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Discussion at India Development Coalition of the Americas, Chicago, Illinois
May 26, 2007
• Urbanization, urban poverty and health of the urban poor in India
• Challenges and Opportunities in improving health of the urban poor
• Program Experiences and Lessons
Urban population - 328 million Projections for 2007 by Technical Group on Population Projections
India is expected to be approximately 40% (550 million) urban by 2026 Census, 2001 population, Projections, 2001-26
2-3-4-5 phenomenon of population growth
Urban poor estimated at 80.74 -100 million; projected to increase to 202 million by 2020 Planning Commission, Poverty Estimates for 2004-05 and National
Population Policy, 2000; State of World’s Cities, 2006/07
Estimated annual births among urban poor: 2 million Based on CBR 19.1 for urban population and 100 million urban poor
population3
Urban Poverty inEAG States
EAG states43%
Rest of
India57%
Urban Population in EAG States
EAG states32%
Rest of
India68%
4
•Data from Census 2001 and NSSO 55th round, 1999-2000•EAG (Empowered Action Group, Govt. of India, 2001) identified 8 states that lag behind on demographic and health indicators. These are: UP, MP, Rajasthan, Bihar, Orissa,, Jharkhand, Chhatisgarh, Uttaranchal
Health conditions of urban poor are similar to or worse than rural population and far worse than urban averages
[Re-analysis of NFHS 2 (1998-99) by Standard of Living Index, EHP: 2003]
Urban Average
Urban Poor
103.7
63.1
* Mortality per 1000 live births
Poor Child Health and SurvivalD
eath
s P
er 1
000
Live
Birt
hs
0
20
40
60
80
100
120
140
160
Under 5 Mortality *
101.3
Rural Average
0
20
40
60
80
100
Childhood under-nutrition among urban poor is worse than rural population and far worse than urban averages
[Re-analysis of NFHS 2 (1998-99) by Standard of Living Index, EHP: 2003]
Rural Average
49.638.4
Urban Average Urban Poor
Nutritional Status
Childhood Under-nutrition
Per
cent
age
of u
nder
3 y
ears
un
derw
eigh
t for
age
(< –
2 S
D)
56.0101.3
0
10
20
30
40
50
60
70
Complete ANC (3ANC+IFA+TT)
Institutional deliveries
24.8
52.7
24.6
Re-analysis of NFHS 2 (1998-99) by Standard of Living Index, EHP: 2003
65.1
Rural Average
Urban Average
30.4
41.9
Urban Poor
Over 1million babies are born every year in slum homes
152.2
58.4
12.1
82.9
44.349.1
0
20
40
60
80
100
120
140
160
Under 5 Mortality Nutritional Status Institutional Delivery
Rural Average Urban Average
131.9
72.4
24.8
Urban Poor
Madhya Pradesh
Almost 90% of urban poor are involved in urban informal sector.1
Urban sector contributes 60% of Gross Domestic Product (GDP).2
Informal sector’s contribution to non agricultural GDP is 45%.3
1. USAID (2002). Making cities work, India Urban Profile. 2 Chaudhary O. New vistas in financing for development of real state. National Real Estate Summit. FICCI-3rd September 2004 3 International Labour Office.2002.Women and Men in Informal Economy.
Urban Health a low priority with India having remained primarily rural for many decades
Lack of credible data for urban poor related planning
Urban Slums face social exclusion, illegality and many overlooked by official enumeration systems
12
13
328 unlisted slums (population 510,397)
452 listed slums (population 820,139)
780 slums (Total)
According to NSSO 58th Round (2002) 49.4% slums are non-notified in India
ity lums on official List nlisted Slums
gra 15 78
ehradun 8 8
ally 5 5
amshedpur 4 7
52 28
Urban poor grossly underserved and having low access to health services
Greater focus on curative services resulting in neglect of primary and preventive health care
Lack of coordination among multiple stakeholders
Lack of risk pooling and health insurance mechanisms for the poor
14
Lack of knowledge and social capital among slum dwellers: sense of resignation
Weak negotiation capacity
Urban poor struggle against multi-dimensional vulnerability
Weak family support to mother, need to resume wage earning
15
Very few examples of coordinated, planned slum health programs in most States
Weak capacity among government and NGO managers on urban health
16
Growing recognition of the issue and increasing interest among Government, donors and NGOs in India. National “Task Force to advise the National Rural Health Mission on
Urban Health Care” has submitted recommendations to the Ministry of Health and Family Welfare. Report released by Govt of India.
