Urban Health Reading Pack C - Interventions and Service Provision

1. Dr Siddharth Agarwal and Dr Helen Elsey
May 2016
DfID Urban Health Reading Pack Slides

2. Challenges in urban public health
• Urban Primary health care infrastructure is weak with poor access to the poor.
• The poor utilise private providers - expensive, poor quality and exploitative.
• Quality of care is low in terms of service infrastructure, equipment, capacity/skills of health
workers in most LMICs (HERD 2014, Zirabab, 2009).
• High child undernutrition including stunting among urban poor in LIMICs indicates food
insecurity, susceptibility to infections owing to poor access to water supply, sanitation, a
infection-prone physical environment
• Insufficient 2nd tier, including maternity hospitals open 24x7hrs with weak services
• Tertiary care hospitals overloaded and not easy to access for urban poor
• Urban poor women perceive quality of facilities as poor, avoid govt. Facilities for deliveries

3. Coordination across government
• Mixed, unclear responsibility for urban health care and regulatory authority
between departments of health and municipal authorities; weak regulatory
systems result in sizable market for informal and formal private care.
• Lack of role clarity, little coordination between MoH, municipal bodies, Nutrition
service department, other agencies responsible for health, nutrition, food subsidy
and environment improvement.
• Basic municipal services such as sewage system, piped water supply, construction
and cleaning of drains also suffer from not being able to meet the rapidly growing
needs of urban populations.

4. User perspectives, service gaps
• Urban migrant women's unawareness (particularly recent, seasonal migrants) of
maternal healthcare, danger signs of complications, urgency of care seeking; where
and how to avail service at appropriate government hospital service; and vulnerable
living status, contribute to poor maternal health care, and MMR
• With both men and increasingly women, engaging in wage-labour during the day,
provision of affordable and comprehensive quality care close to urban poor
settlements, with opening times of urban health facilities early morning and evening
is crucial
• Learnings also point to community-based outreach focused on increasing the health
literacy of the urban poor, and familiarity with the advantages of formal services
• With lack of toilets in slum houses, women and girls eat less and drink less water to
reduce the urge for defecation and urination.They pass urine or stools before dawn to
experience whatever little privacy is possible

5. Public Private Partnerships
• Public Private Partnerships (PPP) have been taken up by governments in India,
Bangladesh to help expand primary, secondary including 24x7 Maternity Centres,
tertiary services.
• Examples of PPP:
• Contracting-in at Sawai Man Singh Hospital, Jaipur - Life Line Fluid Drug Store was contracted
for low cost high quality medicines, surgical items 24 x 7 in hospital.
• Rajiv Gandhi Super-specialty Hospital, Raichur, Karnataka is a joint venture of Government of
Karnataka andApollo Hospitals Group, with financial support from OPEC
• Utilising private financing, through the Private Finance Initiative (PFI), the UK built
approximately 100 new NHS hospital buildings in 12 years
• In Delhi, the MunicipalCorporation of Delhi (MCD) partnered with Arpana (a PrivateTrust) to
run a dysfunctional MCD urban health center in an urban poor community
• In Guwahati,Assam, the government partnered with Marwari Maternity Hospital, a charitable
hospital to provide outpatient and in-patient services, at the hospital and outreach services in
eight selected low-income wards of the city.

6. Public Private Partnerships ..
• There are challenges with both forms:
• The private-for-profit sector has no incentive to reach out to the urban poor and is not keen to partner for
outreach healthcare which is the key of preventive healthcare and most crucial for urban deprived
communities
• Non-profit agencies usually have few resources,
• Bangladesh’s Urban Primary Health Care Programme uses partnerships with NGOs to expand
services to slum communities, vulnerbale populations
• Vouchers for family planning, safe motherhood, diagnostic, gender based violence services have
been used to help urban poor women access private services paid by government agency
• Tools for public-private partnerships: example terms of reference for identifying private health
providers, expression of interest document, method of private provider selection, Memorandum
of Understanding between Government agency and private providers, role of personnel,
managers engaged by private provider used in different States in India available at Government of
India'sCentral Bureau of Health Intelligence website and on the Bihar Health Society website

7. Social protection: cash transfers and insurance
• Cash transfers for food subsidy and long-term livelihood improvement was successful in
Nairobi using the mobile cash transfer method M-PESA. R
• Recipients spent monthly transfers as they wished.The were encouraged to spend on food
initially.Once basic needs were met, they were encouraged to use them for school fees,
start/expand business, save in merry-go-rounds
• Health insurance schemes:
• Increased utilisation - outpatient visits and hospitalisation.
• Did not reduce reduce out-of-pocket health expenses; the effect for the poorest was weaker
than for the near poor.
• No strong evidence to support widespread scaling up of social health insurance as a means of
increasing financial protection from health shocks or of improving access to health care

8. Community capacity to demand services with
gentle “pull” and tact
• Negotiation capacity among urban poor community associations enable them exert a
"pull" effect with tact on health, environmental improvement, nutrition schemes,
entitlements and services.
• Most sustainable urban vulnerability alleviation approach since it invests in human
capability enhancement over long periods of time.
• Experience in Bangladesh, India shows community networks, community groups, trained
CHWs improve maternal, new-born health behaviours and service access.
• Beyond “providing health care” to nurturing the power of social networks as a means to
support the poorest, marginalized in changing behaviour and effectively accessing
appropriate maternal services improves broader wellbeing.

