Transcript Building Public Sector - NGO Partnerships for Urban RCH

Building Public Sector - NGO Partnerships
for Urban RCH
Symposium on Urban RCH
31st Annual National Conference of Indian Association
of Preventive & Social Medicine
February 29, 2004
Dr Siddharth
Country Representative, USAID-EHP Urban Health Program
ENVIRONMENTAL HEALTH PROJECT
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
ENVIRONMENTAL HEALTH PROJECT
ENVIRONMENTAL HEALTH PROJECT
Urban Population Growth
ENVIRONMENTAL HEALTH PROJECT
Especially in Their Smaller Cities
ENVIRONMENTAL HEALTH PROJECT
Urban Growth in India
Percent decadal population grow th by residence in India:
1901-2001
50
30
20
10
0
-10
19
01
-1
1
19
11
-2
1
19
21
-3
1
19
31
-4
1
19
41
-5
1
19
51
-6
1
19
61
-7
1
19
71
-8
1
19
81
-9
19
1
91
-2
00
1
% growth
40
Decades
Urban
Rural
ENVIRONMENTAL HEALTH PROJECT
Total
Where Should
efforts focus?
Urban Population in EAG States
32%
68%
Urban Population of EAG States
Urban Popualtion in Rest of India
Urban Poverty in EAG States
43%
57%
Urban Poor Popualtion in EAG States
Urban Poor Popualtion in Rest of India
ENVIRONMENTAL HEALTH PROJECT
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
ENVIRONMENTAL HEALTH PROJECT
Reproductive and Child Health Conditions among
the Urban Poor
ENVIRONMENTAL HEALTH PROJECT
Coverage of Child Health Services in Urban Slums of 6 Municipal Corporations and
Rural Areas of Gujarat
Coverage
100%
90%
80%
70%
60%
U rban Slums
50%
Rural A reas
40%
30%
20%
10%
0%
BCG
DPT3
O PV 3
M easles
A ll
V itamin
A
State-wide Multi-Indicator Cluster Surveys (MICSs), 1996
ENVIRONMENTAL HEALTH PROJECT
120
Child, Infant and Neonatal Mortality in M.P.
100
80
60
40
20
0
Neonatal mortality
Urban Low
Infant mortality
Urban Medium
Urban High
Child mortality
Urban Average
ENVIRONMENTAL HEALTH PROJECT
Rural Average
Childhood Under-nutrition in Urban M.P.
NFHS 2 Re-analysis, EHP 2003
100
90
Percentage
80
70
60
50
40
30
20
10
0
Underw eight for age – Below –2 SD
Underw eight for age – Below –3 SD
Anthropometric indicator
Urban Low
Urban Medium
Urban Average
Rural Average
ENVIRONMENTAL HEALTH PROJECT
Urban High
Immunization Coverage by Age 1 among Children 12-23 months
Madhya Pradesh – NFHS 2 Re-analysis, EHP 2003
80
70
Percentage
60
50
40
30
20
10
0
Completely
immunized
Received measles left outs from UIP
immunization
Urban Low
Urban Medium
Urban Average
Rural Average
ENVIRONMENTAL HEALTH PROJECT
drop outs from UIP
Urban High
Contraceptive Prevalence in Urban M.P.
NFHS 2 Re-analysis, EHP 2003
70
60
50
40
30
20
10
0
Any Method
Female Sterilization
Urban Low SLI
Urban Medium SLI
Urban Average
Rural Average
ENVIRONMENTAL HEALTH PROJECT
Pill/IUD/Condom
Urban High SLI
Delivery Related Services in Urban M.P.
NFHS 2 Re-analysis, EHP 2003
100
90
80
Percentage
70
60
50
40
30
20
10
0
Deliveries at home
Urban Low
Urban Medium
Deliveries attended by a heath
professional at home or at a health
facility
Urban High
Urban Average
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Rural Average
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
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Issues with Public Sector
Urban Health Services
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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
ENVIRONMENTAL HEALTH PROJECT
Scenario 1: Areas Where Some Public Sector Primary
RCH Services Exist
• 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.
ENVIRONMENTAL HEALTH PROJECT
Scenario 2: 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 major resource
NGOs active in small areas
ENVIRONMENTAL HEALTH PROJECT
Low Utilization of and Access to Public Sector Services
Others
1.0%
Chemists Government
doctors
4.6%
12.3%
Others
4.4%
Health
workers
2.8%
Gov.
doctors
26.1%
Private
doctors
66.7%
Private doctors
82.1%
Urban Slums
Rural Areas
Gujrat State-wide Multi-Indicator Cluster Surveys (MICSs), 1996
ENVIRONMENTAL HEALTH PROJECT
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
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Experiences in Govt. –NGO
Partnerships for Urban RCH
ENVIRONMENTAL HEALTH PROJECT
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
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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
ENVIRONMENTAL HEALTH PROJECT
What Value Can NGOs Add to Urban
RCH Programming?
ENVIRONMENTAL HEALTH PROJECT
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
ENVIRONMENTAL HEALTH PROJECT
Marginalized Social Groups Constitute A Large
Proportion Of Urban Poor
Background Characteristics of Urban Uttar Pradesh - NFHS II
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Urban Low SLI
Urban Medium
SLI
Scheduled Caste
Urban High SLI
Scheduled Tribe
Urban Average
Other Backward Classes
ENVIRONMENTAL HEALTH PROJECT
Rural Average
Others
Marginalized Social Groups Constitute A Large
Proportion Of Urban Poor
Background Characteristics of Urban Delhi – NFHS II
100%
80%
60%
40%
20%
0%
Urban
Low SLI
Urban
Medium
SLI
Urban
High SLI
Scheduled Caste
Other Backward Classes
Urban
Average
Rural
Average
Scheduled Tribe
Others
ENVIRONMENTAL HEALTH PROJECT
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
ENVIRONMENTAL HEALTH PROJECT
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.
ENVIRONMENTAL HEALTH PROJECT
Contribution # 4
Wholly 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
ENVIRONMENTAL HEALTH PROJECT
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
ENVIRONMENTAL HEALTH PROJECT
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
ENVIRONMENTAL HEALTH PROJECT
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
ENVIRONMENTAL HEALTH PROJECT
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”.
ENVIRONMENTAL HEALTH PROJECT
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 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
ENVIRONMENTAL HEALTH PROJECT
Looking Forward To
Urban Health
Program/Policy
Long Lever of :
a) Commitment
b) Knowledge
c) Experience
d) Motivation
e) Proximity to problems
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NGOs
Suggestions and
Recommendations
ENVIRONMENTAL HEALTH PROJECT
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
ENVIRONMENTAL HEALTH PROJECT
Summary and Key Messages
Innovation &
Development
of Models
EAG States a priority
Quality &
Demand
Govt.
NGO
Reach the
Un-reached
Sustainability:
Institutional,
Programmatic,
Financial
ENVIRONMENTAL HEALTH PROJECT
MultiStakeholder
Coordination
Capacity for
Planning,
Management &
Monitoring
ENVIRONMENTAL HEALTH PROJECT