Maternal and Newborn Health in Urban India...Maternal and Newborn Health in Urban India Save the Children, India May 2016 A Monograph based on Literature Review Exercise Contents Letter

Maternal and NewbornHealth in Urban India

Save the Children, IndiaM a y 2 0 1 6

A Monograph based on Literature Review Exercise

Maternal and Newborn Health in Urban India

Save the Children, IndiaMay 2016

A Monograph based on Literature Review Exercise

Contents

Letter from Ministry of Health & Family Welfare 5

Message 6

Preface 7

Message from CEO 8

Acknowledgement 9

Acronyms 10

Executive Summary 12

Outline of the Report 15

I Introduction 16

II Methodology 20

III Findings 24

A. Service Delivery Mechanisms, Logistics and Supply-Chain Management 24

B. Governance 37

C. Human Resources 40

D. Financial Mechanisms 46

E. Health Infrastructure 49

F. Health Management & Information System (HMIS) 50

G. Community Interventions and Innovations 51

H. Innovative Approaches 57

IV Discussion and Conclusions 64

References 72

Annexure 1: Evidence tables of the literature reviewed 84

Annexure 2: Tables on citywise programmes, schemes and innovations 113

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ublic healthcare for the urban poor has lagged behind in India despite good intentions. It suffers from multiplicity of players, non-standardised structure and low investments. Above all, the rich-poor gap is Pstaggering. It has therefore been a challenge to systematically plan priority maternal-newborn health

(MNH) services in cities and towns. Not surprisingly, the National Urban Health Mission has lagged behind the National Rural Health Mission by almost a decade.

One reason for this state of affairs has been a relative lack of reliable information and program relevant research in urban MNH. Diversity and dynamics of urban health system make the available knowledge difficult to comprehend and apply. In this context, Saving Newborn Lives (SNL), Save the Children, has made a tremendous contribution by synthesising available literature and research in MNH in urban India.

This monograph is based on well-researched, painstaking review using robust methods. The credentials of the team are impeccable. The flow of the narrative (service delivery, infrastructure, human resources, etc.) follows the health system framework. Gaps and solutions are captured in precise text at the end of each chapter; and discussions and implications are well captured in the final chapter.

This review brings out several facets of urban MNH. Analytic insights into lack of community processes in urban areas in the report are most insightful. Equally, interesting is the capture of most innovations in MNH in cities. The need to design and test next generation primary care models for urban India is a clear priority. Overall scene of urban MNH cries out for more investment, better governance and coordination, and more research.

The recurring theme in the monograph is the paucity of actionable information and evidence. We need studies on urban MNH epidemiology and innovative interventions; we need implementation research to inform scale up of what is known to be effective; we need demonstration sites to showcase replicable models; and we need technical support teams to facilitate implementation and monitoring. The government, the Indian Council of Medical Research and the public health research community together have the responsibility to bridge the knowledge gap.

The monograph provides highly valuable inputs on MNH for the National Urban Health Mission. MNH and urban health stakeholders would gain immensely by insightful repository of information that this review provides.

A must read document for the public health community of India.

Dr. Vinod PaulProfessor & HeadDepartment of Paediatrics, AIIMS, New Delhi

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Message

Preface

ave the Children’s 2015 State of the World's Mothers Report, The Urban Disadvantage, brings into sharp focus the health inequities found within cities all over the world. Data from the report demonstrate that Swhile great progress has been made in reducing under-5 mortality globally, in about half of the cities where

data are available, the mortality gap between rich and poor children has grown. The poorest children, especially those living in urban slums, have alarmingly high risks of death. These inequalities also exist in cities in high-income countries such as Washington, DC, in the United States.

Given Save the Children's commitment to reaching the most disadvantaged children and families and the growing rates of global urbanization, we believe addressing the challenges surrounding improving health – especially maternal and newborn health – in poor urban areas is increasingly important. We are keen to understand the root causes of these inequalities and to learn from the experience of others about addressing the needs of children and families living in urban slums.

Save the Children's Saving Newborn Lives Program, supported by the Bill and Melinda Gates Foundation, is working actively with appropriate stakeholders and the National Health Mission to explore how the contextual factor differ in urban settings for maternal and newborn health service availability as well as care seeking behaviors. Who are the main service providers to poor urban dwellers? How are those services financed? Are they of sufficient quality to improve health outcomes? How have they targeted the most deprived and poorest families?

A key step in this learning agenda was to undertake a literature review to explore the rich array of programs already in existence in India. The results remind us of how much work has already been undertaken and the rich set of lessons that have emerged. However, it also is evident that most urban health programs have been pilot projects, covering relatively small populations within a fixed time period, and that successful pilots have yet to be scaled up to benefit large population groups. The challenge for India and other countries is to learn how to shape large-scale, well-funded,and sustainable programs such as India's National Health Missions to target services to those who need them the most in varied urban environments. Further, while future investments in urban health must come from government, we must also tap into the vibrant private and corporate sector and involve the service delivery systems of government, nonprofit, and commercial sectors, because everyone has an equal stake in the health and well being of India's women and children.

I would like to thank all of those involved in carrying out this important review and analysis as well as those who guided it. We appreciate the global leadership that India is providing for improving urban approaches to addressing the health of women and children.

Joy Riggs-PerlaDirector, Saving Newborn LivesSave the Children, USA

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Message from CEO

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rbanisation is often thought of as being beneficial for economic and social growth, which is what prompts rural populations to migrate to the cities for a better life and better prospects. Being the world's largest Udemocracy, the second most populous country (1.21 billion as per Census 2011) and the tenth largest

economy (with a Gross Domestic Product of US$ 1377.3 billion in 2009), India has undergone extraordinary socio-economic and demographic changes. In the past 30 years, the geographically-wide, densely-populated and enormously-varied Republic of India has made remarkable efforts in the field of health, including development of a strategic framework on RMNCH+A in 2013 and the recently launched National Health Mission with a sub-mission (NUHM) on Urban Health as a key component.

Save the Children's Saving Newborn Lives (SNL) programme works with governments and partners to put newborn health on global and national agendas. In India, the programme is working towards evidence-generation, consensus-building and supporting policy and programmatic processes on delivering Maternal and Newborn Health (MNH) in urban poor settings. As a part of this process, a need was felt to review both the published and the unpublished literature on mechanisms, programme platforms, service delivery systems, practices and innovations in MNH in the urban areas of India including, literature on scaling up pilots/ innovations and conceptual frameworks with a specific focus on the urban poor.

It is important that the MNH programmes, though variably existing in the urban space of India, gets a thorough prioritisation and reboot. The whole service delivery mechanism is not in place when it comes to most of the cities in the country. Ambiguity on the information, data, role of departments, leadership, personnel, supply chains and logistics continue to remain.

The findings of this review clearly reflect on the gaps in terms of current availability of health services to deliver MNH care along with the clearly defined paucity of service delivery platforms, governance and mechanisms inclusive of infrastructure, human resources, logistics, supply chain, partnerships and community, level efforts. It further draws our attention to the fact that the gaps with regard to the availability of literature and evidence from the research undertaken in all of the abovementioned aspects of health service delivery for MNH care should not be ignored.

At Save the Children, we consider that both the policy and programmatic efforts along with commitment of working towards the betterment of urban poor mothers and newborns should be augmented especially at this juncture, wherein the country is attempting to understand, develop and formalize the mechanisms for delivering health care to the urban poor mothers and newborns.

This review report affirms the overwhelming constraint of better availability of services for MNH care in urban areas and it distinctly provides a direction to future researchers and policy-makers as to what needs to be done to ensure that MNH care services are delivered to the urban poor.

Thomas ChandyCEO, Save the Children, India

Acknowledgements

eepest appreciation is expressed to all those who provided technical and moral support to complete the review of literature and subsequently this report. Special gratitude to Mr. Nikunj Dhal, erstwhile Joint DSecretary, Urban Health and ICT, Ministry of Health and Family Welfare (MoHFW), Government of

India (GOI); Dr. Rakesh Kumar, erstwhile Joint Secretary, Reproductive and Child Health, MoHFW, GOI; Dr. P. K. Prabhakar, Deputy Commissioner - Child Health, MoHFW, GOI; and Ms. Preeti Pant, Director, NHM (Urban), MoHFW, GOI whose continuous patronage and encouragement helped to put this comprehensive report together so as to provide insights to all of those who are keen to know more about maternal and newborn health care in urban poor settings in India.

The study team wishes to express gratitude to the members of national level Technical Advisory Group (TAG) for their suggestions guidance and insights during the whole process of the review exercise. Specific insights and understanding from Prof. Vinod Paul helped in the overall design and finalization of research questions. Inputs from Prof. N. K. Arora, Prof. Rajib Dasgupta, Dr. Sanjay Pandey and Mr. Gautam Chakraborty were extremely helpful and instrumental in finalizing this report. An especially strong appreciation goes to the officials of Municipal Corporations and associated public health teams of few municipal corporations that provided first hand information on the service delivery aspects.

Much appreciation is extended to the staff of Save the Children, USA especially Ms. Joy Riggs-Perla, Director - Saving Newborn Lives (SNL) Program; Dr. Stephen Wall, Senior Technical Advisor; Dr. Uzma Syed, Technical Advisor - Newborn Health; Dr. Lara Vaz, Senior Advisor - Monitoring & Evaluation; who guided the design of the study. A special thanks goes to Dr. Sudeep Singh Gadok, erstwhile Director of Programmes, Ms. DeepaliNath, Director, Knowledge Management and Mr. Prasann Thatte, Manager Research, Save the Children, India, for their untiring support and technical insights.

A special mention of THOT, the research agency, which helped assemble and assimilate the pertinent information and gave valuable suggestions throughout the study.

This study would not have been possible without the abundant support and guidance of the core team of SNL, India which was led by Dr. Rajesh Khanna, Technical Advisor – Newborn Health, Save the Children, India and Dr. Benazir Patil, Advisor – Urban Health, Save the Children, India. The guidance and appreciation of other colleagues are sincerely cherished.

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ANC Ante-Natal Care

ANM Auxiliary Nurse Midwife

ASHA Accredited Social Health Activist

BEmOC Basic Emergency Obstetric Care

BPL Below Poverty Line

CEmOC Comprehensive Emergency Obstetric Care

CHC Community Health Centre

CSSM Child Survival and Safe Motherhood Programme

DCM District Community Mobiliser

DRC District Resource Centre

EmNC Emergency Newborn Care

EmOC Emergency Obstetric Care

EmONC Emergency Obstetric and Newborn Care

FBNC Facility-Based Newborn Care

FRU First Referral Unit

HBNC Home-Based Newborn Care

HMIS Health Management Information System

HR Human Resource

HRH Human Resources for Health

IAP Indian Academy of Paediatrics

IMNCI Integrated Management of Neo-natal and Childhood Illnesses

IMR Infant Mortality Rate

INAP India Newborn Action Plan

IPHS Indian Public Health Standards

IMCI Integrated Management of Childhood Illnesses

IMNCI Integrated Management of Newborn and Childhood Illnesses

JNNURM Jawaharlal Nehru National Urban Renewal Mission

JSSK Janani Shishu Suraksha Karyakram

JSY Janani Suraksha Yojana

KMC Kangaroo Mother Care

Acronyms

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MDG Millennium Development Goal

MNH Maternal Newborn Health

NFHS National Family Health Survey

NHM National Health Mission

NMR Neo-natal Mortality Rate

NRHM National Rural Health Mission

NUHM National Urban Health Mission

PHC Primary Health Centre

PPP Public Private Partnership

RCH Reproductive and Child Health

RBSK Rashtriya Bal Swasthya Karyakram

RKSK Rashtriya Kishore Swasthya Karyakram

RKS Rogi Kalyan Samiti

RMNCH+A Reproductive, Maternal, Newborn, Child and Adolescent Health

SBA Skilled Birth Attendant

SHG Self-Help Group

SN Staff Nurse

SNCU Special Newborn Care Units

SNEHA Society for Nutrition, Education and Health Action

SRS Sample Registration System

TAG Technical Advisory Group

TBA Trained Birth Attendant

U5MR Under-Five Mortality Rate

UNICEF United Nations Children's Fund

UPHC Urban Primary Health Centre

USHA Urban Social Health Activist

VHND Village Health & Nutrition Day

VHSC Village Health & Sanitation Committee

WASH Water Sanitation and Health

WHO World Health Organization

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ith rapid urbanisation, as in most Departments of Publ ic Heal th , Urban developing countries, public health Development, Medical Education, and the Wproblems in India are increasingly Municipal Corporations and the urban local

assuming an urban dimension. Largely viewed as bodies is a greater challenge. a rural society for many decades, the Government Save the Children's Saving Newborn Lives (SNL) of India's conception of primary healthcare was programme, supported by the Bill and Melinda

th almost entirely rural oriented. The 12 Five Year Gates Foundation is a globally recognised leader Plan, stated for the first time that urban expansion in newborn health and a respected voice in many will happen at a speed quite unlike anything that low-resource countries. Since its inception in the India has seen before and, if not well managed, this year 2000, SNL has worked to reach the world's inevitable increase in India's urban population most vulnerable newborns and help them survive

1will place enormous stress on the system . their first month of life. By working with Interestingly, it has been found that the health governments and partners to put newborn health services in urban areas often observe an “inverse on global and national agendas, SNL serves as a care law”: those in greatest need of care have the catalyst for action. To accomplish its goals, the poorest access to it. Despite the fact that few SNL programme works to develop, apply, governments have formulated urban health document and sustain packages of effective, policies that prioritise the poor, even when such evidence-based newborn care services and plans and programmes do exist , their practices at scale. SNL provides technical implementation is hampered by resource leadership, advocacy, and measurement support.

2 .shortages . In India, while the analysis of the The programme facilitates a cycle of evidence-NFHS-III data confirms the inequitable health generation, consensus-building, policy-

3status of the urban poor , a number of other formulation and-guidance, and programme 4studies have also concluded that the health of the implementation and learning.

urban poor is significantly worse than the health of Currently in its third phase (2013-2017) of the rest of the urban population and is often implementation, SNL in India is working toward comparable to health conditions in rural areas. generation of practical and feasible solutions for India contributes to 16% of the global maternal delivery of MNH services for the urban poor in deaths and around 27% of global newborn deaths. India. Reducing the burden of maternal and newborn For designing sensitive, responsive and relevant mortality and morbidity in urban poor settings urban health policy and action, it is important for today requires an expansion of effective Maternal planners and programme managers to understand and Newborn Health (MNH) care services and the context with regard to current systems and lowering the barriers to the use of such services, mechanisms, potential organisations and best especially availability and accessibility. practices, that can be leveraged and built upon to Addressing these barriers can substantially ensure urban institutional reforms and improved improve the utilisation of services, as well as governance for MNH in urban poor settings. In increase inequity in health outcomes. The launch order to address this need, SNL commissioned a of the National Urban Health Mission(NUHM) in study that reviewed the literature and looked at 2013 as a sub-mission of the National Health available secondary data on MNH in urban poor Mission(NHM) is being looked at as the very first settings. The study synthesised quality evidence step to tackle the needs of the urban poor. that identified opportunities and gaps in the health However, the lack of clarity on the ultimate system, looked into the factors affecting responsibility for providing public health services programming and service delivery; and reflected in urban areas, lack of demonstrated political will on potential strategies to help address specific to assume responsibility and accountability for MNH care needs of the urban poor in India.urban services, along with the absence of inter-

The review looked at both published and departmental coordination between the

Executive Summary

Maternal and Newborn Health in Urban India A report on literature review

1 th12 Five Year Plan: Approach paper on “The Challenges of Urbanisation in India”.

2http://www.unsystem.org/scn/archives/scnnews01/ch2.htm

3National Family Health Survey: Round III reveals that the childhood mortality indicators among the urban poor are higher compared to the urban averages – 72.7 vs. 51.9 for U5MR, 54.6 vs. 41.7 for IMR, and 36.8 vs. 28.7 for NMR.

4 Islam, Montgomery, and Taneja (2006); Montgomery and Hewett, (2005); Fotso, Ezeh, and Oronje (2008).

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Save the Children, India

unpublished literature on mechanisms, determinants of MNH and barriers in accessing programme platforms, service delivery systems, services, there is little information available on practices and innovations in MNH in the urban interventions and models that have worked to areas of India including literature on scaling up address these challenges. In exceptional cases, if MNH pilots/innovations and conceptual certain initiatives did work providing some frameworks with a specific focus on the urban piecemeal solutions, the sample size was either not poor. The search for evidence involved examining large enough for confidence of scalability or these of planning and implementation frameworks, case w e r e m o s t l y p r o j e c t - b a s e d i n i t i a t i v e s studies, reports, evaluation and impact implemented and managed by non-governmental assessment reports, strategic frameworks, reports agencies dependent on available resources.of different programmes and interventions, The review affirms the overwhelming constraint research studies, surveys, documents and articles. of better availability of services for MNH care in A total of 250 sources were identified and included urban areas. It further confirms two specific in the present review. aspects: first and foremost, there exists limited or This review report focuses on the evidence base insufficient and inadequate evidence on the pertaining to the status, major milestones, availability of services for MNH in urban areas problems and challenges with regard to the urban and, secondly, whatever evidence is available MNH in India, the existing supply side agencies shows an absence of any defined structures and and its linkages, and the existing financial mechanisms to deliver services for mothers and mechanisms and budgetary provisions for the newborns in urban poor settings. In the end, the urban MNH. review sets out suggestions not only in terms of

requirement of evidence on the aspects of service The findings of the review can be distinctly provision and service delivery mechanism in classified under two different pieces. The first urban settings but also reflects the need for piece reveals the gaps in terms of current undertaking rigorous research in the area of urban availability of health services to deliver MNH care maternal and newborn health which continues to along with the clearly defined paucity of service remain an untouched area of research and delivery platforms, governance and mechanisms learning.inclusive of infrastructure, human resources,

logistics, supply chain, partnerships and Though the study reflects that the evidence base community, level efforts. The second piece focuses with regard to the existence of specific policy on the gaps with regard to the availability of instruments for this purpose is still being literature and evidence from the research developed, nevertheless, it provides a direction to undertaken in all of the abovementioned aspects of future researchers and policy-makers as to what health service delivery for MNH care. needs to be done to ensure that MNH care services

are delivered to the urban poor.While maximum data is available mostly on social

Key Findings

l There is an overall lack of clarity with regard to the ultimate responsibility of providing health services and the information on service-provision mechanisms reveals that the health services, vary from city to city. While a few large cities such as Mumbai, Kolkata, and Chennai have used the Indian Population Project to focus on the health infrastructure establishment in urban slums, just a few large Municipal Corporations with good revenue resources have demarcated special resources to provide urban MNH services.

l There is no mechanism for a health worker to make community or home visits; thus; no holistic outreach and follow-up services are available for MNH.

l Referral services are available in corporation hospitals/ district hospitals/ medical college hospitals as well as in several private hospitals. There is no definite system of referral; no linkages between domiciliary, health centre and hospital; and no protocols for admissions to the primary, secondary and tertiary levels.

l Private health providers are the key players in the overall provisioning of services. Multiplicity of providers and lack of coordination among them has led to dysfunctional referral systems and a consequent overload on tertiary-care providers.

13Maternal and Newborn Health in Urban IndiaA report on literature review


l

been neglected, there are exceptions of larger metropolises such as Mumbai and Delhi that provide primary healthcare by means of dispensaries, health posts and maternity homes.

l The urban health posts (UHPs) are located mainly in big towns. Small towns continue to be deprived of these facilities.

l The findings of the NFHS-III reflect that the private sector is the main provider of healthcare for a majority of people living in urban areas and the main reason for non-utilisation of public facilities is the poor quality of care.

l The literature does not reflect on the aspects such as staffing mechanisms, training, job satisfaction, appraisals and career development of the staff engaged for MNH care.

l Very little information could be traced on details of the guidelines or protocols for the functioning of primary and secondary level healthcare systems or the logistics required for MNH.

l There is no information available on processes adopted for supply chain management, especially training procedures for staff at the primary and secondary levels to manage the supply chain for drugs & equipment and co-ordination with the blood banks & referral support.

l Lack of research in terms of availability and accessibility of services that may concern women living in urban slums comes across as a great deficiency. The existing literature also hints at the existence of private bodies. However, this does not extensively map the same.

l Various studies reflect on the lack of uniformity in delivery/provision of health services within and across cities. However, these hardly touch on the opportunities for the marginalised at the health service centres, especially for MNH.

l The evidence gathered from the National Health Systems Resource Centre’s (NHSRC) city-visit reports indicates a paucity of information on guidelines that govern the health service system and the detail on the facilities available for MNH.

l While some studies do mention the type of facilities providing MNH services which are accessible to the urban poor, it lacks analysis in terms of its functioning, efficiency, governance and monitoring mechanisms.

l Reliable and consistent information on health informatics is scarce. Little or no efforts have been made to conceptualise mechanisms or/and to capture disaggregated, discrete data on health service availability and its performance in relation to urban MNH across cities and states.

l The information from the Health Management Information System (HMIS) features largely around NRHM and the information available for urban and semi-urban places is abysmal. The websites of the National Institute of Health and Family Welfare (NIHFW), NHSRC and urban local bodies (ULBs) such as the Municipal Corporation of Delhi (MCD) mostly include information on communicable diseases, sanitation and hygiene.

l While a number of documents reflect on the role of State Health Departments, Municipal Corporations (MCs), Town Councils, and ULBs in the health sector in general, literature that examines the roles of these bodies in the provision of MNH service is very scanty.

l Very little and inconsistent information is available on financing patterns, the role of local bodies in budget planning, the process adopted for sustaining projects and the decision making in relation to the same across a majority of the cities, especially in urban and semi- urban locations. No information is available on the budgetary allocation process for maternal and newborn health except for some small-scale cash-transfer programmes that exist in various states.

While primary healthcare in urban areas which the poorest sections can easily approach has largely

14 Maternal and Newborn Health in Urban India A report on literature review


This report is organised into the following sections: -

Outline of the Report

Section III presents the findings with regard to each of the components reviewed, and has sub-sections on Service Delivery; Infrastructure; Human Resource; Logistics and Supply-Chain Management; Community-Level Inputs/Processes/Interventions; Governance Mechanisms and Leadership; Financing and Sustainability; Partnerships and Networks; and Inter-sectoral Coordination.

Annexure 1: Evidence tables of the literature reviewed.

Annexure 2: Tables on city-wise programmes, schemes and innovations.

Section I is the introduction that provides an overview of the growing urbanisation in the country, the global, and the Indian urban maternal and newborn health scenario.

Section II focuses on the methodology used in the review and the scope of the study, along with the research questions it intends to address.

Section IV summarises and discusses the results, assesses the strength and weakness of the evidence base, and provides conclusion.



Background

The Urban Context

Being the world's largest democracy, the second most populous country (1.21 billion as per Census 2011) and the tenth largest economy (with a Gross Domestic Product of US$ 1377.3 billion in 2009), India has undergone extraordinary socio-economic and demographic changes. The population pyramid of India has evolved, with an increase in both the very young and the ageing population. An urbanisation process with megacities and expanded shanty-towns has witnessed a 4.6-fold increase between 1951 and 2001, compared to only a 2.8-fold increase in the total population.

For the past 30 years, the geographically-wide, densely-populated and enormously-varied Republic of India has made remarkable efforts in the field of health. The list of initiatives include the adoption of a

rd thNational Health Policy in 1983; the 73 and 74 Constitutional Amendments devolving power to local institutions in 1992; the National Nutrition Policy in 1993; the National Health Policy, the National Policy on Indian System of Medicine and Homoeopathy and Drug Policy in 2002; the introduction of simple health insurance schemes for the poor in 2003; the inclusion of health in the Common Minimum Programme of Government in 2004; the initiation of the National Rural Health Mission in 2005; the development of a strategic framework on RMNCH+A in 2013 and the recently launched National Health Mission with a sub-mission (NUHM) on Urban Health, as one of the key components.

While India accounts for 21% of the world's global burden of disease, and is home to the greatest burden of maternal, newborn and child deaths in the world, there has been a significant achievement with regard to reductions in the Infant Mortality Rate (IMR) from 83 per 1,000 live births in 1990 to 44 per 1,000 live births in 2011, and Maternal Mortality Ratio (MMR) from 570 per 100,000 live births in 1990 to 212 in 2007–2009. Achieving of Millennium Development Goals (MDGs) 4 (reduce child mortality) and 5 (improve maternal health) guided the efforts on ensuring the progress on both the supply and demand side and helped in expanding the availability of effective Maternal, Newnorn and Child Health (MNCH) care services. The most frequently occurring and formidable challenges of modernising the health system, reducing the high out-of-pocket expenditures, addressing the insufficiency &uneven distribution of staff, balancing the service provision (overwhelmingly in private hands) and its quality, and ensuring a better alignment of regulation with present-day needs, continue to remain.

India's urban growth has been described as following a '2-3-4-5' pattern: annual population growth of 52%, urban population growth of 3%, mega-city growth of 4% and slum population growth of 5% . The

urban population increased from 28.6 crore in 2001 to 37.7 crore in 2011. Urban Indians live across 7,935 6towns and cities, of which 468 have populations of at least 100,000 . Nearly 50% of the urban population

of India lives in just five states, namely, Maharashtra, Uttar Pradesh, Tamil Nadu, West Bengal and Andhra Pradesh. Uttar Pradesh, which has just 22% of its population living in urban areas, accounts for almost one-fourth of the total urban population of these five states, purely due to its population size.

Urbanisation is often thought of as being beneficial to economic and social growth and gains, which is what prompts rural populations to migrate to the cities for a better life and better prospects. However, most Indian cities do not have the requisite infrastructure to be able to provide the population with basic amenities such as health. This adversely affects the well-being and health of especially the urban poor. Unaccounted for populations such as the migrant workers and shifting definitions of areas of habitat such as slums, have led to the marginalisation of the urban poor, living alongside drivers of economic growth in India. Being in urban conditions does not provide any advantage to the urban poor.

I. Introduction

5 Source: p.2, Water and sanitation for Urban Poor: Expansion and exclusion? A Briefing Paper on Related Policies, published by Health of the Urban Poor (HUP) Programme, Population Foundation of India, (September 2012).

6 74 cities have been added to this list since Census 2001, which reflects a rapid increase.



The urban poor are seen as a homogenous entity, which they are not. Such a broad definition leads to a greater marginalisation in the provision of basic amenities, because it does not take into account sections of the urban poor population which are excluded, illegal and unaccounted for. As a result, services and provisions do not take them into account and do not reach them. A broad view of the urban poor only plans for services to be delivered to slums, which themselves are not a constantly defined habitat; it also neglects other urban poor populations such as the homeless, migrant labourers, daily-wage workers, construction workers, rag-pickers, people who are institutionalised- male, female & transgender, sex workers and other groups who may not necessarily live in slums, but are socially, economically and

7geographically marginalised in cities .

Various studies have assessed and identified vulnerability factors amongst the slum population that need to be looked into while sketching an overall health programme for the urban population. These have been categorised as residential or habitat-based vulnerability; social vulnerabilities; and

8occupational vulnerabilities .

On the basis of the health burden, it has been found that the vulnerable populations face innumerable barriers, with respect to accessing the public health services, which results in an aversion to seeking care from health centres. Some of the key factors are: lack of comprehensive primary care service in public facilities; ill-timed consultation and long waiting hours; improper location of and long distances to public health services; and disrespectful behaviour by the health providers.

Health outcomes of newborns are shaped by biological factors. Further, the social, economic and cultural environment, make the task complex and demanding. Newborn health is inter-dependent on the health of mothers. Though India has been at the forefront of the global effort to reduce maternal &child mortality and morbidity, given its demographic and cultural diversity, it does face numerous challenges with significant rural-urban, poor-rich, gender, socio-economic and regional differences. Furthermore, maternal and newborn mortality varies considerably between states and regions. Various efforts have been made to address these multi-layered hurdles in achieving optimum MNH care in India. While the two path-breaking interventions, National Rural Health Mission (NRHM 2005) and RMNCH+A strategy (2013), provided unprecedented attention and resources for maternal and newborn health with a focus on rural India, the latter specifically focused on a paradigm shift in perspectives based on the continuum-of-care approach and health system strengthening.

Interventions under NRHM have definitely led to a noticeable increase in the utilisation of hospitals for childbirth, and have resulted in encouraging progress in reducing maternal and newborn mortality rates in rural areas faster than the urban. Thus, a growing realisation that there must now be a more focused approach toward urban MNH, specifically targeted toward the needs of the urban poor, has emerged in the last few years.

Over the years, various committees, such as the Bhore Committee 1946, Jungalwalla Committee 1967, Bajaj Committee 1996, Mashelkar Committee 2003 and the National Commission on Macro-economics and Health 2005 have suggested ways to strengthen the health sector. More significant for policy formulation has been the share of urban population to the total population, which has grown substantially from 1951 to 2011.

On the recommendations of the Krishnan Committee, under the revamping scheme in 1983, the Government established four types of UHPs across 10 states and union territories with a pre-condition of locating them inside or close to the slums. The main functions of the UHPs are to provide outreach, primary healthcare and family welfare as well as MCH services. In reality, however, limited outreach

Maternal and Newborn Health: The Indian Scenario

Health Structures in Urban India

7 Report and Recommendation of the Technical Resource Group for The National Urban Health Mission, MoHFW (2014).8 Report and Recommendation of the Technical Resource Group for The National Urban Health Mission, MoHFW (2014).



activities are being undertaken by the UHPs. Due to the rapid growth of the urban population, efforts were made in the metropolitan cities of Chennai, Bengaluru, Kolkata, Hyderabad, Delhi and Mumbai for improving the healthcare delivery in the urban areas through the World Bank-supported India Population Project (IPP). Only the IPP cities are conducting some outreach activities as community link workers are employed to strengthen demand and access. Limited outreach activities through the provision of link volunteers under the RCH are visible in Indore, Agra, Ahmedabad and Surat.

thThe Government of India's 12 Five Year Plan builds on the National Rural Health Mission and converts it into a National Health Mission for the whole country. In doing so, it incorporates the developing National Urban Health Mission as a sub-mission.The NUHM aims to meet the healthcare needs of the urban population, with a focus on the urban poor, by making essential primary healthcare services available to them and reducing their out-of-pocket expenses for treatment. This will be achieved by strengthening the existing healthcare service delivery system, targeting the people living in slums, and converging with various schemes relating to the wider determinants of health (such as drinking water, sanitation, and school education), implemented by the Ministries of Urban Development, Housing and Urban Poverty Alleviation, Human Resource Development, and Women and Child Development.

The NUHM endeavours to achieve its goal specifically through a need-based, city-specific, urban healthcare system that will meet the diverse healthcare needs of the urban poor and other vulnerable sections, and through institutional mechanism and management systems to meet the health-related challenges of a rapidly growing urban population. In response to the needs for convergence and public health management, the NUHM envisions that every municipal corporation, municipality, notified area committee and town panchayat will be a planning unit in its own right, with its own approved norms for setting up health facilities. These urban local bodies will prioritise services for the urban poor (in both listed and unlisted slums) and for vulnerable groups, such as the homeless, rag-pickers, street children, rickshaw-pullers, construction and brick &lime kiln workers, and sex workers.

The NUHM is currently setting up well-identified, primary healthcare facilities for each segment of the target population that can be accessed conveniently. The UPHC will act as a common platform for availability of all services. Mechanisms of referrals should be operationalised to make the PHC effective; the PHC will also provide outreach services. This will be done by the female health worker, who will be provided mobility support for this purpose. Services will be universal in nature. Community participation will be encouraged by a community link volunteer (Urban ASHA). Creation of community-based institutions, such as Mahila Arogya Samiti (MAS) involving 50-100 households will empower women so that they can demand services.

National Urban Health Mission: The Most Recent Mandate

Structural and Human Resource Propositions of the NUHM

Proposition Serving

Urban Primary Health Centre

U-PHC

50,000 to

60,000 population

Urban Community Health Centre

U-CHC

250,000 to

360,000 population

Five to six U-PHCs in larger cities

Auxiliary Nurse Midwife

ANM

10,000 population

Accredited Social Health Activist

Urban Social Health Activist

ASHA

(USHA)

200 -

500 households

1,000 –

3,000 population



MNH in Urban Poor Settings

While half of India's population is expected to reside in urban areas by 2030, little is known about the appropriate delivery mechanisms or effective intervention strategies for the urban areas. Urban poor newborns are more vulnerable to many health problems as compared to the non-poor urban counterparts. Evidence from NFHS-III indicates that neo-natal mortality among the urban poor (NMR 37/1000 live births) is higher as compared to the urban average (NMR 29/1000 live births). Similarly, analysis of the NFHS-III (2005-2006) data shows that the NMR among the poorest 20 percent of the population is more than double the NMR of the richest 20 percent. The Urban Health Resource Centre looked at urban data from NFHS-III for 8 cities and found that women in the poorest quartile were substantially less likely to make at least three ante-natal care visits (54% compared with 83%) and to have a birth assisted by a health provider. Their children had higher under-five mortality rates, lower immunisation rates (40% compared with 65%) and higher proportions of stunting (54% compared with

933%) . It is important to note that, while data is available for MNH in urban India, reliable & disaggregated urban data or census data that include slums — focusing on the most vulnerable city-dwellers (often not counted)—is completely absent.

The challenges facing MNH for the urban poor in India are many. The inequities and social exclusions that plague the urban poor lead to inequities in accessing services and systems such as ANC care. The environment that the urban poor live in is not conducive for health and well-being, further aggravating their problems. The mandate for provision of municipal services is unclear when settlements are not notified and their residents do not have tenure, with implications for water supply and collection of waste. There is a lack of co-ordination and convergence between the relevant departments dealing with water and sanitation, housing, transport and health. Thus, the paper trail is sketchy, accountability is minimal, and transport is often the responsibility of the family. For maternal and newborn care, there is a lack of norms for service provision at different levels of health facility. No protocols exist for identifying women at risk and referring them for specialised care.



9 NFHS 3

Maternal and New Born Urban Health in Urban India A report of literature review and secondary data analysis

II. Methodology

Objectives of Review

Research Questions

Methodology

This review was undertaken to systematically identify and synthesize evidence from the available literature on the current status of maternal and newborn healthcare services in urban India, particularly with respect to specific components of the health systems and the urban poor population. Additionally, an attempt was made to identify innovations and case studies of the best practices, with reference to their potential for scaling-up. The exercise is expected to help in developing a compendium of relevant literature available on the maternal and newborn health services for the urban poor population in India. This would help the planners, programme managers and researchers in not only identifying the factors and gaps in information affecting delivery of MNH services for the urban poor population, but also plan and design future approaches/models for effective coverage of these services within the context of the NUHM.

a. What are the issues, problems and challenges with regard to urban MNH in India? Specifically with regard to: Service Delivery; Infrastructure; Human Resource; Logistics and Supply-Chain Management; Community-Level Inputs/Processes/Interventions; Governance Mechanisms and Leadership; Financing and Sustainability; Partnerships and Networks; and Inter-sectoral Co-ordination

b. Why do these problems and challenges exist; what are the specific reasons?

c. Which are the various supply-side agencies? What have been their successful interventions along and what are the existing linkages on the supply-side?

d. What are the financial mechanisms and budgetary provisions that exist for the urban MNH?

A systematic literature search was planned to identify evidence on the above-mentioned questions and specific criteria were defined for study selection. These criteria were: –

a) Population: All relevant studies available on maternal and newborn health services for the urban poor population. Studies on rural or peri-urban populations were not included.

b) Interventions: Any study pertaining to selected supply side parameters of health system for the delivery of maternal and newborn health services as given under the WHO framework was included. The parameters were: infrastructure, human resources, logistics & supply-chain management, community-level inputs/processes/interventions, governance mechanisms, financing, partnerships and networks and inter-sectoral coordination. There was no restriction regarding the source of funding for the intervention; that is, both public and private sector-funded initiatives/programmes were included.

c) Time period: Interventions and programmes that had been implemented and/or studied over the last 10 years were included.

The review aimed at focusing on interventions and programmes, which had been implemented in



Maternal and New Born Urban Health in Urban IndiaA report of literature review and secondary data analysis

sizeable urban poor populations, in order to lend themselves to scalability. However, as the review progressed, it became clear that there were very few studies available using the pre-defined criteria and, hence, the initial selection criteria were expanded to include:–

l All interventions and programmes on the delivery of maternal, newborn and child health services.

l All interventions and programmes for the urban poor population, irrespective of population size coverage.

Despite expanding the criteria, only limited literature was identified from the public domain. As a result, the search strategy was expanded to include not just grey literature from manual search and cross-referencing, but also literature identified by interviewing subject experts. Moreover, due to lack of sufficient and credible evidence available from the published studies, the design was modified from a systematic literature review to a narrative/descriptive and thematic review of available literature.

Three data sources were used to collate the evidence: 'computer/ internet-based search', 'manual research' and 'interviews with subject experts'. For the Internet-based search, a combination of free-text words and MeSH words were used to systematically search electronic databases. This process was supplemented by manual search of the grey literature (any unpublished thesis, project report, evaluation, survey etc.), the literature identified from cross-referencing and literature identified by subject experts during interview. Subject experts were interviewed telephonically and/ or in face-to-face meetings using an open-ended questionnaire. Based on their information, efforts were made to contact the local authorities, organisations and institutes concerned, so as to access the relevant literature.

All the studies identified through the search process were indexed for de-duplication and screening. Two review authors independently examined the titles, abstracts and keywords of electronic records according to the eligibility criteria. The results of this initial screening were cross-referenced between the two review authors, and full-text records obtained for all potentially relevant reports. Any disagreements between the two reviewers were resolved by discussion with the review supervisor. Altogether, 300+ sources, over 385 documents and 40+ experts were reached out, to collect the relevant information.

In addition to the above, secondary analysis of the existing data from the urban MNH programmes, processes and large-scale surveys in different parts of the country, was undertaken to substantiate the desk review findings.

The data collected was classified in a theme-based matrix, and further organised in an Evidence Table to tabulate the details of the key aspects that the articles covered .

10The Thematic Synthesis method was used to synthesise and analyse the findings. This enabled the review team to synthesise findings from multiple qualitative studies by identifying the recurring themes or issues in the primary literature, analysing these themes, and drawing conclusions in the review. The purpose of this method was to develop analytical themes through a descriptive synthesis and find explanations relevant to a particular review question. This method was developed to address specific review questions about the need, appropriateness and acceptability of interventions, as well as the effectiveness of the same. The entire process of the literature review is depicted below:–

Search Strategy

Data Collection and Analysis

10 ‘A guide to synthesising qualitative research for researchers undertaking health technology assessments and systematic reviews', Ring N., Ritchie K.,

Mandava L., Jepson R., NHS Quality Improvement, Scotland (2011).



Challenges and Limitations

Initially, the research was planned as a systematic literature research for relevant information, following standard methods of search and literature review. Hence, the inception report and research protocol that were developed, were in keeping with this methodology (Please see Annexures 1 and 2).

However, the research surmised that there was a significant shortage of specific information related to maternal and newborn health services in urban India especially for the urban poor population. This was further complicated by the absence of credible information available on the identified supply side parameters of the health system. More work seemed to have been done on the implementation and research on the demand side and the community accessibility perspective, primarily on the barriers (most commonly, social determinants) while accessing MNH care in the urban areas. Inadequacy also prevails in the innovations and best practices attempted in the areas identified for this exercise.

Moving toward specific health system parameters, information was available for some of these; such as community interventions, human resources and service delivery, where interventions and innovations have also been attempted. However, some of the other parameters; such as supply chain management, logistics, partnerships and inter-sectoral convergence were conspicuously absent with evidence. Moreover, the majority of the available literature was targeted at small population sizes, thereby reducing its application for scalability. Another key limitation was that, where there were interventions or innovations, many were either not documented or were documented inadequately, leaving a large information gap.

Most of the documents that could be accessed were reports, opinion documents and articles, and commentaries. Published studies with a large sample size and statistically significant results covering various sub-sections of the supply side were largely not available. The studies were found to be numerically and statistically insufficient in many sections. While there were some quantitative studies and qualitatively rich research reports, they were mostly for one or two themes, rather than for all the aspects. The researchers also had to face inaccessibility of critical and specific UMNH data, especially with regard to city public health systems & HMIS. An intense snowballing efforts did pave access to a few useful documents; however, they were not yet in the public domain and could not be referenced, as they couldn't be off-the-record insights. Most of the articles covered overlapping themes and therefore



Potentially relevant articles identifiedafter intense electronic search ~ 400

Articles included fromelectronic search ~ 300

Studies from electronicsearch retrieved for moredetailed evaluation ~230

Studies from electronicsearch excluded (after

evaluation of full text) fromreview with reason ~10

Relevant studies includedin the review ~ 220

Experts in field contacted forfeedback on protocol & provide

information for manual search + 40

Studies from manualsearch retrieved for moredetailed evaluation ~20

Studies from manualsearch excluded (after

evaluation of full text) fromreview with reason ~10

Relevant studies includedin the review ~ 10

Synthesis of all studies included in the review

LITERATURE REVIEW PROCESS

impeded segregation. At the same time, these articles did not provide very useful information on possible solutions on those overlapping and multiple themes.

THOT Consultants, a New Delhi-based social and healthcare communications and advocacy consultancy, was commissioned by the Saving Newborn Lives programme of Save the Children to synthesise quality evidence to identify opportunities and gaps in-the health system; factors affecting programming and service delivery; and potential strategies to address the specific MNH care needs of the urban poor in India.

Who has conducted the review?



A. Service Delivery Mechanisms, Logistics and Supply-Chain Management

Service Delivery Mechanism: The Basic Mandate

This section focuses on service delivery mechanisms for MNH, specifically the currently available health services and existing service delivery platforms in the urban areas. The literature reviewed in response to this research question was divided into three sub-sections: service delivery platforms, infrastructure, and logistics and supply-chain management. Though these appeared as three separate areas of enquiry at the very beginning of the study, insufficient or limited literature and inter-linkages between the three resulted in a combined section focusing on all three functional areas.

First and foremost, it is important to understand the definition of service delivery mechanism in general. According to the WHO framework, service delivery is one of the 6 core components or 'building blocks' that define health systems. All women need access to good quality maternal health services during pregnancy, delivery and in the post-partum period to ensure their health and that of their infants, irrespective of the status of their pregnancy. Hence, access to and utilisation of quality health services is

111213an important proximate determinant of maternal mortality . This includes the delivery of interventions to reduce neo-natal, infant, child and maternal mortality, and the burden of various preventable communicable diseases. Service provision or delivery is an immediate output of the inputs into the health system, such as the health workforce, procurement, and supplies and finances. Increased inputs should lead to improved service delivery and enhanced access to services. Ensuring availability and access to health services is one of the main functions of a health system. Such services should meet a minimum quality standard. Different terms such as access, utilisation, availability and coverage are

14often used interchangeably to reflect whether people are receiving the services they need .

Some key characteristics of a good service delivery, which are accepted as necessary in any well-functioning health system, are:

1. Comprehensiveness: A comprehensive range of health services is provided, appropriate to the needs of the target population, including preventive, curative, palliative and rehabilitative services and health promotion activities.

2. Accessibility: Services are directly and permanently accessible with no undue barriers of cost, language, culture or geography. Health services are close to the people, with a routine point of entry to the service network at primary care level (not at the specialist or in hospital level). Services may be provided in the home, the community, the workplace, or health facilities, as appropriate. Access is a broad term with different dimensions.

3. Coverage: Service delivery is designed so that all people in a defined target population are covered, i.e. the sick and the healthy, all income groups and all social groups.

4. Continuity: Service delivery is organised to provide an individual with continuity of care across the network of services, health conditions, levels of care, and over the life-cycle.

5. Quality: Health services are of high quality, i.e. they are effective, safe, centered on the patient's needs and are given in a timely fashion.

6. Person-centered/ Responsive: Services are organised around the person, not the disease or the

III. Findings

11Bhatia, J.C. (1993). Levels & Causes of Maternal Mortality in South India. Studies in Family Planning, 24(5), 310-318.

12 McCarthy,J., and Maine,D. (1992).A Framework for Analyzing the Determinants of Maternal Mortality:Studies in FamilyPlanning, 23(1), 23-33.13 Fauveau,V., Koenig M., Chakraborty, T., and Choudhary, A. (1988). Causes of Maternal Mortality in Rural Bangladesh; 1978, 1985. Bulletin of WHO, 66(5)

643-651.14

Tanahashi, T. (1978). Health Services Coverage and its Evaluation. Bulletin of the World Health Organization, 56:295–303.



financing. Users perceive that health services are responsive and are acceptable to them. There is participation from the target population in the design and assessment of service delivery. People are partners in their own health care.