JNNURM presents opportunities for health infrastructure and basic services to the poor
Presence of experienced and interested NGOs in urban areas
Growing body of urban poor specific research & data.
Geographical accessibility in urban areas is an advantage.
More options for communication activities
May be more early adopters
Develop and test effective approaches Evolve program approaches for different types of cities (size,
capacity of public & private stakeholders) particularly in less developed States to inspire confidence among Govt. officials and NGOs
Develop capacity among slum communities to effectively contribute to health improvements
Provide capacity building to influence Govt and other stakeholders For hands-on capacity building of Govt./other stakeholders Influence state and national level urban health programming
Program research in slum context on different crucial public health interventions: e.g. maternal-neonatal care solutions among slum populations; identification, assessment, plotting of listed, un-listed and most vulnerable slums
Purpose of Demonstration Programs
20
Listing ofSlums
ensuring Identification of all Poverty
Pockets
DevelopingVulnerability
Criteria through Slum
Visits and Discussions
Slum-based Data
Collection
Triangulation of Results for Vulnerability,
Slum Location and Hidden
Areas
Consolidation of Data and
Categorization of Slums; Mapping
•Identification, assessment and plotting of slums in the city
•Understanding the local context , needs
•Identification of motivated individuals/groups to nurture leadership
Listed SlumsUn-listed Slums
INDORE
22
City map with slums, facilities plotted an important planning and monitoring tool
The partnership is based on the principle of enabling and connecting people (vulnerable slum communities) to health providers (public and private) with capacity building support from trained local NGOs.
Community level organizations have strong grassroots presence, are more accountable and informed about urban vulnerability.
Improve Community
Improve Supply and
Demand for Services
Quality of Services
Improved Health Outcome
Improved Health Outcome
Slum CBOs
Cluster Coordination Team (Lead CBO)
Health Dept.& ICDS
MunicipalCorporationCharitable
Organizations
Private Doctors
Capacity Building, supervision & coordination by NGO and Technical Agency
Linking Slum Communities with Public and Private Services
Community- Provider- Linkage
Coverage1,50,000 slum population
9 CLUSTER COORDINATION TEAMS
(also called Lead CBOs; 7-9 slums per cluster)
Seven registered as voluntary organizations.Plan and negotiate regular health services
Referral linkages & coordination with service providers (Health, Water & Sanitation, drainage) Monitor and support Basti CBOs in health activities as necessary
NGOs with support from UHRC undertake periodic program review and implement appropriate improvement measures as identified during review
Building Sustainable Institutions in Slum Communities
BASTI (Slum) LEVEL CBOs(90 community groups of 7-12 members, including dais across 75 slums or bastis)
Community based monitoring Counsel slum families on healthy behaviours
Identify un-reached families and ensure access for them
Support regular MCH camps in slums
Building Sustainable Institutions in Underserved Urban Communities
Information and community motivation – women arrive for immunization day
Registration of beneficiaries - identifying left-outs and drop-outs
Linkage with the Auxiliary Nurse-Midwife for vaccine administration
Improved Health Indicators in Indore Slums
55
38
59
23
46
32
69
52
85
43
29
72
0
25
50
75
100
% mothersreceived 3
ANC
% mothersdelivered in
healthfacilities
% infantsbreast fedwithin one
day of birth
Children 0-3months who
areexclusivelybreastfed
% children<2yrs
underweightfor age (<–2 SD)
% children (12-23 mths)completely
immunized by1 yr of age
Baseline (October 2003) Midline (After Intervention- March 2006)
slum-home56%
Maternal Village
16%
Govt./charitable
hospital21%
private doctor/nur
se7%
41.436.1
28.2
43.949.6
14.8
72.9
3833.5
96.6
50
100
46
61.4
0
10
20
30
40
50
60
70
80
90
100
Trained BA Warm BirthRoom
CleanSurface
CleanHands
Newbornwrapped
untilplacenta
wasremoved
Clean Cordtie
New Blade Clean CordStump
Baseline survey (Oct - Nov 2003) MNH Survey (Jan - Sept 2005) (N=312)
Ward levelWard level Core GroupCore Group
NGOs & CBOs
Charitable Organizations
Elected Representatives
Municipal Corporation(Zonal office)
DUDA Local Resources
(Local Clubs, Schools)
Health dept
ICDS
Total Coverage: 70, 000 slum population in 2 wards in Indore
32
6553
6476
9
0
25
50
75
100
% Children (12-23 months)completely immunized by 1yr of
age
% Children (12-23 months)received measles by 12 mths
% of children (12-23 months)dropping out from UIP (DPT1-
DPT3)
Baseline (October-November 2003)Midline (After Intervention- March-April 2006)
Improved Health Indicators in Ward 5 of Indore
G O V E R N M E N T
Periodic Coordination
SuppliesMonitoring
Monthly RCH
Reports
UHRC provides support for capacity building, coordination and system strengthening
Referral to Identified FRUs
2 such UHCs are operational covering approximately 106,250 population (approx. 17650 households)
Regular outreach
Services.
