environmental health project building public sector - ngo partnerships for urban rch symposium on...

ENVIRONMENTAL HEALTH PROJECT

Building Public Sector - NGO Partnerships for Urban RCH

Symposium on Urban RCH31st Annual National Conference of Indian

Association of Preventive & Social MedicineFebruary 29, 2004

Dr Siddharth

Country Representative, USAID-EHP Urban Health Program


Presentation Outline

Urban Growth and Urban Poverty

Reproductive Child Health Scenario among the Urban Poor

Public Sector Services for the Urban Poor Existing Infrastructure and programs: UFWCs, Health Posts, IPP VIII etc Issues around present RCH services for urban slums

Experiences/ Lessons in Government-NGO Partnerships in IPP VIII and Other Programs

What Value can NGOs Contribute to Urban RCH Programs?

Suggestions and Recommendations


Urban Population Growth


Especially in Their Smaller Cities


Urban Growth in India

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

-10

0

10

20

30

40

50

Decades

% g

row

th

Urban Rural Total


Urban Poverty in EAG States

43%

57%

Urban Poor Popualtion in EAG States

Urban Poor Popualtion in Rest of India

Urban Population in EAG States

32%

68%

Urban Population of EAG States

Urban Popualtion in Rest of India

Where Should efforts focus?


Take Home Messages

• Virtually all growth will be urban in the future

• Growth is fastest in concentrations of urban poor – e.g. slums

(2-3-4-5 syndrome)

• Most growth and population will be in small and medium size cities

• Mega-cities will continue to grow – and have importance beyond their proportion of the urban population

• Urban growth in India has been exponential over the last few decades

• In India, 43% of urban poor reside in the 8 EAG States


Reproductive and Child Health Conditions among the Urban Poor


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

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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BCG DPT3 OPV3 Measles All VitaminA

Urban Slums

Rural Areas

Coverage


0

20

40

60

80

100

120

Neonatal mortality Infant mortality Child mortality

Urban Low Urban Medium Urban High Urban Average Rural Average

Child, Infant and Neonatal Mortality in M.P.


0

10

20

30

40

50

60

70

80

90

100

Underw eight for age – Below –2 SD Underw eight for age – Below –3 SD

Anthropometric indicator

Per

cent

age

Urban Low Urban Medium Urban High

Urban Average Rural Average

Childhood Under-nutrition in Urban M.P.

NFHS 2 Re-analysis, EHP 2003


Immunization Coverage by Age 1 among Children 12-23 months

Madhya Pradesh – NFHS 2 Re-analysis, EHP 2003

0

10

20

30

40

50

60

70

80

Completelyimmunized

Received measlesimmunization

left outs from UIP drop outs from UIP

Perc

enta

ge

Urban Low Urban Medium Urban High



0

10

20

30

40

50

60

70

Any Method Female Sterilization Pill/IUD/Condom

Urban Low SLI Urban Medium SLI Urban High SLI


Contraceptive Prevalence in Urban M.P.

NFHS 2 Re-analysis, EHP 2003


0

10

20

30

40

50

60

70

80

90

100

Deliveries at home Deliveries attended by a heathprofessional at home or at a health

facility

Per

cen

tag

e

Urban Low Urban Medium Urban High Urban Average Rural Average

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


Take Home Messages

• Urban averages mask sharp disparities between the rich and poor in urban settings

• By many health indicators, urban poor populations are comparable to nearby rural populations – or worse in many cases


Issues with Public Sector Urban Health Services


Urban Health Infrastructure in the Public Sector

UFWCs (1950), Health Posts (under Urban Revamping Sceme1983) :

• 1083 UFWCs & 871 Health Posts, many run from hospitals, not proximal to slums

• With the total urban population of 290 million, (with 1954 UFWCs & HPs), this works out to one UFWC/HP per 148,413 Urban population

PP Centres(1966): 1562 (many closed owing to discontinuation of Central funding)

IPP VIII (1993 to 2003) covered 7 million slum population in 4 mega cities and 94 smaller towns in 4 states


• Inadequate physical and social access

• Low demand for services among slum dwellers

and weak community linkages

• Poor quality (timing, attitude, atmosphere) of

services

• Insufficient reach to the under-served slums

• Weak monitoring and tracking of coverage

• Low focus on behavior change

• Little emphasis focus on sustainability

• NGOs active in several areas.

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


• 2nd tier hospitals are burdened with primary care

• Large pockets of urban poor left out• Private informal providers are the major

resource• NGOs active in small areas

Scenario 2: Areas where Public Sector RCH services are Not Existing


Low Utilization of and Access to Public Sector Services

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

Health workers

2.8%

Others4.4%

Private doctors66.7%

Gov. doctors26.1%

Others1.0%

Chemists4.6%

Government doctors12.3%

Private doctors82.1%

Urban Slums Rural Areas


Cross-cutting Issues

• Weak inter-sectoral linkages with non-health sectors e.g. Dept. of Urban Development

• Insufficient focus on hygiene & sanitation improvement and on other basic services

• Limited experience with and capacity for effective partnerships in diverse settings

• Every city/town is different, hence context appropriate strategies remain vital


Experiences in Govt. –NGO Partnerships for Urban RCH


Some Examples of Government- NGO partnership for Urban Health

IPP VIII - A.P./Bangalore: • Link Volunteers & Women's Health Groups promoted

through NGO • Financial incentives to WHGs through revolving funds.• Emphasis on empowering women (NGO supported)• Behaviour counseling (child health, nutrition and

hygiene)• First tier facilities operated by NGOs

IPP VIII - Delhi• First tier facility and maternity services operated by

NGOs

EC Supported UH Program in Guwahati• First and 2nd tier facilities operated by Charitable

Hospital


Learnings

• Govt.-NGO partnership helped in institutional capacity building of NGOs and community groups and improving health coverage among slums.