7. Coordination: Local area health service networks are actively coordinated, across types of provider, types of care, levels of service delivery, and for both routine and emergency preparedness.

8. Accountability and Efficiency: Health services are well managed so as to achieve the core elements described above, with a minimum wastage of resources. Managers are allocated the necessary authority to achieve planned objectives and held accountable for overall performance and results.

9. Availability refers to the physical access or reachability of services that meet a minimum standard. The latter often requires specification in terms of the elements of service delivery, such as basic equipment, drugs and commodities, health workforce (presence and training), and guidelines for treatment.

10. Affordability refers to the ability of the client to pay for the services.

11. Acceptability of the service predominantly has a socio-psychological dimension and is a pre-condition for quality.

The process of developing a healthcare delivery system in urban areas has not as yet received the desired attention. Unlike the rural health services, there have been no efforts to provide well-planned and an organised primary, secondary and tertiary care services in geographically delineated urban areas. As a result, in many areas primary health facilities are not available; the limited but the existing primary care services remain underutilised while there is over-crowding in most of the secondary and tertiary

15centres .

The Constitution of India mandates that primary healthcare in urban areas is the responsibility of the Urban Local Bodies (ULBs). As of now, the country has four types of urban health posts, A, B, C and D. The Urban Family Welfare Centres are also of three types, I, II and III. They differ mainly in staffing patterns and, accordingly, in the services provided. They are supposed to mainly provide integrated Reproductive and Child Health (RCH) care. According to the Report and Recommendations of the Technical Resource Group, National Urban Health Mission (TRG, NUHM), Ministry of Health and Family

16Welfare, 2014) , it identifies three broad institutional patterns from the perspective of which government 17takes primary responsibility for organising healthcare in the city .

In the first pattern, healthcare facilities are entirely provided by the state departments of health, with no involvement of the Urban Local Body (ULB). There is usually a Municipal Health Officer who is in-charge of a number of non-medical services relating to public health, but even this post is often vacant or lacks the necessary support staff and importance. This is the pattern in all urban areas of states such as Himachal Pradesh and Bihar, and in small towns (typically less than 2 lakh population) in almost all the states.

In the second pattern, a minority of care provision is by healthcare facilities under the ULB and this role is receding. Typically, it is usually a maternity hospital and a few UHPs/ dispensaries and sometimes a cadre of health volunteers who are under the ULB. For the main part, it is the district hospital or medical college hospital that provides the healthcare services and there may be some UHCs under the state government as well. Bhubaneswar is a typical example of this.

In the third pattern, most of the healthcare facilities are under the ULB, which looks after the medical and non-medical public health functions in an integrated manner. The state government may have a few

Health Service Delivery in Urban Areas

15 Planning Commission, Government of India ; Tenth Plan Document (2002-2007, Volume II)16

NUHM (2014). Report and Recommendation of Technical Resource Group for the National Urban Health Mission. New Delhi: Ministry of Health and Family Welfare, Government of India.

17 rd th th73 and 74 Constitutional Amendment Acts (12 Five Year Plan, 2012).



facilities, usually medical college hospitals; but the rest of the functions are delivered effectively by the ULB. This is the pattern in all the major metros: Mumbai, Kolkata, Chennai, Bengaluru, Ahmedabad and Delhi, though in the last the state government too administers several facilities. Among the non-metros, Pimpri- Chinchwad Municipal Corporation, Visakhapatnam, Burdwan and Madurai show this pattern.

Primary care is being accessed at all the five levels: medical college hospitals, secondary care hospitals (two levels), primary care facilities and outreach services. In terms of the frequency of use, an inverse pyramid phenomenon works. The major proportion of curative primary care provision may be occurring at the medical colleges and the district hospitals, with the urban health centres and maternity homes catering to a much smaller proportion and almost no care being delivered at the outreach or community level for a major part of the population. This does not happen to such an extent in a rural setting, because of the distances. However, in urban areas, geographical distance is not a major barrier, and since services are more assured at a higher level, the poor prefer to go there.

The National Urban Health Mission aims to address the health concerns of the urban poor through facilitating equitable access to available health facilities by rationalising and strengthening of the existing capacity of health delivery for improving the health status of the urban poor. This is to be done in a manner to ensure that well-identified facilities are set up for each segment of the target population, which can be accessed conveniently.

The NUHM proposes a broad framework rationalising the available manpower and resources, improving access through a communitised risk-pooling mechanism and enhancing participation of the community in the planning and management of the health care service delivery by ensuring a community link volunteer (Accredited Social Health Activist-ASHA/Link Workers from other programmes such as the JNNURM, ICDS, etc.) and establishment of Mahila Arogya Samiti (MAS) and

Health Service Delivery System as provided in the NUHM Implementation Framework



Public orempanelledSecondary/

Tertiary privateProviders

Urban Health Centre (One forabout 50,000 population - 20-30

thousand slum population)*

Strengthenedexisting Public

HealthCareFacility

EmpanelledPrivateService

providers

Community Outreach Service(Outreach points in government/ public domain Empanelled

private services provider)Urban Social Health Activist (200-500 HH)

Mahila Arogya Samiti (20-100 HH)

*This may be adapted flexibly based on spatial situation of the city

Refe

rral

PrimaryLevel HealthCare Facility

CommunityLevel

URBAN HEALTH DELIVERY SYSTEM

18Rogi Kalyan Samiti (RKS) , ensuring effective participation of urban local bodies and their capacitybuilding, along with key stakeholders, and by making special provision for inclusion of the most vulnerable amongst the poor, development of an e-enabled monitoring system. The quality of the services provided will be constantly monitored for improvement (IPHS/ Revised IPHS for Urban areas).

The framework states that all the services delivered under the urban health delivery system through the Urban-PHCs and Urban-CHCs will be universal in nature, whereas the outreach services will be targeted to the target groups (slum dwellers and other vulnerable groups). Unlike rural areas, sub-centres will not be set up in the urban areas, as distances and modes of transportation are much better. Outreach services will be provided through the Female Health Workers (FHWs), essentially ANMs with an induction training of three to six months, who will be headquartered at the Urban-PHCs. These ANMs will report at the U-PHC and then move to their respective areas for outreach services (including school health) on designated days. They will be provided with mobility support for providing outreach services. On other days, they will conduct Immunisation and ANC clinics at the U-PHC itself. Apart from these, quality antenatal care, including prevention and treatment of anaemia, institutional/safe delivery services, essential obstetric care, post-natal and neo-natal care is to be provided.

To further strengthen the delivery of services, the framework provides for cities to also periodically engage the services of specialist doctors to provide services at the U-PHC based on needs, on a reimbursement basis. The U-PHC can also serve as a collection centre for diagnostic tests in partnership with empanelled private diagnostic centres. Under the NUHM, a uniform healthcare service delivery mechanism with IPHS norms will be developed and the states would be encouraged to adopt these norms for the U-PHCs. Existing hospitals, including ULB maternity homes, state government hospitals and medical colleges, apart from private hospitals, will be empanelled/ accredited to act as referral points for different types of healthcare services; such as reproductive, maternal, newborn and child health.

Despite the supposed proximity of the urban poor to urban health facilities, their access to them is severely restricted. The lack of standards and norms for the urban health delivery system, when contrasted with the rural network, makes the urban poor more vulnerable and worse off than their rural counterpart. Many components of the NRHM cover urban areas as well. These include funding support for the Urban Health &Family Welfare Centres and Urban Health Posts, funding of National Health Programmes such as TB, immunisation, malaria, etc., urban health component of the Reproductive and Child Health Programmes (including support for the Janani Suraksha Yojana in urban areas), strengthening of health infrastructure such as District and Block level Hospitals, Maternity Centres under the NRHM etc. The only limitation has been the fact that norms for urban area primary health infrastructure were not part of the NRHM proposal, setting a limit to the support for basic health infrastructure in urban areas. Municipal Corporations, Municipalities, Notified Area Committees and Nagar (Town) Panchayats with their own distinctive normative were not units of planning under the NRHM.

One primary healthcare facility in an urban area caters to a much higher population as compared to the government norm of one centre for every 50,000 of the population. From the providers' perspective, service delivery in slums is an enormous challenge, given the large and sometimes mobile nature of the slum population. This leaves them with little scope for persuasion for appropriate behaviour with target families. In cities, particularly in the large ones, there is an over-emphasis on super-speciality care centres within the private sector, which are clearly out of the reach of the urban poor.

Currently available Service Delivery Platforms

18Rogi Kalyan Samiti (Patient Welfare Committee) / Hospital Management Committee is a simple yet effective management structure. This committee, which would be a registered society, acts as a group of trustees for the hospitals to manage the affairs of the hospital. It consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials from the Government sector who are responsible for the proper functioning and management of the Hospital / Community Health Centre / FRUs. RKS / HMS is free to prescribe, generate and use the funds with it as per its best judgement for smooth functioning and maintaining the quality of services.

19 NUHM framework: Table 17:1, Indicative Service Norms by Levels of Service Delivery. No. L 1907/1/2008-UH, Government of India. Ministry of Health & Family Welfare, Department of Health & Family Welfare.



thThe ULBs, in line with the mandate of the 74 Amendment, manage the primary healthcare services. However, in many cities, such as Delhi, the urban local body, (that is the Municipal Corporation of Delhi (MCD), the New Delhi Municipal Corporation (NDMC), the Delhi Cantonment Board and other para-statal agencies)and the state government jointly provide primary healthcare services.

Two models of service delivery are seen to be prevalent in urban areas. In states such as Uttar Pradesh, Bihar and Madhya Pradesh, healthcare programmes are being planned and managed by the state government. The involvement of the Urban Local Bodies is limited to the provisioning of public health initiatives, such as sanitation, conservancy provision of potable water and fogging for malaria. In other states such as Karnataka, West Bengal, Tamil Nadu and Gujarat, healthcare programmes are being primarily planned and managed by the Urban Local Bodies. In some of the bigger municipal bodies, such as Ahmedabad, Chennai, Surat, Delhi and Mumbai the medical or health officers are employed by the local body, whereas in smaller bodies, the health officers are mostly on deputation from the state health department. Andhra Pradesh has completely outsourced its service delivery to NGOs in the newly created 191 urban health posts across 73 towns. The experimentation, it appears, has been quite satisfactory, with reduced cost.

Seven metropolitan cities, viz. Mumbai, New Delhi, Chennai, Kolkata, Hyderabad, Bengaluru and Ahmedabad, will be treated differently. These cities are expected to manage the NUHM directly through their municipal corporations. Funds will be transferred to them through the state health society on the basis of their PIPs approved by the Government of India.

Efforts were made in the metropolitan cities of Chennai, Bengaluru, Kolkata, Hyderabad, Delhi and Mumbai for improving the healthcare delivery through the WorldBank-supported IPP. Under the programme, 479 urban health posts, 85 maternity homes and 244 sub-centres were created in Mumbai and Chennai as part of the IPP-V and in Delhi, Bengaluru, Hyderabad and Kolkata as part of the IPP-VIII. In several the IPP-VIII cities, partnerships with profit or not-for-profit providers has helped in expanding services. Kolkata had the distinction of implementing the programme through the establishment of an effective partnership with private medical officers and specialists on a part-time basis, fee-sharing basis in different health facilities, resulting in ensuring community participation and enhancing the scope of fund generation.

The Municipal Corporation of Greater Mumbai (MCGM) has a network of teaching hospitals, general

Sub District Hospital

Hospital

1. Civil Hospital

Hospital

2. Attached to Media Collage

Hospital

3. Municipal Corporation

Hospital

4. ESIS

Maternal and Child HealthCenters/ Homes



Urban HealthPost/ Center





Tertiary Level

Primary Level(Managed by MunicipalCorporation Council)

Secondary Level(Managed by MC/

State Govt.)

PERI

URBAN

URBAN PUBLIC HEALTH STRUCTURE



hospitals and maternity homes across Mumbai. In Kolkata, strong political ownership by elected representatives has played a positive role in the smooth implementation of the project and sustainability of the reforms introduced. Bengaluru and Kolkata have fully dedicated maternity homes in adequate numbers that facilitate better follow-up care. In Bengaluru, the management of health facilities has been handed over to the NGOs.

The following box reflects the different systems of urban healthcare present in India especially in the B-level cities or Tier II cities that are immediately next to the mega and metro, cities in the country. This gives an indication of the diversity of health delivery systems in urban India :

The Report and Recommendations of the TRG, NUHM, Ministry of Health and Family Welfare, 2014, notes that there is an inverse pyramid phenomenon when it comes to the organisation of healthcare services. The major proportion of curative primary care provision is occurring at the medical college and the district hospitals, with the UHC and maternity homes catering to a much smaller proportion, and almost no care occurring at the outreach of community level for a major part of the population. In rural settings, to some extent, it is the distances that disallow, such a pattern. But in most urban areas, geographical distance is not such a major barrier and since services are more assured at the higher site, the poor often prefer to go there. Another big issue in the organisation of primary care services is that primary healthcare in the urban setting is not population-based.

Typically, the urban peripheral facility, be it a health post or health centre, treats all those who come for

AgraIn 2004, the UHRC was designated by the Government of India as the coordinating agency for developing a sample health proposal for Agra city. The proposal was to guide the District Health Department as well as the Municipal Corporation to expand health services to the large urban poor population in the city. Based on the assessment, two approaches were followed, that clearly focused on: the involvement of NGOs to recruit and train Community Link Volunteers (CLVs), formulation of Mahila Arogya Samiti (MAS), and NGOs operating the Urban Health Centres, along with the facilitation of linkages between the community and the service providers

CoimbatoreThere are nearly 750 hospitals in and around Coimbatore with a capacity of 5,000 beds. The first healthcare centre in the city was started in 1909. In 1969, it was upgraded to the Coimbatore Medical College Hospital (CMCH). It is a government hospital with a bed strength of 1,020 and provides free healthcare. Including the CMCH, the corporation maintains 16 dispensaries and two maternity homes. The city also has many large multi-facility private hospitals. It remains the preferred healthcare destination for people from nearby districts and also from the neighbouring state of Kerala.

IndoreIn partnership with the Department of Public Health, the Municipal Corporation of Indore, the district administration, NGO partners and local communities, the Indore Urban Health City Demonstration Programme was initiated in March 2003. The programme operates with the objective of improving maternal as well as child health and nutrition among the slum dwellers. Two programme strategies, the demand-supply and linkage approach and multi-stakeholder ward coordination approach were developed in order to improve the health of slum-dwellers in a consultative manner.

PuneThePune Municipal Corporation has a robust health infrastructure comprising 34 OPD units,2 mobile healthcare units operated out of 11 urban health posts, 14 family welfare centres, one general hospital, two secondary hospitals, one special hospital for communicable diseases and one tertiary-care hospital.

LucknowHealth services in the city are provided by the Department of Medical, Health and Family Welfare, the Lucknow Municipal Corporation, the private sector, Railways Hospital, ESI Hospital & dispensaries and Cantonment Hospitals. Primary healthcare is provided through Tier I centres which include Urban Family Welfare Centres (UFWCs), urban RCH health, school health dispensary, medical care unit and urban RCH nodal unit.

Navi MumbaiInnovations in health infrastructure in 1992, led to the formation of a five-tier health system consisting of mobile clinics, 20 health posts, 4 maternity and child health hospitals (50-bedded), a general hospital and a super-speciality hospital. A total of 182 link workers were appointed by the NMMC under the RCH-II. Parallel to the RCH, Navi Mumbai rolled out the Sure Start Project and developed excellent mechanisms for maternal and newborn healthcare.

SuratIt has a four-tier system. The first tier comprises a link worker who provides home-based care and support. The second tier includes trained ANMs, trained doctors and visiting paediatricians at the UHCs. The third tier comprises maternity homes and the fourth tier consists of tertiary-care centres, the medical college hospital and civil hospital. Thus, most of the structure at the SMC is similar to the rural structure in Gujarat. The same administration and management pattern has been replicated in the urban areas.

Other Tier II or B-level cities: Key Features, Initiatives and Innovations



services; there isn't a priority responsibility for the health of the population in a defined catchment area. This lack of definition of a catchment area and the connection between the health centre to a given population base has a direct adverse consequence for reaching the vulnerable. Another consequence is that all outreach services are limited and this implies that those with latent illness or inadequate health-seeking behaviours are altogether missed.

Another pattern is that primary health services in most cities are restricted mostly to RCH services and, even within these, to family planning, immunisation and a limited quality of ante-natal care. This is a major reason for reliance on tertiary hospitals or private care providers. The NHRC reports from 31

20urban cities in India reflected that, despite being the key facility for providing RCH services in slum areas, post- natal care and newborn care have not been provided by most of these centres, as the ANMs deputed here are not trained to do so. Also, the weak referral mechanisms and poor facilities prevent them from being effective in primary healthcare provisioning. The primary health institutions should be managed by the local governments and ULBs/ PRIs in order to achieve decentralisation and enhance

rd th th 21local participation, as mandated in the 73 and 74 Constitutional Amendment Acts (XII Plan, 2012) .

The IPP- VIII completion report also states that multiplicity of agencies providing health services posed management and implementation problems in all the project cities.

In many urban areas the institution functions under a Municipal Health Officer, who should be a public health officer having qualifications for the same. In most of the states the healthcare centres are being taken over by the state department. So, the Municipal Health Officer often lacks his managerial leadership, which undermines both convergence and effective response if any disease breaks out (NHSRC, 2013).

According to the National Family Health Surveys (NFHS-III, 2006), maternal and child health has st nd remained an integral part of the family planning programme since the time of the 1 & 2 Five Year Plans

th (1951-56 and 1956-61). As part of the Minimum Needs Programme initiated during the 5 FiveYear Plan (1974-79), maternal health, child health and nutrition services were integrated with family planning services. In 1992-93, the Child Survival and Safe Motherhood Programme continued the process of integration by bringing together several key child-survival interventions with safe motherhood and family planning activities. In 1996, safe motherhood and child health services were incorporated into the Reproductive and Child Health (RCH) Programme.

22A brief review of the chapter on 'maternal health' in the NFHS-III report provides with details of the status of maternal health service and delivery platforms – ante-natal care services, assistance during child delivery and post-natal care services. The services and programmemes specific to urban maternal and neo-natal health cannot be found directly as it is integrated into the components of general health service system. According to the National Family Health Survey (NFHS-III) report on maternal healthcare services, there is a wide variation in the coverage and quality of antenatal care services, percentage of deliveries by trained professionals and the number of post-natal visits among the states and within the states, with considerable rural-urban differences.

Undoubtedly, India has experienced considerable improvement in accelerating coverage in MNCH care since the Millennium Declaration, 2000. However, the persistent inequity in access to maternal and newborn healthcare across different economic groups masks the average improvement in the majority of states. An important hurdle in addressing this issue has been the identification of the marginalised,

23deprived people who deserve special attention . Even the migratory nature of the population poses a

problem in the delivery of services. Similar concerns have also been raised in the IPP-VIII completion report which states the lack of homogeneity among slum residents, coming from the neighbouring

Limitations and Challenges in Expanding the Range of Services

20 Ahmedabad, Ambala, Aligarh, Bengaluru, Bardhaman, Bhopal, Bhubaneswar, Chennai, Delhi, Dhamtari, Gangtok, Guwahati, Indore, Jorhat, Kochi, Kolkata, Madurai, Mumbai, Muzaffarpur, Patna, Pimpri – Chinchwad, Pune, Raipur, Satara, Shimla, Trissur, Tumkur, Valsad, Villupurum, Vishakhapatnam, Viziangaram.

21Health Mission(NRHM) for the tweflth Five Year Plan (2012-2-17). New Delhi: Planning Commission, Government of India.22 NFHS-3. (2007). National Family Health Survey (NFHS-3), Volume I, (2005-2006). Mumbai, India: Indian Institute of Population Sciences (IIPS) and Macro

International.



states/countries to the large metropolitan cities, made planning and implementation of social mobilisation activities very challenging.

Limited budgetary allocation from the central and state governments is a hurdle. The current government health expenditure in India amounts to less than 1 per cent of the GDP (these account for less than 20 per cent of the overall health spending). Further, this ratio is not only low internationally but is even lower compared to our own past experience. This low spending on health and the dominance of private sources of financing make India unique. This reflects the very low priority that governments have

24accorded to the health sector (High Level Expert Group, 2011) .

Currently, the secondary level of care is provided by the District hospitals and their equivalents, like combined and base hospitals, while tertiary care is provided by the Medical Colleges. However, these are not linked to primary care institutions such as health posts or dispensaries. Consequently, patients approach tertiary hospitals for primary care, which could have been provided elsewhere. The emphasis should be on primary prevention, primary healthcare and secondary prevention, in that order. This

25approach would be cost-effective and optimise resources at all levels (WG NRHM,XII FYP, 2011) .

Primary healthcare in urban areas, where the poorest sections can easily approach it has largely been neglected. Larger metropolises such as Mumbai and Delhi provide primary healthcare by means of dispensaries, health posts and maternity homes. In Mumbai, a Public Health nurse usually heads them. They provide basic ante-natal care and primary healthcare through Community Health Volunteers. Maternity homes, headed by an MBBS Medical Officer, are meant for conducting normal deliveries and

26have support staff for the purpose .

27 A study aimed to find out different aspects and perspectives of a quality maternal care to bring about favourable changes to reach MDG-5, recommends that there is a strong need to improve both coverage & quality of maternal healthcare services with the special emphasis on early registration of pregnancy, percentage of deliveries attended to by skilled personnel, improvement in the consumption of IFA and the number of post-natal visits, in order to achieve the target sets in MDGs.

At the primary healthcare level, Delhi has a network of 987 clinics and dispensaries through theDelhi Government, MCD, NDMC, Delhi Cantonment Board, Central agencies (CGHS, ESIC) and Railways. Under the IPP-VIII, several maternity homes, health centres and health posts have been opened and are

28being run by the MCD (PHRN, 2010) . Multiple state agencies are providing services. There is an overlapping of services and a lack of coordination among these agencies. Private health providers are the key players in the overall provisioning of services.

The Urban Resource Centres (URCs) are one of the steps taken in response to the needs of the urban poor living in the slums. States such as Andhra Pradesh built 192 urban slum health centres with aid from the World Bank. After the end of the project, the State is running the centres with its own finances (USAID,

292006) . Public-private partnership models are adopted in most of the urban cities to address the needs of the poor living in the slums. Involving NGOs focusing mainly on service delivery, community

Limited Budgetary Allocation

Limited Reach and Scope of Primary Healthcare

Unclear and Overlapping Roles and Responsibilities

23Singh, Prashant Kumar, Rai, Rajesh Kumar and Kumar Chandan (2013). Equity in maternal, newborn, and child healthcare coverage in India,Global Health

Action, 6: 22217 - http://dx.doi.org/10.3402/gha.v6i0.22217.24

HLEG Report on UHC. (2011). High Level Expert Group Report on Universal Health Coverage for India. New Delhi: Planning Commission.25 th th

WG Tertiary Care XII FYP(2011). Report of the Working Group on Tertiary Care Institutions for the 12 Five Year Plan. New Delhi: Planning

Commission.26 National Health Policy, 2002.27 Kansal, S., Akhtar, M.A. and Kumar, Alok (2011)T Maternal Health Care Services in an Urban Setting of Northern India, International Journal of

Current Research, Vol. 33, Issue, 6, Pp.284-286, June.28

PHRN. (2010). Public Health Resource Network: Issues in Public Health, Book 16. Delhi: Capital Printers.29

USAID, (2006). Review of Public-Private Partnerships Models, published by PAIMAN (Pakistan Initiative for Mothers and Newborns).



collaboration, behaviour change communication and needs assessment of the urban poor living in the slums is also one common response adopted by the Governments towards MNH services. However, lack of institutionalised linkages lead to lack of coordination and, therefore, of accountability.

Multiplicity of providers and lack of coordination among them has led to dysfunctional referral systems and a consequent overload on the tertiary care providers. Even in states where primary healthcare is managed by ULBs, and secondary and tertiary healthcare by the state, the referral chain is not functional

30(NUHM, 2012) .

Das Gupta (2005) reviewed the state of public health in India and found several conditions and factors responsible for the poor state of public health in India. Some of these conditions reflect the limitations of public health in contemporary India and most of its states.

The private sector is the main provider of healthcare for a majority of the people living in urban areas 31(NFHS-III, 2007) . Private doctors and private clinics are the most commonly accessed source of

healthcare. Use of private hospitals increases with increasing wealth quintiles. However, the poor also utilise the private sector more than the public sector (NFHS-III, 2007). A study done in Mumbai from 2005-2007 showed that 16 percent of the women still preferred home delivery, citing reasons such as

32custom and tradition, rapid progress of labour and fear of hospital staff .

33An article by Fernandez, A. and Osrin, D ., describes the critical first steps taken to revitalise the vast public health system of Mumbai city through the active participation of personnel from within the system. It focuses on one of two components of an ambitious action-research project aimed at improving the survival and health of newborn infants and mothers living in slum communities in Mumbai. The article mentions that while the public health infrastructure is impressive in Mumbai, there are weaknesses in its provision for mothers and infants, and that the special needs of newborn babies are not

adequately recognised or addressed. Several inter-related factors are responsible for this weakness.

Tertiary hospitals tend to be overburdened as sources of routine pre-natal and delivery care; maternity homes, specifically oriented to the management of routine deliveries, are underused; there is limited or

no provision of pre-natal and post-natal care at health posts; inter-sectoral linkages are weak and patterns of referral between institutions have not yet been systematised; there is a lack of standardisation of clinical and administrative protocols, particularly in terms of coherence across a range of healthcare institutions; care provider efficiency and morale are low; and the coverage of home-based care and

home-visit systems for the vulnerable, newborn period is generally poor.

Medicalisation has resulted into substantial proportions of the urban health budgets being used for expanding subsidised medical training, public sector employment for medical graduates and high-end tertiary medical services. All of which benefit the middle classes and detract from the provision of public and primary health services in urban slums that are important to address the healthcare needs of the urban poor.

Secondly, there are no major programmes focused on strengthening urban community processes. Another important issue faced (NHSRC reports), is weak institutional mechanisms of urban primary healthcare services with other government-run schemes responsible for health determinants related to sanitation, drinking water and environment, along with Integrated Child Development Services. There

Narrowing of Public Health

Medicalization of all Financial Resources

30NUHM. (2012). National Urban Health Mission, Framework for Implementation. New Delhi: Ministry of Health and Family Welfare, Government of India.

31 NFHS-3. (2007). National Family Health Survey (NFHS-3), Volume I, 2005-2006. Mumbai, India: Indian Institute of Population Sciences (IIPS) and Macro International.

32 More, Neena Shah, Alcock Glyn , Das, Sushmita , Bapat, Ujwala , Joshi, Wasundhara, and, Osrin David (2010) 'Spoilt for Choice? Cross-sectional study of Care-seeking for Health Problems During Pregnancy in Mumbai Slums', Global Public Health, First published on: 27 October 2010 (iFirst) DOI:10.1080/17441692.2010.520725

33 Fernandez A, Osrin D (2006). The City Initiative for Newborn Health. PLoS Med 3(9): e339.DOI: 10.1371/journal.pmed.0030339. Fernandez, A., and Osrin, D.



is also no coordination between the private caregivers and UHCs, which results in duplication of services in certain areas and complete lack of services in other areas.

Studying systems alone may not give us the required answer. A study on health-seeking behaviour with regard to newborn care in urban slums and villages of Anand, Gujarat, revealed wide socio-economic

34gaps between slums and villages . It revealed that the proximity of the slums to two multi-specialty hospitals and smaller private hospitals did not improve utilization of services. Urban slum dwellers are ignorant about their health needs and also lack a positive attitude for seeking healthcare. Acceptability of existing public health infrastructure in both the areas was poor in contrast to the studies undertaken

35earlier . Neonatal follow-up, and care for infants that required medical advice, was largely provided by unqualified professionals as high as 72% in the slum areas.

36Similarly, a multi-centric study also found that education of immediate healthcare providers and mothers in basic newborn care is a must in urban slums, as similar provisions exist in villages under various government efforts. The study also describes a wide gap in newborn practices in slums of a smaller town as compared to the surrounding villages, which had better practices than slums. Urban slum dwellers were 6 times less likely to seek care. Not seeking ANC and illiteracy were also associated with more home deliveries. Though, a single district study did pose its limitations, similar gaps between rural and urban health settings undoubtedly exist not only in the rest of the state Gujarat but in most other states of India.

Responsiveness of the health system to the service-seekers is an important factor that directly impacts health outcome. This involves providing culturally appropriate services with adequate clinical quality. The latter is determined by the availability, efficiency and quality of human resources as well as by the adequacy and regularity in supply of essential commodities such as pharmaceuticals, blood, fluids, contraceptives, and consumables. To ensure these outcomes, the health systems need to provide adequate financing through revenue generation, risk- pooling, and efforts to enhance efficiency through

37competitive purchasing of services from the private sector (World Bank, 2005) . It is an accepted fact that rapid urbanisation in India is characterised by the growing poor/non-poor divides in health and utilisation of the MCH services.

38A study on the utilisation of maternal health services among pregnant women in the slums of Delhi suggested that the awareness and accessibility of healthcare equipped with modern maternity facilities has a significant influence on the health-seeking behaviour of women. Since, it may not be possible to establish a health facility staffed with a doctor or a nurse in every slum area of each city, there is a need to increase awareness of the community about benefits of using modern maternity care at nearby health centres for better health outcomes.

The available logistics and supply chain management mechanisms have not taken into account the real needs of the community. A number of studies undertaken across cities to understand the health-seeking behaviours and existing patterns of accessibility reflect that the Urban Health Centres (UHCs) continue to remain underutilised due to lack of medicines, inadequate or inefficient health functionaries, leading

Health-Seeking Behaviours of the Urban Poor

Lack of Responsive Healthcare

Logistics and Supply-Chain Management

34 Archana S Nimbalkar, Vivek V Shukla, Ajay G Phatak and Somashekhar M Nimbalkar, 2013. 'Newborn Care Practices and Health Seeking Behaviour in Urban Slums and Villages of Anand, Gujarat', Indian Paediatrics, Volume 50__April 16.

35Gupta, M., Thakur, J.S., Kumar R. Reproductive and Child Health Inequities in Chandigarh Union Territory of India. 2008. Journal of Urban Health, 85:291-9

36Srivastava, N.M., Awasthi, S., Mishra, R. (2008).Neo-natal Morbidity and Care-seeking Behaviour in Urban Lucknow. Indian Paediatrics, 45:229-32

37 World Bank, (2005). Achieving the Millennium Development Goal of Improving Maternal Health: Determinants, Interventions and Challenges; Health, Nutrition and Population (HNP) Discussion Paper. Eds. Lule, Elizabeth,. Ramana,G.N.V., Oomman, Nandini, Epp,Joanne, Huntington, Dale And Rosen, James E., The International Bank for Reconstruction and Development / The World Bank.

38 Agarwal, Paras. Singh,M.M. Garg, Suneela (2007). Maternal Health-Care Utilisation among Women in an Urban Slum in Delhi, Indian Journal of Community Medicine Vol. 32, No. 3, July.



to a strong preference for private services, especially in the case of MNH services (NHSRC DATA 39BASE) .

The situation worsens as one moves to semi-urban locations. A study conducted in Murshidabad town of 40West Bengal reflects that deliveries are mostly attended to by unskilled personnel. Factors such as

distance, connectivity and availability of infrastructural facilities play a predominant role in the 41underutilisation of maternal and newborn healthcare services . Dealing with a large number of

populations in most of the sub-centres increases the work pressure on the ANMs and affects the quality of work. Other infrastructural problems and logistical challenges such as the availability of life saving medicines and vaccines at the health centres compel them to go to private doctors. Nevertheless, the issues of affordability for seeking treatment and childbirth at the facility cost eventually results in

42women giving birth at home without any trained assistance .

In terms of logistics, major gaps were revealed in both the process of review of literature, as well as the issues pertaining to execution of the programme. The prime issue with the litertature available is that a very minor portion of the information deals specifically with the aspects of urban maternal newborn care and is eligible for dicussion on this topic. Some of the existing literature discusses the lack of trust from the communities, with respect to the system. From the literature reviewed, it is evident that the existing resources are underutilised, mainly due to under-staffed facilities and non-availability of services. Moreover, there is also a dearth of literature that focuses on protocols and guidelines with regard to the functioning of primary and secondary level healthcare systems and logistics, specfically for maternal and newborn health in urban spaces.

The insufficiency of logistics and supply chain management surfaces sharply from the data obtained 43through these studies . Inadequate ratio of health functionaries versus the population it is catering to,

lack of equipment and of trained personnel, are some of the shortfalls when one discusses Bhubaneswar city (NHSRC DATA BASE). Most of the ANMs and AWWs largely involved in the delivery of services, lack adequate training. The special programmes, such as JSSK and JSY, are not functioning well enough and provision of MNH services is restricted to immunisation and educating women for institutional delivery (NHSRC DATA BASE). The supply of medicines is inadequate to meet the demands of the people at the community level. To cover a population of nearly 30,000, medicines worth Rs. 6,000 are provided to each urban slum health centre every month. Apart from this, Rs. 5,000 is provided to buy the essential medicines to meet the need of OPD or outreach camps or emergencies; these funds are highly

44inadequate to meet the demand, both at the OPD and outreach camps .

Lack of information on processes adopted for supply chain management, training of staff at primary and secondary-level care, supply chain for drugs and equipment, availability of blood through blood banks and referral support for MNH care reflects a massive gap in secondary literature and calls for research on the availability and accessibility factors that concern pregnant mothers and newborns living in urban slums. The existing literature also hints at the existence of private bodies; however, it does not extensively map the same.

Convergence in the health sector occurs broadly at two levels: one is at the policy level and the other at the functional level. The matter of convergence at the level of policy- making, planning, and framing of

45programmes and schemes is very important for designing better implementation strategies (GOI, 2014) . At a functional level, convergence occurs at different levels via actions by various players, including health department officials and community health workers. Various actions are to be performed by

Convergence and Coordination: The Need of the Hour

39NHSRC DATA BASE (2014): City Study Reports.

40Shodhganga (2013),”Maternal and Child Healthcare Service in West Bengal – a Comparative Study”

41Shodhganga (2013),”Maternal and Child Healthcare Service in West Bengal – a Comparative Study”

42Devasenapathy, N., et al (2014)”Why Women Choose to Give Birthat Home: a Situational Analysis from Urban Slums of Delhi”,British Medical Journal,Downloaded from bmjopen.bmj.com on, September 27 2014 - Published by group.bmj.com

43NHSRC Database.

44 Bhubaneswar city report, NHSRC Database.45 GOI(2014), Understanding Urban Health : An Analysis of Secondary Literature and Data



46 GOI (2014), Reaching Health Care to the Unreached : Making the Urban Health Mission Work for the Urban Poor

47 Ibid GOI ( 2014), Understanding Urban Health: An Analysis of Secondary Literature and Data. 48

GOI( 2014), Reaching Health Care to the Unreached: Making the Urban Health Mission Work for the Urban Poor.49 GOI ( 2014) Reaching Health Care to the Unreached: Making the Urban Health Mission Work for the Urban Poor.50 Bannerjee M, Sharma D (2007) Exchange for the Maternal and Child healthCommunity Consolidated Reply. 51Ibid Bannerjee, M, Sharma D( 2007).

52 NHSRC data base ( 2014, Pune city report ).53 Acharya A, Paul MacNamee (2009),”Assessing Gujarat's Chiranjeevi' Scheme” Economic and Political Weekly.54 Ibid Acharya A, Paul MacNamee (2009),”55 Ibid Bannerjee M, Sharma D( 2007).56 Ibid Bannerjee M, Sharma D( 2007).57 GOI (2013) January 2013, A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India. For healthy

mother and child.58 GOI (2013), “NUHM, Implementation framework

59 Ibid Bannerjee, M., and Sharma D( 2007)

different departments in provisioning of health services by collective action (where the goal is set or defined) and different stakeholders engage in a coordinated, inter-departmental effort to achieve the

46broad goals (GOI, 2014)

An urban health programme focusing on the needs of mothers and newborns needs to promote both 47inter-sectoral as well as intra-sectoral convergence (GOI, 2014) . The required actions include

convergence with Ministries; such as the Ministry of Urban Development, Housing and Poverty Alleviation, Ministry of Women and Child Development, Ministry of Human Resource Development

48and core departments such as the Ministry of Health and Family Welfare(GOI, 2014) . The Health of the Urban Poor Project (HUP) by the Population Foundation of India (PFI), emphasises the creation of a common platform for the various relevant programmes and departments, to improve the provision of

49urban health services (GOI, 2014) .

There have been some efforts made at mission convergence across the metropolitan cities in the country 50(Bannerjee, Sharma, 2007) . One of the functional examples can be found in Delhi. The Government of

Delhi created 'Samajik Suvidha Sangam', registered as a society, setting an example for mission 51convergence in the National Capital (Bannerjee, Sharma, 2007) . Similarly, “Mahila Milan” was

successful in the design, building and management of toilet blocks in Pune. Further, the Pune Municipal Corporation set a good example through a participatory approach, as it provided an alternative housing solution in the densely populated urban slums, to address the socio-economic determinants of health

52(NHSRC Data base) . Gujarat also designed a scheme based on public-private partnership (Chiranjeevi Yojana) that aims to increase institutional deliveries in partnership with private nursing

53homes(Acharya, MacNamee, 2009) . However, the challenges still continue, with a majority of obstetricians and gynaecologists not registering for this scheme and also not many private nursing

54homes located in remote areas opting to be a partner .

The mission convergence in the urban slums emphasises tackling the unsanitary, unhealthy environment and the socio-economic conditions of the poor, as major challenges to attaining better

55health standards (Bannerjee, Sharma, 2007) . In this regard, the mission recommends a framework for pro-active partnership with NGOs/civil society groups for strengthening the preventive and health

56promotion activities at the community level (Bannerjee, Sharma, 2007) .

Given the current urban provider landscape and consumer preferences, for any scheme such as the RMNCH+A to provide universal comprehensive public healthcare, it must be supplemented through

57contracting accredited private providers, organisations and NGOs (GOI, 2013) . There are many programmes that have been successfully launched with inter-sectoral coordination, for example, the National Vector-Borne Disease Control Programme (NVBDCP), National AIDS Control Society

58(NACO), AYUSH, and now the NUHM, (GOI, 2013) . The most critical aspect of all these programmes is to follow a holistic approach to achieve the target goals. The synergy between all these partner agencies and governments, both at the central and state levels, plays a pivotal role.

In Delhi, a few NGOs have successfully engaged the community to improve service delivery. In Andhra Pradesh, the government has used decentralised monitoring and implementation systems along with people's participation, to provide basic primary healthcare and family welfare services to the urban

59poor . Across and within states, the arrangements for the governance of each of the services and the



Key Findings :

l Unclear responsibility of providing health services, unlike that of rural areas.

l Resources are geared to provide curative care.

l The urban healthcare system is focused on secondary and tertiary care with little or no focus on primary care.

l Urban Health Posts/ Centres (UHPs/UHCs) mainly provide three types of services: Regular (including preventive, curative, IEC activities and training), seasonal (pre-monsoon and monsoon-related activities) and disaster relief (in specific areas in the country).

l Few larger Municipal Corporations with good revenue resources such as Surat, Navi Mumbai, Pune and Pimpri-Chinchwad, have demarcated special resources to provide urban health services.

l There is no definite system of referral; no linkages between domiciliary, health centre and hospital; and no defined protocols for admissions to primary, secondary and tertiary levels.

l The unorganised urban poor have no relationship with healthcare providers and, therefore, mostly access expensive private healthcare, often at the expense of nutrition and other basic necessities.

mechanisms provided for the urban slum population are very different, so the effectiveness of co-ordination between them also varies widely.

S. No.

Intervention/ Implementing Organisation

City/State Inference

2 Mukhyamantri

Swasthya Yojana

Dhamtari

3 Mahila Arogyam

Samiti (MAS)

Pune Tackle issues of maternal and newborn healthcare through

spreading awareness and assisting the beneficiaries in availing

of

ANC and institutional delivery in healthcare centers

4

Chiranjeevi Scheme

Municipal

Corporation

Launched

in 2006

The scheme based on public - private partnership (Chiranjeevi

Yojana) that aims to increase institutional deliveries in

partnership with private nursing homes

1 Urban Health

Units, Kolkata

Municipal

Corporation

Kolkata Key features of the programme are the Honorary Health

Workers (HHW), the Sub - Centres and th e Health

Administrative Units (HAU). Although the programme has

Reproductive and Child Health as its core, its only focus seems

to be on assisting delivery for pregnant women and

immunisation



B. Governance

Governance Mechanisms in Urban Health

60In their recent book, Drèze and Sen call for a public welfare system that works better for the millions of people living in destitution. They question the pitiable investments in health and education made by the Indian government and pertinently ask- 'what difference does it make to lift millions above some notional poverty line, if they still lack the basics for a decent quality of life'. The NRHM is widely acknowledged as an outcome of the grassroots pressure generated by India's vibrant democracy, which

61is capable of influencing government policy in pro-poor directions . Over the past few decades, popular movements, non-governmental organisations and other forms of grass roots mobilisation have emerged as local and supra-local forces that have buffered, accelerated, ameliorated and even challenged the

62state's shifting development agendas . Rather than understanding policies as instructions flowing down from above, policy implementation should be understood as practices that must be situated in the

63broader domains of knowledge and power in which they are embedded .

At this juncture, it is important to study the objectives of the NRHM. The NRHM aimed at architectural correction of the rural health service system and laid great significance on reducing maternal and child mortality through a systematic approach of tracking pregnant women, care during pregnancy,

64institutional or assisted delivery, and educating communities in new born care . The triad of ASHA, ANM and AWW are entrusted with the responsibility of acting as a catalyst for ensuring change in

65knowledge, attitude and practices of the community with relation to motherhood and newborn care . The Primary Health Centres and sub-centres are bound to follow specific operational guidelines to

66manage assisted delivery as well as newborn care corners . However, the challenges of urban health are much more complex, with an unequal access to healthcare facilities. The structure of the city is diverse in nature, with unequal living conditions and inequitable access to basic resources such as water,

67sanitation, and food . As far as availability is concerned, an ample number of outlets (both government-68run and private) exist in the city . The expansion of private bodies in the city has transformed health into

a commodity—making it inaccessible for a majority of the population, specifically for the urban poor.

The urban local bodies, state health departments and other social welfare departments are at the core of 69governance systems in the city . Although as a policy, management of MNH care needs to be paid

70attention to, so as to reduce the proportion of maternal and newborn deaths , it is an irony that the Municipal Corporation, (the basic unit of local governance in cities) is presently playing a minimal role as

71far as providing of MNH care is concerned . A perusal of the city visit reports by the NHSRC experts conducted across 31 cities, suggests that most of the Municipal Corporations have been restricting

72themselves to public health engineering .

One of the reports clearly says: “They mainly have the responsibility regarding water and sanitation. Only a single person, who is designated as a Health Officer in the Municipal Corporation, has the responsibility with regards to health. His responsibility is looking after the cleanliness of the drains, dealing with dog bite cases/rabies prevention. There is some fund allocation for insecticide sprayed

73.mosquito nets and people are provided with the same.” (NHSRC-Data base)

60 Jean Drèze & Amartya Sen, An Uncertain Glory: India and its Contradictions, Princeton University Press, (2013)61 Chatterjee P. “Lineages of Political Society: Studies in Postcolonial Democracy”. New York, NY: Columbia University Press (2011)

Sen, A. ( 1999). “Development as Freedom”. Oxford: Oxford University Press.6 Ray, R., Katzenstein, M.F., (2005)Social Movements in India: Poverty, Power, and Politics (Rowman and Littlefield Publishers, USA)63 ., Roalkvam S. (2013) Health Governance in India: Citizenship as Situated Practice, Good Public Health. 2014 Sep 14; 9(8): 910–926.

Published online 2014 Aug 18. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166913/)64 MOHFW (2011), Guidelines on Newborn Care.65 MOHFW (2006), Guidelines for ASHA.66 MOHFW( 2011) Guidelines on Newborn Care.67

GOI (2014), Reaching Healthcare to the Unreached: Making the Urban Health Mission Work for the Urban Poor.68

Baru (2000), “Privatisation and Corporatisation” http://www.indiaseminar.com/2000/489/489%20baru.htm69 Ibid, NHSRC ( 2014).70

Ibid GOI ( 2014).71

Ibid GOI ( 2014).72 NHSRC data base ( city reports ) .73 NHSRC Data base ( 2014 ) City report.



