solid or

semi-solid food and breast milk (%) 56.2 66.1 63.1 54.7 56.7 52.7Children who are stunted (%) 54.2 33.2 39.6 50.7 48.0 52.5Children who are underweight (%) 47.1 26.2 32.7 45.6 42.5 48.0Children with anaemia (%) 71.4 59.0 63.0 71.5 69.5 79.0Neonatal Mortality 34.9 25.5 28.7 42.5 39.0 45.5Infant Mortality 54.6 35.5 41.7 62.1 57.0 69.8Under-5 Mortality 72.7 41.8 51.9 81.9 74.3 102.0


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Poor Child Health among Urban Poor


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Family Planning Indicators of Urban


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UrbanNon

PoorOverall

UrbanOverall

RuralAll

IndiaUrban

poorNFHS 2

Any modern method (%)

48.7 58.0

55.8

45.3

48.5

43.0

Spacing method (%) 7.6 19.8 16.9 7.2 10.1 4.6Permanent sterilization method rate

(%) 41.1 38.2 38.9 38.1 38.3 38.4Total unmet need (%) 14.1 8.3 10.0 14.6 13.2 16.7Unmet need for spacing (%) 5.7 4.1 4.5 6.9 6.2 8.5Unmet need for limiting (%) 8.4 4.2 5.2 7.2 6.6 8.2


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Environmental Conditions, Infectious

Diseases and access to Health Care in

Urban Poor : NFHS 3

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UrbanNon

PoorOverall

UrbanOverall

RuralAll

IndiaUrban

poorNFHS 2

Households with access to piped water supply

at home (%) 18.5 62.2 50.7 11.8 24.5 13.2Households accessing public tap / hand pump

for drinking water (%) 72.4 30.7 41.6 69.3 42.0 72.4Household using a sanitary facility for the

disposal of excreta (flush / pit toilet) (%) 47.2 95.9 83.2 26.0 44.7 40.5Prevalence of medically treated TB (per

100,000 persons) 461 258 307 469 418 535

Women (age 15-49) who have heard of AIDS

63.4 89.1

83.2

50.0

60.9

42.1

Prevalence of HIV among adult population

(age 15-49) 0.47 0.31 0.35 0.25 0.28 naChildren under age six living in enumeration

areas covered by an AWC (%) 53.3 49.1 50.4 91.6 81.1 naWomen who had at least one contact with a

health worker in the last three months (%)10.1 5.8 6.8 14.2 11.8 16.7


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Double Burden of Diseases

Overcrowding and related health issues

Rapid growth of urban centers has led tosubstandard housing on marginal land and

overcrowding Outbreaks of diseases transmitted through

respiratory and faeco-oral route due to increased

population density

It exacerbates health risks related to insufficient andpoor water supply and poor sanitation systems

Lack of privacy leading to depression, anxiety,

stress etc 19


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Air pollution and its consequences

Due to increase in the numbers of motorized vehiclesand industries in the cities of the developing world

Problems of noise and air pollution Air pollution can affect our health in many ways with

both short-term and long-term effects

Short-term air pollution can aggravate medical

conditions like asthma and emphysema Long-term health effects can include chronic

respiratory disease, lung cancer, heart disease, andeven damage to other vital organs

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Water and sanitation problems

Due to increasing urbanization coupled withexisting un-sustainability factors and

conventional urban water management Nealy 1.1 billion people worldwide who do not

have access to clean drinking water and 2.6billion people i.e. over 400 million people, lack

even a simple improved latrine Can lead to increased episodes of diarrhea and

economic burden

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Upsurge of Non-communicable diseases

The rising trends of non-communicable diseasesare a consequence of the demographic and

dietary transition Decreases in activity combined with access to

processed food high in calories and low innutrition have played a key role

Urbanization is an example of social change thathas a remarkable effect on diet in thedeveloping world

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Traditional staples are often more expensive in urbanareas than in rural areas, whereas processed foods areless expensive

This favors the consumption of new processed foods

This places the urban population at increasedrisk of NCDs

In India, chronic diseases are estimated to account for53% of all deaths and 44% of disability-adjusted life-years (DALYs) lost in 2005

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Health challenges in urban India(Cont..)Inadequate public health infrastructure in urban slums

Health programs- The scheme on Urban Family Welfare Centers (UFWCs) 1950.

Urban Revamping Scheme (1983)-

India Population Project (IPP) VIII (19932003) Nationwide RCH I (19972003) Project.

Current status- 1,083 Urban Family Welfare Centers (UFWCs)

871 Urban Health Posts(UHP) - many of which are run byhospitals.

It means 1UFWC/UHP per 148,413 urban population.