9. Health and Nutrition Promotion
• Helping people remain healthy and not in need of health services is a fundamental goal of
any urban health strategy
• Lack of evidence on which health promotion approaches are likely to be effective in
changing ‘lifestyle behaviours’ such as tobacco use, diet, exercise among urban poor
• Encouraging waist measurement, desired diet, physical activity and mental wellbeing at
community level; peer education approaches to nutrition, physical activity, promoting
optimal behaviours in schools have shown some success
• CHWs have been effective in Bangladesh, India, Ehtiopia. CHW and slum women’s groups
promoting peer to peer health promotion shows promise.
• Mass media through print, radio, and television have wide audience reach in urban
centres
• ‘Maternal Heath radio program’ in Malawi andWazazi Nipendeni ("Love me parents") in
Tanzania showed improved maternal, infant health practices and outcomes.

10. Identifying and defining urban poor
• Urban poverty is multidimensional, with many deprivations. It is a dynamic
condition of changing vulnerability to risks.
• Deprivations are rooted in lack of employability skills, low access to employment
opportunities, capacity and resource constraints, inadequate/insecure housing and
services, little or no social protection mechanisms, violent and unhealthy
environments, limited access to adequate health and education opportunities.
• Many LMICs set poverty lines minimalistic, based on average monthly per capita
expenditure for obtaining a modest caloric intake.
• Using a social protection scheme benchmark e.g. Food Security Act, Govt. Of India
offers a more reasonable method of defining urban poor (50% in India).

11. Needs of children, young people, women
• Education:
• Primary education remains beyond the reach of most girl and boy children in slums, informal settlements
LMICs inAfrican and Asia
• Secondary education is harder to access for young persons in urban poor communities.
• Girls less likely to attend school owing to many underlying factors associated with the slum
environment, and lack of toilets in schools.
• Girls work as manual labour and often face enslavement in many African countries
• 20% urban migrants that used temporary birth-spacing measures (condoms, oral contraceptives and
injections), all usually available free at government health (India)
• Becoming a mother before age 18 years is quite common among urban poor. (26% in the poorest
quartile in urban India)
• Chreche services:
• In India a NGO Mobile Chreches runs day care centres in partnership with government’s National Creche
scheme and with support of funding agencies. Day care centres operate in coordination builders and
contractors near construction sites
• In Kenya Kidogo social enterprise works at scale in Nairobi’s slums, using a ‘hub & spoke’ model which
combines ‘hubs’ – centres with early childhood development expertise with a microfinance model where
women residents in the slum are provided with a ‘creche in a box’ to look after fewer children at home

12. Approach towards power to slum women
• Urban poor women's and children-youth groups promoting girl child and youth
education have demonstrated promise in reducing gender inequity.
• Education that embodies inclusion as well as teaching about the risks of exclusion has
an important role in changing long standing norms that perpetuate and reinforce
social inequalities
• Formation and steadily empowering informal settlement women's groups across large
urban poor population (about 200,000 in one city) to gently, tactfully negotiate for
services, infrastructure from civic authorities (through community petitions,
reminders, maintaining paper trail) has demonstrate existence of unlisted needy
pockets and co-produce solutions with civic authorities
• Capacity building input to help women’s groups generate and manage collective social
needs funds has gradually helped improve family economics, health, education,
nutrition, house improvement and overall social well-being

13. Strengthened Demand, Improved supply of health,
nutrition, environment services for urban deprived
Improve supply
and
responsiveness
civic services,
entitlements
Strong
demand
among urban
disadvantaged
communities
Capacity building of community
groups,(women, children, youth, men)
volunteers
Negotiation skills, governance,
accountability tools
Health services: preventive, promotive
outreach services, Primary, 2nd tier,
tertiary care facilities
Housing, streets, drains, water
supply, sewage, toilets, garbage
Nutrition behaviour promotion,
services, ECD, creche, education
Civic services, transport, improved
governance, accountability mechanisms
Urban poor savings groups, training
Ward/Zone/local area level
platforms for demand & supply
side interaction
Labour welfare services for
especially for informal sector
Steadily
improvement,
equitable
urban health,
nutrition,
wellbeing