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					Building Public Sector - NGO Partnerships
              for Urban RCH

                   Symposium on Urban RCH
    31st Annual National Conference of Indian Association
              of Preventive & Social Medicine
                     February 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




    ENVIRONMENTAL HEALTH PROJECT
Especially in Their Smaller Cities




         ENVIRONMENTAL HEALTH PROJECT
                          Urban Growth in India

             Percent decadal population grow th by residence in India:
                                    1901-2001


           50
           40
% growth




           30
           20
           10
            0
           -10




                            1
                           1

                           1

                           1

                           1

                           1

                           1

                           1

                           1

                           1

                        00
                         -1

                         -2

                         -3

                         -4

                         -5

                         -6

                         -7

                         -8

                         -9
                     01

                     11

                     21

                     31

                     41

                     51

                     61

                     71

                     81


                      -2
                   91
                   19

                   19

                   19

                   19

                   19

                   19

                   19

                   19

                   19

                 19
                                            Decades

                                  Urban             Rural      Total


                                ENVIRONMENTAL HEALTH PROJECT
Urban Population in EAG States
                                                             Where Should
                                                             efforts focus?
                                       32%



 68%



       Urban Population of EAG States          Urban Poverty in EAG States
       Urban Popualtion in Rest of India




                                                                            43%


                                             57%



                                             Urban Poor Popualtion in EAG States
                                             Urban Poor Popualtion in Rest of India
                              ENVIRONMENTAL HEALTH PROJECT
                    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
                        ENVIRONMENTAL HEALTH PROJECT
Reproductive and Child Health Conditions among
                 the Urban Poor




                ENVIRONMENTAL HEALTH PROJECT
  Coverage of Child Health Services in Urban Slums of 6 Municipal Corporations and
                               Rural Areas of Gujarat




       Coverage
100%
90%
80%
70%
60%
                                                                               U rban Slums
50%
                                                                               Rural A reas
40%
30%
20%
10%
 0%
         BCG       DPT3     O PV 3    M easles       A ll      V itamin
                                                                   A
                                      State-wide Multi-Indicator Cluster Surveys (MICSs), 1996


                             ENVIRONMENTAL HEALTH PROJECT
120
           Child, Infant and Neonatal Mortality in M.P.

100


80


60


40


20


 0
          Neonatal mortality            Infant mortality                   Child mortality

      Urban Low     Urban Medium      Urban High           Urban Average        Rural Average
                               ENVIRONMENTAL HEALTH PROJECT
             Childhood Under-nutrition in Urban M.P.
                                   NFHS 2 Re-analysis, EHP 2003
             100
             90
             80
             70
Percentage




             60
             50
             40
             30
             20
             10
              0
                     Underw eight for age – Below –2 SD       Underw eight for age – Below –3 SD
                                              Anthropometric indicator

                   Urban Low                     Urban Medium                    Urban High
                   Urban Average                 Rural Average

                                        ENVIRONMENTAL HEALTH PROJECT
Immunization Coverage by Age 1 among Children 12-23 months

                      Madhya Pradesh – NFHS 2 Re-analysis, EHP 2003




             80
             70
             60
Percentage




             50
             40
             30
             20

             10
             0
                  Completely   Received measles left outs from UIP    drop outs from UIP
                  immunized      immunization

                          Urban Low           Urban Medium       Urban High
                          Urban Average       Rural Average


                                  ENVIRONMENTAL HEALTH PROJECT
      Contraceptive Prevalence in Urban M.P.
                      NFHS 2 Re-analysis, EHP 2003

70
60
50
40
30
20
10
 0
         Any Method          Female Sterilization        Pill/IUD/Condom

     Urban Low SLI              Urban Medium SLI           Urban High SLI
     Urban Average              Rural Average


                          ENVIRONMENTAL HEALTH PROJECT
             Delivery Related Services in Urban M.P.
                              NFHS 2 Re-analysis, EHP 2003


             100
             90
             80
             70
Percentage




             60
             50
             40
             30
             20
             10
              0
                         Deliveries at home                   Deliveries attended by a heath
                                                           professional at home or at a health
                                                                          facility


             Urban Low   Urban Medium         Urban High      Urban Average        Rural Average

