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Indian Journal of Community Medicine

Building Public Sector - NGO Partnerships for Urban RCH Services

Author(s): Siddharth

Vol. 29, No. 4 (2004-10 - 2004-12)

The quest for better livelihood opportunities has led to large-scale migration and the mushrooming of slums in several Indian cities. Unfortunately, a significant section of the urban poor do not have access to many of the benefits of urban dev elopment. Much of the challenge of delivering services to the marginalized groups lies in identifying them and effectively approaching them. So that limited resources are utilized well and programs ad dress real needs. There is a presence of the public sector as well as NGO's in urban areas. The growing requirement for health services for the urban poor, owing to rapid urban population growth, necessitates thinking about the collaborative approach of the public and non-profit sector for health services in urban areas.

Urban growth and urban poverty

Uncontrolled migration, natural growth of population and increased density is resulting in the unplanned development of cities. Between 1991-2001, the rural population in India grew by 18%, whereas the urban population showed a growth of 31 %. The UN projections (See Figure 1)2 indicate that urban growth is overtaking rural growth, a scenario that is likely to occur in all less developed countries.

Figure 1 2 Urban and Rural Population, Less Developed Countries, 1950 to 2025

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The 9th five year plan of India had estimated that urban population will be 605 - 618 million during 2021-20253. In the past, poverty was assumed to be mainly rural phenomena, owing to its relatively greater magnitude and visibility in comparison to the urban poverty which is largely camouflaged within its rich neighborhoods. Although the majority of people, in absolute numbers, still live in the rural areas, a large and rapidly growing segment of the population lives in cities (see Figure 24). Many of these do so in conditions of extreme poverty, without access to adequate shelter, other basic services and health services.

32% of the total Indian urban population (based on Census of India 2001) dwells in the 8 EAG§ states (UP, MP, Orissa, Bihar, Jharkhand, Chattisgarh, Rajasthan and Uttaranchal). An estimated 43% of the total urban poor of India live in these eight EAG states'. This clearly underscores the significance of focusing the urban health programming efforts in these eight states for optimum impact. (Fig. 3)

Percent decadal population growth by residence in India: 1901-2001

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Figure 3 Urban poverty in EAG states

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EAG (Empowered Action Group): In order to facilitate the preparation of area-specific programmes, with special emphasis on five states (MP UP, Orissa, Bihar and Rajasthan which later split and totaled to eight states) that have been lagging behind in containing population growth (contributes 45% of the population of the country) to manageable limits, the Government of India constituted an Empowered Action Group in the Ministry of Health and Family Welfare w.e.f. 20th March, 2001. Members of the group consist of Minister for Health and Family Welfare, Chairman, Minister of State for H&FW, Vice Chairman , Secretaries of these 8 states, Secretaries of different Central Govt. Departments, Advisor (Health) Planning Commission, other Central Govt. officials and Joint Secretary (P) D/O Family Welfare as its convener.

Reproductive Child health scenario among the urban poor in an EAG state (Madhya Pradesh) (Fig. 4)

Infant and child mortality rates reflect the level of socio economic development and quality of life. They are useful indicators for monitoring and evaluating health programs and policies.

It emerges from the re-analysis of Madhya Pradesh NFHS 2 data that neonatal mortality is significantly high among the urban poor (Urban low SLI(C) at 69.7 in comparison to the urban average of 44. Also, the infant mortality rate among the urban poor is 99.4 as against the urban average of 61.9.

Figure 4 - Child, Infant and Neonatal Mortality in Madhya Pradesh - NFHS 2 Re-analysis, EHP 2003

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The Child mortality rates (CMR) vary dramatically among the various categories of urban areas from 63.8 among the urban low SLI to the urban average of 26.5. The USMR is 131.0 amorig the urban poor as compared to the urban average of 82.9 which is a consequence of the family's compromised ability to recover from the existing limiting environment, paucity of time to seek health care as parents/ caretakers are daily wagers and often preoccupied with younger (often more vulnerable) children and low health awareness.

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.

The vaccination of children against six serious preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, polio and measles) has been a cornerstone of the child health care system in India. The reanalysis of NFHS 2 data, Madhya Pradesh reveals that only one-fifth of all children aged 12-23 months had received complete immunization (Fig 5). 43 percent of children from urban poor households had been vaccinated against measles by the age of 12 months as compared to the urban average coverage of 55 percent. Dropout and left out rates are far higher among urban poor households (36.1 and 25.2 respectively), in comparison to the urban average (26.1 and 17.4 respectively).

