National Urban Health Mission (NUHM): A Framework for Urban Health Reform in India

India’s cities are growing faster than ever. By 2030, nearly half the country’s population is expected to live in urban areas, and a significant share of that growth is concentrated in slums and informal settlements. Yet for decades, public health policy treated urban areas as if they were already well-served simply because hospitals and private clinics were physically nearby. The reality on the ground told a different story. The launch of the National Urban Health Mission (NUHM) in May 2013 was the government’s formal acknowledgment that the urban poor needed a dedicated, structured response, not just an extension of rural programmes.

Why NUHM was needed 🔗

Before NUHM, urban health was a fragmented affair. Municipal corporations, state health departments, ESI hospitals, and private providers all operated in silos, while slum dwellers were left to navigate this maze on their own. The result was high out-of-pocket expenditure, low immunisation coverage, and worse maternal health indicators among the urban poor than even some rural populations.

NUHM was approved as a sub-mission of the National Health Mission to specifically address these gaps. According to the Ministry of Health and Family Welfare, every Municipal Corporation, Municipality, Notified Area Committee, and Town Panchayat became a unit of planning with its own norms for setting up health facilities. The mission currently covers cities with a population above 50,000, which translates to over 1,000 cities across the country.

Focus areas: who NUHM is built for 🔗

NUHM is unambiguous about its target population. It is not a generic urban scheme; it is designed for those who fall through the cracks of the formal economy and the formal healthcare system.

Slum populations 🔗

The primary focus is on residents of both listed and unlisted slums. The distinction matters because, as the Implementation Framework points out, many slums are not officially notified, which historically meant their residents were invisible to government schemes. NUHM mandates vulnerability mapping so that even unlisted clusters receive attention. One Urban Primary Health Centre (UPHC) is planned for every 50,000 residents, with one Urban Community Health Centre (UCHC) for every 250,000 to 500,000 people depending on city size.

Other vulnerable groups 🔗

Slums are not the only concern. The framework specifically calls out construction workers, rag pickers, sex workers, brick kiln workers, rickshaw pullers, street children, homeless individuals, and pavement dwellers. These groups often lack documentation, fixed addresses, or stable employment, making them invisible to standard service delivery. NUHM mandates outreach camps and mobile health units to reach them where they live and work. As detailed in the Maharashtra NHM portal, special outreach camps with a budget of around Rs. 10,000 per camp are conducted to provide specialist services, diagnostics, and medicines to these populations.

Public health determinants: sanitation, water, and food safety 🔗

NUHM recognises that clinical care alone cannot fix urban health. A child treated for diarrhoea at a UPHC will return next month if the family still drinks contaminated water. The framework therefore emphasises coordination with municipal bodies on clean drinking water, solid waste management, vector control, and street food safety. This is why NUHM works in convergence with schemes like the Swachh Bharat Mission and the National Urban Livelihood Mission, treating sanitation and hygiene as integral to health outcomes rather than as a separate sector’s responsibility.

Implementation strategies 🔗

What makes NUHM distinctive is not just what it does, but how it is designed to be done. Three strategies sit at the core of its implementation logic.

Participatory health planning 🔗

NUHM rejects top-down planning. Each city is expected to prepare its own City Health Plan based on a baseline assessment of existing infrastructure, service gaps, and disease patterns. The reasoning is straightforward: a port city like Visakhapatnam has very different health needs from a textile town in Punjab. Local planning units, supported by State and City Programme Management Units, build plans that are then consolidated into District Health Action Plans. This bottom-up approach is meant to ensure that resources actually match local realities rather than national averages.

Community involvement through ASHAs and MAS 🔗

Community involvement is operationalised through two structures. The first is the urban Accredited Social Health Activist (ASHA), a female frontline worker who lives in the slum she serves and covers roughly 1,000 to 2,500 people, or 200 to 500 households. She is the bridge between the community and the UPHC, helping families access antenatal care, immunisation, and referrals.

The second is the Mahila Arogya Samiti (MAS), a women’s collective formed for every 50 to 100 households. According to the NUHM guidelines, the MAS functions as a community-based peer education group, with the ASHA serving as Member Secretary. Each MAS receives an annual untied grant of Rs. 5,000 to spend on sanitation activities, monthly meetings, or emergency health needs. A study from Chhattisgarh found that MAS collectives are most effective when they have genuine autonomy to act on social determinants of health, not just promote services chosen for them.