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Urban Health Programmes of the

Government:

The scheme on Urban Family Welfare Centers (UFWCs) has been functioningsince 1950 to provide family welfare services in urban areas through existinghealth institutions and newly established clinics.

The urban Revamping Scheme (1983), where the Health posts have been

established to provide outreach services, Primary health care, MCH andFamily welfare services in urban slums. Health posts and post-partum centersin urban areas have by and large become hospital based programs which donot cater effectively to slum populations.

The World Bank assisted the Nation wide RCH I Project, wherein sub-projects

were implemented in seven cities, which included local capacity building foroptimizing the use of available resources, strengthening infrastructure andimplementing innovative approaches.


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National Urban Health Mission

Goal :to improve the health status of the urban poor particularlythe slum dwellers and other disadvantaged sections, byfacilitating equitable access to quality health care through an

effective public health system, partnerships, community basedrisk pooling and insurance mechanism with the activeinvolvement of the urban local bodies.


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Scope, Coverage and Duration of the

Mission The Mission would be covering 430 cities, i.e. all cities with

population one lakh and above and all the state capitals inPhase I.

In the first year 100 cities would be accorded priority forinitiating the mission.

All District Head- Quarter towns with population less than onelakh will be covered under Phase II of the Mission if NRHM

does not cover it in the interim. The cities with population less than one lakh would be covered

under NRHM and norms of service delivery as proposed underthe NUHM would be made applicable in such cities.


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Mission For targeting the urban poor the NUHM would focus on the people

living in listed and unlisted slums.

The following definition a combination of the description (a) used by

Census 2001 and (b) `National Slum Policy (Draft) to be used for

identification of Slums.

Any compact habitation of at least 300 people or about 60-70

households of poorly built congested tenaments, unhygienic

environments, usually without adequate infrastructure and lacking in

proper sanitary and drinking water facilities in these townsirrespective of the fact as to whether such slums have been notified or

not as Slum by State/Local Government and Union Territory (UT)

administration under any Act, recognized or not, are legal or not,

would be covered under NUHM.


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Mission The duration of the Mission would be for the remaining period of the 11th

Plan (2008-2012).

While the initial focus would be on the urban slums it is envisioned that asthe capacity at city level grows the scope may be broadened based on Mid-

Term Appraisal to cover the entire urban poor population.


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Core Strategies: (i) Improving the efficiency ofpublic health system in the cities by strengthening,

revamping and rationalizing urban primary health structure

Provision for a need based contractual human resource,equipments and drugs & provision of RKS.

The provision of health care delivery with the help of outreach

sessions in the slums. On the basis of the GIS map the referrals would also be clearly

defined and communicated to the community.

Rationalization of the existing public health care facilities and

human resources


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(ii) Partnership with non-government providers

for filling up of the health delivery gaps:

A large number of urban slum clusters do not have physicalaccess to public health facilities whereas there are nongovernment providers being accessed by the urban poor.

Specialized care, diagnostics and referral transport isprominently available in the non government sector.

To leverage the existing non government providers to improveaccess to curative care.


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(iii) Promotion of access to improved health care

at household level through community based groups

: Mahila Arogya Samittees In view of the usefulness of such women led community/ self

help groups; it is proposed to promote MAS for enhancedcommunity participation and empowerment

The USHA may provide the leadership and promote the MAS. The USHA may be preferably co-located with the Anganwadi

Centres located in the slums for optimisation of healthoutcomes.

Each of the MAS may have 5-20 members with an elected

Chairperson/ Secretary and other representative like Treasurer. The mobilization of the MAS may also be facilitated by a

contracted agency/NGO, working along with the USHA.


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(iv) Strengthening public health

through preventive and promotive

action A major focus of the Mission.

Urban Poor face greater environmental health risks due to poorsanitation, lack of safe drinking water, poor drainage, high densityof population etc. the urban local bodies for improved water and

environmental sanitation, nutrition and Resources for public health action would be provided as per city

specific need.

(v) Increased access to health care through risk pooling

and community health insurance models NUHM also proposes to promote Community based Health

Insurance models to meet costs arising out of hospitalization andcritical illnesses.


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(vi) Capacity building of

stakeholders

NUHM proposes to build managerial, technical and public healthcompetencies among the health care providers and the ULBsthrough capacity building, monetary and non monetaryincentives, and managerial support.

(vii) Prioritizing the most vulnerable amongst the poor

Under the NUHM special emphasis would be on improving the

reach of health care services to the vulnerable among the urbanpoor, falling in the category of destitute, beggars, streetchildren, construction workers, coolies, rickshaw pullers, sexworkers, street vendors and other such migrant workers.