SLI: Standard of LIving Index (SLI) is an asset-based index developed by considering many socioeconomic parameters. The SLI is a summary household measure and is calculated by adding the scores for house type. toilet facility, source of lighting, main fuel for cooking. source of drinking water, separate room for cooking, ownership of house. ownership of agricultural land, ownership of irrigated land, ownership of livestock and ownership of durable goods. The index is calculated by summing the weights, which have been developed by International Institute of popula-tion Sciences, Mumbai for National Family Health SurveyII. These weights are based upon the relative significance of ownership of these items, rather than on a more formal analysis.

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Dropout rate is the proportion of eligible children who received DPT I but did not received DPT3 and left out rate is the proportion of eligible children did not receive any vaccination in first nine months of life

The reach and effectiveness of immunization services in urban slums are strained by a number of challenges. Disease transmission can be interrupted with a lower immunization coverage rate in less densely populated areas, whereas the coverage rate needs to be much higher in urban areas to have the same effect, owing to higher population density and the consequent ease of disease transmission.

There are multitude of healthcare service providers such as the Municipality, Ministry of Health, Private Sector, NGO's etc with ill defined roles and poor coordination. The range of health problems in urban areas demands integration of the poor as a priority into urban health planning and for RCH services. Comparison of urban rural disease incidence indicates a particular urban risk for measles. Urban sanitation and proximity to other people clearly affect transmission of disease. Heterogeneity of slum dwellers, lack of common meeting area, fewer extended family connections and more women engaged in work away from home effect flow of information about health services and facilities.

Public sector services for the urban poor in India

Public health management in India has in the past suffered from overly centralized and inflexible planning and control of resources; political interference in staff postings and transfer; a failure to integrate programs devoted to family welfare, nutrition and disease control and different levels of health care. Most programs have neglected approaches that would encourage the private sector to meet public sector objectives'. The health infrastructure in public sector for the urban poor is inadequate. Consider the example of Madhya Pradesh - the public sector share of total health expenditure is about 22%. This is about the lowest in the world. The lowest figure for any developed nation is for the U.S.. but even that is 44% - double the Madhva Pradesh figure9;

The scheme on Urban Family Welfare Centers (UFWCs) is functioning since 1950 to provide Family Welfare Serv ices in the urban areas through existing health institutions and new ly established clinics. Also, through the Urban Revamping Scheme (1983 ). Health Posts have been established to provide outreach services. primary health care, family welfare and MCH services in urban areas. particularly slums"'. Currently there are 1083 UFVv'Cs and 871 Health Posts, many running 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. There are 1562 Postpartum Centers (PP Centres, 1966) many closing down owing to discontinuation of central funding. Through India Population Project VIII (1993 to 2003) which covered 7 million slum population in 4 mega cities and 94 smaller towns in 4 states new health centers were established. Eg. In Bangalore city 55 health centers were established in the project adding to the existing 37. Nevertheless problems of delivering health services and improving reach continue as described in various scenarios below.

Scenario 1.-Areas Where Some Public Sector Primary RCH Services Exist is among the rural population (See figure 6).

  • 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 underserved slums

Figure 6- Low Utilization of and Access to Public Sector Services

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  • Weak- monitoring and tracking of coverage
  • Low focus on behavior change
  • Little emphasis focus on sustainability
  • NGO's active in several areas

Areas where Public Sector RCH services are Not Existing

  • 2nd tier hospitals are burdened with primary care
  • Large pockets of urban poor left out
  • Private Informal Providers are the main Resource
  • NGO's active in small areas

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The problem of inadequate infrastructure is compounded by low utilization of and access, both physical and social, to public sector services Source: Gujarat, State wide Multi indicator cluster survey (MICS), 1996

The findings of the MICS, 1996 of Gujarat State indicates that utilization of public sector facilities among slum dwellers is less than half of what it is among the rural population (See figure 6).