There exists some evidence on certain activities related to health carried out by the Municipal Corporations across a few large towns and metropolitan cities such as Mumbai, Pune and Surat; however, health per se is run in a piece-meal approach, with MNH holding a small segment in the entire

74system . The reports for cities such as Kolkata and Madurai show the presence of a system within their Municipal Corporations for the delivery of healthcare. There is an initiative from the Kolkata Municipal Corporation for running of primary healthcare and secondary healthcare services and Medical Education. It runs 144 Ward Health Units (WHUs) in the vicinity of urban poor settings. It has launched an Urban Health Programme in 2002 with key features of Honorary Health Workers (HHW), the Sub-Centres and the Health Administrative Units (HAU). Although the programme has Reproductive and Child Health as its core, its only focus seems to be on assisting delivery for pregnant women and immunisation. Moreover, the facilities available in terms of drugs and equipment are also very limited.

Some of the other urban local bodies studied by the NHSRC field teams, such as those in Madurai, Bhubaneshwar, Gangtok and Ambala are apparently also not very proactive when it comes to providing

75maternal and newborn healthcare . There are a few facilities such as maternity homes and hospitals that are run by corporations. However, these lack any special focus on maternal and newborn health and the corporations seem much more focused on the prevention of communicable diseases, solid waste

76management and drainage systems . Urban Health Centres with an ANM stationed for registration of pregnant mothers and immunisation do exist in very few cities. However, many of the community members interviewed reported that they do not prefer the services offered at these urban health centres. In the Dhamtatri district of Chhattisgarh, the maternal and newborn health system was somewhat strengthened with the recruitment of additional urban ANMs and larger involvement of Anganwadi workers for maternal, newborn and child health services under the Mukhyamantri Shahari Swasthya

77Yojana .

The governance mechanisms also lack adequate norms of standardisation as far as logistics and supply 78chain management are concerned . At present, the urban MNH care programmes do not operate under

79one uniform umbrella . Secondly, there are no major programmes that are focused on strengthening urban community processes. There is also no coordination between the private caregivers and UHCs,

80which results in the duplication of services in certain areas and a complete lack of services in other areas .

Governance also has a crucial role in bringing accountability and transparency in the health systems as well as in the effectiveness of programmes implemented on the ground. While it maybe difficult to correlate health governance directly with health outcomes, there are processes that can be measured for good governance (such as community participation in the decision-making process). In recent times, the

81role of governance in monitoring and evaluation has also gained recognition and acknowledgement .

The role of State Health Departments, Municipal Corporations (MCs), Town Councils and ULBs is immense; however, the existing literature does not delve deeper into the roles of these bodies in the provisioning of services related to MNH. As this process of review of literature has already revealed, there is a comparative abundance of information on other public health issues and very little on urban MNH in relation to governance (specifically with regard to the role of MCs). As large cities contain a lot of diversity in their social fabric, the provisioning of services is recommended to be consistent with the cultural ethos and felt needs of the community. The health authorities here have to not only play the role of a service provider but also create innovations to address diverse issues of the heterogeneous, marginalised and poor urban population.

The literature available also lacks a detailed analysis ofthe roles of various departments in providing services to the urban mothers and newborns,except for a few examples wherein PPP models are functioning in coordination with NGOs or other private providers/bodies.

74 NHSRC Data base ( 2014), City reports Mumbai, Surat , Pune.75 NHSRC Data base ( 2014) , Bhubaneshwar, Gangtok, Ambala.76

Ibid NHSRC ( 2014).77

NHSRC Database, Dhamtari.78Ibid GOI ( 2014).79

Ibid GOI ( 2014).80

Ibid NHSRC Database ( 2014), city reports.81 SOIN (2014).



The governance issue is acute when it comes to implementation and execution. The local self-governance mechanism is not connected to the grassroots and there is immense distrust of the quality and efficiency of the services provided by them. Indeed, the structures of the corporations are mostly non-functional, with very few health services available.

Key Findings:

l Lack of clarity with regard to the specific tasks to be undertaken for maternal and newborn care at Municipal Corporation level.

l No coordination between the private caregivers and UHCs, resulting in the duplication of services in certain areas and a complete lack of services in other areas.

l Governance mechanisms also lack adequate norms of standardisation as far as logistics and supply chain management is concerned.

l Absence of programmes that are focused on strengthening urban community processes.

l Municipal Corporation facilities that exist, lack special focus on maternal and newborn health.



C. Human Resources

Staffing Mechanisms

thIn the early 20 century, industrialised countries halved their maternal mortality by providing professional midwifery care at childbirth, and in the 1950s, improving access to hospitals further reduced maternal mortality. A similar picture has been generated by various studies in India, where increased access to skilled attendance at birth with the back-up of a well-functioning health system has resulted in a

82markedly decreased maternal mortality (Graham, W., Bell, JS., and Bullough, CHW., 2001) .Based on these experiences, long-term initiatives and efforts to provide skilled professional care at birth are believed to be the way forward when aiming at addressing maternal mortality. The consensus on the importance of skilled attendance at delivery is also reflected in the MDGs, where the proportion of births attended by skilled health personnel is considered to be a key indicator for the MDG-5 of improving maternal health and reducing maternal mortality.

Unfortunately, in India, with an uneven distribution of overall workforce, the scenario reflects asymmetry in the distribution of health professionals. India also faces difficulties in producing, recruiting and retaining health professionals. Insufficient number of medical schools, low salaries of the existing health workforce, poor working conditions, lack of supervision, low morale, low motivation and lack of infrastructure are the other prominent causes of losing them, for which they tend to migrate to

83wealthier countries (Lehmann, U., Dieleman, M., Martineau, T., 2008) . To overcome the failure of providing birthing women with skilled attendance, the country had to invest in training Traditional Birth Attendants (TBAs) under the NRHM and in schemes like Janani Suraksha Yojana. (Berer, M.,

842003) .

The shortage of emergency obstetric services over the last decade has attracted substantial attention. In response to this situation, the government and health organisations have been addressing the challenges related to human resources for health (HRH) planning and management, that deal with both coverage and equity aspects. There is an increasing body of evidence that documents bold initiatives and innovative actions that allow for improved efficiency in using existing human resources, including team approaches to the delivery of intervention, multi-tasking, task-shifting and sharing increased involvement of communities in responding to different health needs etc. However, most of these innovative approaches have been implemented as pilots or time-limited projects, with negligible evidence of success at scale.

As the review reveals, the Human Resource for Health (HRH) function faces a diverse set of issues and challenges from both the internal and external environment. Global competition, technological advancement, changing profile of employees, skill shortages, retention, downsizing and outsourcing are some of the most common HRH challenges. In order to effectively meet these challenges, HRH has to play different roles, as proposed by different scholars. The following section also focuses on the identified gaps, lessons learned, and recommendations that emerge from studies and implementation experiences of HRH interventions for better maternal and newborn health outcomes.

A report on the Surat Municipal Corporation (SMC) reflects that the NUHM norms will take some time to come into universal practice. Currently, the SMC is following its own norms with regard to the UHCs and the number of link workers is as per the RCH recommendations. The UHCs were set up on the basis of rural PHC standards and cater to 100,000 population per UHC. The staffing plan is also as per the PHC pattern; hence the UHC staff is much more than what is recommended in the NUHM guidelines. A broader challenge faced by the SMC is with regard to the constantly expanding municipal limits and the

82 Graham, W., Bell JS, Bullough CHW. 2001. Can skilled attendance at delivery reduce maternal mortality in developing countries? Safe motherhood strategies: A review of the evidence, 17:97–130.

83 Lehmann, U., Dieleman, M., Martineau, T., (2008). Staffing remote rural areas in middle and low-income countries: A literature review of attraction and retention. BMC health services research. 8(1):19.

84 Berer M (2003). Traditional birth attendants in developing countries cannot be expected to carry out HIV/AIDS prevention and treatment activities.Reproductive Health Matters. 11(22):36-39.



new villages consequently getting merged in the SMC. Also, no formal 'handing over' process of these new areas has been designed or institutionalised for transfer of authority from the rural to the urban functionaries. Apart from this, there exists an Urban Health Training Centre in Surat (the only one in the

85entire state of Gujarat), however, no clear guidelines or modules exist on training for MNH care .

86A case study by Padmanaban et al. 2009 in Tamil Nadu, reviewed available literature and secondary data that were drawn from various national surveys and service statistics compiled by the State Government. The study reflects that the state has become one of the top performers in the country in terms of maternal health- with its MMR now at 90 (2007)- as compared to other states, while the overall efforts focused on improvement in: availability of human resources; drugs and supplies; management capacity; monitoring of health services and analysis of maternal deaths. Major challenges still remain in improving the quality of infrastructure and services in rural and peri-urban areas for maternal and newborn health.

87According to the World Bank (2010) , human resources for maternal and newborn health are limited, with only 0.6 physicians per 1,000 population but nurses and midwives are slightly more common, at 1.27 per 1,000 population. A study conducted by the Urban Health Resource Center (UHRC) in collaboration with the Johns Hopkins Bloomberg School of Public Health, USA and Chhatrapati Shahuji Maharaj Medical University, Lucknow assessed the status of maternal, neonatal, child and reproductive

88health in the urban slums of Meerut city in Uttar Pradesh . The study used both qualitative and quantitative methods. The household survey from October 2007 to March 2008, covered 15,025 women who had a live or stillbirth in the preceding three years. Referred to as “recently delivered

89women”(RDW), these were drawn from 44,888 households across 45 slums within the city . The scope of the survey was very similar to the District Level Health Survey (DLHS)/ National Family Health Survey (NFHS), except that the study collected more detailed information on newborn care and was adapted to capture information specific to the urban slum context. The study found that capacity- building of the existing health and paramedical staff on essential newborn care practices, (including cord care, thermal protection, detection of danger signs and timely treatment of the newborn)needs to be a regular event. The staff should be trained at the facility and community level to follow recommended guidelines under

90the Integrated Management of Newborn and Childhood Illnesses (IMNCI) . Since only 0.5% of the mothers in the study availed of newborn care from a public health facility, due to inhibitions related to the attitude of the staffs there is a need to sensitise the health service providers on communicating compassionately with the poor to help the latter overcome their reservations of availing of services at the public health facilities.

The study also showed that 40% of the home deliveries in the slums were conducted by untrained local dais. It also highlighted that majority of the newborns received post-natal check-up and treatment from unqualified practitioners. The study recommended that there is an urgent need to complement the efforts to encourage hospital deliveries with training and competence enhancement of slum level dais and local private practitioners to provide essential newborn care. It suggested that they should be skilled enough to identify the signs of common acute conditions & complications, provide timely initial treatment and appropriate referral.

Another facility level study found that the availability of an adequate number of doctors and nurses is critical for providing quality appropriate newborn care. Besides staff numbers, the skills and the

85 Benazir Patil (2014). A brief report on urban newborn sub-group as a part of India Newborn Action Plan. Save the Children, India.86 Padmanaban P, Raman PS, Mavalankar DV (2009). Innovations and challenges in reducing maternal mortality in Tamil Nadu, India. Journal of Health,

Population and Nutrition.2009; 27(2):202.87 World Bank. (2010). World Development Indicators. Washington DC.88 Meerut was selected for the study, in view of the presence of a large urban slum population (highest among cities in Uttar Pradesh). Situation analysis of

the slums revealed the existence of unlisted slums, pockets of underserved slum population and underutilizsation of the existing health services.89

The indexed women were the ones who had a live birth during the last 36 months preceding the survey.90Under the Reproductive and Child Health(RCH II) programme of the GOI, the Integrated Management of Newborn and Childhood Illnesses (IMNCI) package has been adapted from WHO/UNICEF's Integrated Management of Childhood Illnesses (IMCI). Since newborn care is an important issue for bringing down the infant mortality rate in India, this aspect has been included in the package adapted by India. This package includes interventions for the care of newborns and young infants (infants under 2 months) by keeping the child warm, initiation of breastfeeding immediately after birth and counselling for exclusive breast feeding and non-use of pre-lacteal feeds, cord, skin and eye care, recognition of illness in newborns and management and/or referral, immunisation and home visits in the post-natal period.



motivation level of caregiving personnel are prime prerequisites, since it has been estimated that the odds of mortality of newborns admitted in Special Newborn Care Units (SNCUs) increase significantly when one nurse cares for more than 1.7 newborns. Paediatric staff ratios are obviously inversely related to mortality rates. While nurses are critical at all levels of care, the availability of neonatologists is also very important, especially for those units providing higher levels of sophisticated care, (such as ventilation) and for the survival of low-birth-weight babies. In the authors' assessment, it was noted that three out of the eight units studied had less number of nurses than the recommended nurse: bed ratio of 1:1.2 and 3 had fewer doctors than the recommended doctor : bed ratio of 1:4. Nurses appeared to play a crucial role in improving newborn survival in these units – the mortality rate across the units dropped with improved nurse:bed ratios. Units with poor ratios had worse outcomes, as expected, and almost 15% of the variation in neonatal mortality rates across the units could be explained due to the factor of nurse:bed ratio. The number of doctors, though an important factor, did not appear to directly influence the NMR as compared to the number of trained nursing staff allocated.

A recent study by Sumit Malhotra et al, (2014), assessed all facilities for the availability of trained personnel in the labour room or operation theatre in the Nagaur and Chhattarpur districts of India. A competency assessment of healthcare providers in ENC was conducted with a total of 38 healthcare providers, 19 each from Nagaur and Chhattarpur districts. Among them, 14 were doctors (9 specialists and 5 general-duty medical officers), and 24 providers belonged to nursing staff categories (15 staff nurses, 9 ANMs). The individual domainand category-wise average scores revealed that, in most of the domains, knowledge and skill scores were found to be higher or similar in doctors when compared with nursing staff, except for skill domains relating to preparation at birth and breast feeding, where the nursing staff scored higher than doctors. The results in different domains were based on the grading of knowledge and skills into three categories. The majority of the providers scored only moderately satisfactory scores for most of the knowledge domains, except Kangaroo Mother Care (KMC) and breast-feeding, where it was largely satisfactory. The skill scores for all domains were predominantly non-satisfactory.

A useful study on the role of informal providers in healthcare delivery by the Centre for Health Market Innovations (CHMI) discussed the role of informal providers (IPs) that comprises a plethora of independent and largely unregulated healthcare practitioners. They are a vital source of care for many in the lower and middle - income countries, comprising over 50% of healthcare workers in India and close to 96% in rural Bangladesh, according to some estimates. They are utilised for a wide variety of health interventions and often represent the first point of care for patients, particularly for the urban poor. Although they are heavily utilised, IPs pose a number of significant challenges. They generally have little formally recognised training and usually operate outside the purview of the regulatory authority; hence, the quality of care is not well understood with respect to urban maternal newborn health. Despite these challenges, IPs represent a large component of the private health sector and routinely fill the human resource gaps in formal healthcare provision.

l Task-shifting: Lowering the Bar from Paediatricians to Graduate Doctors

In Gujarat, to combat the shortage of paediatricians for newborn care, the state government launched a short course on “Emergency Newborn Care for Medical Officers” (EmNC) for graduate medical officers. The duration of the course is 120 days, out of which 30 days are spent in an FRU or district hospital,

Training and Skill-sets

Role of Informal Providers

Innovations and Interventions

Sutapa Bandyopadhyay Neogi, Sumit Malhotra, Sanjay Zodpey and Pavitra Mohan (2011). Challenges in scaling-up of special- care newborn units- Lessons from India, Indian Paediatrics, Volume 48, December 17, pp 931-935

Sumit Malhotra, Sanjay P. Zodpey, Aishwarya L. Vidyasagaran, Kavya Sharma, Sunil S. Raj, Sutapa B. Neogi, Garima Pathak, Abhay Saraf (2014). Assessment of Essential Newborn Care Services In Secondary-Level Facilities From Two Districts of India, Journal of Health Population Nutrition, March 32(1): 130-141



managing newborn babies. The nomination is based on an undertaking sought by the state government that, after training, the medical officers will be posted in one of the pre-identified FRUs or CHCs. An online course has also been rolled out on FBNC and medical graduates working in SNCUs can undergo training through these courses.

l From Nurses to Nursing Aides and Yashoda

Nurses perform both specialised and unspecialised functions. In Purulia district in West Bengal, in order to partly overcome the severe shortage of trained nurses for SCNU, newborn nursing aides were engaged. Local young women with 10 to 12 years of school education were given hands-on training for six months, followed by a six-month internship at a SNCU. Yashoda, a facility-based ASHA, was introduced in NIPI districts in 2008, as an innovative pilot effort to improve the quality of newborn and related maternal care in those district hospital maternity wards which had a high delivery load. They performed simple housekeeping functions and took care of newborns, under the supervision of trained nurses. Assessment by external experts suggested that they had acquired reasonable levels of skills and their involvement freed up the time of the limited number of trained nurses for more specialised functions.

l Slum-based Health Volunteers

The Meerut study by the Urban Health Resource Centre (UHRC) also found that slum-based health volunteers are the crucial agents for influencing community health behaviours, for providing home-based health advice and for building linkages of the community to health facilities. Therefore, a key programme component should be appropriate training, with regular refreshers, as well as supportive supervision of these workers in newborn care. This would enable them to inform the community of correct care practices and also to detect newborns with high-risk of hypothermia and other complications, and refer them to timely and appropriate medical care. The study reflected that slum-based health volunteers not only created a demand for the services in the slums but were also instrumental in facilitating the provision of existing benefits such as the Janani Suraksha Yojana and encouraging the women to deliver at a facility. This helped in building linkages with affordable public/private facilities for appropriate treatment and timely referral. Similar approaches have been proposed in the NUHM framework.





Innovations in Human Resources

S. No.

Name of the Programme

Place Where Functional

Status of the Programme

Inferences

1.

Short course on “Emergency Newborn Care for Medical Officers” (EmNC) for graduate medical officers

Gujarat

undergo training through these courses

The duration of the course is 120 days, out of which 30 days are spent in an FRU or district hospital, managing newborns. The nomination is based on an undertaking sought by the state government that,

after

training, the medical officers will be posted in one of the pre-identified FRUs or CHCs. An online course has also been rolled out on FBNC and medical graduates working in SNCUs can

.

2.

Yashoda

Purulia District, West Bengal

2008

To partly overcome the severe shortage of trained nurses for SCNU, newborn nursing aides were engaged. Local young women with 10 to 12 years of school education were givenhands-on training for six months, followed by a six-month internship at an

SNCU. They performed simple housekeeping functions and took care of newborns, under the supervision of trained nurses. Assessment by external experts suggested that they had acquired reasonable levels of skills and their involvement freed up the time of the limited number of trained nurses for more specialised functions.

3. Slum-based Health Vounteers

Lucknow, U.P.

Crucial agents for influencing community health behaviours, for providing home-based health advice and for building linkages of the community to health facilities. Slum-based health volunteers can create a demand for the services in the slums.The volunteers were also instrumental in facilitating the provision of existing benefits such as theJanani Suraksha Yojana and encouraging

the women to deliver at a facility. Similar approaches have been proposed in the Government of India’s National Urban Health Mission (NUHM). Thus, these volunteers can be forced

multipliers and be very instrumental in helping the screened pregnant mothers

& newborns reach the right facilities at the right time.

Key Findings :

l No publications were found regarding the individual outcomes of components, such as the shortage of human resource, lack of staff motivation, appraisals, workplace safety and career development on urban maternal and newborn healthcare.

l Availability, retention and training of skilled birth attendants was a major issue. It was seen that in most places doctors and midwives were not available at the time they were most needed, i.e. at night.

l Professional qualification does not necessarily mean that the provider is actually skilled.

l Little information was available regarding the efficacy of the midwife training programme.

l No study was found on the financial component addressing the budget allocation for salaries and allowances, education &training and HRH expenditure data.

l Migration of skilled birth attendants is one of the main causes of workforce crisis.



D. Financial Mechanisms

With the advent of stronger private entities in the area of health service provision, the aspect of overall 93health financing in India needs to be looked at critically (GOI, 2008) . Although the idea of “health for

all” has been restated in many of the committee reports, since the days of the Bhore Committee, it is a 94relatively low priority in our national economic planning . The expenditure incurred on health in the

context of budgetary allocation is rather dismal in developing nations, with India standing much lower 95 thin rank (GOI, 2006) . In the 12 Five Year Plan, the health allocation of budgets was increased by about

25% (the base was the total GDP) and states were encouraged to enhance the outlays for health in their 96annual plans as well (GOI, 2014) . The analysis of recent programmes indicates that the concerns

regarding financial management continue to prevail, as obstacles such as governance; transparency and accountability hinder appropriate utilisation of the funds allocated.

There is a lack of clarity on the proportion of funds specifically designated for maternal and newborn health in urban areas in the overall health budget of the city corporation. In recent times, for the country, however, there has been an increase of funds for a broad range of reproductive and child health-related aspects, from 5,288 crore in Phase- I (1997-1998 to 2003-04) to 40,000 crore in Phase- II (covering 2005-06 to

972009-2010) . There is indeed an increase in the funding process with many donor organisations entering into the picture, yet ensuring quality maternal and newborn care services has remained a problem owing to confusion at the stage of implementation, inability to absorb more funds and health workers' discomfort with spending because of their lack of experience with identifying funding priorities and

98managing money . Corruption has also remained at the core of non-utilisation of the money that has 99been reserved for health-related action (Singh et al, 2006) .

Moreover, many of the primary and secondary care services are considered to be free, the mixture of public-private creates a precarious situation as quality care is only seen to be promised by the private

100bodies . The scenario, hence, is a cause of a big concern for the urban poor pregnant women and their newborns, since it usually saddles their breadwinners with the burden of high out-of-pocket

101expenditure (Singh et al, 2006) . As far as the health of the mother and newborn are concerned, the financing of the same is again limited and almost restricted to the cash transfer policy for institutional

102delivery . The utility of such a cash transfer policy run by various states has remained problematic as the sheer incentive mechanism to generate demands for institutional delivery, does not encompass a holistic approach to handle issues of inadequate health infrastructure, especially for essential emergency obstetric-newborn care; wrong cultural attitudes (that professional pre-natal, intra-natal, post-natal and neo-natal care are unnecessary); provider bias and discrimination against women belonging to

103marginalised groups and a chronic scarcity of domain specialists .

Secondly, the financial allocation for maternal and newborn care is dependent on the state budgetary allocations through its different units. To begin with, the expenditure to be incurred on maternal and newborn healthcare has very little space in the health planning of the family. One of the major findings of a study conducted indicates that, although health-seeking amongst urban women is better than in rural

104 105India , the realistic expenditure is surely far higher when it comes to the urban poor .

93 thGOI (2008): 11 Five Year Plan of India, Health and Family Welfare and Ayush” http://planningcommission.nic.in/plans/planrel/fiveyr/11th/11_v2/11th_vol2.pdf

94Mukherjee, S., Singh, A and Chandra R(2013): Maternity or Catastrophe: “A study of Household Expenditure on Maternal Healthcare in India Maternity care in India

95 GOI, 2006, Government Health Expenditure in India: A Benchmark Study” Economic Research Foundation.96 GOI, 2014, “ Report on Health Nutrition and Family Welfare “(http://planningcommission.gov.in/sectors/index.php?sectors).97 Mukherjee, S., Singh, A. and Chandra, R. (2013): Maternity or Catastrophe: “A Study of Household Expenditure on Maternal Healthcare in India

Maternity care in India98

Singh S et al (2009) “Barriers to Safe Motherhood in India” www.guttmacher.org99

Ibid Singh, S. et al ( 2009).100

Ibid Singh, S. et al ( 2009).101 Ibid Singh, S. et al ( 2009).102 Ibid Singh, S. et al ( 2009).103

Ibid Singh, S. et al ( 2009).104

Jogdand, K.S., Yerpude, P., Jogdand, M. (2013): A Perception of Maternal Mortality among Women in an Urban Slum Area of South India. International Journal of Recent Trends in Science And Technology.

105Mukherjee, S. Singh, A. Chandra R(2013) : Maternity or Catastrophe: “A study of household expenditure on maternal healthcare in India



The possibility of impoverishment after obtaining maternal and newborn care is much higher amongst the educated section of women. This counterintuitive study indicates that women with middle-level education were 33% less likely to enter into poverty due to out-of-pocket (OOP) maternal healthcare expenditure in urban areas, whereas women with higher education were more likely (76% for rural and

10687% for urban) to be impoverished by out-of- pocket expenditure (Mukherjee, Singh, Chandra,2013) . The percentage of impoverishment due to out-of-pocket expenditure is also lower amongst the socially backward sections, by approximately 99% and 98%, for women belonging to the schedule castes (SCs) and schedule tribes (STs) respectively, as compared to women belonging to the 'others' caste category in

107urban areas . Certain studies also indicate that, in the urban scenario, home birth comes across as an 108easier and viable option for the poorer sections of the society .

Furthermore, the role of the Municipal Corporations (MCs) and Urban Local Bodies (ULBs) in decentralised budgetary planning for MNH care is neither detailed nor fully enshrined in the current

109NUHM guidelines(NUHM, 2013) . A perusal of the city-level data has details of food, sanitation and money dispersed to its dispensaries but lacksspecific details on MNH expenditure. Moreover, in recent times, many of the cities have concentrated primarily on the aspect of introducing schemes through

110public-private partnerships (PPP) . Cities located in the state of Gujarat have been one of the important examples of those that have adopted many such schemes for ensuring affordable MNH care (Database,

111NHSRC) .

l Janani Suraksha Yojana (JSY)

Under this scheme, the main aim of the NHRM is to reduce maternal and neo-natal mortality rate by incentivising institutional delivery for the mothers falling in the category of below poverty line (BPL), SC and ST, about 8 to 12 weeks prior to the delivery. It is also available to those residing in peri-urban areas as per the NUHM TRG report,usually this area comprises migrants and marginalised populations.

l Chiranjeevi Yojana (CY)

Under this scheme, poor women are provided free delivery services by the hospitals of both government andprivate sectors and the obstetricians are paid a flat rate of Rs. 2,800/- (twenty eight hundred rupees) per normal delivery, payable upon conducting every batch of 100 deliveries.

l Bal Sakha Yojana (BSY)

Under this scheme, the costs of neonatal care are exempted for BPL mothers who give birth to live babies. All participating paediatricians are paid a flat rate of Rs. 1,300/- (thirteen hundred rupees) per live newborn and the obstetricians are also paid a lump sum of Rs. 30,000 (thirty thousand rupees) in case of a minimum 48 hours of hospital stay, for a batch of every 100 newborns treated.

l Kasturba Poshan Sahay Yojana (KPSY)

Under this scheme, Rs. 700/- (seven hundred rupees) are paid to pregnant women on three occasions, i.e. at the time of registration for ANC, for institutional delivery in government hospitals and for immunisation of newborns in government hospitals.

Ahmedabad Municipal Corporation in Gujarat also started a public-private partnership in collaboration with the Red Cross Society, where a thalassemia test costs Rs.185/- (one hundred and eighty five rupees)

112at a subsidised rate, as the same costs up to Rs.500/- (five hundred rupees) at other private hospitals . It is noteworthy that, though cash assistance has been counted as a great measure, criticisms of the

Public-Private Partnerships

106 Ibid Mukherjee, S. Singh, A.and Chandra, R. ( 2013)107 Ibid Mukherjee, S.,Singh, A. and Chandra, R. ( 2013)108

Ibid Jogdand, K. S., Yerpude, P.and Jogdand, M. (2013)109 NUHM( 2014), Executive summary of Technical Resource Group, for National Urban Health Mission.110 NHSRC, City Study Report, Ahmedabad111

Ibid Database NHSRC.112Ibid Database NHSRC.



Chiranjeevi experience in Gujarat show that it may have lacked foresight regarding issues such as 113transportation cost, distances to fair-quality institutions, etc. in its budget planning . Another thesis

study reiterates that a major drawback in every programme designed for healthcare, including MNH care, is that vast sums of money are being invested without sufficient attention being paid to the key management aspects such as the training of human resources and capacity-building of the government health departments to mentor their officials efficiently for counseling, check-ups, institutional delivery

114and operating available modern diagnostic tools(Shodhganga, 2013) . Hence, this study suggests major concentration on such issues, both while designing programmes and allocating budgets to the respective

115programme (Shodhganga, 2013) .

116Sambhav Voucher Scheme (http://futuresgroup.com/files/publications) is another innovative way to harness the resources of the private sector, as well as increase access to quality healthcare services through public-private partnerships (PPP). This approach involves the Government paying private providers for maternal health services rendered to those below poverty line (BPL). It was created under the Innovations in Family Planning Services (IFPS) project, along with the Government of India (GOI) and the United States Agency for International Development (USAID). This is potentially useful in urban areas, where there is a strong presence of the private sector, giving the urban poor an opportunity to avail of quality maternal health services from private hospitals covered under the scheme, thereby improving their access to maternal-newborn healthcare services, assuming proper regulation

117(http://futuresgroup.com/files/publications) .

113 Acharya, A. and McNamee, M. (2009) ,”Assessing Gujarat Chiranjeevi Scheme”,Economic & Political Weekly.114Shodhganga (2013), “Maternal and Child Healthcare Service in West Bengal – a Comparative Study, Conclusion.115

Ibid Shodhganga ( 2013).116

http://futuresgroup.com/files/publications117Ibid http://futuresgroup.com/files/publications

Key Findings :

l There is an absence of adequate information on financing patterns, the role of local bodies in budget planning and the process adopted for sustaining projects across cities.

l The budgetary allocation is also not segregated for maternal and newborn health, creating an ambiguous state of the evidence.

l Health financing in India needs revisiting, most importantly, taking in view both the demand and the supply side of the maternal newborn care service.

l As far as execution is concerned, there is an urgent need to ensure timely allo-cation and release of earmarked budgets. There are cash transfer programmes that exist in various states.



E. Health Infrastructure

Present Situation

Transport Facilities

Adequate infrastructure, including sufficient space, functional equipments, transport facilities and special care divisions such as ICUs, are some of the key requirements for providing health services. While discussing MNH, one needs to look into the aspects of space and the basic instruments used for ante-natal, intra-natal, post-natal and newborn care. Tables shared in the Annexure- 2 provide an overview of the status of infrastructure for MNH care in some cities across the country. These cities were assessed as a part of the NHSRC assessment done by the Technical Resource Group (TRG) team. The cities and towns were selected randomly with no specific criteria.

The situation pertaining to infrastructure across the states is very grave. As reflected from the city reports the majority of the health service facilities are managed out of rented apartments. Most of the urban health centres lack facilities of transport and specialised care for the mothers and newborns. Although in a few of the city reports, it has been clearly mentioned that the building provided for primary and secondary care services was inadequate, the information available on the status of the building is unclear. The reports of the metro cities reveal that the available diagnostics facilities are not sufficient and the special newborn care units, as well as emergency obstetric care, were found to be operating in just a few

118cities .

An important aspect that deters connecting pregnant women to health facilities is lack of transport. Although the facilities are well connected through public transport in many metro and bigger cities, transportation, along with communication, continues to remain a challenge in smaller towns.

118City Analysis Reports of the TRG, (2013).



S.

No.

Programme/

Scheme

Place

Status

Inferences

1.

Janani

Suraksha Yojana (JSY)

Ahmedabad

2005

Under this scheme, the main aim of the NHRM is to reduce maternal and

neonatal mortality rate by incentivizing institutional delivery and Rs.500/-

(five hundred

rupees) areto

be paid to those below poverty line

(BPL), SC and ST women, about 8 to 12 weeks prior to the delivery. It is

also available to those residing in peri-urban areas;usually this area

comprises migrants and marginalised populations, as per the NUHM

TRG report.

2.

Chiranjeevi

Yojana (CY)

Ahmedabad

2006

Under this well-publicised and well-published scheme, the poor women

are provided free delivery services by the hospitals of both government

& private sectors, and the obstetricians are paid a flat rate of Rs.2,800/- (twenty eight hundredrupees) per normal delivery, payable onconducting every batch of 100 deliveries.

3. Kasturba Poshan

Sahay Yojana (KPSY)

Ahmedabad

2002-03 Under this scheme, Rs.700 (seven hundred rupees) arepaid to pregnant women on three occasions, i.e. at the time of registration for ANC, for

institutional delivery in government hospitals and their newborns’ immunisation in government hospitals.

4

Bal Sakha Yojana (BSY)

Ahmedabad

2008

Under this scheme, the costs of neonatal care are exempted for BPL mothers who give birth to live babies. All participating paediatricians are

paid a flat rate of Rs.1,300/-

(rupees thirteen hundred

rupees ) per live

newborn and the obstetricians are also paid a lump sum of Rs.30,000/-

(thirty thousand rupees ) in case of a minimum 48 hours of hospital stay,

for a batch of every 100 newborns treated.

5

Sambhav Voucher

Scheme

2005

It is an innovative way to harness the resources of the private sector, as well as increase access to quality healthcare services through public-

private partnerships (PPP). This approach involves the Government-

paying private providers for maternal health services rendered to those

below poverty line (BPL).

Preference for Private Facilities

Lack of Comprehensive Approach

F. Health Management & Information System (HMIS)

In many cities, the public health facilities are charging a user fee, resulting in disinterest of the urban poor in accessing public health systems and preferring treatment at private clinics. The fact remains that the public health system lacks trained personnel and the scenario is worse when it comes to handling diagnostic equipment. In a few of the city reports there are discussions on the availability of equipment; however, there is a dearth of human resource to manage the same.

As reflected from the reports, the healthcare system available in the country is neither sufficient nor comprehensive when it comes to mothers and newborn babies. The UHCs are not functional and the referral system in effective in just a few of the cities, such as in Sikkim. Although the situation and the design of healthcare varies from one city to another based on population size, the need for a planned and systematic effort toward provision of maternal and newborn care holds true to every urban space; especially when one looks at the number of urban slums, it surely raises a question on the adequacy of infrastructure.

The HMIS is essential for an analysis of the existing health scenario. However, both the infrastructure available for health provision in urban settings, (specifically for the poorer sections) and the HMIS, remain abysmal. The reporting of the same is unstructured and needs revamping. The review process for HMIS techniques related to maternal and newborn health care found lacunae in the information management system. The Municipal Corporations and other urban local bodies provide hardly any detailed reporting and analysis for the cities. The MoHFW, in its report, also identifies the loopholes in reporting systems that prevail across the various states at each level of service delivery.

Although Delhi, being the capital of the country, reports of a functional HMIS system, many of the Municipal Corporations in various states of the country seem to be facing issues such as lack of training or absence of management of data. The HMIS implies a system that helps in the management and maintenance of data and the storing of information, on the basis of which one can analyse performance of health units right from the level of sub-centre. As per the protocol given in the NRHM (now part of the NHM), the HMIS process needs to be facility-based (compulsory reporting at every unit of facility) and conducted in monthly, quarterly and annual mode (http://mohfw.nic.in/). However, the overarching problem in the management of HMIS process across the various states is rooted in the inability of the health functionaries to report data in the prescribed format on time. Most of the UHCs are managed without basic facilities such as functional computers (www.nhsrcindia.org). The Project Implementation Plan (PIP) available with the NUHM indicates that every city needs to have a budget and a plan in place for delivering of health services. However, the information on health informatics related to the overall arena of reproductive and child health remains confusing. As mentioned in one of the PIPs, the monetary allocation to the HMIS is 70 lakh rupees (Rs. 70,00,000/-) (http://nrhm.gov.in/nrhm). In the process of review, efforts have been made to have access to guidelines and detailed reporting through the HMIS for the NUHM (on the websites of the NIHFW & NHSRC) and the information on the same is either not accessible or absent with regard to RCH in the NUHM.

Key Findings :

l The existing literature does not provide sufficient information on the aspects of bed: population ratio, status of buildings, drug and device-supply chains, inventories and also the list of equipment available in each of the cities where the field visits/studies have been conducted.

l Most of the services are housed in old and dilapidated buildings as well as in rental arrangements and lack the necessary infrastructure.



The Central Bureau of Health Intelligence deals with information on health; however, most of it pertains to communicable and non-communicable diseases. The engagement of the CBHI in maternal health could be seen in the training of health personnel on various indicators (maternal morbidity, maternal

119mortality, immunisation rate etc.) of RCH . The MCD (Municipal Corporation of Delhi) website of Delhi, however, holds a mechanism of tracking children for immunisation and also assessment of the nutritional status of children. An online tracking system prevails that provides detailed information on the vaccination schedule and centres of vaccination (mcwis/detail.php). It also contains components of health education pertaining to care during pregnancy. There is, however, no information available on morbidity during pregnancy and childbirth.

In a chapter on health informatics (www.nhsrcindia.org), the NHSRC has identified the problems associated with information on human resources, health management, geographical information system and mobile-related services. It further details that the informatics currently used are not following any common mechanisms, lack of common terminology is hindering the creation of a uniform method of information management. Most of the informatics is now developed on the basis of silos, causing redundancy and ambiguity in the information shared (www.nhsrcindia.org).

To conclude, it can be stated that the aspect of health management in the urban context needs thorough revamping and a uniform mechanism that captures systematic information on the facilities available for overall RCH.

The Alma Ata declaration, 1978 brought the essence of community involvement in healthcare planning 120(Alma Ata, 1978) . The major aspect that was put into its core was of self-reliance of communities in the

planning phase of healthcare. The same spirit was also seen in the five-year planning process of India 121with the introduction of community health volunteers. The declaration of Alma Ata (1978) strongly

argued for the significance of social determinants of health and that the community, the best stakeholder, to ensure accountability of the health service system.

However, the essence of community self-reliance was lost in the efforts when the country got engaged in 122selective healthcare, and “Health For All” (Das, 2014) has remained an “elusive goal”. In the current

format of healthcare provisioning, the services to urban mothers and newborns involve the community 123only in terms of mobilisation, with very little participation in the overall planning (Das, 2014) . The

urban healthcare systems for MNH care are advancing with an attitude of correcting healthcare systems in the cities, for the urban poor, and therefore, the learnings from the NRHM ought to be kept in mind

124(NUHM, 2014) .The framework for the NUHM has envisaged ensuring a protective ambit for the mother and newborn and the ideas of community participation surely have to find a place in the same, as it will pose a bigger challenge owing to the densely populated nature of the urban slums and also

125heterogeneity in their backgrounds and way of life (NUHM, 2014)

G. Community Interventions and Innovations

Key Findings :

l The HMIS process that should have indicated the morbidity and mortality issues pertaining to the UMNH is not visible.

l Secondly, as indicated in the reporting formats of MoHFW (a report of various districts within a state), the training required for the health personnel —at the level of PHCs, CHCs and even district hospitals—for maintaining and managing the HMIS is immense.

119 (http://cbhidghs.nic.in/)120 Alma Ata declaration (1978), http://www.who.int/, The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of

September in 1978, to promote and protect health for all.121 Ibid Alma Ata declaration (1978), http://www.who.int/122 Das , .(2014),” Community Participation in Health Care Management in India: Need and Potentials”; India Infrastructure Report 2014.123 Ibid Das, A. (2014).124

NUHM(2014), Executive Summary of Technical Resource Group, for National Urban Health Mission.125

Idid NUHM(2014).



Suggested Framework of the NUHM

Community Interventions and Innovations

The current framework of the NUHM entails the need fora community-based healthcare system, considering the fact that urban areas need a comprehensive system; a single ASHA, as in the rural areas,

126would not be able to tackle the aspects of organising healthcare(NUHM, 2014) . The most common observation across all cities and states is that there is really no major programme in place that is focused on strengthening urban community processes. A further challenge is that in settlements of the urban

127poor, there are fewer organic communities than what one may find in villages (NUHM, 2014) . Avillage is much divided by caste and gender inequalities, but is a stable social identity and also holds a stronger

128social capital(NUHM, 2014) . In cities, however, there is a paucity of structured systems as far as social functioning is concerned and many of the residents living in an urban context are devoid of care owing to

129their migratory status and absence of a large, family support (NUHM, 2014) . So is the case of women living in such a social fabric, they have access to very few support systems during and after pregnancy. Hence, the urban programme needs to keep this context in mind while designing guidelines for MNH

130care (NUHM, 2014) .

The range of services currently offered by urban ASHAs or other Community Health Workers, to the extent that they are in position, is largely limited to the promotion of immunisation, antenatal care and

131family planning (GOI, 2013) . The studies conducted across cities point to the fact that the reach of the ASHA to the vulnerable population is limited, since she has neither been equipped by mandate nor been

132trained to focus on the felt health needs of these marginalised groups (GOI, 2013) . The reach of the ASHA to the marginalized communities is critical, particularly in view of the fact that the NUHM lays substantial emphasis on reaching the invisibles; especially the destitute, the homeless and the

133marginalised (GOI, 2013) .

For bottom-up planning to occur, a community worker operating in isolation is insufficient 134(www.ifrc.org) . She needs a group of people - a community collective - who can support the process of

local planning, given their knowledge of and familiarity with their community and their environments, 135and their interest in positive outcomes (www.ifrc.org) . The proposed Mahila Arogya Samiti (MAS)

under the NUHM is composed of about 15-20 persons, drawn from a neighbourhood cluster (NUHM, 1362014) . The Kudumbashree model in Kerala has useful lessons on how to make this committee more

137representative by drawing one committee member from each cluster of 10 to 20 houses, (NUHM2014) . Promotion of public-private partnerships is required for capacity building, training and building of skills of the health workers and agencies who work on management, monitoring and implementation of

138health programmes (NUHM, 2014) .

The NUHM can adopt and adapt from various community healthcare interventions that have been running across the country. These initiatives are localised and much adapted to the life style of the community they address. A series of experiments has already been conducted for training the existing community with adequate information and hands-on skills for the management of reproductive health issues. A table containing some of the promising community interventions and innovations is shared in Annexure- 2.

126 Ibid NUHM (2014).127 Ibid NUHM (2014).128 Ibid, NUHM (2014).129 Ibid NUHM (2014).

133IbidGOI (2013).

134www.ifrc.org Maternal, Newborn and Child Health Framework, International Federation of Red Cross and Red Crescent Societies.135Ibidwww.ifrc.org136

Ibid NUHM ( 2014).137

Ibid NUHM( 2014).138Ibid NUHM (2014).

130Ibid 14 NUHM (2014).

131GOI (2013), Mission Work for the Urban Poor, Report of the Technical Resource Group, Urban Health Mission.

132Ibid GOI (2013).



A study conducted on Home-Based Newborn Care (HBNC) in the district of Gadchiroli, comprised of women health workers who undertook home visits on a regular basis, collected information on, and observed and examined mothers and newborns, checked the weight of the newborn every week and treated illnesses such as pneumonia. Other than that, the health workers were also trained in treating

139neo-natal illnesses through home-based sepsis management (Bang et al, 1999) . This intervention was replicated in the urban areas of Maharashtra and, later, in five other states, under the aegis of Project

140Ankur (NIPCCD, 2008) . The project focused primarily on building capacity of community-level mobilisers, training of trainers, creating a process to register pregnant women, providing care and also record cases of each newborn. It accorded high importance to attending to neonates right after birth, and

141in monitoring and recording deaths and still-births (NIPCCD, 2008) . The programme also undertook a stringent process of evaluating its training component through reviewing deliverables set for the community mobiliser. This project could not be scaled up to the national level and ended after the pilot

142phase itself. (NIPCCD, 2008)

The identified gap of absence in care-giving has been incorporated in many other schemes developed in recent times. A programme under the Norway-India Partnership Initiative (NIPI) named Yashoda was initiated in 2008 with the main objective to improve the quality of maternal and neonatal care in health

143facilities (http://www.oneindia.com) . The programme was inspired by the concept of legendary Yashoda, the foster mother of Lord Krishna, and “the idea is to give the love and care to the newborns the

144way Yashoda did to Lord Krishna” (http://www.oneindia.com) . This programme has been greatly 145effective in the selected districts of India (Varghese et al, 2014) .Under this programme, the Yashodas

were placed in health facilities where deliveries take place on a regular basis, and their main work was to give care to these pregnant women in the form of counselling on immunisation, breast feeding, family

146planning, and danger signs during pregnancy and newborn care (Varghese et al, 2014) . This programme helped in increasing the support, care and respect given to the expectant mothers and their families. It was found that there was a 50% increase in women who followed immediate breast feeding

147after undergoing Caesarean section in the intervention facilities (Varghese et al, 2014) . It also resulted in four to five times increase in postnatal check-ups in the intervention facilities as compared to the control facilities.

