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City Health Plans

Strengthening the capacity of the urban health management system 

Purpose: To provide a ready reckoner for developing the city-specific health plan with operational guidance for making health services available to the urban poor population by optimal use of available resources.

Audience:

  • Chairman-District Health Society (DHS)
  • Chief Medical and Health Officers (CMHO/CDMO/CMO)
  • Chairman-Urban Local Body (ULB)
  • Nodal Officers Urban Health, District Program Managers (DPM)
  • Urban Health Coordinators/City Program Managers
  • Representatives from Integrated Child Development Services (ICDS)
  • Education, Medical Colleges
  • Representatives of relevant Non-Government Organizations (NGO)
  • Federation of Obstetrics and Gynaecological Societies of India (FOGSI)/ Indian Medical Association (IMA)

Background: The National Urban Health Mission (NUHM) aims 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 healthcare through a revamped public health system, backed by demand aggregation through community based mechanism with the active involvement of the urban local bodies and engaging with private sectors for filling the gaps at the service provision level.

NUHM envisaged that cities would develop an integrated urban health plan covering the city-specific issues and ensuring that stakeholders from various departments are involved in the planning process. This will also help reprioritize and appropriate resource allocation under National Health Mission (NHM) to NUHM and facilitate a seamless flow between the Program Implementation Plan (PIP) and operational plans. The key to this is comprehensive planning, which will lead to impactful convergence and coordination between all stakeholders such as ICDS, ULB, National Urban Livelihood Mission (NULM)/ District Urban Development Agency (DUDA), Education etc.

However, the absence of comprehensive city specific health plan has caused a delay in reaching out to the desired urban population as envisaged under NUHM. This has resulted in low demand and underutilization of resources for an underserved population. It also contributed to the very poor participation of the private sector, which despite having a significant presence doesn’t supplement the efforts of the public health care delivery system.

Evidence of Effectiveness

The city health plan exercise led to the optimal utilization of resources in Health of the Urban Poor (HUP) program. For e.g. in Lucknow and Kanpur as part of the city health plan, a key gap identified was the lack of event space, which often disrupted the routine of health outreach camps. This gap could be easily mitigated as the city health plan identified potential resources also. Thus in this example, for instance, ULBs provided their space for outreach camps as well as for running Urban Primary Health Centres (UPHCs).

At the time of Urban Health Initiative (UHI) and HUP, city health plans were initiated for 131 cities (refer city health plan Aligarh). Based on these plans, a comprehensive state plan was developed for NUHM for approval from the Government of India (GoI). The approval was received at the juncture of program closures. But, the state itself implemented activities identified in the city health plan, for e.g. infrastructure establishment [UPHCs, Urban Community Health Centre (UCHCs)] for service delivery.

Guidance on Preparing a Comprehensive City Health Plan

A city health plan is an integral part of the NUHM framework, which is a comprehensive approach to urban health planning that optimizes resources and reaches out to the urban poor. This requires an understanding of the distribution of population, health indicators, health services, water supply, sanitation, waste disposal system, migration (in & out) and other city-specific issues. In order to do the same, the following pathway can be taken:

Listing and Mapping
  • Identify listed and unlisted slums using existing resources such as Municipal Corporation, Health department, ICDS, National Polio Surveillance Program, UNICEF etc.
  • Ratify and update the slum list identified above through stakeholder consultation.
  • Identify the health providers accessed by the slum population (this can include public, private health facilities) Identify the list of community structures such as Anganwadi Center (AWC) available under DUDA, NULM and ICDS in the city.
  • Plot or superimpose all of the above on the available base city map obtained from potential sources such as Municipal Corporation, National Urban Renewal Mission (NURM), Rajiv Awas Yojana (RAY), NUHM etc.
Rapid Assessment

Conduct rapid assessment of all identified public health facilities (DQAC structured schedule  may be referred and CMHO/CMO/CDMO has to ensure the submission of filled in information schedule of public health facilities).

Assessing Available Schemes & Programs

Assess all available schemes and programs related to urban health and its determinants at the city level.

Stakeholder Analysis

Conduct city stakeholder analysis to understand the current pattern of city administration related to delivery of health services and identify potential areas of convergence.

Identification of Needs

Identify the health needs of the city based on available information (National Family Health Survey (NFHS), District Level Household and Facility Survey (DLHS), Health Management Information System (HMIS), Health Expenditure Pattern etc.)

