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Indian Journal of Community Medicine

Challenges and Options for the Delivery of Primary Health Care in Disadvantaged Urban Areas

Author(s): Sherin Varkey

Vol. 28, No. 2 (2003-04 - 2003-06)

p>Postgraduate student, Deptt, of Community Medicine, MGIMS, Sevagram (Maharashtra)

Introduction:

"Urban areas in India can still be described as -a cultural unity amidst diversity - a bundle of contradictions held together by strong but invisible threads".

Jawaharlal Nehru

Over the last 55 years since independence this Nehruvian view has gradually being reduced to mere rheotoric. The invisible threads no longer seem to be capable of retaining the ever-growing contradictions fuelled by a burgeoning mass of human diversity. India is rapidly transitioning into a nation of cities and according to UN projections, urban India is expected to race ahead of rural India in terms of population by 2025. The new millennium has presented India with an increasingly grim challenge of providing primary health care to millions of disadvantaged urban residents, failing which the health gains achieved till date may soon recede into oblivion.

Situational Analysis:

Urban growth is influenced by both the "pull" forces of economic opportunities in cities and the "push" factors of rural poverty and unempolyment. (Harpham, 1988). According to the Census of India 2001, in the last decade, as India grew at an average annual growth of 2%, urban India grew at 3%, mega cities at 4% and slum population rose by 5%. Though urbanization is a sign of economic progress, the resources needed to meet the increasing demand for facilities and public services in urban areas are lost to potential productive investment elsewhere in the economy (Lob Levyt, 1990). The transfer of rural poverty to urban environment has led to mushrooming of slums in several Indian cities, which are bereft of basic infrastructure, public services, access to health care, water supply and sanitation.

The complexity of the urban environment and the social strata therein presents a tough challenge to the sustainability and relevance of health and development programmes. Recent studies have shown that the health of the urban poor is as bad or as worse than that of their rural counterparts.

Table I: Determinants of child health among urban poor in India.

  Urban Poorest Rural Poorest
IMR 121.2 108.9
U5MR 143.6 155.0
Children stunted % 69.3 55.2
Copmplelte Immunization % 16.6 17.1
Home Deliveries 80.5 93.5

(Source: Socio economic differences in HNP, Gwatkin et al, World Bank, 2000)

Although the health services delivery system is concentrated in the urban setting this area presents great resistance to any fundamental changes in Primary Health Care. There is also a lack of understanding of Primary Health Care on the part of medical professionals and hospitals. The actual implementation of Primary Health Care in urban areas is wrought with special problems:

  • The heterogenity of urban populations
  • Voluntary efforts are less common
  • A multiplicity of agencies are involved
  • It is the poorer sections of the urban population that do not have access to primary health care

Major health problems:

Health problems in the urban poor are practically determined by 3 main groups of factors which act synergistically:

  • Direct problems of poverty: unemployment, low income, limited education, inadequate diet, malnutrition, lack of breast feeding, etc.
  • Environmental problems: leadingdiseases, accidents, etc. to infectious
  • Psychosocial problems: stress alienation, instability and insecurity leading to depression, smoking, drug addiction, alcoholism, abandoned children, etc. (Harpham, 1988)

HIV/AIDS is also emerging as an important problem that is fast spreading and is a potential threat to public health, not only by its biological but also its economic and social consequences (Nabarro, 1989).

Urban health care delivery system:

The existing model of health infrastructure is an expansion of that in the rural areas viz. control of communicable diseases, maternal and child health and Family Planning. By its very design it is biased in favour of public sector employees, workers in the organized sector and persons in the high-income categories. In the urban settings, secondary and tertiary care is provided by a multiplicity of agencies viz. the Medical College hospitals, voluntary and private hospitals and almost 80% of the available private practitioners in the country. The health infrastructure in the public sector includes the: State Governments Primary Health Care centres: PHUs established on the rural PHC pattern, industrial hospitals, dispensaries and hospitals as part of the Employees State Insurance Scheme (ESIS) particularly in larger cities and towns with a large industrial sector and the Urban Health and Family Welfare Centers (UHFWCs) run by the city municipal corporations. All these except the latter provide essentially curative services and do not have outreach services for slum populations. (Sahni and Kshirsagar 1993).

Priorities for intervention in urban health:

The delivery of primary health care in urban areas is intrinsically linked with increased self-reliance among communities especially the poorer sections of slum populations in selecting priorities, their involvement in multisectoral interventions and greater accessibility to better quality health services. Primary health care in urban as well as rural areas is an appropriate strategy for achieving universal coverage on an equitable basis. The case for primary health care in urban settings is overwhelming, but strong advocacy is still required to explain it and gain acceptance for it.