The limited utilization of health services is also reflected in the low contraceptive prevalence rate despite Government's large country wide family welfare program focusing on promotion of contraceptive usage. Pill/IUD, Condoms usage amongst the urban low SLI of Madhya Pradesh is 3.4% in comparison to 12.2% in urban high SLI (Fig 7)

Strengths and Potential of the Public Sector:

Public sector health system, despite its weaknesses, has several inherent strengths: a) there is the unequivocal mandate to reach the underprivileged; b) the system can operate on scale and hence has the potential to reach out to a large population and c) continued financial commitment to support urban health programs. The Public sector also retains the potential of bringing about a multi-disciplinary convergence of resources and programs from different Government Departments and various schemes, even though effectively implementing such intersectoral programs has remained a challenge.

Issues in urban RCH program:

Certain crosscutting issues that characterize public sector health services for the urban slum dwellers include a) weak inter-sectoral linkages with non-health sectors e.g. Dept. of Urban Development b) insufficient focus on hygiene and sanitation improvement and on other basic services c) limited experience with and capacity for effective partnerships in diverse settings and d) unmet challenge of developing context appropriate strategies resulting from the uniqueness of each city. In view of the potential strengths and the operational challenges of public sector urban health services, it is vital for Government programs to seek partnership with NGO's for strengthening different components of the program as is discussed later in the paper.

Experiences/ Lessons in government - NGO partnerships in Health programs

EC supported urban health program in Guwahati - Delivering Primary Health Care for Urban Poor through Partnership with Charitable Hospital (Marwari Maternity Hospital 11).

The Marwari Maternity Hospital has entered in an agreement with the Health and Family Welfare Department, Government of Assam, under the Sector Investment Programme for providing RCH services. The Government is committed to provide free supply of vaccine, contraceptives, RCH Kits, capital investment for hospital equipment, furniture. vehicle, expenditures on mobility of staff for sessions, contingencies, regular fund flow to the trust against achievements and supportive supervision. The Marwari maternity hospital provides first tier health services including outreach camps in slums. Simultaneously, it also functions as a second tier health facility.

However, the present success is dependent only on the commitment of few doctors. Community contacts need to be regularized for establishing faith in the community and improving utilization of services.

Tata Steel Family Initiative Foundation (TSFIF)

Tata Steel Family Initiative Foundation (TSFIF) has been providing health and family welfare services in and around the industrial city of .lamshedpur since the last 50 years. Starting as a corporate initiative in 1950. it is now functioning in partnership with the local and state government. The partnership is well understood by both the partners and each tries to contribute its best. Among the services provided by TSFIF are family planning services such as Insertion of Copper-T, distribution of Condoms and OCP, Sterilization services to both men and women, antenatal and postnatal checkups, immunization and enhancing health awareness. The partnership (though unwritten) involves provision of supplies of contraceptives, vaccines for immunization and IEC/BCC materials by the Government. TSF(F receives a payment of Rs 150/ per case. TSFIF provides its premise and staff for service provision as part of the collaboration. TSFIF for the Government sends a monthly report for tubectomy or vasectomy detailing the utilization of immunization, drugs and FP items. It also shares its monthly plan of out-reach activities on regular basis and take prior concurrence to conduct sterilization camps. TSFIF runs 21 clinics in and around Jamshedpur and operates a mobile clinic which provides additional services like Haemoglobin testing, Pregnancy testing, Urine examination and blood sugar test.

IIP VIII: Enhancing access and utilization to primary health care through NGO run facilities12.

Bangalore

NGO's have been involved in running UFWC under the city corporation with financial support from Government of India and government of Karnataka as well as without financial support. 55 health centers were established in the project in addition to the existing 37.

Andhra Pradesh 13

First tier facilities operated by NGO's. Link Volunteers and Women's Health Groups (WHGs) have been promoted through NGO's. Financial incentives to WHGs are generated from revolving funds.

Delhi

First tier facility and maternity services are operated by NGO's like Mamta, ASHA amongst others.

Since May 2003, Aparna trust is managing the infrastructure of Municipal Corporation of Delhi for delivering primary health care services to a slum population of 50,000 in Molarbandh. User fees and other funds generated by the NGO are used to sustain health services. Other equipment for XRay, Sonography, ECG, and laboratory are also managed by the NGO through funds generated from other sources.