Demand Generation
Community Provider
Linkage
NGO Managed UHC (rented)
Slum com
munities
40,000 population
OPD services CBOs
CLVs
NGO Managed Service Deliveryand Community Mobilization
Monthly outreach services initiated in 47 slums covering 82,400 population.
108 Link Volunteers, each covering 1500-1800 population; negotiation and health promotion capacity developed among 80 of these.
69 women’s health groups formed in 58 slums; negotiation and health promotion capacity developed among 35 of these groups.
52 groups have a health fund.
Improved quality of MCH services through partnership with NGOs:
• More regular services : 2 new UHCs catering to 106,250 slum population
• More comprehensive ANC and other services
• Improved availability of medicines e.g. antibiotics, RTI medicines
Enhanced capacity of NGO partners to generate resources locally
Outcomes / Trends
Partnerships for integrated programs addressing determinants of health such as education, livelihood, water and sanitation.
Demonstration programs in additional states to develop need specific approaches and stimulate replication.
UHRC-JHU collaboration for Program Research to evaluate effective, affordable, scalable and sustainable system of delivering a package of Maternal, Neonatal, Child and Reproductive Health (MNCRH) services to urban poor.
National conference/workshop on Urban Health Series on Urban Health in an International Journal. Continued media advocacy on wellbeing concerns of urban
poor in India.
38
Accountable,Effective
Urban Health Governance Long Lever of :
b) Commitment , Motivationc) Knowledge, Experienced) Proximity to problemse) Accountability, responsibility
Committed, passionate people partnerning with, Civil Society, Govt., slum communities
With Hope and Confidence
““A small body of determined spirits fired by an A small body of determined spirits fired by an unquenchable faith in their mission, can alter the unquenchable faith in their mission, can alter the course of history”course of history” - Mohandas Karamchand Gandhi - Mohandas Karamchand Gandhi
www.uhrc.in
Extra slides
Factors and Situations resulting in Health Vulnerability among urban poor1
Irregular employment, struggle of livelihood
Low access to fair credit Poor access to water and sanitation
services, overcrowding, poor housing, insecure land tenure
Unlisted slums often outside the purview of civic and health services
Constant threat of eviction401Taneja S and Agarwal S. 2004. Situational Analysis for guiding USAID/EHP India’s Technical Assistance Efforts in Indore, MP
Temporary and recent migrants often denied access to health services, difficult to track for follow-up health services
High prevalence of diarrhea, fever and cough among children
Lack of organized community collective efforts in slums
Widespread alcoholism, substance abuse, gender inequity, poor educational status
411Taneja S and Agarwal S. 2004. Situational Analysis for guiding USAID/EHP India’s Technical Assistance Efforts in Indore, MP
Situation analysis helps identify underserved slums, priority needs and local resources
City map with slums and facilities plotted helps effectively plan new Health Centres and outreach services
Building capacity of slum-level institutions and facilitating linkage with public and private providers is important for sustainability
Inter-sectoral linkages to address water and sanitation issues are difficult in weak governance situations like Agra
42
Existing slum leaders/networks evolved as a potent institutional mechanism for slum health (and development) programs.
Coordination among multiple stakeholders helps utilize resources from varied sources and eliminate duplication of efforts.