• Financial contribution from community members helped improve sanitation, wells

• Reach to marginalized groups improved through a) WHGs and b) Link Volunteers.

• Flexible contract (developed through participatory planning workshops) and regular meetings helped in solving problems ensuring better management.

• Complementary and clearly defined roles of partners prevent sense of competition.

• Effective program strategies were replicated


What Value Can NGOs Add to Urban RCH Programming?


Contribution # 1

Identifying, Mapping Underserved Urban Populations

• Locating and mapping all slums and vulnerable pockets including unlisted slums, hidden and marginalized pockets.

• Providing services/linkage to seasonal urban migrants

E.g. NGOs helped identify hidden urban clusters during Pulse Polio Campaigns, CINI ASHA & MUSKAAN mapped slums in Uttaranchal and West Bengal


Marginalized Social Groups Constitute A Large Proportion Of Urban Poor

Background Characteristics of Urban Uttar Pradesh - NFHS II

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Urban Low SLI Urban MediumSLI

Urban High SLI Urban Average Rural Average

Scheduled Caste Scheduled Tribe Other Backward Classes Others


Marginalized Social Groups Constitute A Large Proportion Of Urban Poor

Background Characteristics of Urban Delhi – NFHS II

0%

20%

40%

60%

80%

100%

UrbanLow SLI

UrbanMedium

SLI

UrbanHigh SLI

UrbanAverage

RuralAverage

Scheduled Caste Scheduled Tribe

Other Backward Classes Others


Contribution # 2 Improve Access to Sanitation and Other Basic

Services

• NGOs can facilitate sustainable community managed sanitation programs utilizing resources from National schemes such as Nirmal Bharat Abhiyan

• Forge linkages with NSDP, SJSRY, DWCUA and other Ministry of Urban Development programs

• Can lend an advocacy voice to the basic needs of the underserved slums at the city level

E.g. SPARC, Apnalaya & other NGOs have facilitated sanitation programs in Mumbai, Pune


Contribution # 3 Enhance Demand & Utilization of Services, Build Community

Capacity

• Context appropriate communication activities • Capacity building of community link volunteers for

counseling, linkage to health services• Mobilise slum communities for effective outreach

activities• Promote community institutions e.g. NHG, SHG• Quality Assurance of existing primary care services

and of less qualified providers

E.g. In IPP VIII in A.P. and Bangalore, NGOs helped improve demand for services, SAATH and SEWA in Ahmedabad.


Contribution # 4Wholly Manage Primary Level RCH Facilities

• Where capacity is available and public sector is absent, NGOs/Charitable hospitals can manage First tier facilities

E.g. Govt. of Uttaranchal has proposed this model in Haridwar, FPAI manages one UHC in Bhopal, Marwari Charitable Hospital in Guwahati


Contribution # 5

Effective Partnerships and Convergence

• Partnership building and maintenance. Facilitate coordination of meetings, help record minutes

• Community-Provider (ANM) linkage, support and encourage ANMs

• Linkage with other Departments, ULB, Schools, Traders Associations, Lions etc.

E.g. Counterpart International-AMC partnership, EHP Indore Ward Coordination Model, Janagraha - Bangalore


Contribution #6

Innovate & Develop Models for Replication & Scale-up

• Still a lot to learn about Urban Health Programming: NGOs can serve as learning centres

• They can conduct operations research to provide evidence for larger buy-in

• Study tours, learning lessons, building a critical mass of essential skills needed to create a snowball effect

E.g.: Apnalaya in Mumbai: Arogya Sevikas


Contribution # 7

Capacity Building, Institutional Strengthening and Sustainability

• Serve as trainers on a variety of topics e.g. urban vulnerability, behaviour change communication and counseling

• Strengthen community-based organizations and link volunteers

• Train Private informal providers • Foster Sustainable Programming

Promoting ownership among partners of program objective and processes

Facilitate Health Funds at various through available sources including community contribution

• Encourage the humanistic paradigm in programming and minimize exclusion and inequity

E.g. VHAI and FPAI have served as trainers in many states; Slum Networking Project in Ahmedabad through SEWA and SAATH focus on institutional capacity at slum level


Contribution # 8

Strengthening/Developing Urban HMIS

• Focus on an appropriate unit for monitoring• Promote denominator based monitoring

• Innovations such as “Family Chit” prior to outreach

camp

Murphy’s Law: “One single accurate measurement is infinitely superior to 1000 intelligent opinions”.


Contribution # 9

Develop the Field of Urban Health as a Professional Field

• Emerge as UH Programming and Resource Centres on a Regional basis

• Support State Govts in Planning and Monitoring Urban RCH programs

• Document Urban Health Program experiences and promote cross-learning

• Compile and Disseminate Urban Health Literature including data

E.g. All India Institute of Local Self Governance for Urban Development issues, SPARC for Urban Sanitation issues


Urban Health Program/Policy Long Lever of :

a) Commitmentb) Knowledgec) Experienced) Motivatione) Proximity to problems

NGOs

Looking Forward To


Suggestions and Recommendations


Capacity Building at State and City Level Required

• Capacity to select and identify the right partners: apply appropriate selection criteria

• Capacity to execute and monitor partnerships/agreements

• Capacity to foster and maintain external networks

• Enhance orientation to focusing on the underprivileged


Innovation &Development

of Models

EAG States - a priority

Capacity for Planning,

Management & MonitoringSustainability:

Institutional,Programmatic,

Financial

Reach the Un-reached

Quality &Demand

Multi-StakeholderCoordination

Summary and Key Messages

Govt. NGO

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