'Mamta', an organisation that works on health aspects in Delhi and the National Capital Region (NCR), 148experimented with a group of community-based health educators(Mamta, 2003) . It initiated a YFHS

centre (called “Friends”) in the community of Tigri and its function was to connect adolescents to referral clinics, providing them counselling facility, laboratory and dispensary by building linkages (Mamta,

1492003) . It also started a programme called 'The 10K Club - a club for the health and development of the poorest' which focuses on improving the quality of maternal and newborn health by eliminating poverty through proper mobilisation of the local community and other partners (NGOs). The Regional Resource Centre of Mamta has focused extensively on training, capacity-building and enhancing technical knowledge amongst various NGOs committees and panchayat members across Punjab, Haryana and

150Chandigarh (RRC Mamta, 2011) . This has helped in enhancing the capacity and knowledge of the staff, leading to an increase in the number of women registering pregnancy and availing of health check- ups at

151regular intervals (RRC Mamta, 2011)

152 The NGO, Saath (Annual Report, 2013) located in Gujarat had developed similar programmes with the

139Ibid Bang, A. et al(1999)

140NIPCCD( 2008), DCWC Research Bulletin, Vol. xii.

141Ibid NIPCCD( 2008).142Ibid NIPCCD( 2008).143

http://www.oneindia.com144Ibid http://www.oneindia.com145Verghese, B.et al ( 2014) ”Fostering maternal and newborn care in India the Yashoda way: does this improve maternal and newborn care practices during

institutional delivery?”

http://www.ncbi.nlm.nih.gov/pubmed/24454718146Ibid Verghese, B.et al ( 2014)147

Ibid Verghese, B.et al ( 2014)148

Annual Report (2003) Mamta Organisation 149

Ibid Annual Report (2003) Mamta organisation150

RRC ( 2013), Biannual Report Mamta.151

Ibid RRC( 2013).152Saath ( 2013), Annual Report.



idea of empowering community level health workers and also establishing a system of constant monitoring and follow-up ofcases of pregnancy and child birth. The maternal and child survival programme titled Jeevan Daan began in the year 2004 in association with Ahmedabad Municipal

153Corporation and Saath International (Annual Report, 2013) . It aimed to reduce infant mortality and morbidity by focusing its efforts on five key technical interventions that are major causes for infant mortality, namely: Pneumonia Case Management; Control of Diarrhoeal Diseases; Nutrition/Immediate Breastfeeding; Expanded Programme on immunisation and Maternal & Newborn Care.

Under the maternal health programme, Saath organised fortnightly camps that addressed the concerns 154of sexual and reproductive health aspects (Saath, Annual Report,2013) . It was diligently accompanied

by constant visits to the homes along with street meetings for reducing myths associated with pregnancy and newborn care. The behaviour and attitude of the women living in the targeted areas did see a shift. The number of women availing the services of ante-natal care (ANC), post-natal care (PNC) and also taking better care of nutritional requirements during pregnancy, increased significantly.Apart from the fact that most of the women in the community are devoid of good care during pregnancy, the absence of adequate referral systems stands as a hurdle in ensuring the survival of mothers and newborn babies.

SNEHA, an organisation working in the field of newborn health in Mumbai aimed at establishing an 155improved referral system for maternal and newborn care (http://www.snehamumbai.org/) .In the

first year of the project, workshops were organised, bringing together health providers from different levels of service and action groups were formed which met on a monthly basis. These action groups created a database of existing facilities for maternal and neonatal services, using a self-assessment tool

156(http://www.snehamumbai.org/) . They standardised technical and administrative protocols and ante-natal-neonatal services were also introduced at the health posts, which formed the primary centre at the slums. Besides the participatory approach, 'appreciative inquiry'— a behavioural methodology—was used to empower health providers in the public system and to bring about the change they envisioned in their respective facilities.

Sure Start, an urban maternal and newborn health project implemented by PATH in Maharashtra, revealed that the urban poor face problems due to poor accessibility, weak outreach and inadequate referral systems. Social exclusion, inadequate knowledge and absence of assistance at secondary and tertiary hospitals added to the existing challenges. The main objectives of Sure Start were to generate demand through enhanced individual, household and community mobilisation on the one hand and to strengthen institutional capabilities in order to improve maternal and newborn health in urban areas

157(www.path.org/publications) on the other hand. Sure Start was implemented through partnerships in seven Municipal Corporations of Greater Mumbai, Navi Mumbai, Nagpur, Pune, Malegaon, Nanded

158and Solapur in Maharashtra(www.path.org/publications) . The key strategies comprised: Need-based BCC; Mobilising community groups; Leveraging available resources; and developing collaborations with the local Municipal Corporations, professional bodies, community-based organisations and academic institutions.

To implement all these strategies in every city, a Common Minimum Programme (CMP) was designed; in addition to the CMP, each of the cities tested an approach or a model with an aim to create a safety net for MNH. PPP, convergence, community-based health insurance, emergency health funds, creation of quality-of-care norms, and empowering the self-help groups were some of the approaches that were

159tested in seven cities (www.path.org/publications) .

Quality-of-Care Model, Mumbai: The main objective of this model was to provide care to pregnant mothers and newborns by ensuring availability, accessibility, appropriateness and acceptability of public and private health services. It also aimed at establishing new antenatal, postnatal clinics and community centres.

153Saath( 2013), Annual Report.

154Ibid Saath, Annual Report (2013).

155Ibid http://www.snehamumbai.org

156Ibid http://www.snehamumbai.org

157Ibid www.path.org/publications158Ibid www.path.org/publications, 159

Ibid www.path.org/publications



160 http://www.surestartdata.com Sure Start in Maharashtra, India.

Public-Private Partnership (PPP) Model, Navi Mumbai: This model ensured provision of ANC/PNC and newborn health services through special clinics organised every week at the UHCs. Paediatricians and gynaecologists from the professional bodies such as the IAP and NMOGS attended these clinics under the special partnerships worked out for this project. Under this model, a total of 26,823 pregnant women were examined in 131 clinics and 2,728 cases were sent to special clinics.

The Convergence Model, Pune: The main aim of this model was to create awareness about HIV amongst pregnant women and create a link between Integrated Counselling and Testing Centres and establishing committees such as MOMS (Monitoring of Maternal and Newborn Status). This committee functions by providing health services to mothers who are affected by HIV, with the help of Municipal Corporation & public health facilities. The MOMS committees strictly monitored the families of pregnant women for ensuring ante-natal check-ups, post-natal care and newborn care. It has well incorporated mothers, mothers-in-law and link workers, AWWs to act as a pressure group on families that are not adopting safe health practices for the care of mother and newborns

160(http://www.surestartdata.com/) .

Emergency Health Funds (EHF) Model, Nagpur: The EHF is a financial mechanism which helps in providing health services to mothers and newborns at affordable rates. To attain these objectives, prepaid cards were developed after a thorough assessment of the needs of the community. Nearly 1,160 families have benefited under this EHF model so far and the funds helped in meeting the cost of delivery and treatment of newborns.

Quality of Care Model, Malegaon: Under this model, capacity building of Municipal Corporation staff and participation andmobilization of communities for high quality health services was targeted. Meetings on the quality of care norms in two health posts having an alliance with the Malegaon Municipal Corporation were organized on a regular basis but the major limitation was a lack of trained manpower for providing health services and sustaining this process.

The Volunteerism Model, Solapur: The main objective of this model was to mobilise the community of Solapur by using volunteers to enhance maternal and newborn health services. The model was a success and was accepted by the Solapur Municipal Corporation as a strategy for further improvement. Formulation of a network of 170 Self-Help Groups (SHGs) with adequate knowledge on MNH care was the key aspect.

The Community-Based Health Insurance (CBHI) Model, Nanded: Introduction of service providers' network and a community-based health insurance mechanism known as “Apni Sehat” was introduced in the targeted slum areas of Nanded city. Itensured the availability of funds for the poor slum-dwellerswhocould not meet the cost of institutional deliveries and antenatal care check-ups.

The role of Corporate Social Responsibility (CSR) has also been outlined in some of the interventions across the country. Biocon Foundation reiterated the strategy of first assessing the community needs and then establishing a package of health education amongst expectant mothers targeted through self-help groups. They adopted community awareness and a participatory approach in which they closely associated with the women self-help groups. They also organised workshops for mothers and community members on issues such as malnutrition.



Key Findings :

l

l

There is no nationalised and overarching programme focused on strengthening urban community processes for MNH care.

The literature does not address why many of these interventions were not expanded at a larger scale and there is also a lack of understanding as to why so many of these have failed to address the challenges of MNH care in India.



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H. Innovative Approaches

Innovation is essential to keep pace with the shifting demographics of a country undergoing rapid economic and social changes, such as India. Without the initiatives of the state government in strengthening the health system, innovations cannot achieve their desired outcome. This section delves into the various innovations that have successfully dealt with the complex issues of decaying public health infrastructure, scarcity of human resources and other relevant factors; which can possibly be adapted to develop a nationalised programme for maternal and newborn care in the urban Indian context.

l Strengthened Health Systems

A dedicated public health cadre under the Directorate of Health Services in Tamil Nadu, has three key 161directorates, which are organisationally equal, under the Health Secretary. (Gupta et al.2010) . The

Directorate has trained public health managers, who are promoted to the Directorate after years of experience in planning and overseeing public health services in both rural and urban areas. Thus, one of the reasons why Tamil Nadu is able to achieve relatively good health statistics, even in urban maternal and newborn care, is its strength in implementation—which is reinforced by a dedicated public health workforce that is appropriately trained and has the relevant experience.

l Greater Budgetary Allocation for MNH

A good example of prioritised budgetary allocation is Muthulakshmi Reddy Maternal Assistance Scheme. In India, most of the states are providing Janani Suraksha Yojana (a Centre- sponsored scheme) money to the mothers who deliver in a recognised health facility. In Tamil Nadu, the state has launched a separate state-funded scheme of Conditional Cash Transfer (CCT) for institutional delivery, i.e. the Muthulakshmi Reddy Maternal Assistance Scheme, introduced in 1989, much before the JSY (introduced in the year 2007, October). It started by offering a cash incentive of Rs. 500/- to each pregnant woman. The scheme was initially run by the Social Welfare Department and subsequently handed over to the Health Department. This particular amount was meant to compensate pregnant women for wage losses during pregnancy. Subsequently, the amount was increased to Rs. 2,000/- and then to Rs. 6,000/-. This amount was recently raised to Rs. 12,000/- per pregnancy and is paid by the government for the first two live births. Apart from wage-loss compensation, another purpose of giving the money is to provide additional nutrition to the mother to prevent anaemia and low-birth-weight babies. This scheme is only meant for Below Poverty Line (BPL) families (Padmanaban et al 2009).

l Health System Innovations

The Tamil Nadu Medical Service Corporation (TNMSC) was set up in 1995 with the primary objective to ensure ready availability of all essential medicines at all the government health facilities. The government of Tamil Nadu adopted a streamlined procedure for its procurement, storage and distribution. The list of nearly 900 drugs was reduced to 240 drugs as per the WHO's model list of essential drugs, accounting for around 90% of the budget outlay for the purpose, leaving other drugs of smaller quantities to be purchased locally by the institutions from out of the remaining 10% of the budget. This innovation has improved availability of drugs in nearly 2,000 government medical

162institutions throughout the state .

l Maternal Death Review (MDR)

MDR is an important strategy to improve the quality of obstetric care and reduce maternal mortality and morbidity. It provides detailed information on various factors at the facility, district, community, regional & national levels and the information can be used to adopt measures to fill the gaps in service

161Gupta, M., Desikachari, B.R., Shukla, R., Somananthan, T.V., Padmanaban, P. and Datta, K.K. (2010). 'Special Article: How Might India's Public Health Systems Be Strengthened? Lessons from Tamil Nadu', Economic & Political Weekly, XIV (10).

162Padmanaban, P., Raman, P. and Mavalankar, D. (2009). Innovations and Challenges in Reducing Maternal Mortality in Tamil Nadu, India', Health Population Nutrition, 27(2): 202-19. International Centre for Diarrhoeal Disease Research, Bangladesh.

163(Government of India, 2010) . Government of Tamil Nadu started compulsory audits of all maternal deaths occurring in the state since 1994. Sensitisation workshops were organised among the health functionaries on the importance of reporting maternal death. The system became fully established when the government of Tamil Nadu issued an order in 2004, stating that all maternal deaths should be audited. The reporting of the maternal death itself is the first important step, because many times people do not even report maternal death cases. The state mandates that each maternal death be reported to the Maternal and Child Health Commissioner, within 24 hours of occurrence, through a telegram or FAX, irrespective of the place of death – public facility or private nursing home or during the time of transit. Multiple sources of reporting are also encouraged, to avoid missing out on any incidents and lapses. Maternal deaths are reported by ANMs, the medical officer posted at the periphery, from the First Referral Unit (FRU), non-government hospitals, district public health nurses and Deputy Director of Health Services. Investigations of maternal deaths are carried out through community-based maternal reviews (verbal autopsy) and facility-based maternal death reviews/clinical audits.

Iron Sucrose Injections

Iron Deficiency Anaemia (IDA) is responsible for 95% of anaemia during pregnancy. Over the past years, various oral, intramuscular and intravenous preparations of iron have been used for correction of IDA in expectant mothers. However, they are associated with significant side effects and it is not possible to achieve the target rise in haemoglobin (Hb) level, in a limited period, when the mother is approaching term.

Iron sucrose injection was approved by the United States of America Food and Drug Administration(USFDA) in November 2000. The recommended schedule is to administer 100 mg intravenously over five minutes, once or thrice weekly, until 1,000 mg has been administered. The rate of administration should not exceed 20 mg per minute. A test dose is also not required and is at the

164physician's discretion (Silverstien and Rodgers 2004) . Iron sucrose complex achieves a relatively satisfactory level when used in severely anaemic, iron- deficient, pregnant women. A Few state governments in India are conducting initial research on it and the state governments of Bihar, Uttar Pradesh, Karnataka, Tamil Nadu, Maharashtra and Chattisgarh have allocated resources in their Programme Implementation Plans (PIP) for procurement of iron sucrose, for making it available in all primary healthcare settings. The decision to include it has been based on evidence obtained from very small observational studies and on the experience of clinicians who have been using it. Of the above-mentioned states, Tamil Nadu has implemented the administration of IV iron sucrose in primary

165healthcare settings since 2009 (Srinivasan and Ayyanar 2010) .

The documents sourced from the CHMI (www.healthinnovations.org) profile more than 220 programmes that harness private providers to deliver Maternal, Newborn, and Child Healthcare (MNCH) in Low and Middle-Income Countries (LMICs). The CHMI profiles programmes that use innovative delivery and financing mechanisms to improve access, quality or affordability of healthcare for the poor including clinical social franchises, vouchers for safe deliveries, and high-volume/ low-cost maternity hospitals. The overview of the market-based activities in MNCH programmes highlights that over 70% of the CHMI's MNCH programmes are concentrated in South Asia and East Africa and 58% are private and not-for-profit models. The volume of services delivered by the private sector is estimated to be quite high with considerable experimentation with new approaches and models for care. Social franchising, micro-insurance and vouchers are the most commonly applied approaches and have some

l Technological Innovations

l Innovative Approaches by the Centre for Health Market Innovations (CHMI)



163 Government of India. 2010. Maternal Death Review: Guidebook Maternal Health Division, Ministry of Health and Family Welfare, Government of India.164 Silverstien, S.B. and Rodgers, G.M. (2004). 'Parental Iron Therapy Options', Department of Pharmacy Services and Departments of Medicine and Pathology,

University of Utah Health Sciences Center, Salt Lake, Utah.thTrends in maternal mortality: 1990 to 2013, http://data.unicef.org/, accessed on 28 March , 2015.

165Srinivasan, A.K. and Ayyanar. (2010). 'Intravenous Iron Sucrose Complex Therapy for Iron Deficiency Anaemia in the Pregnant Women'. Published in Compendium of Scientific Papers presented in TNPHCON 2010&2011 and ICONHSS 2010. Department of Health and Preventive Medicine, Dharmapuri District, Tamil Nadu.

evidence of impact such as increased utilisation, improved pro-poor targeting and reduced out-of-pocket spending. More research is, however, needed on the effects on quality, affordability and accessibility.

Innovative use of technology and the development of high-volume, low-cost clinics is becoming more common, particularly to improve operations and processes of care, change patient behaviour and increase access to affordable, quality services. However, evidence on the impact and effectiveness of these models on urban MNCH outcomes is limited.

Launched in the year 2006, this is a national mobile hospital programme, catering to the underprivileged children and women in remote rural areas and urban slums, using primarily volunteer physicians and nurses. Smile-on-Wheels operates in several locations across India—Chhattisgarh, Delhi, Maharashtra, Odisha, Tamil Nadu and Uttarakhand—reaching nearly 750,000 people in 249 villages and urban slums. Three more units are being added in Ahmedabad, Hyderabad, and Lucknow. Implemented by the Smile

166Foundation , a not-for-profit organisation working in education and healthcare for underprivileged children across India, it operates in the areas where governmental healthcare facilities are scarce, non-existent or non-functional. The mobile vans delivering healthcare at a nominal cost to the community are staffed by specialised medical personnel and are equipped with an x-ray machine, electrocardiogram machine, basic pathological services for blood and urine tests, ante-natal and post-natal services, and an out-patient department for common ailments. The staff performs routine medical examinations, distributes condoms and oral contraceptive pills, and transports severely ill cases to super-specialty clinics. The team also carries out awareness activities on health and hygiene to encourage health-seeking behaviour, focusing equally on preventive and promotive healthcare, including home-based care. The project receives deep community support through a cadre of health volunteers who provide health education, provide counseling and serve as depots for family planning kits, oral rehydration salts, iron tablets etc.

Launched in the year 2002, this is a health programme providing a wide range of targeted medical services to the most vulnerable segments of society through innovative service delivery and risk- pooling. The NICE Foundation operates in Andhra Pradesh and Rajasthan with plans to expand to other states. It is a registered charitable trust based in Hyderabad that designs and implements all health programmes in partnership with state governments, the private sector and civil societies. The NICE Foundation's programmes are financed through public funding sources (including state governments and the central government) and through private donations from individuals and grant-making organisations.

NICE Foundation's Institute for the Newborn: The Institute for the Newborn is a first-of-its-kind specialised institute providing affordable international-quality neonatal care to all segments of society, using a cross-subsidisation model to benefit the poorest. Located in Hyderabad, it is the largest of its kind in South Asia and the institute is a 120-bed facility that networks with all the maternity hospitals in the city and provides neonatal care and referral care to high-risk newborns. The institute runs several 24/7 mobile intensive care units, staffed by a dedicated newborn transport team, that have peri-natal links with its existing government maternity hospitals, private nursing homes and non-governmental organisations. The institute and its clinical care teams also conduct training and research in various areas of neonatology.

Founded in 2005, LHPL is a for-profit, high-volume, low-cost hospital providing quality and affordable

l Innovative Service Delivery by the Smile-on-Wheels Programme in India

l Innovative Service Delivery and Risk Pooling by the NICE Foundation, India

l Life Spring Hospitals Private Limited (LHPL)



166 The Smile Foundation partners with local organisations in each state to run Smile-on-Wheels, including: Ambuja Cement Foundation (Roorkee, Uttaranchal), Berojgar Mahila Sewa Samiti (Bhilai, Chhattisgarh), Operation Blessing India (Delhi), Orissa Institute of Medical Research and Health Services (Cuttack, Odisha), and Sevadham Trust (Pune, Maharashtra). The Smile Foundation receives funding from several domestic and international partner organisations.

healthcare to women and children from lower income households across India. LHPL operates six hospitals serving 23,000 patients, with plans to scale up to 140 hospitals by 2014 in Andhra Pradesh, Karnataka and Maharashtra. Jointly operated by Hindustan Latex Limited and the Acumen Fund, it is a for-profit hospital operated with a 50/50 equity partnership.

LHPL addresses maternal and child healthcare in India through a chain of high-quality, small private hospitals (20–25 beds) that offer efficient, affordable customised care to its customers (“guests”). Its strategy is to provide services at the lowest possible cost, focusing on the working-class poor in high-population-density urban areas. LHPL's niche is standardisation of processes and specialised provision of maternal and child services, including ante-natal care, post-natal care, deliveries, family planning services, medical termination of pregnancy, paediatric care (including immunisation), diagnostics and pharmacy services. To maintain self-sustainability while serving low-income customers, LHPL applies internal cross-subsidisation, with service rates based on the type of accommodation and not on the quality of service. Under this model, hospitals are expected to become profitable within 21 months and to further reduce costs for services; LHPL is developing relationships with several government-sponsored voucher and insurance schemes (such as the Janani Suraksha Yojana).

Customer Relationship Management: LHPL has developed a unique protocol for customer care, Life Spring CARES (courteous, attentive, respectful, enthusiastic and safe), which all hospital employees are required to observe. To ensure high-quality service, client surveys and discussions with customers are used to obtain feedback which is fed into the operational system to improve overall service.

High-quality services: LHPL provides high-quality services at a low cost by leveraging information technology (they are now setting up a data centre to link all their hospitals) and working with the national and international medical equipment vendors to negotiate better prices for equipment through economies of scale.

Launched in 2005, Arogya Raksha Yojana (ARY) is a health micro-insurance scheme providing affordable, high-quality healthcare for the underserved in rural and urban areas of the Indian state of Karnataka through an accessible provider network of private hospitals and clinics supported by leading doctors and surgeons. ARY insures 70,000 people across seven districts of Karnataka. The programme is a joint project between the Biocon Foundation (the foundation of Biocon Pharmaceuticals Ltd.) and Narayana Hrudayalaya Hospital. Several independent rural service providers support them. The risk is covered by ICICI Lombard and funding for the programme is provided through the Arogya Raksha Yojana Trust.

ARY leverages the expertise of the commercial insurer to provide retail insurance to workers in the informal sector in non-rural areas by bearing the risk and undertaking all insurance administration. Local ARY clinics (run by the Biocon Foundation) create a presence in local communities and provide care to both the insured as well as the uninsured, reduce the costs of insurance claims by providing good primary healthcare (thus reducing rates of hospitalisation for surgical procedures). ARY benefits are comprehensive and include free outpatient consultation; generic medicines at special rates from Biocare pharmacies; diagnostic tests at discounted rates at network hospitals, at Biocare Clinics and approved diagnostic centres; hospitalisation (not leading to surgery) and surgical treatment for more than 1,600 types of surgeries. ARY offers health insurance to workers in the informal sector in the slums of Bangalore (India's third-largest city), who are reached through micro-finance organisations and community-based organisations. In places where no strong community institutions exist, ARY sets up enrolment booths for a limited time each year.

Established in 2005, CY is a government-organised, quality-driven voucher programme contracting private obstetricians and gynaecologists to provide delivery services to women who live below the poverty line to reduce the maternal and newborn mortality rates. Initially launched in five poor districts

l Risk-Pooling by Leveraging Commercial Experience for Social Benefits

l Chiranjeevi Yojana (CY): Contracting the Private Sector



of the state of Gujarat, it was later extended to the entire state, with 892 participating providers who have performed 294,635 safe deliveries per data sourced. Established by the government of Gujarat with support from the Indian Institute of Management, (Ahmedabad) and Sewa Rural–Jhagadia and facilitation by GTZ, it is financed by the Government of Gujarat, with support from the Central Government under the National Rural Health Mission.

The CY was created to significantly reduce maternal and infant mortality by harnessing the existing private sector and encouraging it to provide delivery and emergency obstetric care at no cost to families living below the poverty line. Under the scheme, the government contracts private providers that volunteer to render their services by signing a memorandum of understanding with the district administration. In return, they receive an advance payment to commence services and are compensated at about US$4,500 per 100 deliveries (normal, Caesarean, or with other complications). Any qualified private provider with basic facilities, such as labour and operating rooms and access to blood and anaesthetists can enroll in the programme after a thorough orientation. The CY beneficiaries are enrolled through their family health workers but the scheme uses the existing cards issued to families living below the poverty line (BPL) by the Rural Development Department of the State Government. In the first six months since the launch of the scheme, each provider performed 116 deliveries on average. The institutional delivery rate has apparently increased to more than 81% from an about 54.7% in 2005–06. The CY's long-term goal was to achieve an institutional delivery rate of 95% by 2012.

Benefits Package: The CY uses demand-side financing to provide families living below the poverty line with access to a comprehensive benefits package that covers both direct and indirect costs, including free delivery (with no condition exclusions), free medicines after delivery and transport reimbursement. In addition, as a thoughtful gesture, it offers support to the attendant in exchange for lost wages. The payment method and formula encourages providers to reach a certain volume of work, avoid complicated transaction costs and create a disincentive for unnecessary Caesarian sections. The provider compensation package is designed to account for all potential complications during delivery (estimated at approximately 15% of cases).

Contract Management: The CY's district management authorities require participating doctors to maintain a case file for each patient they serve. Weekly records of the deliveries conducted by the providers are submitted to the local authorities and the Block (sub-district) Health Officer, who regularly visits beneficiaries to monitor service quality and address grievances. Payment to providers is also made through block health officers based on instructions from district authorities. All districts send a monthly report to state authorities for review and feedback.

l Engagement of Community-Level Media: Community Radio

Dissemination of information has been one of the major components of maternal and child health programmes in India. Media campaigns can act as an effective mode to transfer information on good

167health behaviours and services available for the issue concerned (southasia.oneworld.net) . Community radio has been designed on many occasions for passing information to a larger audience in our past healthcare programmes. The Annamalai University started its community radio called Putholi with the intention of addressing the issue of stigma associated with HIV/AIDS. This resulted in success

168and the radio station was awarded as well in recent times (southasia.oneworld.net) . The intervention can surely be extended to maternal and newborn healthcare in urban communities. This can be usedwell as a tool to spread information on home-based neonatal care and, in fact, toward creating an environment within communities for building a support system for ensuring safety of the mother and

169the newborn(southasia.oneworld.net) .



167Ibid southasia.oneworld.net

168 Ibid southasia.oneworld.net169 Ibid southasia.oneworld.net

Conclusion

To conclude, the innovations that have been able to cater to the needs of communities dwell primarily on the principles of ensuring affordability, accessibility and availability. In the urban Indian context, where the diversity is wide and a subsidised healthcare system is still not present universally, the innovations of effective health finance (low-cost clinic, e-finance) discussed above can prove to be useful. Secondly, as the heterogeneity aspect and absence of social capital adds to the challenges in urban areas, the need to create safer cocoons of care for mothers and newborns through the involvement of NGOs, hospitals and local governance is a must.



Key Findings :

l The innovations have been designed to address the issues of infrastructural decay, crunch in human resource, depleting finance in health, high-cost treatment processes; however, the best practices of these innovations have not been tested on a large scale for maternal and newborn health.

l There is a dearth of literature on how the learnings from the innovations can be used to create integrated models for a national-level programme.



Promising Innovations in Maternal & Newborn Health in India

1.

Muthulakshmi Reddy

Maternal Assistance

Scheme

Tamil Nadu

Introduced

in 1989

State-funded Scheme of Conditional Cash Transfer (CCT) for institutional

delivery. It started by offering a cash incentive of Rs.500/-

to each pregnant

woman. The scheme was initially run by the Social Welfare department and

subsequently handed over to the health department. This particular amount was

meant to compensate pregnant women for wage losses during pregnancy.

Subsequently,

the amount was increased to Rs.2,000/-

and then to Rs.6,000/-.

This amount was recently raised to Rs.12,000 per pregnancy and is paid by the

government for the first two live births. Apart from wage-loss compensation,

another purpose of giving the money is to provide additional nutrition to the

mother to prevent anaemia

and low birthweight babies. This scheme is only

meant for below poverty line (BPL) families.

2.

Three Staff Nurse Model:

24x7 functional PHCs

Tamil Nadu

Between

2001-2006

This innovation

ensures safe delivery services in a PHC to pregnant women, at

the onset of labour pains, at any time of the day or night.

3.

Technological

Innovations - Iron

Sucrose Injections

Tamil Nadu

2009

Iron sucrose is an iron hydroxide sucrose complex in water. It is administered by

intravenous (IV) injection or infusion. The recommended schedule is to

administer 100 mg intravenously over five minutes, once or thrice weekly, until

1,000 mg has been administered. The rate of administration should not exceed 20

mg per minute. A test dose is also not required and is at the physician’s

discretion. Iron sucrose complex achieves a relatively satisfactory level when used

in severely anaemic iron-deficient pregnant women. 4. Non-Pneumatic Anti -

Shock Garment (NASG)

Tamil Nadu The Government of Tamil Nadu has incorporated the use of the NASG into its

protocols for active management of the third stage of labourand routinely trains

staff at all levels for its use. The NASG is now also being kept in all 108

Emergency Management and Research Institute (EMRI) ambulances in Tamil

Nadu. 5. Raksha Project Bihar, Rajasthan,

Tamil Nadu

To implement the ‘Continuum of Care’ philosophy and, within that, introduce the

NASG.

6. Development of Embrace

Baby -Warmer

Bengaluru,

Karnataka

2011 The current form of the baby-warmer was also being used as a transport device.

Here, if the LBW baby is required to be transported intra-hospital or inter-hospital

for any laboratory checks or referrals, the baby-warmer might be used to keep the

baby warm. It is seen to be a suitable alternative which is easy to use and cost-

effective. 7. Smile-on- Wheels

Programme

Chhattisgarh,

Delhi,Maharashtr

a, Odisha, Tamil

Nadu,

Uttarakhand,

Ahmedabad,

Hyderabad,

Lucknow

2006 Focusing on women and children, Smile-on-Wheels is a national, multi-centric

mobile hospital programme that provides medical care to rural and semi-rural

areas and urban slums where governmental healthcare facilities are scarce, non-

existent or non-functional. Provide both preventive and curative services to those

in need, including outpatient, ante-natal and post-natal services, identification of

difficult pregnancies and referral for institutional care, immunisation for mothers

and children, minor surgery, blood pressure examinations, electrocardiograms,

first aid, iron folic acid tablets, vitamin A prophylaxis and treatment of

malnutrition.

8. Innovative Service

Delivery and Risk-

Pooling by-NICE

Foundation, India

Andhra Pradesh

and Rajasthan

2002 It runs two health programmes in Andhra Pradesh - the School Newborn

Healthcare Plan, the Tribal Reproductive Newborn Health Programme and also

operates the specialised Institute for the Newborn, Hyderabad, which provides

neonatal care and conducts training and research. The School Newborn

Healthcare Plan has been replicated in three districts of Rajasthan and further

rollout is planned in the state.

9. Innovative Service

Delivery by Life Spring

Hospitals Private

Limited (LHPL)

Andhra Pradesh,

Karnataka, and

Maharashtra

2005 Specialised provision of maternal and child services, including ante-natal care,

post-natal care, deliveries, family planning services, medical termination of

pregnancy, paediatric care (including immunisation), diagnostics and pharmacy

services.

10.

Arogya Raksha Yojana

(ARY)

Karnataka 2005 Health micro-insurance scheme providing affordable, high-quality healthcare for

the underserved in rural and urban areas of the Indian state of Karnataka,

through an accessible provider network of private hospitals and clinics supported

by leading doctors and surgeons.

11

. Chiranjeevi Yojana (CY) Gujarat 2005 This is a government-organised, quality-driven voucher programme contracting

private obstetricians and gynaecologists to provide delivery services to women

who live below the poverty line to reduce the maternal and newborn mortality

rates.



Summary of Findings

Irregularities and complications during pregnancy, child-birth and post-natal period are the leading causes of death and disability among women of reproductive age and newborn babies & infants in developing countries. Providing healthcare services, especially maternal and newborn care, is increasingly understood to be a dynamic system of entitlement and obligations among people, communities, providers and governments. However, the paradox in a country like India is that while the global community still concentrates on efforts to attain health-related Millennium Development Goals (MDGs) based on national strategies to reach high and equitable coverage of health services, the provision of health services, though absolutely necessary, is insufficient and unstructured in urban areas. Thus, on the one hand, the quality of treatment and care provided by the health system in rural areas does become complementary to the global efforts to reach and maintain coverage of health services, the pregnant mother and her newborn from the vulnerable sections of urban settings still struggle for the availability and accessibility of public health services. This only proves that on the other hand, the straightforward indicators for measurement in urban areas are, first and foremost, about the provision of services because unlike its rural counterpart there is no envisaged Primary Health Centre with its planned network in urban slums. Moreover, administration of health services through multiple health authorities, which are not effectively organised, has resulted in duplication of services in some

170.areas and non- existence of health services in other areas

The urban poor are at the interface between underdevelopment and industrialisation. Urban health in the slums presents serious public health concerns and challenges; predominant among them is maternal and newborn health and mortality. Although urban mortality statistics are comparatively better than the rural, there is a wide disparity between the settled urban population and the marginalised slum-dwellers. Hence, the existing urban statistics do not give a true representation of urban slums. Vulnerable urban communities continue to be poorly served. Though this is a result of “service” barriers, it is also a product of inter-related variables, such as poverty, inequitable distribution of primary healthcare services, poor referral systems, vertical programming and attitudinal & management challenges. Understanding how policies and programmes can address both service and demand-side barriers is a central question today.

With the growing urbanisation of poverty—with almost one out of four poor persons living in urban slums—the available indicators for the urban poor compare unfavourably with both the urban and national averages. There is a widespread awareness of the issue in research literature and a growing need for significant increase in research in this area has been felt for the last one decade. The findings of this review also spell out this need reasonably well as the evidence available is relatively meagre. The findings of the review can be distinctly classified under two different pieces. The first piece reveals the gaps in terms of the current availability of health services to deliver maternal and newborn healthcare along with the clearly defined paucity of service-delivery platforms, governance and mechanisms— inclusive of infrastructure, human resources, logistics, supply chain, partnerships and community-level efforts. The second piece focuses on the gaps with regard to the availability of literature and evidence from the research undertaken in all of the above-mentioned aspects of health service delivery for maternal and newborn healthcare.

The conclusions from this review are based on very peculiar findings that dwell largely on the following key facts. While maximum data is available mostly on social determinants of maternal and newborn health and barriers in accessing services, there is little information available on interventions and models that have worked to address these challenges. In exceptional cases certain initiatives did work, providing some piece-meal solutions, then first, the sample size of these interventions was not large enough for confidence of scalability and second, these were mostly project-based initiatives

IV. Discussion and Conclusions

170 Armida Fernandez, Jayshree Mondkar and Sheila Mathai. Urban Slum-Specific Issues in Neo-natal Survival, Indian Paediatrics(2003); 40:1161-1166.



implemented and managed by non-governmental agencies. Thus, the review sets out suggestions not only in terms of requirement of evidence on the aspects of the service-provision and service-delivery mechanism in urban settings but also reflects the need for undertaking rigorous research in the area of urban maternal and newborn health which continues to remain an untouched area of research and learning.

Although not much information can be derived from the literature review on the status of maternal and newborn health services in urban India, oflate there are a few stand-alone initiatives that are being undertaken in different parts of the country to strengthen the health service delivery mechanism. The most specific initiativethat is being implemented uniformly across the entire country is the National

thUrban Health Mission (NUHM). The Government of India's 12 Five Year Plan built on the National Rural Health Mission and converted it into a National Health Mission (NHM) for the whole country. In doing so, it incorporated the developing of the National Urban Health Mission as a sub-mission of the NHM.

The information on the overall lack of clarity with regard to the ultimate responsibility of providing health services in urban areas as it is in rural areas is most well covered. The information on service provision mechanisms reveal that the health services vary from city to city, while a few large cities (such as Mumbai, Kolkata and Chennai) have used the Indian Population Project to focus on health infrastructure establishment in urban slums, only a few large Municipal Corporations with good revenue resources like Surat, have demarcated special resources to provide urban MNH services. In addition, the lack of demonstrated political will to assume responsibility and accountability for urban services, as well as the absence of inter-departmental coordination between the Departments of Public Health, Urban Development, Medical Education, the Municipal Corporations and the local bodies have made matters worse.

A number of studies reveal that the resources invested in urban healthcare deal primarily with curative services; urban health posts/centres (UHPs/UHCs) mainly provide three types of services: regular (including preventive, curative, IEC activities and training), seasonal (pre-monsoon and monsoon-related activities) and disaster management; and the urban healthcare system is focused on secondary and tertiary care, and not on comprehensive promotion, preventive and primary-level services. There is no mechanism for a health worker to make community or home visits and, thus, no holistic outreach and follow-up services are available. A link worker or community health volunteer has been appointed in a few cities that are effectively implementing the NRHM (Urban Component) and RCH-II project. The main role of the link worker is family welfare, maternal and child health, immunisation, health education and demand generation.

Referral services are available in corporation hospitals/district hospitals/medical college hospitals as well as several private hospitals. There is no definite system of referral; no linkages between domiciliary, health centre and hospital; and no protocols for admissions to primary, secondary and tertiary levels. Currently, secondary level of care is provided by District Hospitals and their equivalents(such as combined and base hospitals) while tertiary care is provided by Medical Colleges. However, these are not linked to primary care institutions such as health posts or dispensaries. Consequently, patients approach tertiary hospitals for primary care which could have been provided elsewhere. This is a major reason for their high workload; challenging adequate quality.

A number of policy documents reviewed, reveal that by and large, the service delivery structure and mechanisms in the urban areas continue to be rudderless with a complete lack of clarity on roles and responsibilities vis-à-vis the rural areas, where the district administration is structured and responsible for service provision. Multiple state agencies are providing services. There is anoverlapping of services and lack of coordination among these agencies. Private health providers are the key players in the overall provisioning of services. Multiplicity of providers and lack of coordination among them has led to dysfunctional referral systems and a consequent overload on tertiarycare providers. Even in states where primary healthcare is managed by ULBs and secondary & tertiary healthcare by the state, the referral chain is not functional (NUHM, 2012).

While primary healthcare in urban areas (where the poorest sections can easily approach has largely



been neglected, there are exceptions of larger metropolises such as Mumbai and Delhi that provide primary healthcare by means of dispensaries, health posts and maternity homes. Health posts have been established under the India Population Project, e.g. in Mumbai basic ante-natal care and primary healthcare is provided through Community Health Volunteers and maternity homes, headed by an MBBS Medical Officer; these are meant for conducting normal deliveries and have support staff for this purpose. Similarly, at the primary healthcare level, Delhi has a network of 987 clinics and dispensaries through the Delhi Government, MCD, NDMC and Delhi Cantonment Board and central agencies though the CGHS, ESIC and Railways. (PHRN, 2010).

The UHPs, however, are located mainly in the big towns. Small towns continue to be deprived of these facilities. Though the UHPs are expected to carry out the same activities as the PHCs, their sanctioned staff strength is less. NUHM aims to meet the healthcare needs of the urban population, with a focus on the urban poor, by making available to them essential primary healthcare services and reducing their out-of-pocket expenses for treatment. This will be achieved by strengthening the existing healthcare service delivery system, targeting the marginalised and the people living in slums, and converging with various schemes relating to wider determinants of health (such as drinking water, sanitation and school education) implemented by the Ministries of Urban Development, Housing and Urban Poverty Alleviation, Human Resource Development, and Women and Child Development.

The urban poor are a diverse group of vulnerable populations, such as the homeless, rag-pickers, street children, rickshaw-pullers, construction, brick &lime kiln workers, sex workers and temporary migrants. They do not have stability, lack family support structures and are from varied cultures. Very few documents reflect the responsiveness to the needs of the poorest and the most vulnerable. While the availability of a large number of for-profit and not-for profit private providers encourages them to access private care more than the public facilities, they can hardly form any relationship with healthcare providers. The National Health Policy (2002) states that the public health facilities (with their poor infrastructure and inconvenient timings) are least accessed by the poorer populations and this has a serious implication for increased out-of-pocket payments for accessing private healthcare at the cost of items such as basic nutrition. The findings of the NFHS-III reflect that the private sector is the main provider of healthcare for a majority of the people living in urban areas. Use of private hospitals increases with increasing wealth quintiles. However, the poor also utilise the private sector more than the public sector. The main reason for non-utilisation of public facilities is the poor quality of care.

Studies on the availability of human resources reflect retention and training of the skilled birth attendants as the key bottleneck. Professional qualification does not necessarily mean that the provider is actually skilled. These also reflect the gaps identified in the guidelines on care and practices during pregnancy and the non-availability of doctors and midwives at the time they are most needed, i.e. at night. None of the studies reflect aspects such as staffing mechanisms, training, job satisfaction, appraisals, workplace safety and career development of the staff engaged for urban maternal and newborn healthcare.

Very little information could be traced on details of the guidelines or protocols for the functioning of primary and secondary level healthcare systems or the logistics required for maternal and newborn health in urban spaces. There is no information available on processes adopted for supply chain management, especially training procedures for staff at the primary and secondary level, to manage the supply chain of drugs and equipment and coordination with the blood banks and referral support. Lack of research in terms of availability and accessibility of services that may concern women living in urban slums comes across as a great deficiency. The existing literature also hints at the existence of private bodies however, does not extensively map the same.

Various studies reflect the lack of uniformity in delivery/provision of health services within and across cities. However, these hardly touch upon the opportunities for the marginalised at the health service centres, especially for MNH. The evidence gathered from the NHSRC 31-city-visit reports indicate a paucity of information on guidelines that govern the health service system and the details on facilities available for maternal and newborn health. The existing literature does not provide sufficient information on the aspects of bed: population ratio, status of buildings, drug and device supply-chains, inventories and also a list of the equipment available in each of the cities where the field visits/studies



were conducted. While some studies do mention the type of facilities providing MNH services, which are accessible to the urban poor, they lacks analysis in terms their functioning, efficiency, governance and monitoring mechanisms.

Reliable and consistent information on health informatics is scarce. Little or no efforts have been made to conceptualise mechanisms or/and to capture disaggregated, discrete data on health service availability and its performance in relation to urban MNH across cities and states. The information from HMIS features largely around NRHM and the information available for urban and semi-urban places isabysmal. The websites of the NIHFW, NHSRC, CBHI and ULBs such as MCD, mostly include information on communicable diseases and sanitation and hygiene. The reporting formats of MoHFW on various districts within a state reflect the training required for the health personnel at the level of PHCs, CHCs and even in District Hospitals for maintaining and managing HMIS. Reports of a few city corporations such as Delhi and Mumbai reflect on the adequate reporting system that undertakes necessary actions for training, creation of tracking sheets and monitoring of planned activities.

While a number of documents reflect on the role of State Health Departments, Municipal Corporations (MCs), Town Councils and ULBs in the health sector in general, there is very scanty literature that examine the roles of these bodies in provision of services related to maternal and newborn health. Abundant information is available on other public health issues and the role of Municipal Corporations in managing these. With specific reference to convergence, very little literature is available on the coordination that exists between various departments at the city level. A couple of studies discuss the Public-Private Partnership model that functions in coordination with the NGOs or other private providers/bodies. Scantily available literature on the ULBs reflects the immense distrust on the quality and efficiency of the services provided and talks about the non-functionality of the few available facilities.

Very little and inconsistent information is available on financing patterns, the role of local bodies in budget planning, the process adopted for sustaining projects and the decision-making in relation to the same, across a majority of the cities, especially in the urban and semi-urban locations. No information is available on the budgetary allocation process for maternal and newborn health except for some small-scale cash-transfer programmes that exist in various states.

Despite emerging evidence on the challenges and issues faced by a rapidly urbanising India, knowledge on, and availability of, information for understanding the health situation of urban poor mothers and newborns continues to remain insufficient and inadequate. This review examined the evidence on maternal and newborn health in the urban poor environments specifically with regard to the opportunities and gaps in the health system, factors affecting programming and service delivery, and potential strategies that address specific MNH care needs of the urban poor in India. Apparently, the evidence has significantly improved in quantity and quality over the past few decades, but it remains patchy in terms of geography, issues and methods. Broad generalisations are difficult to make, both state-wise and for the different cities specifically.

First and foremost, MNH care calls for a dire necessity of public health services, specifically the primary level care for mothers and newborns in all the urban areas of the country; this is logically followed by the requirement of easy accessibility and its affordability by the urban poor. While the absence of defined and structured primary healthcare in urban areas directly affects the health of the mothers and babies, its indirect impact is seen in the coping strategies and care-seeking behaviours that households adopt in response to their circumstances. Additionally, the evidence also suggests that poor households often face a state of confusion when it comes to dealing with MNH situations. Confusion about their access to peri-natal healthcare services mirrors the confusion of the services themselves – why should a tertiary

171hospital routinely deliver preventive care? Needless to say, social and cultural barriers are more common in slums where healthcare services are not reachable.