Stakeholder Consultation

Conduct a stakeholder consultation among the city health officials and frontline health workers to finalize the essential health package, and develop city-specific health plan.

Structuring the City Health Plan

Structure the activity based city health plan within the outline of the existing district NHM PIP budget

Monitoring Progress

The city plan is ready and will give guidance for implementation. It is a reference point for monitoring the progress of the health of the city.

A city health plan takes into account the needs of the most vulnerable population in the city. It matches these needs with the existing resources and lays down a clear action plan with milestones, timelines and accountability assigned to various stakeholders involved.

The city coordination committee, convened by the CMHO/CMO/CDMO and constituted by all stakeholders, oversees the implementation and monitoring of the progress of the city health plan. The committee should have regular contact with the organizations or individuals leading each strategy to make sure that the activities are implemented as designed and any barriers in the way get swiftly addressed. The progress of the city health plan is reviewed quarterly. Based on this, the committee can improvise the plan for the next quarter.

Roles and Responsibilities towards Development of a Comprehensive City Health Plan

Role
Responsibility
Chairman, District Health Society
  • Facilitate the process of development of city health plan by ensuring participation of key stakeholders
  • Periodic review of development of city health plan
  • Ratify and finalize the city health plans and submit to state health society
CMHO/CDMO/CMO
  • Facilitate the process of development of city health plans by ensuring participation of key stakeholders
  • Convene Stakeholder Consultations and develop a mutually agreeable city health plan
  • Mandate field assessment forms to be duly filled in and returned to CMHO/CDMO/CMO
  • Identify the areas of support for technical assistance from development partners
  • Structure the activity based city health plan within the outline of the existing district NUHM PIP budget template
  • Ratify and finalize the city health plans and submit to district health society
Nodal NUHM/NGO/NGI Partner
  • List and map resources including slum list, healthcare provider list, base map etc.
  • Coordinate to get information through rapid assessment schedule from all the identified public health facilities
  • Do gap analysis of existing schemes and programs, and identify potential areas of convergence.
  • Conduct a stakeholder consultation among the city health officials and frontline health workers to finalize the essential health package, and develop city specific health plan.
  • Facilitate the implementation of the approved city health plans.
DPM/Urban Health Coordinator
  • Timely collection of data from various stakeholders.
  • Convene and document the consultation process.
  • Assist the Nodal NUHM in completing the city health plan.
Health Facility in-Charge
  • Consolidate existing resources such as record of listed and unlisted slums; private health facilities; accredited private health facilities; AWCs and community structures available under NURM, NULM and ICDS in the city.
  • Guide ANM for the collection of primary data such as updating the Mother and Child Tracking System (MCTS) register for migrants.

Monitoring Benchmarks for Developing City Health Plan

The Chairman District Health Society (DHS) with assistance from CMHO/CDMO/CMO can regularly monitor the following indicators:

  • City Health Plan completed and submitted on time
  • Urban city coordination committee formed meetings
  • Stakeholder consultation workshops organized
  • Draft city health prepared and submitted to DHS for approval
  • Approval from DHS and submission to State Health Society

Cost Elements

The following line items in the NUHM PIP can be used for requesting for City Health Planning:

Cost Elements FMR Code Source
Planning & Mapping including Baseline/ end line surveys P.1 NHM PIP, Part II NUHM
Administrative expenses (including Review meetings, workshops,  etc.) P.2.2.3 NHM PIP, Part II NUHM
Maternal Health A.1 NHM PIP, Part I RMNCH+A
Child Health A.2 NHM PIP, Part I RMNCH+A
Family Planning A.3 NHM PIP, Part I RMNCH+A

This table is indicative and illustrates the manner in which cost elements are provisioned in a government PIP, thus giving guidance to the audience on where to look for elements related to a particular task, such as developing city health plans.

Sustainability

A city health plan can be a very productive tool as it provides practical guidance on how to make a city health plan and refer it for monitoring the work plan (i.e. is the city health plan working) and thereby assess the PIP consumption rate. Thus, it can lay the foundation and make the implementation smooth and thus sustain its shelf life.

Disclaimer: This document is based on the learnings collated from Urban Health Initiative, Health of the Urban Poor (supported by USAID) and Expanded Access and Quality (EAQ) to broaden method choice in Uttar Pradesh. This document is not prescriptive in nature but provides overall guidance of how this particular aspect was dealt with in these projects for possible adoption and adaptation.

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