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ENVIRONMENTAL HEALTH PROJECT
Building Public Sector - NGO Partnerships for Urban RCH
Symposium on Urban RCH31st Annual National Conference of Indian
Association of Preventive & Social MedicineFebruary 29, 2004
Dr Siddharth
Country Representative, USAID-EHP Urban Health Program
ENVIRONMENTAL HEALTH PROJECT
Presentation Outline
Urban Growth and Urban Poverty
Reproductive Child Health Scenario among the Urban Poor
Public Sector Services for the Urban Poor Existing Infrastructure and programs: UFWCs, Health Posts, IPP VIII etc Issues around present RCH services for urban slums
Experiences/ Lessons in Government-NGO Partnerships in IPP VIII and Other Programs
What Value can NGOs Contribute to Urban RCH Programs?
Suggestions and Recommendations
ENVIRONMENTAL HEALTH PROJECT
ENVIRONMENTAL HEALTH PROJECT
Urban Population Growth
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Especially in Their Smaller Cities
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Urban Growth in India
Percent decadal population grow th by residence in India: 1901-2001
-10
0
10
20
30
40
50
Decades
% g
row
th
Urban Rural Total
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Urban Poverty in EAG States
43%
57%
Urban Poor Popualtion in EAG States
Urban Poor Popualtion in Rest of India
Urban Population in EAG States
32%
68%
Urban Population of EAG States
Urban Popualtion in Rest of India
Where Should efforts focus?
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Take Home Messages
• Virtually all growth will be urban in the future
• Growth is fastest in concentrations of urban poor – e.g. slums
(2-3-4-5 syndrome)
• Most growth and population will be in small and medium size cities
• Mega-cities will continue to grow – and have importance beyond their proportion of the urban population
• Urban growth in India has been exponential over the last few decades
• In India, 43% of urban poor reside in the 8 EAG States
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Reproductive and Child Health Conditions among the Urban Poor
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Coverage of Child Health Services in Urban Slums of 6 Municipal Corporations and Rural Areas of Gujarat
State-wide Multi-Indicator Cluster Surveys (MICSs), 1996
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
BCG DPT3 OPV3 Measles All VitaminA
Urban Slums
Rural Areas
Coverage
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0
20
40
60
80
100
120
Neonatal mortality Infant mortality Child mortality
Urban Low Urban Medium Urban High Urban Average Rural Average
Child, Infant and Neonatal Mortality in M.P.
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0
10
20
30
40
50
60
70
80
90
100
Underw eight for age – Below –2 SD Underw eight for age – Below –3 SD
Anthropometric indicator
Per
cent
age
Urban Low Urban Medium Urban High
Urban Average Rural Average
Childhood Under-nutrition in Urban M.P.
NFHS 2 Re-analysis, EHP 2003
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Immunization Coverage by Age 1 among Children 12-23 months
Madhya Pradesh – NFHS 2 Re-analysis, EHP 2003
0
10
20
30
40
50
60
70
80
Completelyimmunized
Received measlesimmunization
left outs from UIP drop outs from UIP
Perc
enta
ge
Urban Low Urban Medium Urban High
Urban Average Rural Average
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0
10
20
30
40
50
60
70
Any Method Female Sterilization Pill/IUD/Condom
Urban Low SLI Urban Medium SLI Urban High SLI
Urban Average Rural Average
Contraceptive Prevalence in Urban M.P.