Discussion

171 Bhaumik, (2012).



Strengths and Weaknesses of the Evidence Base

This section assesses the strengths and weaknesses of the evidence base with regard to each of the four 172research questions presented during the review . Two general weaknesses in the available data are

discussed first. Firstly, this review of literature on MNH care in urban poor settings has revealed a lack of substantial and robust evidence on the availability of services associated with ante-natal, intra-natal, peri-natal and post-natal care for pregnant mothers and their newborns. Most of the studies located, examine the differences and diversities of service provision in the rural and urban areas in a comparative mode. Accurate and reliable findings on the specific service-delivery structures and platforms, their uniformity across the country, the proposed models by several committees and commissions and its actual implementation, are fairly limited. Further, in the literature available there is virtually very little or no coverage identified on the nitty-gritty of a functional health system, particularly aspects such as human resources, logistics, supply chain management and financing mechanisms. The lack of these data represents a critical gap in the evidence base.

A second weakness in the reviewed literature communicates on the generality of the write-ups, articles and documents, wherein all are trying to touch upon all the aspects of urban health. There are limited number of studies and research documents that talk exclusively about maternal and newborn health in a stand-alone manner rather than considering everything under the broader garb of reproductive and child health. While the evidence base with regard to MNH in the country is strong, with several good quality studies from different states, there are very few that are urban with a handful of these focusing on the urban poor. Another challenging area is the absence of uniformity in terms of pre-requisite and anticipated services in the light of the newly rolled-out NUHM which, nevertheless, is in a nascent stage, plagued by challenges of the very acceptance of proposed uniform structures.

The evidence base on the issues regarding maternal and newborn health in urban India is of better quality because a number of research studies, peer-reviewed articles, projects and programmes have narrated the problems and challenges faced by the urban poor. The results of several studies that are reviewed, although reliable, are somewhat compromised by the want of disaggregated data that can clarify the difference between slum versus non-slum, poor versus non-poor, and long standing residents versus recently migrated populations, in the urban locations.

On the reasons for the existing problems and challenges, the prevalent evidence-base is of medium quality. Examining challenges in relation to the provision of MNH services—that can help assess the situation and suggest solutions—has important limitations. What is obtained is essentially a snapshot of the problems and challenges that have existed for long in some of the larger cities and are now emerging rapidly in most of the cities. This, however, does not capture all the potentially valid reasons for this distressing situation.

The evidence base with regard to third research question on various supply side agencies, the successful interventions along and the existing linkages on supply side is varying for all the three aspects. Insufficient data is available on establishment of outreach services and their effectiveness. Few studies mention mass media campaigns and community education as standalone interventions, though many interventions use the delivery platform of community, including clinical interventions. Many of these community-based interventions reflect a great rate of success but are way beyond scalability because the population covered is minuscule. The studies reviewed also reflect that the state governments and city corporations often collaborate with NGOs & CBOs as satellite nodes linked with larger central offices as a structural arrangement for community outreach programmes.

Evidence is available on overall urban governance that reflect gaps and challenges but lacks reflections on urban health governance, with a complete absence on governance for MNH programmes. Data also reflects generic information on the desirability of inter-sectoral coordination but lacks evidence on any specific coordination beyond the ICDS programme.

172 a. What are the issues with regard to urban MNH? b. Why do these issues exist- what are the reasons? c. Who are the various supplyside agencies and what have their successful Interventions been along and what are the existing linkages on the supply side? d. What are the financial mechanisms/financial availability/budgetary provisions that exist for urban MNH?



The evidence-base on financial mechanisms/financial availability/budgetary provisions that exist for urban MNH is largely scarce. However, secondary data from a number of Municipal Corporations reflect the expenditure incurred on reproductive and child health services of which MNH is one of the core areas. Robust information is available from two specific documents (the NUHM framework and the Technical Resource Group's report on Urban Health), as these incorporate inferences and recommendations of various committees and sub-committees that worked during the phase of the

th12 Five Year Plan. Once again however, the information provides a broader spectrum of expenditure, budgets and finances in the urban areas and cities but does not specifically reflect the disaggregated information on financial mechanisms for MNH.

There are studies that focus on the evaluation of mechanisms established for JSY, JSSK, RBSK, RSBY and Chiranjeevi Yojana; however, there is very little coverage for urban areas. Some evidence on social franchising, micro-insurance and voucher schemes does exist in terms of its impacts such as increased utilization, improved pro-poor targeting and perceived reduced out-of-pocket spending. However, none of the studies focuses on the quality, affordability and accessibility of the services targeted by these vouchers and scheme.

The overwhelming constraint on better availability of services for MNH care in urban areas is starkly visible. The findings presented in this review suggest two specific aspects: first and foremost, there exists very poor evidence on availability of services for MNH in urban areas and, secondly, there exist no defined structures for MNH services for the urban poor. Similarly, the evidence base is relatively weak with regard to the existence of specific policy instruments. Nevertheless, the following tentative conclusions may be reached with regard to what direction researchers and policy-makers should take in order to ensure that MNH care services are delivered to the urban poor.

The possible solutions vis-à-vis the conclusions stated can be mapped from the perspective of the AAAQ (Availability, Accessibility, Affordability and Quality) framework that was laid out in the terms of reference and the initial study protocol under the following sub-heads.

a. Physical Infrastructure

The need of the hour is certainly to conduct an extensive research on finding the gaps in the existing health structure for MNH care in terms of: number and type of facilities available for urban mother and newborns; the status of infrastructure in the urban centre (as in the few cases where information was available, the health facilities were running in rented spaces, poorly designed, or dilapidated structures); presence of basic facilities such as x–ray, ultrasound, labs and other essential equipment; SNCU and emergency obstetric care units; and suitably equipped transport facilities for pregnant women.

a. Responsive, Sensitive and Standardised Mechanisms

Setting up of standards for institutions for providing primary healthcare and making them accountable to the local government and, in turn, to the citizens, are vital aspects that need attention. The process of providing managerial oversight to UHCs needs to be defined by strengthening primary care services, which means allocating more resources to them and creating a well-defined referral system for secondary and tertiary care. The urban poor are a diverse group of migrants and 'outsiders', mainly from rural areas. They endure tough working conditions and have a poor health status. They have an unsteady relationship with service providers, unlike other city-dwellers. Consequently, any planning for them needs to take this diversity into account. This city-specific planning would require micro-planning by the ULBs. Therefore, urban health centres must be built in adequate numbers to ensure

Policy Recommendations and Areas of Future Research

Availability

Accessibility



universal access to slum populations. Urban health posts must be distributed evenly to avoid concentration of facilities in a few cities, or in parts of a city.

b. Effective Outreach

Most of the resources under the NUHM should be allocated for outreach work. Corporations should be strongly encouraged to appoint an ASHA/USHA for every 2,000 population. Effective outreach depends primarily on these link workers.

c. Functional Referral Chain

There is a need of strengthening the referral system as well as managing the issue of variable distance from the health service system. The placement of the health service system within the localities of the urban poor as well as the need of transport facilities must be urgently considered. The tertiary care institutions can provide better quality of specialised care, if the primary level institutions are efficient, and the referral chain is functional. This requires strengthening of the primary and secondary levels of care and a functional referral linkage, with an emphasis on primary prevention, primary healthcare and secondary prevention (WG NRHM,XII FYP, 2011).

a. Financing Mechanisms

Research in the field of cost-effective methods of sustainable financing needs to be looked at by the state health departments, donors and NGOs. There should be a sense of urgency and prioritisation in the entire planning process and a dedicated, focused plan of action for urban marginalised maternal and newborn care. The provisioning of funds should be timely and regular to ensure smooth, round-the-clock functioning of the urban, maternal and newborn health services. There should be a detailed study on the needs of the target urban communities before designing any financial plan.

a. Policy Guidelines

Guidelines that will strictly govern the UMNH facilities at the primary and secondary healthcare centre need to be formulated. Evidence-based effective interventions need to be clearly defined for each level of service delivery. Policy decisions should take into account the specific contexts of the city, as well as the needs of various population groups.

b. Effective Monitoring and Reporting Systems

There is a need to establish an effective monitoring system as the provisioning of services for the urban poor is almost redundant in the space provided. As some of the city reports indicated, in many of the facilities,the absence of trained personnel was an evident issue. There is a need to recruit and trainboth community level workers as well as engage trained professionals to manage the equipment.

c. Incorporating Learning from NRHM

Implementation of NUHM must incorporate lessons learnt through NRHM. Policy decisions need to be taken to address the overt focus on curative services, poor public health and hygiene, problems of pollution, collapsing public healthcare facilities, unregulated private sector expansion in healthcare and the lack of ethics and self-regulation amongst medical professionals. Policy documents must clarify responsible who is the authority to for urban health, after reorganising the public health administration in urban local bodies. There should be uniformity in the basic structure and services, such as sanitation, electricity, waiting rooms and laboratories.

d. Human Resource Planning

Task-shifting and lowering the bar, especially capacitating the graduate doctors to provide essential

Affordability

Quality



newborn care will make a difference. Successful experiments to that effect have been undertaken in states like Gujarat. Involvement of paramedics such as the Yashodas in West Bengal, could be another strategy to support the nurses in the facilities, as the involvement paramedics freed the limited number of nurses for more specialised functions. It is equally important to attract, retain and motivate human resources that are involved in providing special care to newborns. By providing improved work conditions, higher remuneration and recognition of their work in public, the state government of Madhya Pradesh and UNICEF have been able to attract and retain paediatricians and nurses for the special-care newborn units.

Further, the need for a multi-sectoral approach for maternal and newborn health should be emphasised; which includes training of staff, their employment, retention and improved management systems in formal healthcare. The training and education programmes implemented by some of the countries, which improved maternal mortality, need to be taken on alarger scale and implemented. Government, partners, stakeholders and donors need to work together to suit the needs of the urban poor in managing emergency obstetric care and decreasing maternal mortality. More studies need to be conducted focusing on the other HRH management system components, such as supervision, partnership and proper HRH information system development, and their impact on the maternal and newborn healthcare in urban areas.

e. Standardised Service Delivery Protocols

A standard protocol that mandates the existing health service system in the cities to ensure timely care for pregnant mothers and newborns. Research on the current of urban health service delivery mechanisms, from a demand-side perspective is expressly needed.

f. Governance Mechanisms

It is time to strongly underline the roles of local bodies and also ensure convergence within various departments. Special provision that dwells on a bottom-up approach and mandatorily engages the community in the decision-making for UMNH systems. The governance system should also look into the aspects of involvement of the CBOs, training of home-based caregivers, strengthening of services for EOC-ENC, training of link workers for home-based care and facility-based professionals in essential newborn care.

To conclude, it is important that the maternal and newborn health programmes, though variably existing in the urban space of India, gets a thorough prioritisation and reboot. The whole service delivery mechanism, adopted along with the NUHM guidelines, is not in place when it comes to most of the cities in the country. Ambiguity on the information, data, role of departments, leadership, personnel, supply chains andlogistics continues to remain. Most facilities remain under utilised due to an inefficient mechanism of functioning. Extensive research needs to be conducted on the social fabric and the needs of diverse urban target populations. The local bodies that have been eluding or excluded from the key responsibilities; need to create a comprehensive bottom-up plan for urban mothers and newborns. In this case, the community-based interventions (discussed in the chapter for innovations) that have taken place across the country, can be taken as a base for designing & extending a programme that caters to the issues of availability, accessibility, affordability and sustainability of quality-assured services.

A final recommendation for future research is conceptual rather than methodological. Future researchers should make a greater effort to examine the associated linkages with maternal and newborn healthcare in urban poor settings, which are areas that have hitherto received less attention than the other aspects of health. While it is acknowledged that data on MNH care provided outside the formal health sector is more difficult to collect, the lack of such data is critical in settings where a majority of residents live in vulnerable conditions. This reinforces the need to undertake research on the existing health systems and service delivery mechanisms for the urban poor so as to ensure the establishment and management of appropriate mechanisms in the coming years.

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Annex

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inio

n a

rtic

le

Co

mm

un

ity

inte

rven

tio

ns,

se

rvic

e del

iver

y

Th

e A

SH

As

mo

del

sho

uld

be

repl

icat

ed i

n u

rban

m

ater

nal

hea

lth

car

e se

rvic

e del

iver

y

8

Ass

essi

ng

Gu

jara

t’s

‘C

hir

anje

evi’ S

chem

e

Ak

ash

Ach

arya

, P

aul

McN

amee

E

con

om

ic &

Po

liti

cal

Wee

kly

, n

ov

ember

28

, 2

00

9

vo

l x

liv

no

48

Co

mm

enta

ry

Ser

vic

e D

eliv

ery

Th

e ar

ticl

e sa

ys t

hat

th

e C

hir

anje

evi

Yoj

ana

aim

s ro

re

mov

e fi

nan

cial

bar

rier

s fo

r p

oo

r w

om

en t

o a

cces

s p

riv

ate

pro

vid

ers

but

sin

ce m

ost

of

them

tak

e o

nly

‘sa

fe

case

s’,

it d

efea

ts t

he

pu

rpo

se o

f ac

cess

ing

pro

vid

ers

in

com

pli

cati

on

s.

9

Bar

rier

s to

Saf

e M

oth

erh

oo

d i

n I

ndia

S

ush

eela

Sin

gh,

Lis

a R

emez

, U

sha

Ram

, A

nn

M.

Mo

ore

an

d S

uze

tte

Aud

am

Gu

ttm

ach

er

Inst

itu

te, 2

00

9

Rep

ort

S

erv

ice

Del

iver

y T

he

rep

ort

pro

vid

es a

des

crip

tive

ov

ervi

ew o

f m

ater

nal

h

ealt

h i

n I

nd

ia a

nd

hig

hli

ghts

th

e cu

rren

t st

atu

s o

f an

d

rece

nt

tren

ds

in g

aps

in t

he

rece

ipt

of m

ater

nal

hea

lth

ca

re an

d a

ssoci

ated

fac

tors

.

10

H

ealt

h o

f th

e U

rban

Po

or

–

Po

pu

lati

on

F

ou

nd

atio

n o

f In

dia

(HU

P-P

FI)

Pu

ne

Cit

y P

roje

ct

Po

pu

lati

on

Fo

un

dat

ion

of

Ind

ia

Po

pu

lati

on

Fo

un

dat

ion

of

Ind

ia, 2

014

Cit

y re

po

rt

Urb

an h

ealt

h T

he

rep

ort

is

bas

ed o

n a

Pu

ne

city

vis

it b

y th

e H

UP

-P

FI

team

, w

hic

h l

oo

ked

at

var

iou

s d

eter

min

ants

an

d

hu

rdle

s in

mat

ern

al h

ealt

hca

re d

eliv

ery

and

acce

ss.

11

In

dia

New

bo

rn A

ctio

n P

lan

, M

inis

try

of H

ealt

h &

F

amil

y W

elfa

re, G

ov

t o

f In

dia

, 20

14

S

trat

egy

do

cum

ent

New

bo

rn h

ealt

h T

his

str

ateg

y do

cum

ent

anal

ysis

th

e cu

rren

t sc

enar

io

wit

h r

espec

t to

new

bo

rn h

ealt

h i

n I

nd

ia a

nd

lays

do

wn

a

fram

ewo

rk t

o b

ette

r ad

dre

ss t

he

nee

ds

of

new

bo

rn

hea

lth

care

. 1

2

Th

e M

ille

nn

ium

Dev

elo

pmen

t G

oal

s R

epo

rt,

Un

ited

Nat

ion

s, 2

01

4

Sta

tus

rep

ort

M

DG

4&

5 T

his

is

a re

port

on

th

e st

atu

s o

f M

DG

4&

5 i

n v

ario

us

par

ts o

f th

e w

orl

d in

20

13.

1

3

Gro

wth

par

amet

ers

at b

irth

of

bab

ies

bo

rn i

n

Gam

pah

a di

stri

ct, S

ri L

ank

a an

d f

acto

rs

infl

uen

cin

g th

em; P

riya

nth

a J.

Per

era,

Nay

om

i R

anat

hu

nga

, M

eran

thi

P.

Fer

nan

do,

Tan

ia D

. W

arn

aku

lasu

riya

, R

ajit

ha

A.

Wic

krem

asin

ghe

Ori

gin

al

rese

arch

d

ocu

men

t

Infa

nt

mo

rtal

ity

Th

is r

esea

rch

lo

ok

s at

th

e gr

ow

th p

aram

eter

s fo

r re

cord

ing

the

dev

elo

pm

ent

of

infa

nts

in

Sri

Lan

ka.

14

D

istr

ict

pla

nn

ing

too

l fo

r m

ater

nal

an

d n

ewb

orn

h

ealt

h s

trat

egy

imple

men

tati

on

; W

HO

R

eso

urc

e G

uid

e P

lan

nin

g an

d im

ple

men

tati

on

, p

rogr

am

Pro

vid

es n

atio

nal

an

d d

istr

ict

hea

lth

man

ager

s /

pla

nn

ers

wit

h p

ract

ical

res

ou

rces

fo

r th

e p

lan

nin

g an

d im

ple

men

tati

on

of

Mat

ern

al a

nd

New

bo

rn H

ealt

h



m

anag

emen

t, dis

tric

t le

vel

M

ater

nal

an

d

New

born

Hea

lth

(M

NH

) se

rvic

es

(MN

H)

serv

ices

tow

ards

mak

ing

pre

gnan

cy s

afer

. It

is

a an

d p

ract

ical

tool

for

anyo

ne

wh

o i

s re

spon

sible

for

M

NH

pro

gram

me

man

agem

ent

and

all

stak

ehold

ers

at

dis

tric

t le

vel

. It

in

cludes

a t

ech

nic

al o

ver

vie

w o

n

pre

val

ence

an

d c

ause

s of

mat

ern

al a

nd n

ewborn

dea

th

and d

isab

ilit

y; h

igh

ligh

ts s

trat

egic

dir

ecti

on

s fo

r im

pro

vin

g m

ater

nal

an

d n

ewborn

hea

lth

an

d t

he

key

10 s

teps

requ

ired

for

the

pro

pose

d dis

tric

t pla

nn

ing

fram

ework

for

MN

H.

15

Id

enti

fyin

g, C

ateg

ori

zin

g, a

nd

Eval

uat

ing

Hea

lth

C

are

Eff

icie

ncy

Mea

sure

s; E

liza

bet

h A

. M

cGly

nn

, P

aul

G.

Sh

ekel

le, S

usa

n C

hen

, D

ana

P. G

old

man

, Jo

hn

A. R

om

ley,

Pet

er S

. H

uss

ey, H

an d

e V

ries

, M

arga

ret

C. W

ang,

Mar

tha

J. T

imm

er, Ja

son

C

arte

r, C

arlo

Tri

nga

le, R

obe

rta

M.

Sh

anm

an

Res

earc

h r

eport

H

ealt

hca

re

effi

cien

cy

Pre

sen

t cr

iter

ia f

or

eval

uati

ng

hea

lth

car

e ef

fici

ency

m

easu

res,

an

d dis

cuss

to w

hat

deg

ree

exis

tin

g m

easu

res

mee

t th

ese

crit

eria

.

16

U

rban

izat

ion

, Urb

an P

ove

rty

and H

ealt

h o

f th

e U

rban

Poor:

Sta

tus,

Ch

alle

nge

s an

d t

he

Way

Forw

ard;

Sid

dh

arth

Aga

rwal

, A

ravin

da

Sat

yavad

a,

S.

Kau

shik

an

d R

ajee

v K

umar

+

Art

icle

U

rban

hea

lth

Th

is p

aper

an

alyz

es t

he

asso

ciat

ion

bet

wee

n u

rban

pover

ty a

nd h

ealt

h o

f th

e urb

an p

oor

in

In

dia

. T

he

hea

lth

sit

uat

ion

am

on

g th

e urb

an p

oor

is d

escr

ibed

on

th

e ba

sis

of t

he

anal

ysis

of

the

NFH

S-2

dat

a by

econ

om

ic s

tatu

s. T

he

pap

er a

lso o

utl

ines

som

e of

the

chal

len

ges

in i

mpro

vin

g h

ealt

h o

utc

om

es o

f th

e urb

an

poor

and t

he

pote

nti

al o

per

atio

nal

solu

tion

s to

addre

ss

such

ch

alle

nge

s. 17

T

he

Sta

te o

f th

e W

orl

d's

Mid

wif

ery,

2011 –

D

eliv

erin

g

Hea

lth

, S

avin

g L

ives

; U

NFP

A

An

nual

Rep

ort

S

kil

led

bir

th

atte

nda

nts

, qual

ity

mat

ern

al

hea

lth

ser

vic

es

Pro

vid

es t

he

firs

t co

mpr

ehen

sive

anal

ysis

of

mid

wif

ery

serv

ices

an

d i

ssues

in

coun

trie

s w

her

e th

e n

eeds

are

grea

test

. T

he

report

pro

vides

new

in

form

atio

n a

nd

dat

a ga

ther

ed f

rom

58 c

oun

trie

s in

all

reg

ion

s of

the

worl

d.

Its

anal

ysis

con

firm

s th

at t

he

wor

ld l

acks

som

e 350

,000

skil

led m

idw

ives

--

112,0

00 i

n t

he

nee

die

st 3

8 co

un

trie

s su

rvey

ed -

-

to f

ull

y m

eet

the

nee

ds

of

wom

en

aroun

d th

e w

orl

d. T

he

report

explo

res

a ra

nge

of

issu

es

rela

ted t

o b

uild

ing

up t

his

key

hea

lth

work

forc

e.

18

R

each

ing

Hea

lth

Car

e to

th

e U

nre

ach

ed: M

akin

g th

e U

rban

Hea

lth

Mis

sion

Work

for

the

Urb

an

TR

G r

eport

U

rban

hea

lth

, urb

an p

oor

A T

ech

nic

al R

esourc

e G

roup (

TR

G)

on

Nat

ion

al

Urb

an H

ealt

h M

issi

on

was

con

stit

ute

d b

ased

on

‘Ter

ms

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



P

oor;

MoH

FW

of

Ref

eren

ce’ i

ssued

by

Min

istr

y of

Hea

lth

& F

amil

y W

elfa

re, G

ovt

of

India

. T

her

e w

ere

four

Work

ing

Gro

ups

un

der

th

e T

RG

. T

hes

e ar

e th

e ‘R

eport

an

d

Rec

om

men

dati

on

s’ f

or

NU

HM

subm

itte

d b

y N

HS

RC

19

S

yste

mat

ic R

evie

w o

n H

um

an R

esourc

es f

or

Hea

lth

In

terv

enti

on

s to

Im

pro

ve

Mat

ern

al H

ealt

h

Outc

om

es: E

vid

ence

fro

m D

evel

opi

ng

Coun

trie

s;

Zulf

iqar

A. B

hutt

a, Z

oh

ra S

. L

assi

an

d N

adia

M

anso

or

Rev

iew

rep

ort

H

RH

, m

ater

nal

h

ealt

h T

his

rev

iew

focu

ses

on

th

e im

pact

of H

RH

in

terv

enti

on

s on

hea

lth

car

e pro

fess

ion

als

def

ined

as

skil

led b

irth

att

endan

ts t

o d

ecre

ase

mat

ern

al m

ort

alit

y an

d m

orb

idit

y. I

t der

ives

les

son

s, g

aps

and

reco

mm

enda

tion

s bas

ed o

n t

he

studi

es c

on

duct

ed o

n

HR

H i

mpl

emen

tati

on

s in

dev

elopin

g co

un

trie

s.

20

U

rban

Hea

lth

-

Th

e E

mer

gin

g S

oci

al I

mper

ativ

e For

India

In

Th

e N

ew M

ille

nn

ium

; S

. A

garw

al,

K.

Sri

vas

tava

Rev

iew

art

icle

U

rban

hea

lth

n

eeds

Th

is a

rtic

le l

ooke

d a

t an

d l

iste

d o

ut

the

spec

ial

nee

ds

of

urb

an h

ealt

hca

re, gi

ven

th

e div

ersi

ty i

n p

opul

atio

n

an n

eeds,

as

wel

l as

th

e pro

ble

ms

that

wer

e un

ique

to

urb

an h

ealt

h. It

th

en g

oes

on

to

sugg

est

som

e poss

ible

so

luti

on

s to

th

e id

enti

fied

pro

blem

s.

21

M

ater

nal

an

d N

ewborn

Hea

lth

Toolk

it;

MoH

FW

G

uid

elin

es

docu

men

t M

CH

res

ourc

e gu

de

Pro

vid

es su

pport

an

d g

uid

ance

to p

oli

cym

aker

s,

pro

gram

me

off

icer

s, a

nd

man

ager

s to

est

abli

sh h

ealt

h

faci

liti

es p

rovid

ing

qual

ity

m

ater

nal

an

d n

eon

atal

se

rvic

es.

22

M

ater

nal

Mort

alit

y:

An

In

dica

tor

of

Inte

rsec

tin

g In

equal

itie

s; M

abel

Bia

nco

, S

usa

nn

a M

oore

D

ebat

es a

nd

rese

arch

fi

ndin

gs a

rtic

le

Mat

ern

al

mort

alit

y, s

ocio

-ec

on

omic

fa

ctors

, ge

nde

r eq

ual

ity

Gen

der

in

equal

ity,

pove

rty

and d

ispar

itie

s in

wom

en’s

an

d g

irls

’ acc

ess

to h

ealt

h, ed

uca

tion

an

d i

nco

me

as

wel

l as

soci

o-c

ult

ura

l st

atus

are

all

key

fac

tors

th

at

impac

t m

ater

nal

hea

lth

. B

ased

on

mon

itori

ng

dev

elope

d i

n A

fric

a, A

sia

Pac

ific

an

d L

atin

Am

eric

a an

d t

he

Car

ibbe

an, div

erse

Sex

ual

an

d R

epro

duct

ive

Hea

lth

an

d R

igh

ts n

etw

ork

s, i

ncl

udi

ng

those

work

ing

on

HIV

, re

sear

ched

th

e li

nkag

es b

etw

een

MD

G 5

an

d

MD

Gs

3 an

d 6

. It

was

aff

irm

ed t

hat

th

e on

ly w

ay t

o

impro

ve

mat

ern

al h

ealt

h i

s by

buil

din

g an

d

stre

ngt

hen

ing

a co

mpr

ehen

sive

appro

ach

th

at

inco

rpora

tes

cross

-cutt

ing

issu

es o

f ge

nder

equa

lity

an

d

wom

en’s

an

d g

irls

’ educa

tion

an

d e

mpow

erm

ent,

el

imin

atio

n o

f ea

rly

mar

riag

e, p

over

ty a

llev

iati

on

, ac

cess

to s

exual

an

d r

epro

duct

ive

hea

lth

com

modi

ties

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



cover

ed

and s

ervic

es i

ncl

udin

g sa

fe a

bort

ion

, H

IV p

reve

nti

on

an

d d

eliv

ery

hea

lth

car

e. 23

M

ater

nal

an

d N

ewborn

Car

e P

ract

ices

Am

on

g th

e U

rban

Poor

in I

ndore

, In

dia

: G

aps,

rea

son

s an

d

pote

nti

al p

rogr

am o

pti

on

s

Res

earc

h r

eport

M

ater

nal

an

d

new

born

soci

al

pra

ctic

es

Th

is r

eport

des

crib

es m

ater

nal

-new

born

car

e pra

ctic

es

and c

are

of

infa

nts

age

d 2

-4 m

on

ths

(fee

din

g pra

ctic

es,

morb

idit

y st

atus,

im

mun

izat

ion

sta

tus

and n

utr

itio

nal

st

atus)

in

urb

an s

lum

dw

elli

ngs

of

Indore

cit

y, M

adya

P

rades

h (

India

). A

lso d

iscu

ssed

in

th

is r

eport

, ar

e re

ason

s fo

r fo

llow

ing

thes

e pra

ctic

es, w

hat

fac

ilit

ates

an

d w

hat

hin

der

s fo

llow

ing

opt

imal

pra

ctic

es a

nd

pote

nti

al p

rogr

am o

pti

on

s fo

r th

eir

impro

vem

ent.

24

E

xam

inin

g th

e “U

rban

A

dva

nta

ge”

in M

ater

nal

H

ealt

h C

are

in D

evel

opin

g C

oun

trie

s; Z

oe¨

M

atth

ews,

Am

os

Ch

ann

on

, S

arah

Nea

l, D

avid

O

srin

, N

yovan

i M

adis

e, W

illi

am S

ton

es

Poli

cy a

rtic

le

Urb

an m

ater

nal

h

ealt

h T

his

Pol

icy

Foru

m a

rtic

le i

nves

tiga

tes

the

“urb

an

advan

tage

” to

det

erm

ine

w

het

her

th

e ur

ban

poor

in a

ra

nge

of

dif

fere

nt

coun

trie

s re

ally

do

hav

e an

adva

nta

ge

over

rura

l popula

tion

s in

hea

lth

an

d a

cces

s to

ser

vic

es.

It a

lso q

uan

tifi

es t

he

gap b

etw

een

th

e urb

an p

oor

and

oth

er r

esid

ents

of

tow

ns

and c

itie

s.

25

R

educ

ing

Neo

nat

al M

ort

alit

y in

In

dia:

Cri

tica

l R

ole

of A

cces

s to

Em

erge

ncy

Obst

etri

c C

are;

R

amm

oh

an, Iq

bal

K, A

wofe

so N

.

Art

icle

N

eon

atal

hea

lth

; fa

cili

ties

an

d

serv

ices

Addre

ssin

g th

e m

ain

cau

ses

of

neo

nat

al d

eath

s in

In

dia

--pre

term

del

iver

ies,

asp

hyx

ia, a

nd s

epsi

s--r

equir

es

adeq

uac

y of

spec

iali

sed w

ork

forc

e an

d f

acil

itie

s fo

r del

iver

y an

d n

eon

atal

in

ten

sive

car

e an

d e

asy

acce

ss b

y m

oth

ers

and n

eon

ates

. T

he

slow

dec

lin

e in

neo

nat

al

dea

th r

ates

ref

lect

s a

lim

ited

att

enti

on

to

fact

ors

, w

hic

h

con

trib

ute

to

neo

nat

al d

eath

s. T

he

subopti

mal

qual

ity

and c

over

age

of

Em

erge

ncy

Obst

etri

c C

are

faci

liti

es i

n

India

req

uir

e ur

gen

t at

ten

tion

.

26

A

n A

sses

smen

t of

th

e Q

ual

ity

of

Pri

mar

y H

ealt

h

Car

e in

In

dia

; T

imoth

y P

ow

ell-

Jack

son

, A

rnab

A

char

ya, an

d A

nn

e M

ills

Spec

ial

arti

cle

Qual

ity

of

PH

C T

her

e is

lim

ited

evid

ence

on

th

e qual

ity

of

pri

mar

y h

ealt

h c

are

pro

vis

ion

in

In

dia

. U

sin

g dat

a on

th

e av

aila

bil

ity

of

inputs

fro

m a

nat

ion

ally

rep

rese

nta

tive

su

rvey

of

pri

mar

y h

ealt

h c

entr

es, a

com

posi

te m

easu

re

of

stru

ctura

l qu

alit

y of

car

e fo

r pri

mar

y h

ealt

h c

entr

es

was

dev

eloped

wit

h a

vie

w t

o ex

amin

e it

s ge

ogra

ph

ical

var

iati

on

, as

soci

atio

ns

wit

h m

ort

alit

y an

d h

ealt

hca

re

uti

lisa

tion

, an

d th

e det

erm

inan

ts o

f bet

ter

qua

lity

, gi

vin

g par

ticu

lar

atte

nti

on

to t

he

role

of

man

agem

ent.

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



Th

e m

ean

qual

ity

score

was

52%

, w

ith

lar

ge d

iffe

ren

ces

acro

ss r

egio

ns,

sta

tes

and d

istr

icts

. Q

ual

ity

of

care

was

th

e w

ors

t an

d t

he

var

iati

on

gre

ates

t in

sta

tes

des

ign

ated

by

the

gover

nm

ent

as l

ow

per

form

ing.

Good

man

agem

ent

pra

ctic

es i

n a

fac

ilit

y w

ere

hig

hly

co

rrel

ated

wit

h b

ette

r qual

ity

of

care

. T

he

maj

ori

ty o

f pri

mar

y h

ealt

h f

acil

itie

s in

In

dia

fal

l fa

r sh

ort

of

gover

nm

ent

min

imum

sta

ndar

ds,

in

par

t ex

pla

inin

g w

hy

most

peo

ple

in

rura

l ar

eas

use

pri

vat

e pro

vid

ers

for

outp

atie

nt

care

. Futu

re r

esea

rch

sh

ould

explo

re t

he

causa

l re

lati

on

ship

bet

wee

n m

anag

emen

t pra

ctic

es,

qual

ity

of

care

an

d p

atie

nt

outc

om

es.

27

S

oci

al I

nfr

astr

uct

ure

: U

rban

Hea

lth

An

d

Educa

tion

; L

avee

sh B

han

dar

i

Art

icle

In

fras

truct

ure

, se

rvic

es

Both

for

educa

tion

as

wel

l as

th

e urb

an h

ealt

h c

are,

it

is p

oor

del

iver

y of

the

serv

ices

th

at h

as e

xac

erbat

ed t

he

con

sequen

ces

of

poor

infr

astr

uct

ure

. B

oth

are

sy

mpto

ms

of

fail

ure

of

the

inst

ituti

on

al s

et-u

p i

n

del

iver

ing

wh

at t

hey

set

out

to d

o a

nd i

mpro

vem

ents

ca

n b

e bro

ugh

t ab

out

by

alte

rin

g th

e del

iver

y an

d

inst

ituti

on

al m

ech

anis

m.

28

S

oci

al I

nfr

astr

uct

ure

; D

DA

A

rtic

le

Str

ateg

ies

for

hea

lth

rel

ated

in

fras

truct

ure

in

D

elh

i

Th

e qual

ity

of

life

in

an

y urb

an c

entr

e dep

ends

upon

th

e av

aila

bil

ity

of

and a

cces

sibil

ity

to q

ual

ity

soci

al

infr

astr

uct

ure

. S

oci

al i

nfr

astr

uct

ure

can

be

looked

at

in

term

s of

the

faci

liti

es i

ndic

ated

in

th

e C

ity

Lev

el

Mas

ter

Pla

n, an

d C

om

mun

ity

Fac

ilit

ies,

wh

ich

are

in

dic

ated

at

the

layo

ut

pla

n l

evel

in

var

ious

use

zon

es.

Th

e pro

pose

d P

lan

nin

g n

orm

s an

d d

evel

opm

ent

con

trols

an

d c

on

dit

ion

s in

res

pec

t of

var

ious

soci

al

infr

astr

uct

ure

fac

ilit

ies

are

bro

ugh

t out

in t

he

arti

cle.

29

Is

sues

In

Soci

al I

nfr

astr

uct

ure

: P

ubli

c H

ealt

h

Infr

astr

uct

ure

in

Mum

bai

; M

um

bai

T

ran

sform

atio

n S

upport

Un

it

Vis

ion

docu

men

t

Soci

al

infr

astr

uct

ure

in

M

um

bai

V

isio

n M

um

bai

docu

men

t ta

rget

s at

hea

lth

an

d

educa

tion

as

the

key

are

as o

f im

pro

vem

ent

for

soci

al

infr

astr

uct

ure

wh

ich

would

lea

d t

o b

ette

r

qual

ity

of

life

fo

r th

e co

mm

on

cit

izen

of

Mum

bai

. In

ord

er t

o

tran

sform

Mum

bai

in

to a

cit

y w

ith

glo

bal

ly c

om

par

able

in

fras

truct

ure

an

d o

ffer

a c

om

fort

able

qual

ity

of

life

,

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



ther

e is

a n

eed t

o i

den

tify

th

e pro

ble

ms

and c

om

e up

wit

h a

str

ateg

y to

rea

ch o

ur

goal

s. F

irst

rep

ort

of

the

Ch

ief

Min

iste

r’s

Tas

k f

orc

e se

eks

to i

mpro

ve

ph

ysic

al

and s

oci

al i

nfr

astr

uct

ure

in

Mum

bai

wh

ere

del

iver

y of

soci

al s

ervic

es w

ill

be

upgr

aded

to w

orl

d c

lass

lev

els.

T

his

would

req

uir

e dra

stic

im

pro

vem

ent

in t

he

infr

astr

uct

ure

for

hea

lth

an

d e

duca

tion

i.e

. im

pro

vem

ent

in g

over

nm

ent

run

hosp

ital

s an

d s

chools

w

hic

h c

ater

to t

he

com

mon

man

.

30

In

novat

ive

Way

s to

Mee

t H

ealt

h C

hal

len

ges

of

Urb

an I

ndia

; R

adh

ika

Aro

ra,

Soura

v N

eogi

, M

adh

avi

Mis

ra

An

alys

is a

rtic

le

Inn

ovat

ion

s in

m

ater

nal

an

d

new

born

hea

lth

A l

andsc

ape

anal

ysis

, to

cre

ate

a dir

ecto

ry o

f in

novat

ive

appro

ach

es t

ow

ards

impro

vin

g m

ater

nal

an

d n

ewborn

hea

lth

in

In

dia

, w

as u

nder

taken

by

the

Publi

c H

ealt

h F

oun

dat

ion

of

India

(P

HFI)

. T

he

aim

of

crea

tin

g su

ch a

dat

abas

e w

as t

o u

se t

he

info

rmat

ion

to

dev

elop d

etai

led a

udio

-vis

ual

cas

e st

udie

s of

sele

ct

inn

ovat

ion

s w

hic

h i

ndic

ated

a p

ote

nti

al f

or

scal

ing-

up.

Man

y of

thes

e in

novat

ion

s in

cludin

g th

ose

un

der

N

RH

M s

ucc

eeded

in

pro

vid

ing

pro

mis

ing

resu

lts

in

addre

ssin

g th

e h

ealt

h n

eeds

of

the

loca

l popula

ce. A

dir

ecto

ry o

f 204 i

nn

ovat

ion

s ad

dre

ssin

g m

ater

nal

, n

ewborn

an

d a

dole

scen

t h

ealt

h, as

wel

l as

fam

ily

pla

nn

ing

was

com

pil

ed. O

ut

of

thes

e 11 i

nn

ovat

ion

s sp

ecif

ical

ly t

arge

ted u

rban

popula

tion

s. T

his

pap

er

dis

cuss

es f

our

inn

ovat

ion

s fr

om

th

e dir

ecto

ry,

w

hic

h

targ

et u

rban

popula

tion

s to

red

uce

mat

ern

al a

nd i

nfa

nt

mort

alit

y an

d i

mpro

ve

youth

an

d a

dole

scen

t h

ealt

h, as

w

ell

as d

iscu

sses

th

eir

pote

nti

al f

or

scal

e-up.

31

T

arge

tin

g P

over

ty A

nd G

ender

In

equal

ity

To

Impro

ve

Mat

ern

al H

ealt

h;

Sil

via

Par

uzz

olo

, R

ekh

a M

ehra

, A

slih

an K

es,

Ch

arle

s A

shbau

gh

Rep

ort

G

ender

an

d

mat

ern

al h

ealt

h

Th

is p

aper

arg

ues

th

at i

n o

rder

to s

ust

ain

ably

red

uce

M

MR

an

d i

mpro

ve

the

over

all

life

ch

ance

s of

poor

moth

ers,

poli

cy a

nd p

rogr

ams

nee

d, as

a m

atte

r of

urg

ency

, to

add

ress

tw

o i

nte

rrel

ated

, ro

ot

cause

s of

m

ater

nal

dea

th: pover

ty, w

hic

h c

reat

es t

he

con

dit

ion

s fo

r in

adeq

uat

e, i

nac

cess

ible

an

d c

ost

ly m

ater

nal

hea

lth

se

rvic

es i

n p

oor

and u

nder

serv

ed a

reas

, an

d g

ender

n

orm

s th

at t

end t

o p

rivil

ege

the

wel

l-bei

ng

of

m

en a

nd

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



boys

at

the

expen

se o

f w

om

en a

nd g

irls

, le

adin

g to

w

om

en’s

lac

k o

f ec

on

om

ic opti

on

s an

d l

ack o

f au

ton

omy.

Th

is p

aper

exa

min

es t

he

way

s in

wh

ich

pover

ty a

nd g

ender

in

equal

ity

impac

t m

ater

nal

m

ort

alit

y by

crea

tin

g ba

rrie

rs t

o m

ater

nal

hea

lth

care

ac

cess

an

d u

tili

zati

on

. It

als

o a

nal

yzes

str

ateg

ies

des

ign

ed t

o i

ncr

ease

uti

liza

tion

to i

den

tify

bes

t pra

ctic

es.

32

T

ran

slat

ing

Res

earc

h F

indin

gs I

nto

Hea

lth

Poli

cy;

Dav

is P

, H

owden

-Ch

apm

an P

.

Pap

er

Hea

lth

res

earc

h

hea

lth

poli

cy

Evid

ence

of

the

infl

uen

ce o

f re

sear

ch o

n h

ealt

h p

oli

cy

is p

arad

oxic

al. W

hil

e th

ere

is s

can

t ev

iden

ce t

hat

re

sear

ch h

as h

ad a

ny

impac

t on

th

e dir

ecti

on

or

imple

men

tati

on

of

wid

espre

ad h

ealt

h r

eform

s, r

esea

rch

on

evi

den

ce-b

ased

med

icin

e h

as d

ram

atic

ally

in

crea

sed, de

spit

e li

mit

ed e

vid

ence

th

at i

t h

as a

ffec

ted

clin

ical

pra

ctic

e. T

hes

e dev

elopm

ents

hav

e oc

curr

ed i

n

the

con

text

of a

gen

eral

dec

lin

e in

sta

te i

nte

rven

tion

an

d p

rovis

ion

an

d a

post

-mode

rn q

ues

tion

ing

of

rese

arch

ers'

auth

ori

ty. M

odel

s of

the

rela

tion

ship

bet

wee

n r

esea

rch

an

d p

oli

cy r

ange

fro

m o

ne

wh

ere

empir

ical

res

earc

h r

atio

nal

ly i

nfo

rms

dec

isio

n-m

akin

g,

thro

ugh

res

earc

h i

ncr

emen

tall

y af

fect

ing

pol

icy,

to a

n

"en

ligh

ten

men

t" o

r "i

nfi

ltra

tion

" m

ode

l, w

hic

h m

ay

oper

ate

on

a c

on

ceptu

al l

evel

. H

ealt

h r

esea

rch

th

at

con

trib

ute

s to

lar

ge-s

cale

soci

o-p

oli

tica

l ch

ange

may

re

quir

e m

ore

met

hodolo

gica

l plu

rali

sm a

nd g

reat

er

focu

s on

key

in

stit

uti

on

al s

truc

ture

s.

33

S

tren

gth

enin

g M

ater

nal

an

d C

hil

d ca

re, N

utr

itio

n

& H

ealt

h i

n U

rban

Set

tin

gs; N

IPC

CD

S

um

mar

y R

eport

IC

DS

, urb

an

mat

ern

al a

nd

chil

d h

ealt

h

Th

is i

s a

report

of

a tw

o

day

work

shop o

rgan

ised

by

the

Min

istr

y of

Wom

en a

nd C

hil

d D

evel

opm

ent

(MW

CD

) on

18th

an

d 1

9th

July

201

2 a

t N

IPC

CD

. T

he

obje

ctiv

e of

the

work

shop

was

to u

nde

rsta

nd t

he

chal

len

ges

in

imple

men

tati

on

of

ICD

S i

n u

rban

set

tin

gs a

nd t

o ev

olv

e st

rate

gies

fro

m c

ross

lea

rnin

g.

34

N

eon

atal

Hea

lth

in

In

dia

; C

om

mon

Hea

lth

P

rese

nta

tion

N

eon

atal

su

rviv

al

Stu

dy

of

chil

dbir

th p

ract

ices

in

Raj

asth

an a

nd

appro

ach

es f

or

neo

nat

al s

urv

ival

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



35

C

ity

Init

iati

ve

for

new

born

hea

lth

, M

umbai

: O

ver

vie

w a

nd P

roto

col;

Arm

ida

Fer

nan

dez

A

rtic

le

Hum

an r

esourc

es

Th

is a

rtic

le d

escr

ibes

th

e cr

itic

al f

irst

ste

ps

taken

to

revit

aliz

e th

e va

st p

ubli

c h

ealt

h s

yste

m o

f M

um

bai

Cit

y th

rough

th

e ac

tive

par

tici

pat

ion

of

per

son

nel

fro

m

wit

hin

th

e sy

stem

. It

foc

use

s on

on

e of

two c

om

pon

ents

of

an a

mbit

ious

acti

on

-res

earc

h p

roje

ct a

imed

at

impro

vin

g th

e su

rviv

al a

nd

hea

lth

of

new

born

in

fan

ts

and m

oth

ers

livi

ng

in s

lum

com

mun

itie

s in

Mum

bai

.