These programming efforts indicate that Govt./NGO partnership is helpful in institutional capacity building of NGO's and community groups and improving health coverage among slums. The financial contribution from community members can be utilized for improving water and sanitation situation. Through WHGs and Link Volunteers programmers can reach the marginalized groups. Flexible contract (developed through participatory planning workshops) and regular meetings help in solving problems, ensuring better management. Complementary and clearly defined roles of partners prevent a sense of competition as well as duplication of efforts.

Indore - Ward coordination model for improving utilization of immunization services

A pilot project at the ward level (smallest administrative unit for planning) is being implemented through coordinated efforts of the municipal corporation, health department, ICDS, DUDA, local leaders, an NGO and a community based organization to provide immunization services in 24 slums. The presence of children and women in the camp is used as an opportune moment for distribution of ORS sachets, contraceptives and chlorine tablets by the service providers. The ward committee ensures provision of services beyond immunization camps such as organizing tubectomy camps, issuing birth certificates, conducting beneficiary surveys in the ward and developing resource maps of the ward. A recent assessment revealed the results of this model impressive enough for replication in other wards of Indore.

What value can NGO's add to Urban RCH programs?

Contribution 1 - Identification and mapping vulnerable slums

NGO's have the ability to locate and plot on a map all slums, recognized and non recognized and vulnerable pockets including unlisted clusters. hidden and marginalized pockets.

E.g. NGO's helped identify hidden urban clusters during Pulse Polio Campaigns; CINI ASHA & MUSKAAN mapped slums in West Bengal and Uttaranchal respectively"

Contribution 2 - Improve access to sanitation and other basic services

NGO's can facilitate sustainable community managed sanitation programs utilizing resources from National schemes such as Nirmal BharatAbhiyan. They can forge linkages to derive benefits from poverty alleviation schemes such as National Slum Development Program (NSDP), Swarna Jayanti Sahari Rojgar Yojana (SJSRY), Development of Women and Children in Urban Areas (DWCUA) and other Ministry of Urban Development programs. NGO's can also advocate for the basic needs of the underserved slums at the city level.

E.g. The community toilet construction program in Pune city involving the municipal corporation and eight NGO's, Shelter associates being one of them15. In Mumbai SPARC was involved in a similar toilet construction program in collaboration with the Municipal Corporation.

Contribution 3 - Enhance demand and utilization of services, building capacities

The involvement of NGO's enables development of context appropriate communication activities, capacity building of community link volunteers for counseling. mobilizing slum communities for effective outreach activities. linkage to health services and promotion of community institutions e.g. SHG. Concomitantly, the quality of existing primary care services and of less qualified providers can be monitored and assured.

E.g. in IPP VIII in A.P. and Bangalore, NGO's helped improve demand for services. SAATH in Ahmadabad have been involved in the Slum Networking Project where its primarily involved in community mobilization and capacity building of CBOs .

Sanchetna - An Ahmedabad based voluntary organization implements a community RCH program targeting urban poor which aims at generating awareness about the situation. increased participation of the people, organized community action and attaining self reliance. Women of the community trained as community health workers (CHWs) impart health education; both clinic and outreach services are provided. The two clinics treat general diseases and provide primary health care. It operates on alternate days for 4 hours per center: 4 local CHW assist the program officer and the doctor. The team interacts with the community at various levels, and encourages them to seek prompt medical attention. In 2000, a total of 407 clinic days were organized and 3,942 patients were treated.

Contribution 4 - Manage primary level RCH facility independently

Where NGO capacity is available and public sector is absent, NGO's/ Charitable hospitals are managing first tier facilities and provide services to urban poor.

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

Contribution 5 - Building effective partnerships and convergence

NGO's can work towards 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 club etc.

E.g. Counterpart International (Cl) - Ahmedabad Municipal Corporation (AMC) partnership. EHP Indore Ward Coordination Model are examples of NGO's. Sanchetna and Bal Niketan Sangh respectively playing vital roles in maintaining these partnerships for provision of quality immunization services to the urban poor. These NGO's support the public sector providers in identifying high risk areas, planning immunization outreach activities. ensuring quality of services and reducing missed opportunities for immunization. Janagraha or Team Spirit, is a public-private initiative in the city of Bangalore through which people participate in urban planning. they even facilitate making the Bangalore City Corporation's budget. The plan is to get resident associations and local corporate and civic authorities to identify the city's key issues and have them implemented within budget.19

The Streehitkarani (Mumbai based NGO) program has succeeded in bringing together a pool of existing resources. This has enabled them to provide a more comprehensive health and social welfare program than they would have been able to if they had worked as a single agency. Municipal and State Govt. authorities provide vaccines and family planning supplies, medical agencies and individual private doctors provide treatment services and social agencies provide related support to the program 20 .