                                      ENVIRONMENTAL HEALTH PROJECT
                 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




                     ENVIRONMENTAL HEALTH PROJECT
Issues with Public Sector
  Urban Health Services




       ENVIRONMENTAL HEALTH PROJECT
    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
                        ENVIRONMENTAL HEALTH PROJECT
 Scenario 1: Areas Where Some Public Sector Primary
                 RCH Services Exist



• 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.
                     ENVIRONMENTAL HEALTH PROJECT
Scenario 2: Areas where Public Sector RCH services are
                    Not Existing




•   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




                    ENVIRONMENTAL HEALTH PROJECT
         Low Utilization of and Access to Public Sector Services


                              Chemists Government
                     Others              doctors
                                4.6%                                   Others                  Health
                      1.0%                12.3%
                                                                        4.4%                  workers
                                                                                                2.8%



                                                                                                         Gov.
                                                                                                        doctors
                                                                                                         26.1%




                                                        Private
                                                        doctors
Private doctors
                                                         66.7%
     82.1%


                  Urban Slums                                            Rural Areas

                                                    Gujrat State-wide Multi-Indicator Cluster Surveys (MICSs), 1996


                                       ENVIRONMENTAL HEALTH PROJECT
                  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




                    ENVIRONMENTAL HEALTH PROJECT
Experiences in Govt. –NGO
 Partnerships for Urban RCH




        ENVIRONMENTAL HEALTH PROJECT
  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



                        ENVIRONMENTAL HEALTH PROJECT
                                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

                           ENVIRONMENTAL HEALTH PROJECT
What Value Can NGOs Add to Urban
         RCH Programming?




           ENVIRONMENTAL HEALTH PROJECT
                              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




                         ENVIRONMENTAL HEALTH PROJECT
        Marginalized Social Groups Constitute A Large
                  Proportion Of Urban Poor
                  Background Characteristics of Urban Uttar Pradesh - NFHS II



100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

 0%
       Urban Low SLI   Urban Medium    Urban High SLI   Urban Average       Rural Average
                            SLI
               Scheduled Caste   Scheduled Tribe   Other Backward Classes      Others

                                 ENVIRONMENTAL HEALTH PROJECT
       Marginalized Social Groups Constitute A Large
                 Proportion Of Urban Poor
                   Background Characteristics of Urban Delhi – NFHS II


100%



80%



60%



40%



20%



 0%
          Urban        Urban      Urban       Urban       Rural
         Low SLI      Medium     High SLI    Average     Average
                        SLI

         Scheduled Caste                      Scheduled Tribe
         Other Backward Classes               Others
                             ENVIRONMENTAL HEALTH PROJECT
                           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


                        ENVIRONMENTAL HEALTH PROJECT
                            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.


                         ENVIRONMENTAL HEALTH PROJECT
                            Contribution # 4
            Wholly 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




                        ENVIRONMENTAL HEALTH PROJECT
                          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




                        ENVIRONMENTAL HEALTH PROJECT
                               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



                             ENVIRONMENTAL HEALTH PROJECT
                                    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



                                ENVIRONMENTAL HEALTH PROJECT
                         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”.




                       ENVIRONMENTAL HEALTH PROJECT
                                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

                            ENVIRONMENTAL HEALTH PROJECT
                 Looking Forward To




Urban Health
                            Long Lever of :
Program/Policy
                            a) Commitment
                            b) Knowledge               NGOs
                            c) Experience
                            d) Motivation
                            e) Proximity to problems




                     ENVIRONMENTAL HEALTH PROJECT
Suggestions and
Recommendations



  ENVIRONMENTAL HEALTH PROJECT
      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




                         ENVIRONMENTAL HEALTH PROJECT
                    Summary and Key Messages

                                                          Innovation &
   EAG States -                                           Development
     a priority                                             of Models




                                                                  Multi-
Quality &                Govt.             NGO                 Stakeholder
Demand                                                         Coordination




                                                         Capacity for
       Reach the                                          Planning,
       Un-reached                                       Management &
                               Sustainability:            Monitoring
                                Institutional,
                               Programmatic,
                                  Financial

                         ENVIRONMENTAL HEALTH PROJECT
ENVIRONMENTAL HEALTH PROJECT

				
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