36

S

cali

ng

up M

ater

nal

, N

ewborn

an

d C

hil

d H

ealt

h

Inte

rven

tion

s: T

he

Nee

d fo

r S

trat

egie

s to

Rea

ch

the

Urb

an P

oor;

Rober

t B

lack

Pre

sen

tati

on

S

trat

egie

s fo

r m

ater

nal

an

d

new

born

hea

lth

Burd

en o

f dis

ease

in

moth

ers,

new

born

an

d c

hil

dren

gl

obal

ly a

nd i

n I

ndia

. E

vid

ence

bas

ed i

nte

rven

tion

s th

at s

ave

live

s. G

ran

d c

hal

len

ges

for

impro

vin

g outc

omes

37

S

ugg

este

d U

rban

Hea

lth

Post

Model

an

d S

ure

S

tart

Mah

aras

htr

a Fra

mew

ork

; P

AT

H

Str

ateg

y docu

men

t M

odel

for

mat

ern

al a

nd

new

born

hea

lth

in

terv

enti

on

Th

is d

ocu

men

t pre

sen

ts a

sugg

este

d m

odel

for

urb

an

inte

rven

tion

in

mat

ern

al a

nd n

ewborn

hea

lth

aft

er t

he

succ

essf

ul

imple

men

tati

on

of

th

e S

ure

Sta

rt p

roje

ct i

n

urb

an s

lum

s of

Mah

aras

htr

a, I

ndia

. In

add

itio

n, th

e docu

men

t pro

vid

es a

dia

gram

mat

ic r

epre

sen

tati

on

of

the

stra

tegy

an

d a

ppro

ach

adopte

d b

y S

ure

Sta

rt i

n

Mah

aras

htr

a fo

r dem

and g

ener

atio

n a

nd

syst

em

lin

kag

es.

38

S

ure

Sta

rt i

n M

ahar

ash

tra,

In

dia

; P

AT

H

Pro

ject

su

mm

ary

docu

men

t

Inn

ovat

ion

s A

sn

apsh

ot

of

the

Sure

Sta

rt i

nit

iati

ve,

a s

even

-yea

r pro

ject

to i

mpro

ve

birt

h o

utc

om

es a

nd

ensu

re t

he

hea

lth

of m

oth

ers

and n

ewborn

s in

sev

en c

itie

s of

Mah

aras

htr

a, I

ndi

a. T

his

doc

um

ent

pre

sen

ts

a co

nci

se

over

view

of

the

impro

vem

ents

in

mat

ern

al a

nd h

ealt

h

pra

ctic

es i

n t

he

inte

rven

tion

are

as.

39

S

ure

Sta

rt:

En

suri

ng

the

Hea

lth

an

d S

afet

y of

Moth

ers

and N

ewborn

s in

In

dia

Th

rough

B

ehav

ior

Ch

ange

an

d C

om

mun

ity

Act

ion

; P

AT

H

Fac

t sh

eet

Com

mun

ity

bas

ed

inte

rven

tion

s

Th

is f

act

shee

t outl

ines

com

mun

ity-

bas

ed

inte

rven

tion

s th

at e

xpan

ded

acc

ess

to s

kil

led b

irth

at

ten

dan

ts, es

tabli

shed

support

gro

ups

for

wom

en, an

d in

troduc

ed c

om

mun

icat

ion

s ap

pro

ach

es t

o c

han

ge

beh

avio

rs.

41

S

ure

Sta

rt: H

elpin

g M

oth

ers

and

New

born

s T

hri

ve;

PA

TH

Fac

t sh

eet

Com

mun

ity

acti

on

Sure

Sta

rt i

s an

in

itia

tive

in

ten

ded

to c

atal

yze

sust

ain

able

im

pro

vem

ents

in

mat

ern

al a

nd n

ewborn

h

ealt

h t

hro

ugh

eff

ecti

ve

com

mun

ity

acti

on

in

sel

ecte

d

dis

tric

ts o

f U

ttar

Pra

des

h a

nd

urb

an s

ites

of

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



M

ahar

ash

tra,

In

dia.

Th

e S

ure

Sta

rt p

roje

ct h

as b

een

des

ign

ed t

o c

ompl

emen

t an

d su

pport

th

e G

ove

rnm

ent

of

Indi

a’s

com

mit

men

t to

im

pro

vin

g m

ater

nal

an

d n

ewborn

hea

lth

. T

his

fac

t sh

eet

gives

an

over

all

pic

ture

an

d p

rogr

ess

of

the

pro

ject

to d

ate.

42

S

ure

Sta

rt:

Sav

ing

Liv

es o

f M

oth

ers

and N

ewborn

s in

Mah

aras

htr

a: C

ity-

Spec

ific

In

terv

enti

on

M

odel

s; P

AT

H

Str

ateg

y docu

men

t M

odel

s fo

r qual

ity

care

an

d

med

ical

as

sist

ance

Th

is d

ocu

men

t su

mm

ariz

es t

he

model

s em

plo

yed b

y S

ure

Sta

rt i

n u

rban

slu

m a

reas

of

Mah

aras

htr

a, I

ndia

,

to

ensu

re g

ood-q

ual

ity

care

an

d m

edic

al a

ssis

tan

ce t

o

expec

tan

t m

oth

ers

and n

ewborn

s: v

olu

nte

eris

m,

publi

c-pri

vat

e par

tner

ship

, qua

lity

of

care

, co

mm

un

ity-

bas

ed h

ealt

h i

nsu

ran

ce, co

nver

gen

ce o

f m

ater

nal

an

d

new

born

hea

lth

an

d H

IV s

ervic

es, an

d a

n e

mer

gen

cy

hea

lth

fun

d an

d p

repai

d c

ard.

43

T

read

ing

a N

ew P

ath

: S

tori

es F

rom

th

e S

ure

Sta

rt

Pro

ject

in

Utt

ar P

rades

h;

PA

TH

R

eport

H

ealt

h w

ork

ers

Th

is r

eport

sh

ow

s h

ow

hea

lth

work

ers

in U

ttar

Pra

desh

off

ered

in

form

atio

n, pra

ctic

al s

olu

tion

s, a

nd e

moti

on

al

support

, en

abli

ng

wom

en t

o ta

ke

char

ge o

f th

eir

hea

lth

an

d t

hat

of

thei

r n

ewborn

s.

44

E

ffec

t of

hom

e-bas

ed n

eon

atal

car

e an

d

man

agem

ent

of

sepsi

s on

neo

nat

al m

ort

alit

y: f

ield

tr

ial

in r

ura

l In

dia

; B

ang

AT

, B

ang

RA

, B

aitu

le

SB

, R

eddy

MH

, D

esh

mukh

MD

Stu

dy

report

H

om

e-bas

ed

neo

nat

al c

are

Neo

nat

al c

are

is n

ot

avai

lable

to m

ost

neo

nat

es i

n

dev

elopi

ng

coun

trie

s bec

ause

hosp

ital

s ar

e in

acce

ssib

le

and c

ost

ly.

We

dev

eloped

a p

acka

ge o

f h

om

e

bas

ed

neo

nat

al c

are,

in

cludin

g m

anag

emen

t of

sep

sis

(sep

tica

emia

, m

enin

giti

s, p

neu

mon

ia),

an

d t

este

d it

in

th

e fi

eld,

wit

h t

he

hyp

oth

esis

th

at i

t w

ould

red

uce

th

e n

eon

atal

mort

alit

y ra

te b

y at

lea

st 2

5%

in

3 y

ears

.

45

S

poil

t fo

r ch

oic

e? C

ross

-sec

tion

al s

tudy

of c

are-

seek

ing

for

hea

lth

pro

ble

ms

duri

ng

pre

gnan

cy i

n

Mum

bai

slu

ms;

More

NS

1,

A

lcock

G, D

as S

, B

apat

U,

Josh

i W

, O

srin

D.

Stu

dy

report

C

are

seek

ing

beh

avio

r of

wom

en

Th

is s

tudy

con

sider

s ca

re-s

eekin

g pat

tern

s fo

r m

ater

nal

m

orb

idit

y in

Mum

bai

’s s

lum

s. T

he

obje

ctiv

es w

ere

to

docu

men

t w

om

en’s

sel

f-re

port

ed s

ympto

ms

and c

are-

seek

ing,

an

d t

o q

uan

tify

th

eir

choi

ce o

f h

ealt

h

pro

vid

er, ca

re-s

eekin

g del

ays

and r

efer

rals

bet

wee

n

pro

vid

ers.

46

P

rosp

ecti

ve

study

of

dete

rmin

ants

an

d c

ost

s of

h

om

e bir

ths

in M

um

bai

slu

ms;

S

ush

mit

a D

as,

Ujw

ala

Bap

at, N

een

a S

hah

More

, L

atik

a C

hord

hek

ar, W

asun

dh

ara

Jo

shi

an

d D

avid

Osr

in

Stu

dy

report

H

om

e bir

ths

and

fact

ors

in

fluen

cin

g th

e sa

me

Aro

un

d 86%

of

birt

hs

in M

umba

i, I

ndi

a, o

ccur

in

hea

lth

care

in

stit

uti

on

s, b

ut

this

agg

rega

te f

igure

hid

es

subst

anti

al v

aria

tion

an

d l

ittl

e is

kn

ow

n a

bout

urb

an

hom

e bir

ths.

Th

e st

udy

ai

med

to e

xplo

re f

acto

rs

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



in

fluen

cin

g th

e ch

oic

e of

hom

e de

liver

y, c

are

pra

ctic

es

and c

ost

s, a

nd t

o i

den

tify

ch

arac

teri

stic

s of

wom

en,

house

hold

s an

d t

he

envir

on

men

t, w

hic

h m

igh

t in

crea

se t

he

like

lih

ood o

f h

om

e bir

th.

47

S

till

bir

ths

and n

ewbo

rn d

eath

s in

slu

m s

ettl

emen

ts

in M

um

bai

, In

dia

: a

pro

spec

tive

ver

bal

auto

psy

st

udy;

Ujw

ala

Bap

at, G

lyn

Alc

ock

, N

een

a S

hah

M

ore

, S

ush

mit

a D

as, W

asun

dh

ara

Josh

i an

d D

avid

O

srin

Stu

dy

report

C

ause

s of

del

ay

in s

eekin

g an

d re

ceiv

ing

hea

lth

care

for

mat

ern

al a

nd

new

born

hea

lth

pro

ble

ms

Th

ree

mil

lion

bab

ies

are

stil

lborn

eac

h y

ear

and

3.6

m

illi

on

die

in

th

e fi

rst

mon

th o

f li

fe. In

In

dia

, ea

rly

neo

nat

al d

eath

s m

ake

up f

our-

fift

hs

of

neo

nat

al d

eath

s an

d i

nfa

nt

mort

alit

y th

ree-

quar

ters

of

un

der

-fiv

e m

ort

alit

y. I

nfo

rmat

ion

is

scar

ce o

n c

ause

-spec

ific

per

inat

al a

nd n

eon

atal

mort

alit

y in

urb

an s

etti

ngs

in

lo

w-i

nco

me

coun

trie

s. T

he

study

co

nduc

ted v

erba

l au

topsi

es f

or

stil

lbir

ths

and n

eon

atal

dea

ths

in M

um

bai

sl

um

sett

lem

ents

. T

he

obje

ctiv

es w

ere

to c

lass

ify

dea

ths

acco

rdin

g to

in

tern

atio

nal

cau

se-s

pec

ific

cri

teri

a an

d t

o

iden

tify

maj

or

cause

s of

del

ay i

n s

eekin

g an

d r

ecei

vin

g h

ealt

h c

are

for

mat

ern

al a

nd n

ewbo

rn h

ealt

h p

roble

ms.

48

M

ater

nal

an

d n

eon

atal

hea

lth

ex

pen

ditu

re i

n

Mum

bai

slu

ms

(In

dia

): A

cro

ss s

ecti

on

al s

tudy;

Jo

len

e S

kord

is-W

orr

all, N

oem

i P

ace,

Ujw

ala

Bap

at, S

ush

mit

a D

as, N

een

a S

More

, W

asun

dh

ara

Josh

i, A

nn

i-M

aria

Pulk

ki-

Bra

nn

stro

m an

d D

avid

O

srin

Dat

a an

alys

is

docu

men

t M

ater

nal

hea

lth

ex

pen

ditu

re T

he

cost

of

mat

ern

ity

care

can

be

a ba

rrie

r to

acc

ess

that

may

in

crea

se m

ater

nal

an

d n

eon

atal

mort

alit

y ri

sk.

Th

e ar

ticl

e an

alyz

ed s

pen

din

g on

mat

ern

ity

care

in

urb

an s

lum

com

mun

itie

s in

Mum

bai

to b

ette

r un

der

stan

d t

he

equit

y of

spen

din

g an

d t

he

impac

t of

spen

din

g on

house

hold

pove

rty

49

In

tim

ate

par

tner

vio

len

ce a

gain

st w

omen

duri

ng

and a

fter

pre

gnan

cy: a

cross

-sec

tion

al s

tudy

in

Mum

bai

slu

ms;

Sush

mit

a D

as, U

jwal

a B

apat

, N

een

a S

hah

More

, Gly

n A

lcock

, W

asun

dh

ara

Josh

i, S

han

ti P

antv

aidya

an

d D

avid

Osr

in

Stu

dy

report

P

artn

er v

iole

nce

At

leas

t on

e-th

ird o

f w

omen

in

In

dia

exper

ien

ce

inti

mat

e pa

rtn

er v

iole

nce

(IP

V)

at s

om

e poin

t in

ad

ult

hood. T

he

study

obje

ctiv

es w

ere

to d

escr

ibe

the

pre

val

ence

of

IPV

duri

ng

pre

gnan

cy a

nd a

fter

del

iver

y in

an

urb

an s

lum

set

tin

g, t

o r

evie

w i

ts s

oci

al

det

erm

inan

ts, a

nd t

o e

xplo

re i

ts e

ffec

ts o

n m

ater

nal

an

d n

ewborn

hea

lth

.

50

C

om

mun

ity-

bas

ed h

ealt

h p

rogr

amm

es: ro

le

per

cepti

on

s an

d e

xper

ien

ces

of

fem

ale

peer

fa

cili

tato

rs i

n M

umbai

’s u

rban

slu

ms;

Alc

ock

G,

More

NS

, P

atil

S, P

ore

l M

, V

aidya

L, O

srin

D.

Stu

dy

fin

din

gs

Pee

r fa

cili

tato

rs T

his

art

icle

pre

sen

ts f

indin

gs f

rom

a s

tudy

of

fem

ale

pee

r fa

cili

tato

rs i

nvolv

ed i

n a

com

mun

ity-

bas

ed

mat

ern

al a

nd n

ewborn

hea

lth

in

terv

enti

on

in

urb

an

slum

are

as o

f M

um

bai

. U

sin

g qual

itat

ive

met

hods

we

explo

re t

hei

r ro

le p

erce

pti

on

s an

d e

xpe

rien

ces.

Our

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



fin

din

gs f

ocu

s on

how

th

e fa

cili

tato

rs u

nder

stan

d a

nd

enac

t th

eir

role

in

th

e co

mm

un

ity

sett

ing,

how

th

ey

neg

oti

ate

rela

tion

ship

s an

d h

ealt

h i

ssues

wit

h p

eer

groups,

an

d t

he

infl

uen

ce o

f cr

edib

ilit

y.

51

In

equal

itie

s in

mat

ern

ity

care

an

d n

ewborn

outc

om

es: on

e-ye

ar s

urv

eill

ance

of

bir

ths

in

vuln

erab

le s

lum

com

mun

itie

s in

Mum

bai

; M

ore

N

S, B

apat

U, D

as S

, B

arn

ett

S,

Cost

ello

A,

Fer

nan

dez

A, O

srin

D.

An

alys

is

docu

men

t C

are

dif

fere

nti

al

acco

rdin

g to

ec

on

om

ic s

tatu

s

Agg

rega

te u

rban

hea

lth

sta

tist

ics

mas

k i

neq

ual

itie

s.

Th

e an

alys

is des

crib

ed m

ater

nit

y ca

re i

n v

uln

erab

le

slum

in M

um

bai

, an

d e

xam

ined

dif

fere

nce

s in

car

e an

d

outc

om

es b

etw

een

more

an

d l

ess

dep

rived

gro

ups.

52

T

raci

ng

pat

hw

ays

from

an

ten

atal

to d

eliv

ery

care

fo

r w

om

en i

n M

um

bai

, In

dia

: cr

oss

-sec

tion

al s

tudy

of

mat

ern

ity

in l

ow

-in

com

e ar

eas;

More

NS

, A

lcock

G, B

apat

U, D

as S

, Jo

shi

W, O

srin

D.

Stu

dy

fin

din

gs

Sec

tors

an

d

resp

on

sibil

itie

s in

mat

ern

al a

nd

new

born

hea

lth

In m

any

citi

es, h

ealt

hca

re i

s av

aila

ble

th

rough

a

com

ple

x m

ix o

f pri

vat

e an

d p

ubli

c pro

vid

ers.

Th

e li

ne

bet

wee

n t

he

form

al a

nd i

nfo

rmal

sec

tors

may

be

blu

rred

an

d m

ovem

ent

bet

wee

n t

hem

un

char

ted. W

e quan

tifi

ed t

he

use

of

pri

vat

e an

d p

ubli

c pro

vid

ers

of

mat

ern

ity

care

in

low

-in

com

e ar

eas

of

Mum

bai

, In

dia

.

53

A

Rap

id A

sses

smen

t S

core

card

to I

den

tify

In

form

al S

ettl

emen

ts a

t H

igh

er M

ater

nal

an

d

Ch

ild H

ealt

h R

isk i

n M

um

bai

; O

srin

D., D

as S

, B

apat

U, A

lcock

G, Jo

shi

W, M

ore

NS

Rap

id

asse

ssm

ent

report

Info

rmal

se

ttle

men

ts,

hig

h

risk

popula

tion

s

Th

e co

mm

un

itie

s w

ho l

ive

in u

rban

in

form

al

sett

lem

ents

are

div

erse

, as

are

th

eir

envir

on

men

tal

con

dit

ion

s. C

har

acte

rist

ics

incl

ude

inad

equat

e ac

cess

to

saf

e w

ater

an

d s

anit

atio

n, poor

qual

ity

of

housi

ng,

over

crow

din

g, a

nd i

nse

cure

res

iden

tial

sta

tus.

In

terv

enti

on

s to

im

pro

ve

hea

lth

sh

ould

be

equit

y-dri

ven

an

d t

arge

t th

ose

at

hig

her

ris

k, but

it i

s n

ot

clea

r h

ow

to p

riori

tise

in

form

al s

ettl

emen

ts f

or

hea

lth

ac

tion

. In

im

ple

men

tin

g a

mat

ern

al a

nd c

hil

d h

ealt

h

pro

gram

me

in M

um

bai

, In

dia

, w

e h

ad c

on

duct

ed a

det

aile

d vuln

erab

ilit

y as

sess

men

t w

hic

h, th

ough

im

port

ant,

was

tim

e co

nsu

min

g an

d m

ay h

ave

incl

uded

co

llec

tion

of

redun

dan

t in

form

atio

n. S

ubse

quen

t dat

a co

llec

tion

all

ow

ed u

s to

exam

ine

thre

e is

sues

: w

het

her

co

mm

un

ity

envir

on

men

tal

char

acte

rist

ics

wer

e as

soci

ated

wit

h m

ater

nal

an

d n

ewborn

hea

lth

care

an

d

outc

om

es; w

het

her

it

was

poss

ible

to d

evel

op a

tri

age

score

card

to r

ank t

he

hea

lth

vuln

erab

ilit

y of

info

rmal

se

ttle

men

ts b

ased

on

a f

ew r

apid

ly o

bse

rvab

le

char

acte

rist

ics;

an

d w

het

her

th

e sc

ore

card

mig

ht

be

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



use

ful

for

futu

re p

riori

tisa

tion

.

54

N

utr

itio

nal

sta

tus

of

youn

g ch

ildre

n i

n M

um

bai

slum

s: a

foll

ow

-up a

nth

ropo

met

ric

study;

Das

S1,

Bap

at U

, M

ore

NS

, A

lcock

G, Fe

rnan

dez

A, O

srin

D

.

Stu

dy

fin

din

gs

Ch

ild

mal

nutr

itio

n C

hro

nic

ch

ildh

ood

mal

nutr

itio

n r

emai

ns

com

mon

in

In

dia

. A

s par

t of

an

in

itia

tive

to i

mpro

ve m

ater

nal

an

d

chil

d h

ealt

h i

n u

rban

slu

ms,

we

coll

ecte

d an

thro

pom

etri

c dat

a fr

om

a s

ampl

e of

chil

dre

n

foll

ow

ed u

p f

rom

bir

th. W

e des

crib

ed t

he

pro

port

ion

s of

un

derw

eigh

t, s

tun

tin

g, a

nd w

asti

ng

in y

oun

g ch

ildre

n, a

nd e

xam

ined

th

eir

rela

tion

ship

s w

ith

age

.

55

C

on

flic

t, C

risi

s, a

nd A

buse

in

Dh

arav

i, M

um

bai

: E

xper

ien

ces

from

Six

Yea

rs a

t a

Cen

tre

for

Vuln

erab

le W

om

en a

nd C

hil

dre

n; N

ayre

en

Dar

uw

alla

, A

rmid

a Fer

nan

dez

,

Jen

ny

Sal

am,

N

ikh

at S

hai

kh

,

Dav

id O

srin

Art

icle

A

buse

T

he

Cen

tre

for

Vuln

erab

le W

om

en a

nd C

hil

dre

n

serv

es c

lien

ts c

opin

g w

ith

cri

sis

and v

iole

nce

in

th

e ch

alle

ngi

ng

urb

an s

etti

ng

of

Dh

arav

i, M

um

bai

. W

e dis

cuss

fac

tors

th

at s

hap

ed t

he

dev

elopm

ent

of

the

Cen

tre

over

six

yea

rs I

nte

rven

tion

was

oft

en g

uid

ed b

y cl

ien

ts’ d

esir

e to

kee

p th

eir

fam

ilie

s to

geth

er.

Succ

essf

ul i

nte

rven

tion

req

uir

es s

tron

g li

nks

wit

h

hea

lth

car

e pro

vid

ers,

th

e po

lice

, le

gal

serv

ices

, an

d

com

mun

ity-

bas

ed o

rgan

isat

ion

s

56

C

om

mun

ity

Mobil

izat

ion

in

Mum

bai

Slu

ms

to

Impro

ve P

erin

atal

Car

e an

d O

utc

om

es: A

Clu

ster

R

andom

ized

Con

troll

ed T

rial

; N

een

a S

hah

More

, U

jwal

a B

apat

, S

ush

mit

a D

as, G

lyn

Alc

ock

, S

arit

a P

atil

, M

aya

Pore

l, L

een

a V

aidya

, A

rmid

a Fer

nan

dez,

Was

un

dh

ara

Josh

i, D

avid

Osr

in

Res

earc

h

Art

icle

C

om

mun

ity

mobil

izat

ion

, m

ater

nal

hea

lth

, urb

an s

lum

s

Impro

vin

g m

ater

nal

an

d n

ewborn

hea

lth

in

low

-in

com

e se

ttin

gs r

equir

es b

oth

hea

lth

ser

vic

e an

d

com

mun

ity

acti

on

. P

revio

us

com

mun

ity

init

iati

ves

h

ave

bee

n p

redom

inan

tly

rura

l, b

ut

India

is

urb

aniz

ing.

W

hil

e w

orkin

g to

im

pro

ve

hea

lth

ser

vic

e qual

ity,

we

test

ed a

n i

nte

rven

tion

in

wh

ich

urb

an s

lum

-dw

elle

r w

om

en’s

gro

ups

work

ed t

o i

mpro

ve

loca

l per

inat

al

hea

lth

. 57

P

oli

ce i

nves

tiga

tion

s: d

iscr

etio

n d

enie

d y

et

un

den

iably

exer

cise

d; J

. B

elura

, N

. T

ille

ya, D

. O

srin

b, N

. D

aruw

alla

c, M

. K

um

ard &

V.

Tiw

arie

Journ

al a

rtic

le

Poli

ce, w

om

en’s

dea

ths

Dra

win

g on

fie

ldw

ork

in

Del

hi

and

Mum

bai

, th

is p

aper

ex

plo

res

how

poli

ce i

nves

tiga

tion

s un

fold

ed i

n t

he

spec

ific

con

text

of

wom

en’s

dea

ths

by

burn

ing

in I

ndia

. In

par

ticu

lar,

it

focu

ses

on

th

e us

e of

dis

cret

ion

des

pit

e it

s de

nia

l by

those

exer

cisi

ng

it.

58

T

he

soci

al c

on

stru

ctio

n o

f ‘d

ow

ry d

eath

s’; Jy

oti

B

elur,

*, N

ick

Til

ley,

Nay

reen

Dar

uw

alla

, M

een

a K

um

ar, V

inay

Tiw

ari

d,

Dav

id O

srin

Art

icle

D

ow

ry d

eath

s T

he

clas

sifi

cati

on

of

cause

of

deat

h i

s re

al i

n i

ts

con

seque

nce

s: f

or

the

reput

atio

n o

f th

e dec

ease

d, fo

r h

er f

amil

y, f

or

those

wh

o m

ay b

e im

plic

ated

, an

d f

or

epid

emio

logi

cal

and

soci

al r

esea

rch

an

d p

oli

cies

an

d

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



pra

ctic

es t

hat

may

foll

ow

fro

m i

t. T

he

study

report

ed

her

e re

fers

spe

cifi

call

y to

th

e pro

cess

es i

nv

olv

ed i

n

clas

sify

ing

dea

ths

of w

om

en f

rom

burn

s in

In

dia

. In

par

ticu

lar,

it

exam

ines

th

e det

erm

inat

ion

of

‘dow

ry

dea

th’,

a cl

ass

use

d i

n I

ndia

, but

not

in o

ther

ju

risd

icti

on

s. 59

S

hap

ing

citi

es f

or

hea

lth

: co

mple

xit

y an

d t

he

pla

nn

ing

of u

rban

en

vir

on

men

ts

in t

he

21st

ce

ntu

ry; Y

von

ne

Ryd

in, A

na

Ble

ahu, M

ich

ael

Dav

ies,

Jul

io D

Dáv

ila,

Sh

aron

Fri

el, G

iovan

ni

De

Gra

ndis

, Nora

Gro

ce, P

edro

C H

alla

l, I

an

Ham

ilto

n,

P

hil

ippa

How

den

-Ch

apm

an, K

a-M

an L

ai,

C J

L

im, Ju

lian

a M

arti

ns,

Dav

id O

srin

, Ia

n R

idle

y, I

an

Sco

tt, M

yfan

wy

Tay

lor,

Pau

l W

ilkin

son

, Ja

mes

W

ilso

n

Rep

ort

E

con

om

ic

grow

th,

dem

ogr

aph

ic

chan

ge, urb

an

pla

nn

ing

Th

is r

eport

arg

ues

aga

inst

th

e as

sum

pti

on

th

at u

rban

h

ealt

h o

utc

om

es w

ill

impro

ve

wit

h e

con

om

ic g

row

th

and d

emogr

aph

ic c

han

ge, an

d i

nst

ead h

igh

ligh

ts t

he

nee

d f

or

urb

an p

lan

nin

g fo

r h

ealt

h n

eeds.

60

C

lust

er-r

andom

ised

con

troll

ed t

rial

of

com

mun

ity

mobil

isat

ion

in

Mum

bai

slu

ms

to i

mpro

ve

care

duri

ng

pre

gnan

cy, del

iver

y, p

ost

par

tum

an

d f

or

the

new

born

; N

een

a S

hah

More

, U

jwal

a B

apat

, S

ush

mit

a D

as, S

arit

a P

atil

, M

aya

Pore

l,

Lee

na

Vai

dya

, B

hav

esh

ree

Kori

ya,

Sar

ah B

arn

ett,

A

nth

on

y C

ost

ello

,

Arm

ida

Fer

nan

dez

and

Dav

id

Osr

in

Pro

toco

l

Com

mun

ity

inte

rven

tion

Th

e pro

toco

l des

crib

es a

tri

al o

f co

mm

un

ity

inte

rven

tion

aim

ed a

t im

pro

vin

g pre

ven

tion

, ca

re

seek

ing

and o

utc

om

es.

61

C

om

mun

ity

reso

urc

e ce

ntr

es t

o i

mpro

ve

the

hea

lth

of

wom

en a

nd c

hil

dre

n i

n M

umbai

slu

ms:

st

udy

pro

toco

l fo

r a

clust

er r

andom

ized

con

trol

led

tria

l; N

een

a S

hah

More

, S

ush

mit

a D

as, U

jwal

a B

apat

, M

ahes

h R

ajgu

ru, G

lyn

Alc

ock

, W

asun

dh

ara

Jo

shi, S

han

ti P

antv

aidya

and

Dav

id

Osr

in

Tri

al r

eport

C

om

mun

ity

reso

urc

e ce

ntr

es T

he

tria

l ad

dre

sses

th

e ge

ner

al q

ues

tion

of

wh

eth

er

com

mun

ity

reso

urc

e ce

nte

rs r

un

by

a n

on

-gov

ern

men

t org

aniz

atio

n i

mpro

ve t

he

hea

lth

of

wom

en a

nd

chil

dre

n i

n s

lum

s.

62

E

xam

inin

g th

e E

ffec

t of

House

hold

Wea

lth

an

d

Mig

rati

on

Sta

tus

on

Saf

e D

eliv

ery

Car

e in

Urb

an

India

, 1992–2006; P

rash

ant

Kum

ar S

ingh

, R

ajes

h

Stu

dy

report

M

ater

nal

hea

lth

ex

pen

ditu

re

Alt

hough

th

e urb

an h

ealt

h i

ssue

has

bee

n o

f lo

ng-

stan

din

g in

tere

st t

o p

ubli

c h

ealt

h r

esea

rch

ers,

maj

ori

ty

of

the

studie

s h

ave

looked

upon

th

e urb

an p

oor

and

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



K

um

ar R

ai, L

uck

y S

ingh

m

igra

nts

as

dist

inct

subgr

oups.

An

oth

er c

on

cern

is,

w

het

her

bei

ng

poor

and a

t th

e sa

me

tim

e m

igra

nt

lead

s to

a d

oub

le d

isad

van

tage

in

th

e ut

iliz

atio

n o

f m

ater

nal

h

ealt

h s

ervic

es?

Th

is s

tudy

aim

s to

exam

ine

the

tren

ds

and f

acto

rs t

hat

aff

ect

safe

del

iver

y ca

re u

tili

zati

on

am

on

g th

e m

igra

nts

an

d t

he

poor

in u

rban

In

dia

.

63

W

ork

shop o

n t

he

Hea

lth

of

the

Urb

an P

oor

in t

he

Con

text

of

NU

HM

; D

r. A

. D

yalc

han

d

Work

shop

report

U

rban

poor

hea

lth

, N

UH

M In

stit

ute

of

Hea

lth

Man

agem

ent,

Pac

hod (

IHM

P)

Pun

e ce

ntr

e, o

rgan

ized

a w

ork

shop o

n “

Hea

lth

of

the

Urb

an P

oor

in M

ahar

ash

tra”

fro

m N

ov. 4th

to

6th

, 2008, in

coll

abora

tion

wit

h Y

ash

wan

trao

Ch

avan

A

cadem

y of

Dev

elopm

ent

Adm

inis

trat

ion

(Y

AS

HA

DA

), P

un

e an

d t

he

Inte

rnat

ion

al I

nst

itute

of

Popula

tion

Sci

ence

s (I

IPS

), M

um

bai

. T

he

pri

nci

pal

obje

ctiv

e of

the

work

shop w

as t

o i

den

tify

str

ateg

ies

for

effe

ctiv

e im

ple

men

tati

on

of

hea

lth

car

e fo

r th

e urb

an

poor

in t

he

con

text

of

the

Nat

ion

al U

rban

Hea

lth

M

issi

on

(N

UH

M)

in M

ahar

ash

tra.

64

P

oor

Per

inat

al C

are

Pra

ctic

es i

n U

rban

Slu

ms:

P

oss

ible

Role

of

Soci

al M

obil

izat

ion

Net

work

s;

Zulf

ia K

han

, S

aira

Meh

naz

, N

ajam

Kh

aliq

ue,

M

oh

d A

thar

An

sari

, an

d A

bdul

Raz

zaque

Sid

diq

ui

Stu

dy

arti

cle

U

rban

per

inat

al

pra

ctic

es

To d

eter

min

e th

e ex

isti

ng

peri

nat

al p

ract

ices

in

an

urb

an s

lum

an

d t

o i

den

tify

bar

rier

s to

uti

liza

tion

of

hea

lth

ser

vic

es b

y m

oth

ers.

65

S

AA

RC

Soci

al C

har

ter:

In

dia

Coun

try

Rep

ort

2014; M

inis

try

of S

tati

stic

s an

d P

rogr

amm

e Im

ple

men

tati

on

Coun

try

report

In

terv

enti

on

s T

he

curr

ent

report

, fi

fth

in

th

e se

ries

, pr

esen

ts t

he

stat

us

of

ach

ievem

ent

on

dif

fere

nt

soci

al d

evel

opm

ent

outc

omes

un

der

dif

fere

nt

chap

ters

as

enum

erat

ed i

n t

he

var

ious

Art

icle

s of

the

Ch

arte

r. T

he

publi

cati

on

sk

etch

es a

luc

id d

escr

ipti

on

of

the

progr

amm

atic

in

terv

enti

on

s of

the

Gover

nm

ent

of I

ndia

aim

ed a

t ra

isin

g th

e li

vin

g st

andar

ds

of

its

citi

zen

s an

d p

rovid

ing

equal

opport

un

itie

s to

hit

her

to m

argi

nal

ized

sec

tion

s of

the

soci

ety.

66

M

ater

nal

, n

ewborn

an

d c

hil

d h

ealt

h f

ram

ework

; In

tern

atio

nal

Fed

erat

ion

of

Red

Cro

ss

and R

ed C

resc

ent

Soci

etie

s,

Fra

mew

ork

docu

men

t R

MN

CH

T

his

fra

mew

ork

pro

vid

es g

uid

ance

an

d d

irec

tion

to

Nat

ion

al S

oci

etie

s, t

hei

r pro

gram

me

man

ager

s an

d al

l oth

er p

arti

es i

nvo

lved

in

th

e pl

ann

ing,

des

ign

an

d

imple

men

tati

on

of

pro

gram

mes

an

d i

nte

rven

tion

s in

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



m

ater

nal

/rep

rodu

ctiv

e, n

ewborn

an

d c

hil

d h

ealt

h

(MN

CH

, als

o re

ferr

ed t

o a

s R

MN

CH

).

67

A

Com

pen

diu

m o

n H

ealt

h o

f U

rban

Poor

in

South

Eas

t A

sia:

Abs

trac

t of

sele

ct P

aper

s an

d

Rep

ort

s; K

amla

Gupt

a, F

red A

rnold

, H

. L

hun

gdim

Rep

ort

U

rban

hea

lth

&

livin

g co

ndit

ion

s T

his

rep

ort

an

alyz

es h

ealt

h a

nd l

ivin

g co

ndi

tion

s in

ei

ght

larg

e In

dia

n c

itie

s (C

hen

nai

, D

elh

i, H

yder

abad

, In

dore

, K

olka

ta,

Mee

rut,

Mum

bai

, an

d N

agpur)

. T

he

report

is

base

d on

dat

a fr

om I

ndia

's 2

005-0

6 N

atio

nal

Fam

ily

Hea

lth

Surv

ey (

NFH

S-3

).

68

M

ater

nal

Hea

lth

Pol

icy

In I

ndia

– Fro

m

Inst

ituti

on

al D

eliv

erie

s to

Saf

e D

eliv

erie

s; B

S

ubh

a S

ri a

nd R

enu K

han

na

Poli

cy p

aper

S

afe

del

iver

y,

mat

ern

al h

ealt

h

poli

cy

Gro

ups

like

the

Jan

Sw

asth

ya A

bh

iyan

an

d

Com

mon

Hea

lth

hav

e bee

n e

xpre

ssin

g th

at t

he

mat

ern

al h

ealt

h p

olic

y in

In

dia

nee

ds

to m

ove

away

fr

om

th

e pa

radi

gm o

f in

stit

uti

on

al d

eliv

erie

s to

a

par

adig

m o

f sa

fe d

eliv

erie

s. W

hat

is

a sa

fe d

eliv

ery?

H

ow

do t

he

Jan

Sw

asth

ya A

bh

iyan

an

d

Com

mon

Hea

lth

en

vis

ion

saf

e del

iver

y? T

his

pap

er

explo

res

thes

e ques

tion

s an

d o

ffer

s an

un

ders

tan

din

g th

at h

as e

vol

ved

th

roug

h c

oll

ecti

ve

dis

cuss

ion

s am

on

gst

thes

e n

etw

ork

s

69

H

ealt

h S

tatu

s of

Mar

gin

aliz

ed G

roups

in I

ndi

a;

Zulu

fkar

Ah

mad

Kh

anda

y , M

oh

amm

ad A

kra

m

Stu

dy

pap

er

Hea

lth

sta

tus

Th

e obje

ctiv

es o

f th

e pre

sen

t pap

er a

re t

o st

udy

the

hea

lth

sta

tus

of

mar

gin

alis

ed g

roups-

w

om

en’s

, ch

ildre

n’s

, sc

hed

uled

cas

tes,

sch

edule

d t

ribes

, per

son

s w

ith

dis

abil

itie

s, m

igra

nts

an

d a

lso

the

hea

lth

sta

tus

of

aged

in

In

dia;

th

e vio

lati

on

of

thei

r ri

ghts

;

the

double

ex

plo

itat

ion

wh

ich

wom

en’s

fac

e in

th

eir

hom

e an

d a

t th

e w

ork p

lace

an

d a

lso t

o st

udy

how

th

e dif

fere

nt

fact

ors

aff

ecti

ng

the

hea

lth

of

the

mar

gin

alis

ed g

roups.

70

In

dia

’s c

oun

try

exper

ien

ce a

ddre

ssin

g so

cial

ex

clusi

on

in

mat

ern

al a

nd c

hil

d h

ealt

h; K

. R

N

ayar

Pap

er

Mat

ern

al h

ealt

h,

soci

al e

xcl

usi

on

Th

is p

aper

pre

sen

t so

me

of

the

key

in

itia

tives

th

at h

ave

bee

n u

nder

taken

an

d t

he

pote

nti

al i

mpl

icat

ion

s of

thes

e m

easu

res

for

wom

en a

nd c

hil

d h

ealt

h b

ased

on

in

terv

iew

s w

ith

pro

gram

man

ager

s an

d h

ealt

h w

ork

ers

as w

ell

as r

evie

w o

f off

icia

l do

cum

ents

, publ

ish

ed

pap

ers,

rel

evan

t co

nte

nt

on

off

icia

l w

ebsi

tes,

an

d d

ata

sourc

es m

ain

ly f

ocu

sin

g on

th

e S

tate

s.

71

V

uln

erab

le G

roups

In

In

dia

; C

han

dri

ma

Ch

atte

rjee

an

d G

un

jan

Sh

eora

n

Res

earc

h

docu

men

t H

ealt

h r

igh

ts o

f vuln

erab

le

Th

e h

ealt

h r

igh

ts o

f vuln

erab

le g

roups

rem

ain

det

ach

ed

from

th

e st

ate

syst

ems

i.e.

poli

cy, pro

gram

me

and

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs

Maternal and Newborn Health in Urban IndiaA report on literature review


99

gr

oups

pra

ctic

e. T

he

docu

men

t id

enti

fies

th

e vuln

erab

le

groups

in I

ndia

, th

eir

hea

lth

an

d h

uman

rig

hts

co

nce

rns

wh

ile

explo

rin

g th

e

deg

ree

and k

inds

of

thei

r vuln

erab

ilit

y vis

-à-v

is t

hei

r lo

cati

on

an

d i

den

tity

.

72

W

hy

wom

en c

hoose

to

give

birt

h a

t h

om

e: a

si

tuat

ion

al a

nal

ysis

fro

m u

rban

slu

ms

of

Del

hi;

N

ived

ith

a D

evas

enap

ath

y, M

ath

ew S

un

il G

eorg

e,

Supar

na

Gh

osh

Jer

ath

, A

rch

na

Sin

gh, H

iman

shu

Neg

andh

i, G

urs

imra

n A

lagh

, A

nura

j H

Sh

anka

r,

San

jay

Zodpey

An

alys

is p

aper

S

ervic

e del

iver

y In

crea

sin

g in

stit

uti

on

al b

irth

s is

an

im

port

ant

stra

tegy

fo

r at

tain

ing

Mil

len

niu

m D

evel

opm

ent

Goal

-5.

How

ever

, ra

pid g

row

th o

f lo

w i

nco

me

and m

igra

nt

popula

tion

s in

urb

an s

etti

ngs

in

low

-in

com

e an

d

mid

dle

-in

com

e co

un

trie

s, i

ncl

udin

g In

dia,

pre

sen

ts

un

ique

chal

len

ges

for

pro

gram

mes

to i

mpro

ve

uti

lisa

tion

of

inst

ituti

on

al c

are.

Bet

ter

un

der

stan

din

g of

the

fact

ors

in

fluen

cin

g h

om

e or

inst

ituti

on

al b

irth

am

on

g th

e urb

an p

oor

is u

rgen

tly

nee

ded

to e

nh

ance

pro

gram

me

impac

t. T

o m

easu

re t

he

pre

val

ence

of

hom

e an

d i

nst

ituti

on

al b

irth

s in

an

urb

an s

lum

popula

tion

an

d i

den

tify

fac

tors

in

fluen

cin

g th

ese

even

ts.

73

L

earn

ing,

Sh

arin

g, A

dap

tin

g: I

nn

ovat

ion

s in

M

ater

nal

Hea

lth

Pro

gram

min

g; C

AR

E

Ref

eren

ce g

uid

e M

ater

nal

hea

lth

CA

RE

’s d

ecad

es o

f ex

peri

ence

in

an

d le

arn

ing

from

m

ater

nal

hea

lth

pro

gram

min

g h

as r

esult

ed i

n t

he

accr

ual

of

a ri

ch b

ody

of

kn

ow

ledg

e. T

his

ref

eren

ce

guid

e on

in

nova

tion

s in

mat

ern

al h

ealt

h p

rogr

amm

ing

pro

vid

es p

ract

ical

exa

mpl

es, ev

iden

ce,

in

novat

ion

s,

less

on

s le

arn

ed a

nd

solu

tion

s to

new

an

d o

ld c

hal

len

ges

to i

mpro

ve

pro

gram

qual

ity

and t

o i

ncr

ease

im

pac

t.

74

N

atio

nal

Con

sult

atio

n o

n "

Pote

nti

al R

ole

of

Pri

vat

e S

ecto

r P

rovi

der

s in

Del

iver

ing

Ess

enti

al

New

born

Car

e in

un

der

-ser

vie

d u

rban

an

d p

eri-

urb

an s

etti

ngs

"; S

ave

the

Ch

ildre

n, L

uck

now

Con

sult

atio

n

report

U

rban

new

born

h

ealt

h c

are,

urb

an p

oor

Th

e co

nsu

ltat

ion

com

pri

sed

of

nat

ion

al c

ham

pio

ns

of

evid

ence

, pro

gram

mes

an

d poli

cy w

ith

reg

ards

to

new

born

car

e fo

r th

e urb

an p

oor.

It

is s

ign

ific

ant

to

note

th

at t

he

reco

mm

endat

ion

s h

ave

per

tin

entl

y fo

cuse

d on

dev

elopi

ng

a st

ate

and c

ity

level

G

over

nan

ce S

truct

ure

s fo

r U

rban

Hea

lth

. T

he

city

in

itia

tives

an

d i

nn

ova

tion

s in

Utt

ar P

rades

h,

Mah

aras

htr

a an

d G

uja

rat

hav

e def

init

ely

bro

ugh

t fo

rth

th

e ev

iden

ces

of

effe

ctiv

enes

s of

BC

C,

KM

C a

nd

oth

er

inn

ovat

ive

stra

tegi

es.