Identifying urban health needs:

The state of health of the urban poor vis-a-vis the rich clearly underlines the significance of targetting resources and efforts where they are most required. This is all the more crucial in urban programming because: (a) averages statistics (which is the common form of data available) reflects a skewed image of the health of the urban poor and (b) poor urban dwellers very often reside in unrecognized pockets and hence are missed by development programmes. More innovative and systematic methods are required for the identification and understanding of urban poor populations in order to target and gauge the effectiveness of interventions. The use of qualitative approaches actively involving slum communities have been found useful and have included mapping and other participatory methods for need assessment as well as the involvement of neighbourhood groups and other community structures.

Identifying the vulnerable groups:

The greatest difficulty in planning urban health programmes is ensuring that the benefits of programmes reach the most vulnerable groups. These include street children, rag pickers, migrant labourers, women, the disabled, unemployed, homeless, night soil carriers, commercial sex workers and child labourers. Certain NGOs have done pioneering work in reaching the un-reached in urban areas. Mobile clinics and community health volunteers could be utilized for achieving the same. Child welfare centres and the Juvenile Service Bureaus run by the department of Women and Child Welfare exist in certain large cities. However, the needs for outreach family and community services for prevention and rehabilitation of health problems arising out of the complex psychosocial environment, e.g. drug abuse, alcoholism, prostitution also need to be provided for.

Improving health infrastructure:

Substantial restructuring in the organization of the public health care delivery system and improvement in its quality are necessary to make it more sensitive to the urban poor. National Health Policy-2002 (NHP-2002) envisages the setting up of an organized urban primary health care structure. Since the physical features of urban settings are different from those in rural areas, the policy envisages the adoption of appropriate population norms for the urban public health infrastructure. The structure conceived under NHP-2002 is a two-tiered one: the primary centre is seen as the first-tier, covering a population of one lakh, with a dispensary providing OPD facility and essential drugs, to enable access to all the national health programmes; and a second tier of the urban health organization at the level of the government general hospital, where referral is made from the primary centre. The policy envisages that the funding for the urban primary health system will be jointly borne by the local self-government institutions, state and central governments. The policy also envisages the establishment of fully equipped 'hub-spoke' trauma care networks in large urban agglomerations to reduce accident mortality.

Urban health as a part of the Reproductive and Child Health Programme:

The RCH programme in Phase-II has the improvement of basic services among the urban poor as an important component, which includes:

  • Creation of a primary and secondary level health care network in urban areas in consonance with the NHP 2002 and NPP 2000.
  • Strengthening for referral linkages
  • Use of lessons learnt from IPP 8 and Urban RCH
  • Use of resident community volunteers engaged in SJSRY as link volunteers.
  • Use of private practitioners on contract.
  • Use of NGOs for service delivery
  • Behaviour change strategy through intensive IPC (Interpersonal communication)

Mental health in urban setting:

Application of available knowledge for the promotion of mental health, prevention of mental disorders and care of mentally ill persons is required for combating the mental health problems in urban settings and can be achieved by:

  • Sehsitization of planners, administrators, architects, welfare personnel and the general public to the increased risk faced by urban populations to mental health problems.
  • Organisation of mental health services, which are accessible, acceptable and affordable beyond the hospital infrastructure.
  • Increasing community level emotional support, at the level of small communities as well as involvement of people in decision-making in development project programmes.
  • Provision of community based services for high-risk population groups namely street children, migrant labourers and slum population.
  • Strengthening of family functioning through education and provision of opportunities for optimal functioning of the family.

Health financing in urban areas:

The persistent poverty and disease syndromes have pushed the families of the unorganized sector workers into debts to meet their day-to-day contingencies, which certainly includes health care. The burden of treatment is unduly large for urban poor when seeking in-patient care (Visaria and Cumber, 1994, Cumber 1997). It is estimated that only a small fraction (less than 9%) of the Indian work force is covered by some form of health insurance through Central Government Health Scheme (CGHS), Employees State Insurance Scheme (ESIS) and Mediclaim and majority of the covered population belongs to the organized sector (Gumber 1998). There is an urgent need to invest more in urban health as well as to subsidize in-patient care and provide health insurance at affordable premiums.

Convergence:

The strengthening of convergence processes within each city, district and state could lead to better utilization of limited resources. However, this also requires the strengthening of municipal bodies, formulation of area and city plans, capacity building and strengthening of management and accountability systems with a more realistic allocation of resources. In the urban context the multisectoral approach including water and sanitation, education, nutrition, housing, legal rights and income generation programmes become especially important. Certain efforts towards the co-ordination and convergence of health services and these programmes to reach the urban poor at the community level have been successfully demonstrated and have led to some visible changes. Their ongoing strengthening process and sustainability remains a challenge.