NGOs can effectively complement Government’s efforts to Quickly expand health services to un-served
areas Strengthening outreach services from existing
Govt facilities43
44
79 slumsNGO-CBO partnership
Popln: 150,000
157 Most Underserved Slums
225 slums (official list)
539 slumsPop: 600,000
Indore Population: 1,800,000
• Growing Urban Poor Population in Indore: • Population - 1.8 million (2001 Census)• Decadal Growth rate- (1991-2001) - 47% • Estimated slum population - 0.6 million • No. of slums – 539; 314 not part of official slum lists
• Inadequate Health Care Service for the Urban Poor:• 17 primary health care facilities, many functioning sub-optimally • Poor Access of urban poor to Health Care • Heavy workload on limited outreach staff insufficient interaction
with community, irregular outreach sessions
• Low Demand and sub-optimal behaviors among the Urban Poor
• Weak Coordination among different Service Providers
• Ministry of Health and Family Welfare lays strong emphasis on partnerships with NGOs to complement govt. efforts to make health services accessible to all.
• Large gap in urban health services.
• UHRC’s Technical Assistance aimed at assisting Govt. of Uttar Pradesh establish working examples of Public-Pvt. Partnerships involving non-profit sector for Urban Health services for replication and scale up
• Serves the following public health purposes:
• Expansion of health services
• Reaching the un-reached/disenfranchised (addressing inequity)
• Community behavior promotion, ownership and demand
Context and Purpose
Influencing National and State Policy and Program and
other Stakeholders
National and State Level Technical
Assistance
U.P., M.P., Bihar, UA, Jharkhand, Rajasthan,
Maharashtra
Research, Knowledge
Management and Advocacy
UH ConferenceSymposiaPublications and ReportsWebsite
City level Demonstration
& Learning Programs
INDOREAGRA
Meerut, Delhi
Development of a capable, independent organization
Urban Health Program Approach
National level Technical Assistance for better targeted policies and increased resource for health and nutrition of the urban poor
Support to National Urban Health Task Force to advise NRHM/MOHFW
State level Technical Assistance for enhanced capacity and institutional mechanisms for planning and implementation: UP, MP, Rajasthan, Maharashtra, Delhi, Bihar and Jharkhand
Facilitating reach to the unlisted and vulnerable
Greater policy focus and enhanced resources at national and State level
Urban Health Guidelines issued by Govt of India, Feb 2004
Recommendations of National Urban Health Task Force shared with all States, available at http://www.mohfw.nic.in/NRHM/Task_grp/Report_of_UHTF_5May2006.pdf
City programs serve as demonstration and learning sites
Inequity and social exclusion addressed by inclusion of unlisted / hidden slums in city health plans
Tools for identifying and mapping unlisted and vulnerable slums
Sites have been utilized as learning universities by government and non-government program managers
Health of Urban Poor receiving greater attention from Government of India, Academia, donors, NGOs
Credible National and State level urban poor specific data made available for need based planning
Complementary resources leveraged from Govt, NGO, other agencies, slum community for Urban Health
Recognition from Government and other stakeholders for urban health program efforts:
Designation as Nodal Technical Agency for Urban Health component of Govt. of India’s RCH II program.
UHRC nominated to National Urban Health Task Force
Generation of data on health of the urban poor (reanalysis of NFHS-2 and other survey data)
Articles in peer reviewed journals
State Urban Health Reports
Compendia on different urban health themes
Operations Research Studies
Baseline and Evaluation Surveys
Urban Health Advocacy events (Bangalore consultation 2003 in collaboration in MoHFW, Govt. of India)
Urban health symposia and conferences (Panel Discussion and Poster Session, March 29, 2007)
Presentations at national and international fora
Attention on the issue in media (print, electronic and websites)
• Library and information centre
• UHRC website
Oct’06 to Dec’06 Jan to Mar’07No. of new documents available at website
7 12
Number of document downloads
620 287
Number of new newsletter subscribers
28 64
Website traffic 148223 HitsUnique visitors-5754
178581 HitsUnique visitors -5695
• New site: Urban Health Gateway launched on March 29, 2007
Mr. Prassana Hota, Secretary to the Ministry of Health and Family Welfare, Govt. of India, acknowledged the role of UHRC in furthering the urban health agenda in a message to UHRC website :
“Technical assistance given to the GOI and State Governments has provided the right momentum for formulating policies and programmes for improving health of the urban poor….. I am confident that UHRC will continue its technical assistance efforts and its crusade for furthering urban health with dedication, commitment and a collaborative spirit.”