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



100

75

S

tatu

s of

bir

th p

repar

edn

ess

and c

ompli

cati

on

re

adin

ess

in U

ttar

Din

ajpur

Dis

tric

t, W

est

Ben

gal;

D

ipta

Kan

ti M

ukh

opad

hya

y, S

ujis

hn

u

Mukh

opad

hya

y, S

har

mis

tha

Bh

atta

char

jee,

S

usm

ita

Nay

ak, A

sit

K B

isw

as, A

kh

il B

Bis

was

Stu

dy

report

B

PC

R, m

ater

nal

m

ort

alit

y B

irth

Pre

pare

dn

ess

and C

ompli

cati

on

Rea

din

ess

(BP

CR

) is

cru

cial

in

aver

tin

g m

ater

nal

morb

idit

y an

d

mort

alit

y. O

bje

ctiv

e of

th

e st

udy

was

to f

ind

out

awar

enes

s an

d p

ract

ices

reg

ardin

g B

PC

R a

mon

g pre

gnan

t an

d r

ecen

tly

del

iver

ed w

om

en i

n U

ttar

D

inaj

pur,

Wes

t B

enga

l. 76

P

rogr

ess

in H

ealt

h-R

elat

ed M

ille

nn

ium

D

evel

opm

ent

Goal

s in

th

e W

HO

South

-Eas

t A

sia

Reg

ion

; P

oon

am K

het

rapa

l S

ingh

Opin

ion

art

icle

M

DG

in

south

-ea

st A

sia

Th

is a

rtic

le p

rovid

es a

sn

ap s

hot

of

pro

gres

s th

us

far,

key

ch

alle

nge

s an

d opport

un

itie

s in

WH

O S

outh

-Eas

t A

sia

Reg

ion

an

d la

ys d

ow

n t

he

way

forw

ard f

or

the

global

hea

lth

age

nda

post

2015.

77

3.6

Mil

lion

Neo

nat

al D

eath

s—W

hat

Is

Pro

gres

sin

g an

d W

hat

Is

Not?

; Jo

y E

. L

awn

, M

BB

S, M

RC

P (

Pae

ds)

, M

PH

, P

hD

, K

ate

Ker

ber

, M

PH

, C

hri

stab

el E

nw

eron

u-L

arye

a, M

BB

S,‡

an

d

Sim

on

Couse

ns,

Dip

Mat

h S

tat

Opin

ion

art

icle

N

eon

atal

dea

ths

global

ly

Th

is a

rtic

le r

evie

ws

pro

gres

s fo

r n

ewborn

hea

lth

gl

obal

ly, w

ith

a fo

cus

on

th

e co

un

trie

s in

wh

ich

most

dea

ths

occ

ur—

w

hat

dat

a do w

e h

ave

to g

uid

e ac

cele

rate

d ef

fort

s? A

ll r

egio

ns

are

advan

cin

g, b

ut

the

level

of

dec

reas

e in

neo

nat

al m

ort

alit

y dif

fers

by

regi

on

, co

un

try,

an

d w

ith

in c

oun

trie

s.

78

S

tren

gth

enin

g M

ater

nal

&

Ch

ildca

re N

utr

itio

n

and H

ealt

h i

n U

rban

Set

tin

gs; N

IPC

CD

W

ork

shop

report

IC

DS

A t

wo d

ay w

ork

shop

was

org

anis

ed b

y th

e M

inis

try

of

Wom

en a

nd C

hil

d D

evel

opm

ent

(MW

CD

) on

18th

an

d 1

9th

Jul

y 2012 a

t N

IPC

CD

. T

he

obj

ecti

ve

of

the

work

shop w

as t

o u

nde

rsta

nd t

he

chal

len

ges

in

imple

men

tati

on

of

ICD

S i

n u

rban

set

tin

gs a

nd t

o ev

olv

e st

rate

gies

fro

m c

ross

lea

rnin

g.

79

Fam

ily

Pla

nn

ing:

Eff

ect

of C

ity

Siz

e; U

HI

W

hit

e pap

er

Fam

ily

plan

nin

g T

he

expan

sion

of

fam

ily

pla

nn

ing

serv

ices

in

Utt

ar

Pra

des

h r

equir

es a

th

oro

ugh

kn

ow

ledge

of

the

poli

cy,

soci

al, an

d e

con

om

ic f

acto

rs t

hat

aff

ect

con

trac

epti

ve

use

. T

his

docu

men

t is

on

e in

a s

erie

s of

wh

ite

pap

ers

that

an

alys

e re

cen

t dat

a w

ith

th

e ai

m o

f un

der

stan

din

g th

e im

pact

of

thes

e fa

ctors

on

fam

ily

pla

nn

ing.

In

crea

sin

g co

ntr

acep

tive

use

pre

ven

ts u

npla

nn

ed

pre

gnan

cy, an

d re

duce

s m

ater

nal

an

d n

ewborn

dea

ths.

In

th

is b

rief

, w

e co

nsi

der

how

cit

y si

ze a

ffec

ts

con

trac

epti

ve u

se. G

iven

th

at c

ity

size

is

asso

ciat

ed

wit

h t

wo c

ruci

al i

ndic

ators

of

repro

duc

tive

an

d ch

ild

hea

lth

, it

would

see

m i

mport

ant

to a

lso

con

side

r ci

ty

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



101

si

ze a

s a

fact

or

that

mig

ht

be

asso

ciat

ed w

ith

co

ntr

acep

tive

use

. T

hus

th

e pu

rpose

of

this

bri

ef i

s to

det

erm

ine

wh

eth

er t

her

e ar

e in

dee

d v

aria

tion

s in

co

ntr

acep

tive

use

ass

oci

ated

wit

h c

ity

size

, an

d i

f th

ere

are,

to p

ropose

str

ateg

ies

that

mig

ht

be e

mplo

yed t

o

incr

ease

volu

nta

ry c

on

trac

epti

ve

use

in

all

are

as.

80

In

equit

y in

In

dia:

th

e ca

se o

f m

ater

nal

an

d

repro

duc

tive

hea

lth

; L

inda

San

nev

ing,

Nad

ja

Try

gg, D

eepa

k S

axen

a, D

ilee

p M

aval

ankar

an

d

Sar

ah T

hom

sen

Rev

iew

docu

men

t S

oci

al

det

erm

inan

ts,

poli

cies

In I

ndia

, ec

on

om

ic s

tatu

s, g

ender

, an

d s

oci

al s

tatu

s ar

e al

l cl

ose

ly i

nte

rrel

ated

wh

en i

nfl

uen

cin

g use

of

and

acce

ss t

o m

ater

nal

an

d r

epro

duct

ive

hea

lth

car

e. I

n t

his

re

vie

w, a

fram

ework

dev

eloped

by

the

Com

mis

sion

on

S

oci

al D

eter

min

ants

of

Hea

lth

(C

SD

H)

is u

sed t

o

cate

gori

ze a

nd e

xpla

in d

eter

min

ants

of

ineq

uit

y in

m

ater

nal

an

d r

epro

duct

ive

hea

lth

in

In

dia

.

81

T

he

Eff

ect

of

Hea

lth

-Fac

ilit

y A

dmis

sion

an

d

Skil

led

Bir

th A

tten

dan

t C

over

age

on

Mat

ern

al

Surv

ival

in

In

dia:

A C

ase-

Con

trol

An

alys

is; A

nn

L

. M

on

tgom

ery,

Sh

aza

Fad

el, R

ajes

h K

um

ar, S

ue

Bon

dy,

Rah

im M

oin

eddin

, P

rabh

at J

ha

Eval

uati

on

re

port

H

um

an r

esourc

e,

acce

ss t

o a

nd

qual

ity

of

serv

ices

Th

e ef

fect

of

hea

lth

-fac

ilit

y ad

mis

sion

did

var

y by

sk

ille

d a

tten

dan

t co

ver

age,

an

d t

his

eff

ect

appe

ars

to b

e dri

ven

par

tial

ly b

y re

ver

se c

ausa

lity

; h

ow

ever

, in

equit

able

acc

ess

to a

nd

poss

ibly

poor

qual

ity

of

hea

lth

care

for

pri

mar

y an

d e

mer

gen

cy s

ervic

es a

ppea

rs

to p

lay

a ro

le i

n m

ater

nal

surv

ival

as

wel

l.

82

U

tili

zati

on

of

Mat

ern

al a

nd

Ch

ild

Hea

lth

Car

e S

ervic

es b

y P

rim

igra

vid

a Fem

ales

in

Urb

an a

nd

Rura

l A

reas

of

India

; H

eman

t M

ahaj

an a

nd

Bh

uw

an S

har

ma

Stu

dy

arti

cle

S

ervic

e del

iver

y an

d a

cces

s M

ater

nal

com

pli

cati

on

s an

d p

oor

per

inat

al o

utc

om

e ar

e h

igh

ly a

ssoci

ated

wit

h n

on

uti

lisa

tion

of

ante

nat

al

and d

eliv

ery

care

ser

vic

es a

nd p

oor

soci

oec

on

om

ic

con

dit

ion

s of

the

pat

ien

t. I

t is

ess

enti

al t

hat

all

pre

gnan

t w

om

en h

ave

acce

ss t

o h

igh

qual

ity

obst

etri

c ca

re t

hro

ugh

out

thei

r pre

gnan

cies

. P

rese

nt

lon

gitu

din

al

study

was

car

ried

out

to c

om

par

e uti

liza

tion

of

mat

ern

al

and c

hil

d h

ealt

h c

are

serv

ices

by

urb

an a

nd r

ura

l pri

mig

ravid

a fe

mal

es.

83

E

xposu

re a

nd L

earn

ing

Vis

it t

o B

est

Pra

ctic

es

Model

s of

Ah

med

abad

Mun

icip

al C

orp

ora

tion

(A

MC

); P

lan

In

dia

-

Hea

lth

of

the

Urb

an P

oor

(HU

P)

Pro

gram

;

Tour

report

U

rban

liv

ing

Aro

un

d 1.3

8 c

rore

peo

ple

in B

ihar

liv

e in

slu

ms

or

info

rmal

set

tlem

ents

an

d on

ly 2

.8 %

urb

an d

wel

lers

h

ave

acce

ss t

o p

iped

wat

er s

uppl

y at

hom

e. I

t is

es

tim

ated

th

at n

earl

y 60%

of

the

popul

atio

n w

ill

be

urb

aniz

ed i

n n

ext

two d

ecad

es; th

ereb

y

crea

tin

g un

pre

cede

nte

d c

hal

len

ges.

Due

to r

apid

urb

aniz

atio

n,

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



102

25%

slu

ms

dwel

ler

live

wit

hout

acce

ss t

o i

mpro

ved

hyg

ien

e an

d s

anit

atio

n f

acil

itie

s. S

upple

men

tin

g th

e pro

ble

m a

re w

ater

qual

ity

issu

es i

n 5

0%

of

the

dis

tric

ts.

Evid

ence

s re

flec

t th

at l

ack o

f sa

fe d

rin

kin

g w

ater

an

d open

def

ecat

ion

lea

d t

o a

ran

ge o

f dis

ease

s, w

hil

e fa

ctors

such

as

over

crow

din

g an

d poll

uti

on

con

trib

ute

to

hea

lth

pro

blem

s. 84

C

over

age

gap

in m

ater

nal

an

d c

hil

d h

ealt

h

serv

ices

in

In

dia

: as

sess

ing

tren

ds

and r

egio

nal

dep

rivat

ion

duri

ng

1992–2006; C

han

dan

Kum

ar,

Pra

shan

t K

um

ar S

ingh

, R

ajes

h K

um

ar R

ai

Stu

dy

report

C

over

age

of

serv

ices

In

crea

sin

g th

e co

ver

age

of

key

mat

ern

al,

new

born

an

d

chil

d h

ealt

h i

nte

rven

tion

s is

ess

enti

al, if

In

dia

has

to

atta

in M

ille

nn

ium

Dev

elopm

ent

Goal

s 4 a

nd

5. T

his

st

udy

asse

sses

th

e co

vera

ge g

ap i

n m

ater

nal

an

d ch

ild

hea

lth

ser

vic

es a

cross

sta

tes

in I

ndia

duri

ng

1992–2006

emph

asiz

ing

the

rura

l–urb

an d

ispar

itie

s. A

ddit

ion

ally

, as

soci

atio

n b

etw

een

th

e co

ver

age

gap a

nd u

nder

-5

mort

alit

y ra

te a

cross

sta

tes

are

illu

stra

ted.

85

P

ubli

c P

rivat

e P

artn

ersh

ips

form

ed b

y S

NE

HA

: C

ity

Init

iati

ve

For

New

born

Hea

lth

, A

SK

par

tner

ship

, A

rogy

a S

arit

a; S

ush

ma

Sh

ende

and

oth

ers

Pap

er

PP

P f

or

urb

an

new

born

hea

lth

Th

is p

aper

sum

mar

ises

on

e N

GO

’s e

xper

ien

ce i

n

buil

din

g par

tner

ship

s w

ith

th

e publ

ic s

ecto

r h

ealt

h

syst

em,

the

outc

om

es a

chie

ved

so f

ar a

nd l

esso

ns

lear

nt.

It

also

des

crib

es t

he

role

of

each

par

tner

an

d

sust

ain

abil

ity

issu

es i

nvolv

ed.

86

B

uil

din

g th

e In

fras

truct

ure

to R

each

an

d c

are

for

the

poo

r: T

ren

ds,

Obst

acle

s an

d S

trat

egie

s to

over

com

e th

em; D

ilee

p V

. M

aval

anka

r, K

.V.

Ram

ani,

Am

it P

atel

, P

arvat

hy

San

kar

Rev

iew

pap

er

MN

H

infr

astr

uct

ure

Th

is p

aper

rev

iew

s av

aila

ble

lit

erat

ure

an

d a

sses

ses

the

cover

age

and g

aps

in i

nfr

astr

uct

ure

in

MN

H. It

als

o

iden

tifi

es c

riti

cal

issu

es i

n m

anag

emen

t of

infr

astr

uct

ure

an

d a

nal

yses

th

eir

cause

s an

d i

mpac

ts o

n

serv

ice

del

iver

y to

th

e poor.

Th

e pap

er a

lso r

evie

ws

impac

t of

refo

rms

on

in

fras

truct

ure

an

d p

rovid

es s

ome

reco

mm

enda

tion

s fo

r im

pro

vem

ent

of

infr

astr

uct

ure

m

anag

emen

t so

as

to e

nsu

re b

ette

r se

rvic

es t

o t

he

poor.

87

T

oolk

it o

n m

on

itori

ng

hea

lth

sys

tem

s st

ren

gth

enin

g; W

HO

S

tren

gth

enin

g se

rvic

e del

iver

y is

a k

ey s

trat

egy

to

ach

ieve

the

Mil

len

niu

m D

evel

opm

ent

Goal

s. T

his

in

cludes

th

e del

iver

y of

inte

rven

tion

s to

red

uce

ch

ild

mort

alit

y, m

ater

nal

mort

alit

y, a

nd t

he

burd

en t

o

HIV

/AID

S, tu

berc

ulosi

s an

d m

alar

ia1. S

ervic

e pro

vis

ion

or

deli

ver

y is

an

im

med

iate

outp

ut

of

the

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



103

in

puts

in

to t

he

hea

lth

sys

tem

, su

ch a

s h

ealt

h

work

forc

e, p

rocu

rem

ent

and s

uppli

es a

nd

fin

ance

s.

Incr

ease

d in

puts

sh

ould

lea

d t

o i

mpro

ved

ser

vic

e del

iver

y an

d e

nh

ance

d ac

cess

to s

ervi

ces.

En

suri

ng

avai

labil

ity

and a

cces

s to

hea

lth

ser

vic

es i

s on

e of

th

e m

ain

fun

ctio

ns

of a

hea

lth

sys

tem

. S

uch

ser

vic

es s

hould

m

eet

a m

inim

um

qual

ity

stan

dar

d.

88

C

hil

d H

ealt

h a

nd

Imm

un

izat

ion

Sta

tus

in a

n

Un

regi

ster

ed M

um

bai

Slu

m; Jo

ya B

aner

jee

T

hes

is

Imm

un

izat

ion

T

his

th

esis

use

s th

e ca

se o

f an

un

regi

ster

ed u

rban

slu

m,

Kau

la B

anda

r (K

B),

in

Mum

bai

, In

dia,

to e

xam

ine

the

det

erm

inan

ts o

f ch

ild m

ort

alit

y an

d i

mm

un

izat

ion

co

ver

age

usi

ng

prim

ary

quan

tita

tive

and q

ual

itat

ive

dat

a fr

om

a h

ouse

hold

surv

ey (

n=

226 h

ouse

hold

s) a

nd

focu

s gr

oups.

Res

ults

In

dic

ate

that

alt

hough

im

mun

izat

ion

ser

vic

es a

re w

idel

y av

aila

ble

in u

rban

ce

nte

rs, a

“kn

ow

ledg

e-ac

tion

gap

” kee

ps

imm

un

izat

ion

ra

tes

low

—an

d c

hil

d m

ort

alit

y h

igh

— in

slu

m

com

mun

itie

s. 89

B

rin

gin

g E

vid

ence

in

to P

ubli

c H

ealt

h P

olic

y (E

PH

P)

2012:

Str

engt

hen

ing

hea

lth

sys

tem

s to

ac

hie

ve

un

iver

sal

hea

lth

cov

erag

e; U

pen

dra

B

hoja

ni,

Ari

ma

Mis

hra

, N

S P

rash

anth

an

d

Wer

ner

Soors

Con

fere

nce

pap

ers

H

ealt

h s

yste

ms

90

A

Soc

ial

Det

erm

inan

ts A

ppro

ach

to M

ater

nal

H

ealt

h; U

ND

P

Dis

cuss

ion

P

aper

S

oci

al

det

erm

inan

ts T

he

fun

dam

enta

l ra

tion

ale

of t

he

soci

al d

eter

min

ants

of

hea

lth

appro

ach

is

not

on

ly t

hat

soci

al d

eter

min

ants

sh

ape

hea

lth

outc

om

es b

ut

that

it

is p

oss

ible

to

im

pro

ve

hea

lth

outc

om

es a

nd r

educe

hea

lth

in

equit

ies

by

anal

yzin

g an

d ac

tin

g on

th

e m

ost

in

fluen

tial

of

those

so

cial

det

erm

inan

ts. T

his

docu

men

t co

ntr

ibute

s to

th

ese

dis

cuss

ion

s th

rough

th

e le

ns

of

on

e par

ticu

lar

global

hea

lth

ch

alle

nge

: m

ater

nal

hea

lth

. M

ater

nal

h

ealt

h p

rovid

es a

sal

ien

t ex

ample

of

how

adopti

ng

a so

cial

det

erm

inan

ts a

ppro

ach

can

buil

d s

yner

gies

acr

oss

dev

elopm

ent

sect

ors

to a

ccel

erat

e pro

gres

s on

a s

pec

ific

h

ealt

h i

ssue.

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



104

91

G

over

nm

ent

of

Wes

t B

enga

l: T

he

Urb

an H

ealt

h

Str

ateg

y; G

ovt

of

Wes

t B

enga

l, D

epar

tnm

ent

of

Hea

lth

& F

amil

y W

elfa

re &

Dep

artm

ent

of

Mun

icip

al A

ffai

rs

Str

ateg

y docu

men

t U

rban

hea

lth

Th

e G

over

nm

ent

of

Wes

t B

enga

l is

com

mit

ted t

o

ensu

rin

g ac

cess

ible

, eq

uit

able

an

d q

ual

ity

hea

lth

car

e se

rvic

es t

o t

he

urb

an p

opula

tion

of

the

S

tate

. T

ow

ards

this

en

d t

he

Dep

artm

ent

of

Hea

lth

& F

amil

y W

elfa

re

(DH

FW

) an

d D

epar

tmen

t of

Mun

icip

al A

ffai

rs &

U

rban

Dev

elopm

ent

(DM

A &

UD

) pro

pose

to

con

textu

aliz

e th

e st

rate

gic

fram

ework

wit

hin

wh

ich

th

e S

tate

sh

all

seek

to a

ddre

ss t

he

hea

lth

con

cern

s o

f th

e urb

an p

oor.

92

S

tren

gth

enin

g H

ealt

h M

anag

emen

t In

form

atio

n

Sys

tem

s fo

r M

ater

nal

an

d C

hil

d H

ealt

h:

Docu

men

tin

g M

CH

IP’s

Con

trib

uti

on

s; M

oll

y S

trac

han

, M

ary

Dra

ke,

Bar

bar

a R

awli

ns,

Vik

as

Dw

ived

i, B

ecca

Lev

ine,

Mouss

a L

y, G

ben

ga I

shola

Pro

ject

docu

men

t H

MIS

A

s par

t of

it i

ts e

ffort

s to

im

pro

ve

the

qual

ity

of

mat

ern

al, n

ewborn

, an

d c

hil

d h

ealt

h (

MN

CH

) ca

re i

n

low

-in

com

e co

un

trie

s, M

CH

IP h

as t

aken

spec

ific

ste

ps

to i

mpro

ve

the

mon

itori

ng

of

MN

CH

ser

vic

es t

hro

ugh

st

ren

gth

enin

g ro

uti

ne

HM

IS. T

hes

e ef

fort

s h

ave

led t

o

bet

ter

mon

itori

ng

and e

val

uat

ion

, h

igh

er-q

ual

ity

dat

a,

and i

nfo

rmed

dec

isio

n-m

akin

g in

28 c

oun

trie

s ac

ross

M

NC

H i

nte

rven

tion

s. O

ngo

ing

effo

rts

to i

mpro

ve

HM

IS w

ill

incr

ease

coun

try

and g

lobal

acc

ess

to

info

rmat

ion

-ric

h s

yste

ms

to s

upport

MN

CH

pro

gram

st

ren

gth

enin

g. T

his

rep

ort

sum

mar

izes

succ

essf

ul

HM

IS-r

elat

ed i

nte

rven

tion

s an

d i

nn

ovat

ion

s in

co

un

trie

s w

her

e M

CH

IP i

s oper

atin

g an

d a

t th

e gl

obal

le

vel

. It

hig

hli

ghts

wh

at M

CH

IP h

as d

on

e to

st

ren

gth

en H

MIS

an

d w

hic

h M

CH

IP c

on

trib

uti

on

s h

ave

bee

n i

nte

grat

ed a

nd i

nst

ituti

on

aliz

ed i

n n

atio

nal

H

MIS

sys

tem

s, a

nd d

escr

ibes

les

son

s le

arn

ed.

93

N

eed f

or

Ded

icat

ed F

ocu

s on

Urb

an H

ealt

h

wit

hin

Nat

ion

al R

ura

l H

ealt

h M

issi

on

; S

. A

garw

al, K

. S

anga

r

Art

icle

U

rban

hea

lth

in

N

RH

M

Th

is p

aper

dis

cuss

es i

ssues

per

tain

ing

to h

ealt

h

con

dit

ion

s of

the

urb

an p

oor,

pre

sen

t st

atus

of

serv

ices

, ch

alle

nge

s an

d s

ugg

ests

opti

on

s fo

r

NR

HM

to b

ridge

th

e la

rge

gap.

94

N

atio

nal

Con

sult

atio

n o

n

"Pote

nti

al R

ole

of

Pri

vat

e S

ecto

r P

rovid

ers

in

Del

iver

ing

Ess

enti

al N

ewborn

Car

e in

un

der

-se

rvie

d u

rban

an

d p

eri-

urb

an s

etti

ngs

"; S

ave

the

Ch

ildre

n

Con

sult

atio

n

report

Pri

vat

e se

ctor

in

urb

an n

ewborn

ca

re

Th

e G

over

nm

ent

of

Utt

ar P

rades

h (

Min

istr

y of

Hea

lth

an

d F

amil

y W

elfa

re)

and U

NIC

EF i

n p

artn

ersh

ip w

ith

S

ave

the

Ch

ildre

n a

nd S

avin

g N

ewborn

Liv

es l

ed a

n

atio

nal

lev

el c

on

sult

atio

n t

itle

d ‘R

ole

of

Pri

vat

e S

ecto

r P

rovid

ers

in N

ewborn

Car

e in

Un

der

ser

vic

ed

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



105

Urb

an a

nd P

eri-

urb

an S

etti

ng’

th

at h

igh

ligh

ted t

hes

e ch

alle

nge

s an

d d

evel

oped

a r

oad

map

wh

ich

pro

vid

es a

sc

ope

for

par

tici

pat

ion

of

var

ious

stak

e h

old

ers

in t

he

stat

e so

as

to t

ake

forw

ard t

he

reco

mm

endat

ion

s at

th

e poli

cy a

nd p

rogr

amm

atic

lev

el.

95

N

ouri

shin

g O

ur

Futu

re: T

ackli

ng

Ch

ild

Mal

nutr

itio

n I

n U

rban

Slu

ms;

DA

SR

A

N

ewborn

n

utr

itio

n N

ouri

shin

g O

ur

Futu

re f

ocu

ses

on

th

e is

sue

of

mal

nutr

itio

n f

or

infa

nts

age

d 0

-36 m

on

ths

in u

rban

sl

um

s. T

his

age

gro

up i

s th

e ‘w

indow

-of

opport

un

ity’

wh

ere

the

foun

dat

ion

for

ph

ysic

al a

nd c

ogn

itiv

e gr

ow

th

pote

nti

al i

s es

tabli

shed

. D

espit

e it

bei

ng

wid

ely

kn

ow

n

that

aft

er 3

6 m

on

ths,

th

e lo

ng-

term

eff

ects

of

mal

nutr

itio

n a

re i

rrev

ersi

ble

, m

ain

stre

am e

ffort

s to

re

duce

mal

nutr

itio

n a

re m

ain

ly t

arge

ted a

t ch

ildre

n

bet

wee

n 3

-6 y

ears

96

U

rban

Slu

m-S

pec

ific

Iss

ues

in

Neo

nat

al S

urv

ival

; A

rmid

a Fer

nan

dez

, Ja

ysh

ree

Mon

dkar

, S

hei

la

Mat

hai

Art

icle

S

yste

ms

for

urb

an m

ater

nal

h

ealt

h

Urb

aniz

atio

n i

s ra

pid

ly s

pre

adin

g th

rough

out

the

dev

elopin

g w

orl

d. A

n u

rban

slu

m p

ose

s sp

ecia

l h

ealt

h

pro

ble

ms

due

to p

over

ty,

over

crow

din

g, u

nh

ygie

nic

su

rroun

din

gs a

nd l

ack o

f an

org

aniz

ed h

ealt

h

Infr

astr

uct

ure

. T

he

pri

mar

y ca

use

s of

neo

nat

al

mort

alit

y ar

e se

psi

s, p

erin

atal

asp

hyx

ia a

nd

pre

mat

uri

ty. H

om

e del

iver

ies,

lat

e re

cogn

itio

n o

f n

eon

atal

ill

nes

s, d

elay

in

see

kin

g m

edic

al h

elp a

nd

inap

pro

pri

ate

trea

tmen

t co

ntr

ibute

to n

eon

atal

m

ort

alit

y. M

easu

res

to r

educe

neo

nat

al m

ort

alit

y in

urb

an s

lum

s sh

ould

focu

s on

hea

lth

educa

tion

, im

pro

vem

ent

of

ante

nat

al p

ract

ices

, in

stit

uti

on

al

del

iver

ies,

an

d e

nsu

rin

g qual

ity

per

inat

al c

are.

Succ

ess

of

a co

mpre

hen

sive

hea

lth

str

ateg

y w

ould

req

uir

e pla

nn

ed h

ealt

h i

nfr

astr

uct

ure

, st

ren

gth

enin

g an

d

un

ific

atio

n o

f ex

isti

ng

hea

lth

car

e pro

gram

an

d

faci

liti

es; fo

rmin

g a

syst

em o

f re

ferr

al a

nd d

evel

opin

g a

pro

gram

wit

h a

ctiv

e par

tici

pat

ion

of

the

com

mun

ity.

97

A

ll S

lum

s ar

e N

ot

Equal

: M

ater

nal

Hea

lth

C

on

dit

ion

s A

mon

g T

wo U

rban

Slu

m D

wel

lers

; Z

ulf

ia K

han

, S

aira

Meh

naz

, A

bdul

Raz

zaq

Stu

dy

arti

cle

M

ater

nal

pra

ctic

es

Th

e st

udy

exam

ines

wh

eth

er h

azar

dous

mat

ern

al c

are

pra

ctic

es e

xis

t in

an

d w

het

her

th

ere

are

dif

fere

nce

s in

th

e uti

liza

tion

rat

es o

f h

ealt

h s

ervic

es i

n t

wo d

iffe

ren

t

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



106

S

iddiq

ui, A

thar

An

sari

, S

alm

an K

hal

il, an

d

San

dee

p S

ach

dev

a

slum

s.

98

Im

pro

vin

g urb

an n

ewborn

hea

lth

: C

hal

len

ges

and

the

way

forw

ard; S

iddh

arth

Aga

rwal

P

aper

C

hal

len

ges

for

neo

nat

al c

are

and s

urv

ival

Th

is p

aper

dis

cuss

es t

he

situ

atio

n o

f n

eon

atal

car

e an

d

surv

ival

am

on

g th

e urb

an p

oor

acro

ss s

tate

s

wh

ich

are

at

dif

fere

nt

level

s of

soci

al d

evel

opm

ent.

Ch

alle

nge

s in

ad

dre

ssin

g n

eeds

of

the

new

born

s in

urb

an p

oor

sett

ings

oper

ate

at c

om

mun

ity

as w

ell

as p

rogr

am l

evel

an

d n

eed t

o be

addre

ssed

sim

ult

aneo

usl

y. T

he

pap

er

des

crib

es t

hes

e ch

alle

nge

s an

d su

gges

ts a

way

forw

ard

in l

igh

t of

the

exis

tin

g opport

un

itie

s an

d le

sson

s fr

om

su

cces

sful

exper

ien

ces.

99

N

ewborn

Car

e P

ract

ices

an

d H

ealt

h S

eekin

g B

ehav

ior

in U

rban

Slu

ms

and V

illa

ges

of A

nan

d,

Guja

rat;

Arc

han

a S

Nim

balk

ar,

Viv

ek V

Sh

ukla

, A

jay

G P

hat

ak A

nd S

om

ash

ekh

ar M

Nim

bal

kar

Stu

dy

fin

din

gs

Soci

o e

con

om

ic

fact

ors

Hea

lth

sta

tus

of

neo

nat

es i

n u

rban

slu

ms

has

not

bee

n

studie

d i

n s

mal

ler

tow

ns.

A q

ues

tion

nai

re w

as

adm

inis

tere

d t

o 1

54 f

amil

ies

of

10 u

rban

slu

ms

of

An

and

(popula

tion

- 197351)

and 1

60 f

amil

ies

fr

om 6

vil

lage

s of

An

and d

istr

ict.

Th

e so

cioec

on

omic

an

d

educa

tion

sta

tus

of

the

slum

dw

elle

rs v

ersu

s ru

ral

par

tici

pan

ts w

ere

sign

ific

antl

y lo

wer

in

urb

an s

lum

s, a

s co

mpar

ed t

o v

illa

ges,

Car

e se

ekin

g w

as l

ow

in

urb

an

slum

s, H

indus

and i

llit

erat

e m

oth

ers.

Hea

lth

car

e an

d

soci

oec

on

om

ic s

tatu

s of

neo

nat

es i

n s

lum

s of

smal

ler

citi

es i

s poore

r th

an i

n s

urr

oun

din

g vil

lage

s.

100

N

eon

atal

Car

e P

ract

ices

in

Urb

an V

illa

ges;

P

eeyu

sh G

rover

, In

tern

,Pra

gti

Ch

hab

ra,

Pro

fess

or

S

tudy

report

N

eon

atal

car

e N

eon

atal

hea

lth

is t

he

key

to c

hil

d su

rviv

al.

Car

e pra

ctic

es d

uri

ng

del

iver

y an

d n

eon

atal

per

iod

con

trib

ute

to

risk

of

mort

alit

y an

d m

orb

idit

y. T

he

pre

sen

t st

udy

was

con

duct

ed i

n t

wo u

rban

vil

lage

s of

east

Del

hi

to s

tudy

pra

ctic

es d

uri

ng

del

iver

y an

d n

eon

atal

per

iod a

mon

gst

moth

ers.

101

C

om

par

ison

Of

Pre

val

ent

New

born

Rea

rin

g P

ract

ices

, In

Urb

an A

nd S

lum

Popula

tion

Of

Ch

andig

arh

, U

t, I

ndia

; S

Puri

, V

Bh

atia

, M

S

har

ma,

H S

wam

i, C

Mag

nat

Stu

dy

report

N

ewborn

pra

ctic

es

To s

tudy

the

hom

e bas

ed n

ewborn

car

e pra

ctic

es i

n

slum

an

d urb

an a

rea

of

Ch

andig

arh

an

d t

o c

om

pare

th

e pra

ctic

es i

n b

oth

set

ups

.

102

N

ewborn

Car

e P

ract

ices

in

Urb

an S

lum

s of

Luck

now

Cit

y, U

P;

Pra

tibh

a G

upta

, V

K

Stu

dy

report

N

ewborn

car

e pra

ctic

es

A c

ross

-sec

tion

al s

tudy

in u

rban

slu

ms

of

Luck

now

cit

y,

UP

, in

cluded

524 w

om

en w

ho h

ad a

liv

e bir

th d

uri

ng

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



107

S

rivas

tava

, V

ish

waj

eet

Kum

ar, S

avit

a Ja

in, Ja

mal

M

asood,

Nai

m A

hm

ad, an

d JP

Sri

vast

ava

la

st 1

yea

r pre

cedin

g dat

a co

llec

tion

. D

ata

wer

e an

alyz

ed u

sin

g st

atis

tica

l so

ftw

are

SP

SS

10.0

for

win

dow

s. 103

M

ater

nal

an

d

neo

nat

al h

ealt

h e

xpen

dit

ure

in

m

um

bai

slu

ms

(In

dia

): A

cro

ss s

ecti

on

al s

tudy;

Jo

len

e S

kord

is-W

orr

all, N

oem

i P

ace,

Ujw

ala

Bap

at, S

ush

mit

a D

as, N

een

a S

More

, W

asun

dh

ara

Josh

i, A

nn

i-M

aria

Pulk

ki-

Bra

nn

stro

m1

and D

avid

O

srin

An

alys

is r

eport

H

ealt

h

expen

ditu

re T

he

cost

of

mat

ern

ity

care

can

be

a bar

rier

to a

cces

s th

at m

ay i

ncr

ease

mat

ern

al a

nd n

eon

atal

mort

alit

y ri

sk.

We

anal

yzed

spen

din

g on

mat

ern

ity

care

in

urb

an s

lum

co

mm

un

itie

s in

Mum

bai

to b

ette

r un

der

stan

d t

he

equit

y of

spen

din

g an

d th

e im

pact

of

spen

din

g on

h

ouse

hold

pover

ty.

104

S

tate

of

India

’s N

ewborn

s 2014;

PH

FI

R

eport

N

ewborn

hea

lth

st

rate

gies

T

his

sec

on

d ed

itio

n o

f th

e S

OIN

rep

ort

rev

iew

s th

e ev

iden

ce g

ener

ated

pro

gres

s an

d l

earn

ing

in n

ewbo

rn

hea

lth

in

In

dia

over

th

e pas

t te

n y

ears

, an

d a

ctio

ns

nee

ded t

o a

ccel

erat

e pro

gres

s in

new

born

hea

lth

an

d su

rviv

al i

n t

he

dec

ade

ahea

d.

105

N

ewborn

car

e pra

ctic

es i

n a

n u

rban

slu

m o

f D

elh

i;

Man

ju R

ahi, D

K T

anej

a, A

mri

ta M

isra

, N

B

Mat

hur,

Sure

sh B

adh

an

Stu

dy

report

N

ewborn

car

e pra

ctic

es

Des

pit

e ef

fort

s by

gover

nm

ent

and o

ther

age

nci

es,

neo

nat

al m

orb

idit

y an

d m

ort

alit

y co

nti

nues

to

be

hig

h

in I

ndia

. A

mon

g oth

er r

easo

ns,

new

born

car

e pra

ctic

es

are

maj

or c

on

trib

uto

rs f

or

such

hig

h r

ates

. T

he

aim

of

the

stud

y w

as t

o fi

nd o

ut

the

new

born

car

e pra

ctic

es

incl

udin

g del

iver

y pr

acti

ces,

im

med

iate

car

e gi

ven

aft

er

bir

th a

nd b

reas

t-fe

edin

g pra

ctic

es i

n a

n u

rban

slu

m o

f D

elh

i. 106

A

Tal

e of

Tw

o A

ppro

ach

es: M

ater

nal

an

d

Neo

nat

al H

ealt

hca

re f

or

the

Urb

an P

oor;

Ush

a G

anes

h

Art

icle

M

DG

T

his

art

icle

exa

min

es t

wo

appro

ach

es i

n B

angl

ades

h

and I

ndia

th

at h

ave

mad

e si

gnif

ican

t in

road

s to

mee

t th

e M

DG

on

mat

ern

al m

ort

alit

y.

107

M

ater

nal

an

d c

hil

d h

ealt

h c

hal

len

ge i

n u

rban

In

dia

: T

he

lack

of

acce

ss t

o p

reve

nti

ve

care

in

form

atio

n; D

r A

par

na

Heg

de,

Foun

der

an

d

Ch

airm

an, A

RM

MA

N

As

MA

MA

pre

par

es t

o la

un

ch i

n I

ndia

nex

t m

on

th,

we

take

a cl

ose

r lo

ok a

t th

e m

ater

nal

, n

ewborn

an

d ch

ild h

ealt

h c

hal

len

ges

face

d i

n i

ts u

rban

are

as

108

D

eman

d-s

ide

Fin

anci

ng

and P

rom

oti

on

of

Mat

ern

al H

ealt

h: w

hat

has

In

dia

lear

nt?

; B

enja

min

M H

un

ter,

Ram

ila

Bis

ht,

In

dir

a C

hak

rava

rth

i, S

usan

F M

urr

ay

Th

is p

aper

un

dert

akes

a s

yste

mat

ic r

evie

w o

f th

e ev

iden

ce t

o c

on

side

r h

ow

dem

and-s

ide

fin

anci

ng

has

bee

n u

sed a

nd w

het

her

th

ere

has

bee

n a

ny

impac

t on

m

ater

nal

hea

lth

ser

vic

e uti

lisa

tion

, m

ater

nal

hea

lth

, or

oth

er o

utc

omes

. T

he

fin

din

gs s

ugg

est

that

a r

elat

ivel

y

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



108

n

arro

w f

ocu

s on

ach

ievi

ng

targ

ets

has

oft

en

over

burd

ened

hea

lth

fac

ilit

ies,

wh

ile

inad

equat

e re

ferr

al s

yste

ms

and u

net

hic

al p

ract

ices

pre

sen

t over

wh

elm

ing

bar

rier

s fo

r w

omen

wit

h o

bst

etri

c co

mpli

cati

on

s. T

he

lim

ited

evid

ence

ava

ilab

le a

lso

sugg

ests

th

at l

ittl

e h

as b

een

don

e to

ch

alle

nge

th

e lo

w

stat

us

of

poor

wom

en a

t h

ome

and i

n t

he

hea

lth

sys

tem

109

N

ewborn

Car

e P

ract

ices

Am

on

g S

lum

Dw

elle

rs I

n

Ali

garh

Cit

y, U

ttar

Pra

des

h;

MH

Kh

an, N

K

hal

ique,

AR

Sid

diq

ui,

A

Am

ir

A c

om

mun

ity-

bas

ed s

tudy

was

con

duc

ted i

n t

he

fiel

d pra

ctic

e ar

ea o

f th

e U

rban

Hea

lth

Tra

inin

g C

entr

e (U

HT

C),

Dep

artn

men

t of

Com

mun

ity

Med

icin

e,

Jaw

ahar

lal

Neh

ru M

edic

al C

oll

ege,

Ali

garh

Mus

lim

U

niv

ersi

ty, A

liga

rh, U

P.

200 p

regn

ant

wom

en w

ere

chose

n f

or

the

stud

y, c

arri

ed o

ut f

or

1 y

ear.

obj

ecti

ve

was

to s

tudy

the

kn

ow

ledge

an

d p

ract

ices

rel

ated

to

new

born

car

e am

on

g sl

um

dw

elle

rs i

n A

liga

rh. fi

nsi

ngs

w

ere

that

th

ere

wer

e poor

new

born

pra

ctic

es a

mon

g sl

um

dw

elle

rs i

n A

liga

rh.

110

P

oor

Per

inat

al C

are

Pra

ctic

es i

n U

rban

Slu

ms:

P

oss

ible

Role

of

Soci

al M

obil

izat

ion

Net

work

s;

Zulf

ia K

han

, S

aira

Meh

naz

, N

ajam

Kh

aliq

ue,

M

oh

d A

thar

An

sari

, an

d A

bdul

Raz

zaque

Sid

diq

ui

To d

eter

min

e th

e ex

isti

ng

peri

nat

al p

ract

ices

in

an

urb

an s

lum

an

d t

o i

den

tify

bar

rier

s to

uti

liza

tion

of

hea

lth

ser

vic

es b

y m

oth

ers.

111

C

om

mun

ity

Bas

ed N

ewborn

Car

e: A

Sys

tem

atic

R

evie

w a

nd M

eta-

anal

ysis

of

Evid

ence

: U

NIC

EF-

PH

FI

Ser

ies

on

New

born

an

d C

hil

d H

ealt

h, In

dia

; S

iddh

arth

a G

ogi

a, S

idda

rth

Ram

ji, $P

iyush

G

upta

, #T

arun

Ger

a, $

Dh

eera

j S

hah

, Jo

seph

L

Mat

hew

, P

avit

ra M

oh

an a

nd R

ajm

oh

an P

anda

To a

sses

s th

e ef

fect

of

com

mun

ity

base

d n

eon

atal

car

e by

com

mun

ity

hea

lth

work

ers

(CH

Ws)

on

NM

R i

n

reso

urc

e-li

mit

ed s

etti

ngs

.

112

C

om

par

ison

Of

Pre

val

ent

New

born

Rea

rin

g P

ract

ices

, In

Urb

an A

nd S

lum

Popula

tion

Of

Ch

andig

arh

, U

t, I

ndia

; S

Puri

, V

Bh

atia

, M

S

har

ma,

H S

wam

i, C

Mag

nat

.

To s

tudy

the

hom

e bas

ed n

ewborn

car

e pra

ctic

es i

n

slum

an

d urb

an a

rea

of

Ch

andig

arh

an

d t

o c

om

pare

th

e pra

ctic

es i

n b

oth

set

ups

.

113

Fost

erin

g M

ater

nal

an

d N

ewborn

Car

e in

In

dia

th

e Y

ash

oda

Way

: D

oes

Th

is I

mpro

ve

Mat

ern

al

and N

ewborn

Car

e P

ract

ices

duri

ng

Inst

ituti

on

al

Th

e Y

ash

oda

pro

gram

, n

amed

aft

er a

leg

endar

y fo

ster

-m

oth

er i

n I

ndia

n m

yth

olo

gy,

un

der

th

e N

orw

ay-I

ndia

P

artn

ersh

ip I

nit

iati

ve

was

lau

nch

ed a

s a

pil

ot

pro

gram

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



109

D

eliv

ery?

; B

een

a V

argh

ese

mai

l, R

eeta

bra

ta R

oy,

S

om

en S

aha,

Sid

sel

Roal

kvam

in

2008

to

impro

ve

the

qual

ity

of

mat

ern

al a

nd

neo

nat

al c

are

at f

acil

itie

s in

sel

ect

dis

tric

ts o

f In

dia

. Y

ash

odas

wer

e pla

ced m

ain

ly a

t dis

tric

t h

osp

ital

s,

wh

ich

are

hig

h d

eliv

ery

load

fac

ilit

ies,

to p

rovi

de

support

an

d c

are

to m

oth

ers

and n

ewborn

s duri

ng

thei

r st

ay a

t th

ese

faci

liti

es. T

his

stu

dy

pre

sen

ts t

he

resu

lts

from

th

e ev

aluat

ion

of

this

in

terv

enti

on

in

tw

o s

tate

s in

In

dia

. 114

C

ash

In

cen

tives

for

Inst

ituti

on

al D

eliv

ery:

Lin

kin

g w

ith

An

ten

atal

an

d P

ost

Nat

al C

are

May

En

sure

‘C

on

tin

uum

of

Car

e’ i

n I

ndia

; C

han

dra

kan

t L

ahar

iya

Eval

uat

ing

the

JSY

sch

eme.