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Community Level

Urban Social Health Activist (USHA)

Each slum would have a well defined grass root level area covering 1000-2,500beneficiaries, 200-500 households

USHA would remain in charge of each area and serve as an effective anddemandgenerating link between the health facility and the urban slum

populations. The USHA would preferably be a woman resident of the slum

married/widowed/ divorced, preferably in the age group of 25 to 45 years withformal education up to class eight, chosen through a community drivenprocess involving ULB Counsellors, SHGs, Anganwadi, ANMs.

The states may also consider of Community Organiser for 10 USHA for moreeffective coordination and mentoring, preferably located at the mentoringNGO. He along with the ANM may be designated as the mentoring andmanagement team at the slum level for the USHAs.


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Mahila Arogya Samiti (MAS)

Act as community based peer education group, involved incommunity monitoring and referral. The MAS may consist of20-100 households (HH) with an elected Chairperson and aTreasurer, supported by an USHA.

ANMProviding preventive and promotive healthcare servicesat the household level through regular visits and outreachsessions. Four ANMs will be posted in each UHC.

Outreach Medical Camps Once in a month the MO would

accompany the ANMs to the outreach sessions. It will includeOPD (consultation), basic lab investigations (usingmobile/disposable kits), and drug dispensing, apart fromcounselling..


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Primary Urban Health Centre

Functional for a population of around approximately50,000, the PUHC may be located preferably within aslum or a half km radius, catering to a slum population of

approximately 20000-30000, with provision for eveningOPD also.

The cities, based upon the local situation may establish aUHC for 75,000 for areas with very high density and canalso establish one for around 5000-10,000, slumpopulation for isolated slum clusters.

It act as first point for curative healthcare.


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Community Risk Pooling and Health

Insurance

NUHM recognizes that state/city specific, community oriented,innovative and flexible insurance policies need to be developed.

The private insurance companies may be encouraged to bring ininnovative insurance products.

A risk pooling system where the Centre, States and the localcommunity would be partners may be set.

This would be done by resource sharing, facility empanelmentand regulation of adherence to quality standards, establishing

standard treatment protocols and costs, apart from encouragingvarious premium financing mechanisms.


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Community Risk Pooling Mechanism

NUHM encourages setting up of MAS, to act as the unit of user groupas well as for designing and managing a need-based and affordablehealth insurance scheme.

The sources of funds for the savings account created by the MAS will

primarily include the savings by the women constituting the MAS, theone-time Seed Money, and annual Performance Grant provided underNUHM.

The money may be spent on the members familys unforeseen healthexpenditure needs and other activities like group meetings,

mobilisation for health camps, etc. The members of the MAS would be encouraged to pool an agreed

amount (say Rs.10- 20 or more - per family, per month). The amountwill be deposited in a savings bank account, managed by the MAS.


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Community Risk Pooling under NUHM

Mahila Arogya

Samiti(MAS)

Slum Women

Seed Money and

Performance Grant

Interest on savings

Interest on loans

Smallloans

Savings


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Budgetary Provisions and

Norms The NUHM would commence as a 100% centrally sponsored Scheme in the firstyear of its implementation during the XIth Plan period.

However, for the sustainability of the Mission from the second year, onward thesharing mechanism between the Central Government State/Urban local bodywould be as follows:

Funds / Resource required *

An estimated allocation of approximately Rs.8600 crores from the CentralGovernment for a period of 4 years (2008-2012) to the NUHM at the central, stateand city level may be required to enable adequate focus on urban health.


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Monitoring and Evaluation

Mechanism

The M&E framework would make use of the IT enabled services for informationcollection and its quick transfer. An appropriate programme based on the needwould be developed.

The NUHM would provide support for developing web based HMIS component

by making provision for developing need based software, provision forhardware procurement, software development, installation, training andmaintenance at PUHC/ City/ State / National level

The Monitoring and evaluation framework would be based on triangulisation ofinformation. The three components would be

(a) Community Based Monitoring

(b) A web based Urban HMIS for reporting and feedback

(c) external evaluations.


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Take Home Messages-4

The possible solutions can be

Ensuring adequate and reliable health related data

Inter-sectoral co-ordination

Sharing of successful experiences and bestpractice models

Application of PURA models

Reducing the financial burden of health care throughimproved financing techniques

Strengthening public private partnerships

Strengthening public health care facilities

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A lot of possibilities are

there in slums.So we cant ignore it.

urban health problems & nuhm

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