Public-private partnerships 🔗

Unlike rural areas where the government is often the only health provider, cities are saturated with private clinics, NGO-run dispensaries, charitable hospitals, and corporate chains. NUHM treats this density as an opportunity. The framework explicitly allows states to contract NGOs or private partners to operate UPHCs, particularly in cities where the public health system is stretched thin. The Asian Development Bank’s tool kit on PPPs in urban primary care documents several arrangements where NGOs run UPHCs at no cost to end users, with the government providing funding and oversight.

States have experimented with different models. Andhra Pradesh launched e-UPHCs that use telemedicine to connect slum dwellers with cardiologists and other specialists. Telangana’s Basti Dawakhana provides free outpatient services in slum clinics. Odisha created ward-level convergence committees with NGO partnerships. Not all these experiments have been equally successful, but they reflect the flexibility NUHM allows in service delivery design.

Governance and financing 🔗

NUHM leverages the existing institutional structures of the NHM rather than creating a parallel bureaucracy. The Mission Steering Group of the NHM also serves as the apex body for NUHM, and Programme Management Units (PMUs) have been established at state, district, and city levels. Funds flow to municipal corporations through State Health Societies based on approved Programme Implementation Plans, typically on a 60:40 Centre-State cost-sharing basis.

By 2021, the mission had supported the operation of more than 5,500 UPHCs, engaged over 77,000 ASHAs, and helped form about 93,600 Mahila Arogya Samitis across the country, according to NHM data. Health human resources grew substantially, with ASHA engagement rising from 41 percent to 87 percent of targets and MAS formation increasing from 22 percent to 86 percent.

Expected outcomes and measurable progress 🔗

NUHM’s outcome targets are framed around access, equity, and governance. The mission aims to reduce infant and maternal mortality in urban areas, lower out-of-pocket expenditure for the urban poor, and ensure equitable access to quality primary health care.

Some of these outcomes have begun to show up in national data. A 2023 review in the Journal of Global Health notes that institutional births in urban government facilities increased from 42.0 percent to 48.3 percent overall, and from 54.0 percent to 62.1 percent for the poorest quintile between 2014 and 2017. Antenatal care coverage rose to 98.0 percent from 92.9 percent, and postnatal care from 84.1 percent to 90.0 percent in the same period. These gains, while modest, reflect a deliberate redirection of services toward the urban poor.

Beyond clinical indicators, NUHM has strengthened governance in less visible ways. It pushed for disaggregated urban health data in the Health Management Information System, established the Mera Aspataal patient feedback platform, and built coordination mechanisms with programmes like the Integrated Disease Surveillance Programme.

Challenges that remain 🔗

Honest assessment is part of good policy analysis. NUHM faces persistent problems: inadequate financing relative to the scale of urban poverty, shortages of medical officers willing to work in slum-area UPHCs, weak coordination between health departments and urban local bodies, and the growing burden of non-communicable diseases like diabetes and hypertension that the original framework did not fully anticipate. Re-emerging vector-borne diseases such as dengue and chikungunya add further pressure on urban systems.

The dual burden of disease, with infectious illnesses among the poor coexisting with lifestyle diseases across all classes, demands that NUHM evolve. The 2023 NUHM Framework refresh and its integration with Ayushman Bharat Health and Wellness Centres are attempts to keep pace.

What do you think? Should NUHM expand its scope to also serve the lower-middle-class urban population that is increasingly squeezed by rising private healthcare costs, or would that dilute its core mandate to serve the poorest? And how can community institutions like Mahila Arogya Samitis be given more real authority over local health priorities rather than functioning largely as service-promotion groups?

References

1. https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=295&lid=158
2. https://nhm.gov.in/images/pdf/NUHM/Implementation_Framework_NUHM.pdf
3. https://nhm.maharashtra.gov.in/en/scheme/national-urban-health-mission-nuhm/
4. https://swachhbharatmission.ddws.gov.in/
5. https://nhm.gov.in/images/pdf/NUHM/Guidelines_for_Asha_and_MAS_in_Urban_Context.pdf
6. https://pmc.ncbi.nlm.nih.gov/articles/PMC11622869/
7. https://www.adb.org/sites/default/files/institutional-document/668741/tool-kit-ppps-urban-primary-health-centers-india.pdf
8. https://nhm.gov.in/New_Update-2021-22/Presentation/PS-MD-Orientation-workshop-26-08-2021/NUHM.pdf
9. https://pmc.ncbi.nlm.nih.gov/articles/PMC9999306/