115

Ja

nan

i S

ura

ksh

a Y

ojan

a: t

he

con

dit

ion

al c

ash

tr

ansf

er s

chem

e to

red

uce

mat

ern

al m

ort

alit

y in

In

dia

–

a n

eed f

or

reas

sess

men

t; R

ajes

h K

umar

R

aia,

Pra

shan

t K

um

ar S

ingh

b

116

A

Tal

e of

Tw

o A

ppro

ach

es: M

ater

nal

an

d

Neo

nat

al H

ealt

hca

re f

or

the

Urb

an P

oor;

Ush

a G

anes

h

Opin

ion

art

icle

P

ubli

c h

ealt

h

infr

astr

uct

ure

Th

is a

rtic

le e

xam

ines

tw

o ap

pro

ach

es i

n B

angl

ades

h

and I

ndia

th

at h

ave

mad

e si

gnif

ican

t in

road

s to

mee

t th

e M

DG

on

mat

ern

al m

ort

alit

y.

117

C

on

trac

tin

g-out

of R

epro

duct

ive

and C

hil

d

Hea

lth

(R

CH

) S

ervi

ces

thro

ugh

Moth

er N

GO

S

chem

e in

In

dia

: E

xper

ien

ces

and I

mpli

cati

on

s;

Ram

esh

Bh

at, S

un

il M

ahes

hw

ari,

Som

en S

aha

Work

ing

pap

er

Par

tner

ship

wit

h

NG

Os,

m

anag

emen

t of

RC

H s

ervic

es

Par

tner

ship

wit

h N

GO

s in

del

iver

ing

and p

rovi

sion

of

Rep

rodu

ctiv

e an

d C

hil

d H

ealt

h (

RC

H)

serv

ices

th

rough

moth

er N

GO

(M

NG

O)

in t

he

un

ser

ved

an

d

un

der

-ser

ved

reg

ion

s is

on

e of

the

import

ant

init

iati

ves

in

In

dia

. T

he

sch

eme

involv

es l

arge

num

ber

of

con

trac

ts b

etw

een

gover

nm

ent

and t

he

NG

Os.

As

of

Apri

l 20

06,

215 M

NG

Os

wer

e w

ork

ing

in 3

24 d

istr

icts

of

the

coun

try.

In

addi

tion

to t

his

th

ere

are

about

3 to

4 F

ield

NG

Os

atta

ched

wit

h e

ach

MN

GO

in

a

dis

tric

t.

Th

is p

aper

dis

cuss

es t

his

sch

eme

wit

h a

n o

bje

ctiv

e to

un

der

stan

d t

he

mak

e up o

f th

e par

tn e

rsh

ip a

nd t

he

dev

elopm

ent

of

man

agem

ent

capac

ity

in t

he

syst

em.

118

C

apac

ity

Buil

din

g on

Man

agem

ent

and

Imple

men

tati

on

of

Urb

an R

CH

Ser

vic

es a

nd

Publi

c P

rivat

e P

artn

ersh

ips;

UH

RC

Stu

dy

tour

report

P

PP

, urb

an

mat

ern

al h

ealt

h U

HR

C h

as b

een

work

ing

close

ly w

ith

th

e M

oH

FW

an

d s

tate

gover

nm

ents

in

dev

elopi

ng

stra

tegi

es,

oper

atio

nal

guid

elin

es a

nd c

apac

ity

to i

mpro

ve

the

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



110

hea

lth

of

the

urb

an p

oor.

In

ord

er t

o i

mpro

ve

capac

ity

of

key

off

icer

s m

anag

ing

urb

an h

ealt

h p

rogr

ams,

an

ex

posu

re v

isit

was

con

duct

ed t

o M

un

icip

al h

ealt

h

cen

ters

in

Ban

galo

re m

anag

ed i

n p

artn

ersh

ip w

ith

th

e pri

vat

e se

ctors

. T

hes

e h

ealt

h c

ente

rs i

nit

iate

d u

nder

th

e W

orl

d B

ank f

un

ded

eig

ht

roun

d o

f th

e In

dia

P

opula

tion

Pro

ject

(IP

P-V

III)

hav

e bee

n o

per

ated

su

cces

sfull

y by

non

-gover

nm

enta

l ag

enci

es f

or

the

pas

t se

ver

al y

ears

an

d s

om

e of

thes

e N

GO

s h

ave

man

aged

to

run

th

ese

faci

liti

es e

ven

aft

er t

he

end o

f th

e pro

ject

cy

cle.

119

B

uil

din

g P

ubli

c S

ecto

r –

N

GO

Par

tner

ship

s fo

r U

rban

RC

H S

ervic

es; S

iddh

arth

E

dit

ori

al

NG

O

Par

tner

ship

s,

Urb

an

par

tner

ship

s

Th

e ques

t fo

r bet

ter

livel

ihood o

pport

un

itie

s h

as l

ed t

o

larg

e-sc

ale

mig

rati

on

an

d t

he

mush

room

ing

of

slum

s in

se

ver

al I

ndia

n c

itie

s. U

nfo

rtun

atel

y, a

sig

nif

ican

t se

ctio

n o

f th

e urb

an p

oor

do n

ot

hav

e ac

cess

to m

any

of

the

ben

efit

s of

urb

an d

evel

opm

ent.

Much

of

the

chal

len

ge o

f del

iver

ing

serv

ices

to t

he

mar

gin

aliz

ed

groups

lies

in

iden

tify

ing

them

an

d e

ffec

tivel

y ap

pro

ach

ing

them

, so

th

at l

imit

ed r

esourc

es a

re u

tili

zed

wel

l an

d p

rogr

ams

addre

ss r

eal

nee

ds1

. T

her

e is

a

pre

sen

ce o

f th

e publi

c se

ctor

as w

ell

as N

GO

s in

urb

an

area

s. T

he

grow

ing

requir

emen

t fo

r h

ealt

h s

ervic

es f

or

the

urb

an p

oor,

ow

ing

to r

apid

urb

an p

opula

tion

gr

ow

th,

nec

essi

tate

s th

inkin

g ab

out

the

coll

abora

tive

appro

ach

of

the

publi

c an

d N

on

pro

fit

sect

or

for

hea

lth

se

rvic

es i

n u

rban

are

as 120

D

esig

n R

esea

rch

in

Neo

nat

al H

ealt

hca

re i

n U

rban

In

dia

; P

rera

k M

ehta

Res

earc

h r

eport

N

eon

atal

hea

lth

in

Urb

an I

ndia

Th

is p

aper

att

empts

at

un

der

stan

din

g th

e co

re i

ssues

pla

guin

g n

eon

atal

hea

lth

care

am

on

gst

the

urb

an s

ecto

r in

In

dia

, th

e ap

pro

ach

tak

en t

o u

nder

stan

d t

hes

e is

sues

an

d t

he

impli

cati

on

s of

the

appro

ach

. It

poin

ts o

ut

the

opport

un

ity

for

des

ign

in

terv

enti

on

s at

var

ious

jun

cture

s. A

n a

ttem

pt

has

bee

n m

ade

to g

o d

eeper

in

to

the

pra

ctic

al p

roble

ms

bei

ng

face

d b

y th

e var

ious

stak

ehold

ers

- M

oth

er a

nd f

amil

y (f

ath

er, m

oth

er-i

n-

law

, an

d m

ater

nal

mem

ber

s),

Doct

or

and s

upport

sta

ff

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t K

ey

Ch

arac

teri

stic

s/a

spec

ts

cover

ed

Abst

ract

/Mai

n f

indi

ngs



111

(nurs

es, at

ten

dan

ts),

Publi

c h

ealt

h o

ffic

er/N

GO

an

d

support

sta

ff (

aan

gan

vadi

an

d c

omm

un

ity

level

hea

lth

w

ork

ers)

, an

d B

aby

pro

duct

s sh

opke

eper

s.

121

L

ife

S

pri

ng

Hosp

ital

s: C

an S

pec

ialt

y C

are

Fac

ilit

ies

Red

uce

Mat

ern

al a

nd

Infa

nt

Mort

alit

y R

ates

in

In

dia

?; C

arli

n C

arr

Art

icle

M

ater

nal

an

d in

fan

t m

orta

lity

in

In

dia

Th

is a

rtic

le d

escr

ibes

PP

P i

n t

he

mat

ern

al a

nd

neo

nat

al c

are

aren

a, L

ifeS

pri

ng

Hosp

ital

s P

rivat

e L

td.,

foun

ded

in

2005

, h

as e

mer

ged a

s a

lead

er i

n p

rovid

ing

routi

ne

obst

etri

c ca

re a

nd d

eliv

ery

serv

ices

for

expec

tin

g m

oth

ers

in u

rban

poor

area

s of

Sou

ther

n

India

.

S.

No.

B

ibli

ogr

aphic

Det

ails

T

ype

of

docu

men

t

Key

C

har

acte

rist

ics

/asp

ects

co

ver

ed

Abst

ract

/Mai

n f

indi

ngs



112

S

n o

Cit

y F

acil

ity

that

p

rov

ides

car

e to

m

oth

er a

nd

chil

d

No

.

of

faci

liti

es

Sta

tus

of

equ

ipm

ent

avai

labl

e/

tran

spo

rt m

ech

anis

m

Nu

mb

er o

f to

tal

po

pu

lati

on

Nu

mb

er o

f sl

um

s

Rem

ark

s

1A

mba

la

RC

H c

entr

e

3

C

aesa

rean

sec

tio

n,

an X

-ray

m

ach

ine,

US

G,

auto

clav

e,

ven

tila

tor,

an

aest

hes

ia,

lapa

rosc

op

y, a

uto

clav

e, S

NC

U,

T

ran

spo

rt n

ot

avai

labl

e

4,0

00

00

4

2 s

lum

s

T

he

typ

e of

car

e p

rov

ided

at

the

pri

mar

y le

vel

RC

H c

entr

es a

re t

hat

of

AN

C,

imm

un

izat

ion

, T

he

maj

or

pro

ble

m r

emai

ns

that

all

th

e fa

cili

ties

are

ru

nn

ing

in r

ente

d

apar

tmen

ts (

pu

cca

bui

ldin

gs n

ot

avai

labl

e in

th

e sl

um

s ).

MC

H

1

M

CH

II

1

Sec

on

dary

car

e u

nit

( F

RU

s)

3

2B

ard

ham

an

Hea

lth

Po

st

5

Av

aila

bil

ity

of u

ltra

sou

nd

and

oth

er d

iagn

ost

ic w

hic

h a

re

char

geab

le,

the

mat

ern

ity

hom

e is

ta

kin

g ca

re o

f an

ten

atal

ch

eck

up,

im

mu

niz

atio

n

34

7,0

16,

To

tal

slu

m

po

pu

lati

on

8

8,0

00

Th

e fa

cili

ties

ava

ilab

le a

re a

lmo

st d

efu

nct

an

d t

her

e is

no

spec

ific

in

form

atio

n o

n t

he

sam

e. T

he

spec

iali

zed

serv

ices

,

tran

spor

t fa

cili

ty f

or

acce

ssin

g th

e se

rvic

es a

vai

lab

le

at m

ater

nit

y w

ard

, th

e d

iscu

ssio

n o

n

emer

gen

cy c

are

pro

vis

ion

ing

fo

r m

oth

er

and

ch

ild

is a

lso

mis

sin

g

Su

b H

ealt

h P

ost

27

Mat

ern

ity

Hom

e at

urb

an h

osp

ital

1

Sat

ish

Sad

hu

Sm

riti

Po

ura

S

was

tha

Ken

dra

(2n

d u

nit

of

IPP

-V

III(

Ex

tn.)

K

ho

sbag

an

1

3

Bh

op

al

Mat

ern

ity

war

d

wit

h b

aby

frie

nd

ly

env

iro

nm

ent

NA

Co

un

seli

ng

faci

liti

es

avai

labl

e fo

r re

pro

duc

tiv

e h

ealt

h,

RK

S i

s av

aila

ble

,

ther

e is

no

clar

ity

on

th

e n

umb

er o

f eq

uip

men

t an

d

stat

us

of

the

bui

ldin

g

19

,14,

83

9

48

6 s

lum

s

Th

e ci

ty r

epo

rt i

nd

icat

es e

xis

ten

ce o

f fa

cili

ties

fo

r re

pro

duc

tive

an

d n

ew b

orn

h

ealt

h h

ow

ever

th

ere

is n

o c

lear

in

dica

tio

n

of

th

e n

um

ber

of

un

its,

ava

ilab

le

dia

gno

stic

an

d n

ew b

orn

car

e fa

cili

ties

Co

un

sell

ing

Ser

vic

es f

or

Do

mes

tic

Vio

len

ce,

Gen

der

V

iole

nce

, A

do

lesc

ents

, et

c

NA

4B

hu

ban

esw

ar

Urb

an h

ealt

h

po

sts

th

at t

akes

ca

re o

f A

NC

, im

mu

niz

atio

n

21

Th

e U

rban

hea

lth

po

sts

are

sup

po

sed

to

pro

vid

e an

ten

atal

ca

re, im

mu

niz

atio

n.

No

lab

te

chn

olo

gies

ava

ilab

le a

sso

ciat

ed

wit

h m

oth

er a

nd

new

bo

rn h

ealt

h

care

.

8,

81

,98

85

0-6

0

slu

ms

Mo

st o

f th

e U

rban

slu

m h

ealt

h c

ente

rs i

n

the

city

are

eit

her

ru

nn

ing

in r

ente

d b

uil

din

gs o

r co

mm

un

ity

cen

ters

. T

her

e ar

e P

PP

un

der

NR

HM

an

d in

dee

d th

ere

is

oft

en d

upl

icat

ion

of

info

rmat

ion

as

the

sam

e po

pu

lati

on

is

bein

g ca

tere

d b

y th

e u

rban

hea

lth

po

sts

and

the

PP

P u

nit

s

An

nex

ure

2

: C

ity

wis

e M

NH

pro

gram

mes

, sc

hem

es &

inn

ovat

ion

s in

som

e se

lect

cit

ies

acro

ss I

ndia



113

Tab

le: A

n a

nal

ysis

of

HM

IS a

cross

dis

tric

ts o

f var

ious

stat

es

Nam

e of

the

dis

tric

t M

eth

od

Sta

tus

of

HM

IS

Nort

h D

inaj

pur

( W

est

Ben

gal)

HM

IS /

MC

TS

( m

oth

er

and c

hil

d tr

acki

ng)

Alt

houg

h H

MIS

/ M

CT

S i

nfo

rmat

ion

is

sen

t to

th

e bl

ock b

ut

feed

bac

k i

s n

ot

rece

ived

pro

perl

y fr

om t

he

blo

ck, at

both

tow

n a

nd

vil

lage

lev

els.

Cooch

beh

ar

(Wes

t B

enga

l) H

MIS

/ M

CT

S S

C l

evel

off

icia

ls a

re n

ot

pro

perl

y tr

ain

ed i

n t

his

form

at. A

lth

ough

HM

IS /

MC

TS

in

form

atio

n i

s s

ent

to t

he

blo

ck

but

feed

bac

k is

not

rece

ived

pro

per

ly f

rom

th

e blo

ck.

Sit

apur

(Utt

ar P

rade

sh)

HM

IS /

MC

TS

Dis

tric

t H

osp

ital

-Sit

apur:

At

the

DH

on

e st

aff

is e

nga

ged

for

HM

IS a

nd

no o

ne

for

MC

TS

. D

H r

eport

s fo

r H

MIS

ar

e n

eith

er t

imel

y n

or

com

ple

te. C

HC

Lah

arpur:

At

the

CH

C t

her

e is

on

e per

son

wh

o lo

oks

afte

r H

MIS

an

d sa

me

per

son

als

o l

ooks

afte

r th

e M

CT

S a

ctiv

itie

s. T

he

HM

IS a

nd

MC

TS

dat

a per

tain

ing

to t

he

CH

C a

re b

ein

g pro

vid

ed

as p

er t

he

pre

scri

bed

tim

elin

es a

nd

are

com

ple

te. D

ata

vali

dati

on

ch

ecks

to s

om

e ex

ten

t fo

r H

MIS

dat

a ar

e be

ing

un

der

taken

pri

or t

o upl

oad

of

the

dat

a on

th

e port

al. P

HC

Bar

ai J

alal

pur

: A

t th

e P

HC

th

ere

are

two

per

son

s w

ho

look

afte

r H

MIS

an

d M

CT

S. T

he

HM

IS a

nd M

CT

S d

ata

per

tain

ing

to t

he

PH

C a

re b

ein

g pro

vid

ed a

s per

th

e

pre

scri

bed t

imel

ines

an

d H

MIS

rep

ort

ing

is c

om

plet

e w

hil

e as

MC

TS

is

com

plet

e to

80 p

erce

nt

level

. D

ata

val

idat

ion

ch

ecks

to H

MIS

dat

a ar

e be

ing

un

dert

aken

pri

or

to u

pload

of

the

data

on

th

e port

al.

MC

H C

entr

e M

adh

avpur

: T

he

AN

M r

eport

ed t

hat

sh

e se

nds

com

plet

e da

ta r

elat

ing

to H

MIS

an

d M

CT

S i

n t

ime

and

it w

as

info

rmed

by

dist

rict

off

icia

ls t

hat

dat

a ar

e of

reas

on

able

qual

ity

as f

ar v

alid

atio

n o

f th

ese

data

are

con

cern

ed.

P

ilib

hit

(Utt

ar P

rade

sh)

HM

IS /

MC

TS

Dis

tric

t H

osp

ital

-Pil

ibh

it: A

t th

e D

H n

o se

par

ate

staf

f is

en

gage

d f

or

HM

IS a

nd

MC

TS

. D

H r

eport

s fo

r H

MIS

are

ti

mel

y an

d c

omple

te.

CH

C P

uran

pur:

At

the

CH

C t

her

e ar

e tw

o per

son

s w

ho l

ook

afte

r H

MIS

an

d t

hre

e per

son

s w

ho l

ook a

fter

th

e M

CT

S a

ctiv

itie

s. T

he

HM

IS a

nd

MC

TS

dat

a pe

rtai

nin

g to

th

e C

HC

are

bei

ng

pro

vided

as

per

th

e pre

scri

bed t

imel

ines

an

d a

re m

ore

or

less

com

ple

te. D

ata

val

idat

ion

ch

ecks

to

som

e ex

ten

t fo

r H

MIS

dat

a ar

e bei

ng

un

dert

aken

pri

or t

o upl

oad

of

the

dat

a on

th

e port

al. P

HC

Mad

hota

nda

: At

the

PH

C t

her

e ar

e tw

o pe

rson

s w

ho l

ook a

fter

HM

IS a

nd

MC

TS

. T

he

HM

IS a

nd M

CT

S d

ata

pert

ain

ing

to t

he

PH

C a

re b

ein

g pro

vid

ed a

s per

th

e pre

scri

bed t

imel

ines

an

d th

ey a

re a

lso c

om

ple

te.

Dat

a va

lidat

ion

ch

ecks

to H

MIS

dat

a ar

e be

ing

un

dert

aken

pri

or t

o uplo

ad o

f th

e dat

a on

th

e port

al. S

C R

am N

agra

: T

he

AN

M r

eport

ed t

hat

sh

e se

nds

com

ple

te d

ata

rela

tin

g to

HM

IS

and M

CT

S i

n t

ime

but

it w

as i

nfo

rmed

by

dis

tric

t of

fici

als

that

dat

a ar

e n

ot a

lway

s va

lidat

ed w

hen

we

rece

ive

them

fr

om

AN

M (

dis

crep

ancy

) L

akh

impur

Kh

eri

(Utt

ar P

rade

sh)

HM

IS /

MC

TS

Dis

tric

t H

osp

ital

- L

akh

impur

Kh

eri:

At

the

DH

, on

e st

aff

is

enga

ged f

or

HM

IS a

nd

MC

TS

. D

H r

eport

s fo

r H

MIS

ar

e ti

mel

y an

d co

mpl

ete

but

no M

CT

S e

ntr

ies

are

bei

ng

don

e. H

MIS

dat

a ar

e n

ot v

alid

ated

bef

ore

sen

din

g to

th

e C

MO

Off

ice.

SC

Kat

oli:

Th

e A

NM

rep

ort

ed t

hat

sh

e se

nds

com

plet

e dat

a re

lati

ng

to H

MIS

an

d M

CT

S i

n t

ime

but

it w

as i

nfo

rmed

by

dis

tric

t of

fici

als

that

dat

a ar

e n

ot

alw

ays

vali

dat

ed w

hen

we

rece

ive

them

fro

m A

NM

.

Kau

sham

bi (U

ttar

Pra

desh

)

HM

IS /

MC

TS

CH

C S

arai

Akee

l: A

t th

e C

HC

no i

nfo

rmat

ion

coul

d be

rece

ived

on

HM

IS a

nd M

CT

S.

Har

doi

(Utt

ar P

rade

sh)

HM

IS /

MC

TS

Dis

tric

t H

osp

ital

-(Fe

mal

e)-H

ardoi:

At

the

DH

on

e se

par

ate

staf

f is

en

gage

d f

or

HM

IS a

nd

MC

TS

. T

imel

ines

s is

ap

par

entl

y m

ain

tain

ed a

nd

data

val

idat

ion

ch

ecks

are

appl

ied.

How

ever

, co

mpl

ete

dat

a is

not

rep

ort

ed.

T

iruch

irap

pal

li

Dis

tric

t (T

amil

Nad

u)

HM

IS /

MC

TS

Dat

a en

try

in t

he

cen

tral

port

als

HM

IS a

nd M

CT

S a

re n

ot

don

e at

th

e per

iph

eral

/ f

acil

ity

level

. T

he

data

fro

m

HM

IS p

orta

l an

d t

he

PIC

ME

port

al a

re t

ran

sfer

red

to t

he

cen

tral

port

als

at t

he

dist

rict

an

d st

ate

level

s re

spec

tive

ly.

Th

e da

ta q

uali

ty i

s fa

r fr

om s

atis

fact

ory

an

d th

e ti

mel

ines

s an

d t

he

accu

racy

nee

d t

o be

im

pro

ved

. U

tili

zati

on

of

the

dat

a fr

om

th

e port

al a

t th

e pe

riph

eral

lev

el i

s n

ot n

oti

ced.

Kri

shn

agir

i H

MIS

/ M

CT

S D

ata

entr

y in

th

e ce

ntr

al p

ort

als

HM

IS a

nd M

CT

S a

re n

ot

don

e at

th

e per

iph

eral

/ f

acil

ity

level

. T

he

data

fro

m



114

Dis

tric

t

(Tam

il N

adu)

TN

HM

IS p

ort

al a

nd t

he

PIC

ME

port

al a

re t

ran

sfer

red t

o t

he

cen

tral

port

als

at t

he

dist

rict

an

d st

ate

leve

ls

resp

ecti

vel

y. T

he

dat

a qu

alit

y is

far

fro

m s

atis

fact

ory

an

d t

he

tim

elin

ess

and t

he

accu

racy

nee

d im

pro

vem

ent.

Bun

di

dis

tric

t

(raj

asth

an)

HM

IS /

MC

TS

It i

s be

cause

in

man

y pl

aces

AN

Ms

are

new

ly a

ppoi

nte

d a

nd

they

did

not

rec

eive

d an

y fo

rmal

tra

inin

g of

HM

IS

reco

rdin

g an

d re

port

ing

HM

IS d

ata

are

usi

ng

for

revie

w o

f pe

rform

ance

of

RC

H i

ndic

ators

. On

e of

the

pro

blem

s in

en

suri

ng

good

HM

IS d

ata

is m

ult

ipli

city

of

reco

rd k

eepin

g of

som

e of

the

indi

cato

rs l

ike

BC

G a

nd

som

e ca

ses

of

del

iver

y al

so.

Del

hi

HM

IS /

MC

TS

Adeq

uat

e n

umbe

r of

trai

ned

per

son

nel

en

gage

d i

n H

MIS

Sourc

e: h

ttps:

//n

rhm

-mis

.nic

.in

/

Som

e pro

mis

ing

com

mun

ity

inte

rven

tion

s an

d in

nova

tion

s

Tab

le o

f C

hap

ter

: C

om

mun

ity

Inte

rven

tion

S

no

Pro

gram

/ im

plem

enta

tion

ag

ency

Sta

te /

Cit

y S

tatu

s In

fere

nce

1.

Mam

ta

Del

hi

( N

CR

)

Pre

-2003

Th

e 10K

Clu

b -

a cl

ub f

or

the

hea

lth

& d

evel

opm

ent

of t

he

poore

st’ w

hic

h f

ocu

ses

on

im

pro

vin

g th

e qual

ity

of m

ater

nal

an

d n

ew b

orn

hea

lth

by

elim

inat

ing

pove

rty

thro

ugh

pro

per

mobil

izat

ion

of

loca

l co

mm

un

ity

and

oth

er p

artn

ers

(NG

Os)

.A

fun

ctio

nal

Reg

ion

al R

esourc

e C

ente

r th

at h

as t

rain

ed N

GO

s , N

GO

com

mit

tees

, P

anch

ayat

mem

ber

s ac

ross

Pun

jab,

Har

yan

a an

d C

han

dig

arh

. Th

is h

as g

iven

spec

ial

emph

asis

on

mobil

isin

g w

omen

fo

r re

gist

rati

on

, A

NC

, P

NC

2 S

aath

A

hm

adab

ad,

Guja

rat

2005

1.

Jeev

an D

aan

Mat

ern

al a

nd

Ch

ild

Surv

ival

pro

gram

aim

s at

a) P

neu

mon

ia C

ase

Man

agem

ent

b).

Con

trol

of

Dia

rrh

eal

Dis

ease

s

c). N

utr

itio

n/B

reas

t Fee

din

g

d).

Expa

nded

pro

gram

on

im

mun

izat

ion

e

)Mat

ern

al a

nd N

ewborn

Car

e

2. A

nga

nw

adi

cen

ters

fun

ctio

nal

in

23

war

ds

that

cat

ers

to n

eon

atal

hea

lth

an

d pre

gnan

t w

omen

.

3. A

n R

CH

pro

gram

wh

ich

is

alig

ned

wit

h t

he

con

cept

of

care

giv

ing

and

indu

lges

lin

k w

ork

ers

for

hom

e vis

its.

* T

he

lin

k w

ork

ers

had

un

der

take

n r

igoro

us

hom

e vi

sits

to

reduce

myt

hs

asso

ciat

ed w

ith

pre

gnan

cy a

n

new

bor

n c

are.

3 S

NE

HA

M

um

bai

Cre

atio

n o

f a

impro

ved r

efer

ral

syst

em t

hro

ugh

fol

low

ing

pro

cess

a)

Work

shops

wer

e co

ndu

cted

, bri

ngi

ng

toge

ther

hea

lth

pro

vide

rs f

rom

dif

fere

nt

leve

ls o

f se

rvic

e an

d

acti

on

gro

ups

wer

e fo

rmed

wh

ich

met

on

a m

on

thly

bas

is.

b)

Th

ese

acti

on

gro

ups

crea

ted

a da

taba

se o

f ex

isti

ng

faci

liti

es f

or

mat

ern

al a

nd n

eon

atal

ser

vic

es,



115

usi

ng

a se

lf-a

sses

smen

t to

ol

c)

Th

ey s

tan

dard

ized

tec

hn

ical

an

d a

dmin

istr

ativ

e pro

toco

ls a

nd a

nte

nat

al a

nd

neo

nat

al s

ervi

ces

wer

e re

nder

ed t

hro

ugh

pri

mar

y ca

re u

nit

s in

slu

m s

ettl

emen

ts.

4 A

nkur

Mah

aras

htr

a 2000, (

Pil

ot

pro

ject

) ,

1.

Buil

din

g c

apac

ity

of

com

mun

ity

level

mobi

lise

rs, tr

ain

ing

of t

rain

ers,

2.

Cre

atin

g a

pro

cess

to

regi

ster

pre

gnan

t w

omen

, gi

ve

care

an

d al

so r

ecord

cas

es o

f e

ach

new

born

. It

ga

ve h

igh

im

port

ance

to

mon

itori

ng

and

reco

rdin

g dea

ths

and s

till

bir

ths.

3.

Th

e pro

gram

als

o h

ad u

nder

take

n a

str

inge

nt

proce

ss o

f ev

aluat

ing

its

trai

nin

g co

mpon

ent

thro

ugh

re

vie

win

g de

live

rabl

es s

et f

or

the

com

mun

ity

mobi

lise

r

5 Y

ash

oda

S

elec

ted

dis

tric

ts o

f In

dia

2007

Yas

hoda

has

bee

n c

ruci

al i

n t

rain

ing

com

mun

ity

level

work

ers

for

fost

er c

are

of n

eon

tas.

6 S

ure

Sta

rt

Mum

bai :

Qual

ity

of

Car

e m

odel

Pri

or

to 2

012

Th

e m

ain

obj

ecti

ve

of

this

model

was

to

pro

vide

care

to p

regn

ant

moth

ers

and

new

born

s w

ith

th

e h

elp o

f av

aila

bil

ity,

acc

essi

bil

ity,

app

ropri

aten

ess,

an

d ac

cepta

bil

ity

of

publi

c an

d pri

vat

e h

ealt

h s

ervi

ces.

It

also

ai

med

at

esta

blis

hin

g n

ew a

nte

nat

al,

post

-nat

al c

lin

ics

and

com

mun

ity

cen

ters

.

Nav

i M

umba

i

Publi

c-P

riva

te P

artn

ersh

ip (

PP

P)

model

NG

O’s

lik

e D

ISH

A c

ame

fort

h f

or

ensu

rin

g co

mm

un

ity

part

icip

atio

n a

nd s

uper

vis

ion

for

impro

vin

g th

e qual

ity

of m

ater

nal

hea

lth

car

e se

rvic

es.

Th

e obj

ecti

ve

of

this

model

was

to

pro

vide

ser

vic

es li

ke A

NC

/PN

C c

lin

ics,

spec

ial

clin

ics

and

yoga

fa

cili

ties

for

pre

gnan

t w

omen

.

#U

nder

th

is m

ode

l, a

tota

l of

26,8

23 p

regn

ant

wom

en w

ere

exam

ined

in

131

cli

nic

s an

d 2

728 c

ases

wer

e se

nt

to s

peci

al c

lin

ics

P

un

e T

he

Con

ver

gen

ce

model

T

he

mai

n a

im o

f th

is m

ode

l w

as t

o c

reat

e aw

aren

ess

amon

gst

pre

gnan

t w

omen

abo

ut

HIV

an

d cr

eati

ng

a li

nk b

etw

een

In

tegr

ated

Coun

seli

ng

and

Tes

tin

g C

ente

rs a

nd e

stab

lish

ing

com

mit

tees

lik

e M

OM

S

(mon

itori

ng

of

mat

ern

al a

nd

new

born

sta

tus)

. It

has

wel

l in

corp

orat

ed m

oth

ers,

moth

er i

n l

aws,

lin

k w

ork

ers,

AW

Ws

to a

ct a

s a

pre

ssure

gro

up

on

fa

mil

ies

for

safe

r m

oth

er a

nd

new

born

car

e

Nag

pur

, E

mer

gen

cy

Hea

lth

Fun

ds

(EH

F)

E

HF i

s a

fin

anci

al m

ech

anis

m w

hic

h h

elps

in p

rovid

ing

hea

lth

ser

vice

s to

moth

ers

and

new

born

s at

af

ford

able

rat

es. T

o at

tain

th

ese

obje

ctiv

es, pre

pai

d c

ards

wer

e de

velo

ped

afte

r a

thoro

ugh

res

earc

h o

n t

he

nee

d as

sess

men

ts o

f th

e co

mm

un

ity

thro

ugh

soc

ial

mar

keti

ng

cam

pai

gns.

Nea

rly

1160

fam

ilie

s h

ave

rece

ived

ben

efit

un

der

this

EH

F m

odel

so f

ar a

nd

the

mon

ey h

as a

ppa

ren

tly

hel

ped i

n m

eeti

ng

the

cost

of

del

iver

y an

d tr

eatm

ent

of

new

born

s.

Mal

egao

n ,

Qual

ity

of

Car

e m

odel

U

nder

th

is m

odel

, ca

paci

ty b

uild

ing

of

mun

icip

al c

orp

orat

ion

sta

ff a

nd

par

tici

pati

on

& m

obil

izat

ion

of

com

mun

itie

s fo

r h

igh

qual

ity

hea

lth

ser

vice

s w

as t

arge

ted.

Mee

tin

gs o

n t

he

qual

ity

of c

are

in t

wo h

ealt

h p

ost

s h

avin

g an

all

ian

ce w

ith

th

e M

aleg

aon

Mun

icip

al

Corp

ora

tion

was

bei

ng

hel

d o

n a

reg

ular

bas

is

*th

e m

ajor

lim

itat

ion

of

this

pro

gram

was

a l

ack

of t

rain

ed m

anpow

er f

or

hea

lth

pro

visi

on

ing

and

sust

ain

ing

this

pro

cess

.

Sola

pur

Th

e m

ain

obj

ecti

ve

of

this

model

was

to

mob

iliz

e th

e co

mm

un

ity

of

Sola

pur

by

usi

ng

volu

nte

ers

to



116

Th

e V

olu

nte

eris

m

model

enh

ance

mat

ern

al a

nd n

eon

atal

hea

lth

ser

vic

es.

Th

e m

ode

l w

as a

suc

cess

an

d ac

cepte

d b

y th

e S

ola

pur

Mun

icip

al C

orp

ora

tion

as

it s

how

ed t

he

dev

elopm

ent

of

its

net

work

of

170

sel

f-h

elp g

roup

s (S

HG

s) w

ho h

eld a

dequat

e kn

ow

ledg

e ab

out

MN

H

care

N

ande

d

Th

e C

om

mun

ity

Bas

ed H

ealt

h

Insu

ran

ce

(CB

HI)

mode

l

In

troduct

ion

of

a se

rvic

e pro

vider

s’ n

etw

ork

an

d em

plo

yin

g co

mm

un

ity

bas

ed h

ealt

h i

nsu

ran

ce k

now

n a

s “A

pn

i S

ehat

”, w

as i

ntr

odu

ced i

n t

arge

ted s

lum

are

as o

f N

anded

cit

y.

Its

aim

was

to

star

t a

hea

lth

in

sura

nce

sch

eme

amon

g th

e poo

r urb

an s

lum

dw

elle

rs, w

ho

coul

d n

ot

mee

t th

e co

st o

f in

stit

uti

on

al d

eliv

erie

s an

d a

nte

nat

al c

are

chec

k-ups.

4.

Muth

ula

ksh

mi

Red

dy M

ater

nal

A

ssis

tan

ce

Sch

eme

Tam

il N

adu

Intr

oduce

d i

n

1989

Sta

te-f

un

ded

sch

eme

of

con

dit

ion

al c

ash

tra

nsf

er (

CC

T)

for

inst

ituti

on

al d

eliv

ery.

It

star

ted b

y off

erin

g a

cash

in

cen

tive

of

Rs.

500 t

o e

ach

pre

gnan

t w

om

an. T

he

sch

eme

was

in

itia

lly

run

by

the

soci

al w

elfa

re

dep

artm

ent

and s

ubse

quen

tly

han

ded o

ver

to

the

hea

lth

dep

artm

ent.

Th

is p

arti

cula

r am

oun

t w

as mea

nt

to

com

pen

sate

pre

gnan

t w

omen

for

wag

e lo

sses

duri

ng

preg

nan

cy.

Subse

que

ntl

y, t

he

amoun

t w

as i

ncr

ease

d to

Rs.

2000

and

then

to

Rs.

6000.

Th

is a

moun

t w

as r

ecen

tly

rais

ed t

o R

s. 1

2,000

per

pre

gnan

cy a

nd i

s pai

d

by

the

gove

rnm

ent

for

the

firs

t tw

o li

ve

birt

hs.

Apa

rt f

rom

wag

e lo

ss c

ompe

nsa

tion

, an

oth

er p

urp

ose

of

givi

ng

the

mon

ey i

s to

pro

vide

addit

ion

al n

utri

tion

to t

he

moth

er t

o p

reve

nt

anem

ia a

nd l

ow

-bir

th w

eigh

t bab

ies.

Th

is s

chem

e is

on

ly m

ean

t fo

r be

low

pov

erty

lin

e (B

PL

) fa

mil

ies.

5.

Th

ree

Sta

ff N

urse

M

odel

: 24x7

fun

ctio

nal

PH

Cs

Tam

il N

adu

Bet

wee

n 2

001

-2006

Th

is i

nn

ovat

ion

en

sure

s sa

fe d

eliv

ery

serv

ices

in

a P

HC

to

the

pre

gnan

t w

om

en, at

th

e on

set

of l

abor

pai

ns,

at

any

tim

e of

th

e day

or

nig

ht.

6.

Tec

hn

olo

gica

l in

novat

ion

s -

Iron

Sucr

ose

In

ject

ion

s

Tam

il N

adu

2009

Iron

suc

rose

is

an i

ron

hyd

roxi

de

sucr

ose

com

ple

x i

n w

ater

. It

is a

dm

inis

tere

d by

in

trav

enous

(IV

) in

ject

ion

or

infu

sion

. T

he

reco

mm

ende

d sc

hed

ule

is

to a

dmin

iste

r 100

mg

intr

aven

ous

ly o

ver

five

min

ute

s, o

nce

or

thri

ce w

eekly

, un

til

1,0

00 m

g h

as b

een

adm

inis

tere

d. T

he

rate

of

adm

inis

trat

ion

sh

oul

d n

ot

exce

ed 2

0 m

g pe

r m

inute

. A

tes

t do

se i

s al

so n

ot

requi

red a

nd

is a

t th

e ph

ysic

ian

’s d

iscr

etio

n.

Iron

su

crose

com

ple

x a

chie

ves

a re

lati

vely

sat

isfa

ctory

lev

el w

hen

use

d i

n s

ever

ely

anae

mic

iro

n d

efic

ien

t pre

gnan

t w

om

en.

7.

Non

-Pn

eum

atic

A

nti

-Sh

ock

G

arm

ent

(NA

SG

)

Tam

il N

adu

T

he

Gove

rnm

ent

of T

amil

Nad

u h

as i

nco

rpora

ted

the

use

of

NA

SG

in

to i

ts p

roto

cols

for

acti

ve

man

agem

ent

of t

hir

d st

age

of l

abou

r an

d r

outi

nel

y tr

ain

s st

aff

at a

ll l

evel

s fo

r it

s use

. N

AS

G i

s n

ow

als

o

bei

ng

kept

in a

ll 1

08 E

mer

gen

cy M

anag

emen

t an

d R

esea

rch

In

stit

ute

(E

MR

I) a

mbula

nce

s in

Tam

il N

adu.

8.

Rak

sha

Pro

ject

Bih

ar,

Raj

asth

an,

Tam

il N

adu

T

o i

mpl

emen

t th

e ‘C

on

tin

uum

of

Car

e’ p

hil

oso

ph

y, a

nd

wit

hin

th

at i

ntr

oduce

d th

e N

AS

G.

9.

Dev

elopm

ent

of

Em

bra

ce B

aby

War

mer

Ben

galu

ru,

Kar

nat

aka

2011

Th

e cu

rren

t fo

rm o

f th

e ba

by w

arm

er w

as a

lso b

ein

g use

d as

a t

ran

sport

dev

ice.

Her

e, i

f th

e L

BW

bab

y i

s re

quir

ed t

o be

tran

sport

ed i

ntr

a-h

osp

ital

or

inte

r-h

osp

ital

for

any

labora

tory

ch

ecks

or

refe

rral

s, t

he

bab

y w

arm

er m

igh

t be

use

d to

kee

p t

he

bab

y w

arm

. It

is

seen

to b

e a

suit

able

alt

ern

ativ

e, w

hic

h i

s ea

sy t

o u

se

and c

ost

eff

ecti

ve.

10.

Sm

ile

on

Wh

eel

Pro

gram

Ch

hat

tisg

arh

, D

elh

i M

ahar

ash

tra,

2006

Focu

sin

g on

wom

en a

nd

chil

dren

, S

mil

e-on

-Wh

eels

is

a n

atio

nal

mul

ti-c

entr

ic m

obil

e h

osp

ital

pro

gram

th

at p

rovid

es m

edic

al c

are

to r

ura

l an

d se

mir

ural

are

as a

nd

urban

slu

ms

wh

ere

gover

nm

enta

l h

ealt

hca

re

faci

liti

es a

re s

carc

e, n

on

exis

ten

t, o

r n

on

fun

ctio

nal

. P

rovi

de

both

pre

ven

tive

and c

ura

tive

ser

vice

s to

th

ose



117

Ori

ssa,

Tam

il

Nad

u,

Utt

arak

han

d,

Ah

med

abad

, H

yder

abad

, L

uck

now

in n

eed,

incl

udin

g outp

atie

nt,

an

ten

atal

, an

d post

nat

al s

ervi

ces,

iden

tifi

cati

on

of

diff

icult

pre

gna

nci

es a

nd

refe

rral

for

inst

ituti

on

al c

are,

im

mun

izat

ion

s fo

r m

oth

ers

and

chil

dre

n, m

inor

surg

ery,

blo

od p

ress

ure

exam

inat

ion

s, e

lect

roca

rdio

gram

s, f

irst

aid

, ir

on

foli

c ac

id t

able

ts, vit

amin

A p

roph

ylax

is a

nd

trea

tmen

t of

mal

nutr

itio

n.

11.

Inn

ovat

ive

serv

ice

deli

ver

y an

d r

isk

pooli

ng

by

NIC

E

Foun

dat

ion

, In

dia

An

dh

ra

Pra

des

h a

nd

Raj

asth

an

2002

It r

un

s tw

o h

ealt

h p

rogr

ams

in A

ndh

ra P

rades

h -

the

Sch

ool

new

born

hea

lth

care

Pla

n, th

e T

ribal

R

epro

duct

ive

New

born

hea

lth

pro

gram

an

d a

lso o

pera

tes

the

spec

iali

zed

Inst

itute

for

the

New

born

, H

yder

abad

, w

hic

h p

rovi

des

neo

-nat

al c

are

and c

on

duc

ts t

rain

ing

and r

esea

rch

. Th

e S

chool

new

born

h

ealt

hca

re P

lan

has

bee

n r

epli

cate

d i

n t

hre

e dis

tric

ts o

f R

ajas

than

, an

d fu

rth

er r

oll

out

is p

lan

ned

in

th

e st

ate.

12.

Inn

ovat

ive

serv

ice

deli

ver

y by

Lif

e S

pri

ng

Hosp

ital

s P

rivat

e L

imit

ed (

LH

PL

)

An

dh

ra P

rades

h,

Kar

nat

aka,

an

d

Mah

aras

htr

a

2005

Spec

iali

zed p

rovis

ion

of

mat

ern

al a

nd

chil

d se

rvic

es, in

cludin

g an

ten

atal

car

e, p

ost

nat

al c

are,

del

iver

ies,

fa

mil

y pla

nn

ing

serv

ices

, m

edic

al t

erm

inat

ion

of

pre

gnan

cy, ped

iatr

ic c

are

(in

cludi

ng

imm

un

izat

ion

),

dia

gnost

ics,

an

d p

har

mac

y se

rvic

es.

13.

Aro

gya

Rak

sha

Yoja

na

(AR

Y)

Kar

nat

aka

2005

Hea

lth

mic

ro-i

nsu

ran

ce s

chem

e pro

vidin

g af

ford

able

, h

igh

-qual

ity

hea

lth

care

for

the

un

der

serv

ed i

n r

ura

l an

d u

rban

are

as o

f th

e In

dian

sta

te o

f K

arn

atak

a, t

hro

ugh

an

acc

essi

ble

pro

vid

er n

etw

ork

of

pri

vate

h

osp

ital

s an

d cl

inic

s su

pport

ed b

y le

adin

g doc

tors

an

d su

rgeo

ns.

14.

Ch

iran

jeev

i Y

oja

na

(CY

)

Guja

rat

2005

Th

is i

s a

gove

rnm

ent

org

aniz

ed, qua

lity

dri

ven

vouc

her

pro

gram

con

trac

tin

g pri

vat

e obst

etri

cian

s an

d

gyn

ecolo

gist

s to

pro

vide

del

iver

y se

rvic

es t

o w

om

en w

ho

live

bel

ow

th

e pove

rty

lin

e, t

o r

educ

e th

e m

ater

nal

an

d n

ewborn

mort

alit

y ra

tes.



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