Contribution 6 - Innovate and develop models for replication and scale up.

There is still a lot to learn about Urban Health Programming: NGO's can serve as learning centers. They can conduct operations research to provide evidence for larger buy-in. Study tours, learning lessons, building a critical mass of essential skills are needed to create a snowball effect.

E.g. Institute of Health Management (IHMP), Pachod has initiated an urban health project in 27 slums of Pune with the objective of developing a model reproductive and child health program through a target free approach.21

Established in 1979, Parivar Seva Sansthan provides RCH services.. diagnostic screening and general health care for common diseases, social marketing of contraceptives and development of innovative projects such as the Tripartite project of family welfare activities in industrial sector, Soap opera Project (TV serial and family quiz on socially relevant issues) etc22 .

The community health worker model is being successfully implemented by Apnalaya (Aarogya Sevikas) and Streehitkarini (Child health worker) both in Mumbai. The experience demonstrated that community level health workers are an effective strategy for promoting appropriate health behaviors and identifying the health needs of women and children in the slums.

Contribution 7 - Capacity building, institutional strengthening and sustainability

NGO's serve as trainers on a variety of topics e.g. urban vulnerability, behavior change communication and counseling. They can provide on the job guidance to community-based organizations and link volunteers and train private informal providers.

They can foster sustainable programming via:

  • 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

Eg. 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 and build capacity of CBOs to effectively manage slum development activities.

The NGO-CBO partnership model in Indore supported by USAID - EHP urban health program works towards sustaining the service coverage and behavior promotion efforts through persistent and needs based capacity building of the community based organizations by the five NGO partners23.

Contribution 8 - Strengthening and developing urban HMIS

HMIS should focus on an appropriate unit for monitoring and promote denominator based monitoring.

E.g. USAID-EHP Urban health program in Indore, NGO's have invented a technique of "Family Chit" distribution prior to outreach camp to reach out to all eligible children and track immunization coverage.

CINI ASHA initiated an urban health program in September 1999 in 37 slums spread across 13 wards to cover about 2,40,000 people in Kolkatta. The program aims to provide RCH services to the target communities through health posts and establishment of an effective network of private medical practitioners who provide referral services at a subsidized cost to slum population. The program invented a monitoring mechanism named ELCO (Eligible Couple) register, wherein family details, family planning status, status of pregnancy, type of delivery. weight of the child, details of antenatal checkup etc are recorded and updated by the Swasthya Sevikas (I per 10,000 population) and Community Health Volunteers ( 1 per 1,000 population).

Contribution 9 - Develop the field of urban health as a professional area

NGO's can emerge as UH Programming and Resource Centers on a regional basis, support state governments in planning and monitoring Urban RCH programs, document Urban Health Program experiences and promote crosslearning, 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

Conclusion and Recommendations

The efforts and resources within urban RCH need to prioritize the EAG states where the need is highest. A well coordinated effort involving both public sector and the NGO's can help address a number of crucial issues for effective urban health programming. NGO's can play an important role in identifying the neediest hidden pockets. Available resources can be better targeted to ensure benefit to the most vulnerable through a sensitive vulnerability assessment of slums. Innovative techniques or models of delivering health services develop which are context appropriate and involve the multitude or urban health stakeholders to avoid duplication of efforts. These can be analyzed for effectiveness and adapted to similar settings. NGO's can be effective community mobilizers to evoke community's awareness and thereby demand for quality health services. The involvement of NGO's and the community per se is critical to sustainability of any program. In view of the contributions that NGO's can make to Urban Health Programming, and the inherent strengths and operational challenges of the Public Sector, Govt.- NGO partnership is vital for strengthening RCH services for underserved urban populations. Carried out with devotion, purpose and commitment, such partnerships will be able to actualize the aphorism: "The whole is greater than the sum of its parts".

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Acknowledgement: The author is grateful to Arti Bhanot and Pradeep Patra for assisting with preparation of this manuscript and research, without whose timely, able contribution, this piece would not have been possible.

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