NFHS 2 Re-analysis, EHP 2003
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0
10
20
30
40
50
60
70
80
90
100
Deliveries at home Deliveries attended by a heathprofessional at home or at a health
facility
Per
cen
tag
e
Urban Low Urban Medium Urban High Urban Average Rural Average
Delivery Related Services in Urban M.P.NFHS 2 Re-analysis, EHP 2003
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Take Home Messages
• Urban averages mask sharp disparities between the rich and poor in urban settings
• By many health indicators, urban poor populations are comparable to nearby rural populations – or worse in many cases
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Issues with Public Sector Urban Health Services
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Urban Health Infrastructure in the Public Sector
UFWCs (1950), Health Posts (under Urban Revamping Sceme1983) :
• 1083 UFWCs & 871 Health Posts, many run from hospitals, not proximal to slums
• With the total urban population of 290 million, (with 1954 UFWCs & HPs), this works out to one UFWC/HP per 148,413 Urban population
PP Centres(1966): 1562 (many closed owing to discontinuation of Central funding)
IPP VIII (1993 to 2003) covered 7 million slum population in 4 mega cities and 94 smaller towns in 4 states
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• Inadequate physical and social access
• Low demand for services among slum dwellers
and weak community linkages
• Poor quality (timing, attitude, atmosphere) of
services
• Insufficient reach to the under-served slums
• Weak monitoring and tracking of coverage
• Low focus on behavior change
• Little emphasis focus on sustainability
• NGOs active in several areas.
Scenario 1: Areas Where Some Public Sector Primary RCH Services Exist
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• 2nd tier hospitals are burdened with primary care
• Large pockets of urban poor left out• Private informal providers are the major
resource• NGOs active in small areas
Scenario 2: Areas where Public Sector RCH services are Not Existing
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Low Utilization of and Access to Public Sector Services
Gujrat State-wide Multi-Indicator Cluster Surveys (MICSs), 1996
Health workers
2.8%
Others4.4%
Private doctors66.7%
Gov. doctors26.1%
Others1.0%
Chemists4.6%
Government doctors12.3%
Private doctors82.1%
Urban Slums Rural Areas
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Cross-cutting Issues
• Weak inter-sectoral linkages with non-health sectors e.g. Dept. of Urban Development
• Insufficient focus on hygiene & sanitation improvement and on other basic services
• Limited experience with and capacity for effective partnerships in diverse settings
• Every city/town is different, hence context appropriate strategies remain vital
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Experiences in Govt. –NGO Partnerships for Urban RCH
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Some Examples of Government- NGO partnership for Urban Health
IPP VIII - A.P./Bangalore: • Link Volunteers & Women's Health Groups promoted
through NGO • Financial incentives to WHGs through revolving funds.• Emphasis on empowering women (NGO supported)• Behaviour counseling (child health, nutrition and
hygiene)• First tier facilities operated by NGOs
IPP VIII - Delhi• First tier facility and maternity services operated by
NGOs
EC Supported UH Program in Guwahati• First and 2nd tier facilities operated by Charitable
Hospital
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Learnings
• Govt.-NGO partnership helped in institutional capacity building of NGOs and community groups and improving health coverage among slums.
• Financial contribution from community members helped improve sanitation, wells
• Reach to marginalized groups improved through a) WHGs and b) Link Volunteers.
• Flexible contract (developed through participatory planning workshops) and regular meetings helped in solving problems ensuring better management.
• Complementary and clearly defined roles of partners prevent sense of competition.
• Effective program strategies were replicated
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What Value Can NGOs Add to Urban RCH Programming?
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Contribution # 1
Identifying, Mapping Underserved Urban Populations
• Locating and mapping all slums and vulnerable pockets including unlisted slums, hidden and marginalized pockets.
• Providing services/linkage to seasonal urban migrants
E.g. NGOs helped identify hidden urban clusters during Pulse Polio Campaigns, CINI ASHA & MUSKAAN mapped slums in Uttaranchal and West Bengal
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Marginalized Social Groups Constitute A Large Proportion Of Urban Poor
Background Characteristics of Urban Uttar Pradesh - NFHS II
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Urban Low SLI Urban MediumSLI
Urban High SLI Urban Average Rural Average
Scheduled Caste Scheduled Tribe Other Backward Classes Others
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Marginalized Social Groups Constitute A Large Proportion Of Urban Poor
Background Characteristics of Urban Delhi – NFHS II
0%
20%
40%
60%
80%
100%
UrbanLow SLI
UrbanMedium
SLI
UrbanHigh SLI
UrbanAverage
RuralAverage
Scheduled Caste Scheduled Tribe
Other Backward Classes Others
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Contribution # 2 Improve Access to Sanitation and Other Basic
Services
• NGOs can facilitate sustainable community managed sanitation programs utilizing resources from National schemes such as Nirmal Bharat Abhiyan
• Forge linkages with NSDP, SJSRY, DWCUA and other Ministry of Urban Development programs
• Can lend an advocacy voice to the basic needs of the underserved slums at the city level
E.g. SPARC, Apnalaya & other NGOs have facilitated sanitation programs in Mumbai, Pune
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Contribution # 3 Enhance Demand & Utilization of Services, Build Community
Capacity
• Context appropriate communication activities • Capacity building of community link volunteers for
counseling, linkage to health services• Mobilise slum communities for effective outreach
activities• Promote community institutions e.g. NHG, SHG• Quality Assurance of existing primary care services
and of less qualified providers
E.g. In IPP VIII in A.P. and Bangalore, NGOs helped improve demand for services, SAATH and SEWA in Ahmedabad.