Proposed Model For Urban Health:
Conceptual Framework:

The suggested model has been conceptualized based on the experience of Department of Community Medicine, MGIMS, Sevagram in managing an Urban Health Centre in Wardha District. This Urban Health Centre works in collaboration with the Gandhi Memorial- Leprosy Foundation, Wardha and is staffed by an Officer In-charge, one Medical Officer, one Intern, one ANM, one social worker and attendants. The main objectives of the centre are to provide primary health care to needy and poor population of sub-urban and urban slums, to impart training to medical students and to conduct community based research on urban health. The centre also caters to the migrant labourers from Chattisgarh, Madhya Pradesh and UttarPradesh,who workin the brick kilns of Wardha. Preliminary studies in the catchment area of the centre have shown that the people are satisfied with the available services. The present model is an amplification of the Urban Health Centre approach, but involves many stakeholders in a collaborative process.

The model will have the following objectives:

  • To increase coverage of services and adoption of key health practicesfor maternal and child health.
  • To improve capacity of the stakeholders involved for primary health care in urban areas.
  • To facilitate the optimum utilization of resources for urban health.

Programme strategy:

Themodel functions with the Urban Health Forum in a pivotal role. This forum will have representation from each of the stakeholders at the district level as well as the ward level committees. The stakeholders envisaged are:

  • Deptt, of Public Health - principal public sector providers of preventive and curative health services.
  • Municipal Corporation - responsible for water supply, sanitation, drainageand overall governance issues.
  • Deptt, of Women and Child Development - provides nutritional supplements (for pregnant and lactating women and children) and health and nutrition education at the community level.
  • Employees State Insurance Services (ESI) - these services have a good presenceinsome parts ofthe city and cater to a good proportion of slum population.
  • Charitable hospitals -provide preventive and curative services inseveral areas of the city.
  • Medical Colleges -for referral services and tertiary care. The departments of Community Medicine could provide the necessary technical guidance.
  • NGOs, which represent organized civil society and engage in efforts at community development and strengthening linkages with development schemes of the Government.
  • CBOs that are the organized face of the community and may have a large presence in slums.
  • Private providers - serving a large proportion of urban slum dwellers;
  • Corporate sector

The Ward Level Committees will be formed by the stakeholders for urban health at the ward level like, local leaders, public and private health providers, community volunteers. The Committee will generate the Urban Health Fund by collections from the community and contributions from public authorities and corporate bodies. The committee will co-ordinate and review all the activities pertaining to urban health. It should be aided in this process by technical inputs from the district health system as well as the Medical College. The committee will engage in situational analysis of the area, which will include health vulnerability assessment and mapping of slums using Participatory Learning and Action (PLA) tools and will then plan accordingly. If possible, the committee can also appoint a volunteer as a Community Health Worker, who will be responsible for the day-to-day activities of the committee. A regular feedback system from the Ward level Committee to the Urban Health Forum can also be put in place.

Lessons from Successful Models:

A number of successful models for urban health delivery have emerged. The chief characteristic of all the models is that they have evolved and imbibed during their development community participation as one of their founding principles. For example in 1979, in Jardin Nordeste, Sao Paulo, Brazil, deaths of children due to measles and other diseases led to the development of the health commission consisting of people from the neighbourhood who, after one year of lobbying, had a health centre installed on rented premises.

The USAID-EHP India Urban Health Programme operates in a situation of numerous stakeholders in Indore city and has demonstrated how a consultative approach focussing on learning from stakeholders and collectively identifying programme directions can evolve a plan more responsive to the presenting challenge. Though various partnership models involving NGOs/CBOs, service providers municipal authorities and ESIS the programme has shown that partnerships and coalition, are a useful approach to programming despite the slow beginning and difficulties associated.

Action for securing health for all (ASHA) is an organization rendering yeoman service in the slums of Delhi and has successfully demonstrated how public authorities can be actively involved in urban health programmes. Although the beneficiaries of ASHA's programme bear only part of the programme cost, substantial capital contributions from public authorities, NGO participation and community beneficiaries have minimized programme costs. Besides these, there are numerous other organizations and committed citizens who have dedicated their lives for the betterment of their less fortunate brethren in urban areas. Partnerships and initiatives by this small group of people promise to usher in a positive change in urban health in the near future.

"Never doubt that a small group of people can change the world; In fact it is the only thing that ever has."

Margaret Mead

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