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Contribution # 4Wholly Manage Primary Level RCH Facilities
• Where capacity is available and public sector is absent, NGOs/Charitable hospitals can manage First tier facilities
E.g. Govt. of Uttaranchal has proposed this model in Haridwar, FPAI manages one UHC in Bhopal, Marwari Charitable Hospital in Guwahati
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Contribution # 5
Effective Partnerships and Convergence
• Partnership building and maintenance. Facilitate coordination of meetings, help record minutes
• Community-Provider (ANM) linkage, support and encourage ANMs
• Linkage with other Departments, ULB, Schools, Traders Associations, Lions etc.
E.g. Counterpart International-AMC partnership, EHP Indore Ward Coordination Model, Janagraha - Bangalore
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Contribution #6
Innovate & Develop Models for Replication & Scale-up
• Still a lot to learn about Urban Health Programming: NGOs can serve as learning centres
• They can conduct operations research to provide evidence for larger buy-in
• Study tours, learning lessons, building a critical mass of essential skills needed to create a snowball effect
E.g.: Apnalaya in Mumbai: Arogya Sevikas
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Contribution # 7
Capacity Building, Institutional Strengthening and Sustainability
• Serve as trainers on a variety of topics e.g. urban vulnerability, behaviour change communication and counseling
• Strengthen community-based organizations and link volunteers
• Train Private informal providers • Foster Sustainable Programming
Promoting ownership among partners of program objective and processes
Facilitate Health Funds at various through available sources including community contribution
• Encourage the humanistic paradigm in programming and minimize exclusion and inequity
E.g. VHAI and FPAI have served as trainers in many states; Slum Networking Project in Ahmedabad through SEWA and SAATH focus on institutional capacity at slum level
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Contribution # 8
Strengthening/Developing Urban HMIS
• Focus on an appropriate unit for monitoring• Promote denominator based monitoring
• Innovations such as “Family Chit” prior to outreach
camp
Murphy’s Law: “One single accurate measurement is infinitely superior to 1000 intelligent opinions”.
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Contribution # 9
Develop the Field of Urban Health as a Professional Field
• Emerge as UH Programming and Resource Centres on a Regional basis
• Support State Govts in Planning and Monitoring Urban RCH programs
• Document Urban Health Program experiences and promote cross-learning
• Compile and Disseminate Urban Health Literature including data
E.g. All India Institute of Local Self Governance for Urban Development issues, SPARC for Urban Sanitation issues
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Urban Health Program/Policy Long Lever of :
a) Commitmentb) Knowledgec) Experienced) Motivatione) Proximity to problems
NGOs
Looking Forward To
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Suggestions and Recommendations
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Capacity Building at State and City Level Required
• Capacity to select and identify the right partners: apply appropriate selection criteria
• Capacity to execute and monitor partnerships/agreements
• Capacity to foster and maintain external networks
• Enhance orientation to focusing on the underprivileged
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Innovation &Development
of Models
EAG States - a priority
Capacity for Planning,
Management & MonitoringSustainability:
Institutional,Programmatic,
Financial
Reach the Un-reached
Quality &Demand
Multi-StakeholderCoordination
Summary and Key Messages
Govt. NGO
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