Improving Access of Healthcare to The Urban Poor In India

Ranbaxy Science Foundation XX Roundtable Conference

Urban India is living in a paradox. One segment harvests the advantages of urbanization where another large section is denied the benefit of urban amenities. Quality healthcare combined with safe water and sanitation, housing, etc are the inevitable needs of every citizen. However, urban poor face constant struggle to access quality healthcare within their economic capacity. Factors responsible for the lack of access of the urban poor to healthcare include supply as well as demand side constraints, inadequate convergence and weak capacity. Insufficient public healthcare infrastructure, weak outreach, unclear accountability, weak coordination, weakly defined catchments and lack of empathy towards the poor limit optimal reach of services. On the other hand, lack of knowledge and awareness about health facilities among the urban poor, weak linkages between service providers and communities and weak community negotiating capacity, impede the demand for healthcare services.

Though India is only 29% urbanized, one fourth of the urban population, constituting over 80 million people, live below poverty line. Numbers are increasing every second. This coupled with insufficiency of health services leaves a considerable percentage of this population with little or no access to basic healthcare facilities.

To discuss the above critical aspects that impinge upon the health of urban poor and to share experiences of various efforts to improve access of healthcare to this vulnerable group, UHRC, in collaboration with Ranbaxy Science Foundation organized the ‘Ranbaxy XX Round Table Conference on Improving Access of Healthcare to the Urban Poor in India’. This one day convention was held on April 11, 2008 at India Habitat Centre, New Delhi.

Addressing Critical Issues to Improve Health Access to the Poor
Dr. O.P Sood, Member Governing Council, Ranbaxy Science Foundation (RSF) gave a brief about the Foundation and its commitment towards addressing issues related to public health. He stressed upon the deplorable situation in slums with problem of sanitation, drinking water, education largely prevalent. He emphasized on three critical issues that need to be addressed in order to improve health access to the poor. The most important factor referred being the ever increasing number of people, followed by lack of education, and insensitivity of the people and government. He informed that the conference proceedings will be published and circulated to the concerned institutions for reference and appropriate action. He thanked USAID, UHRC and MoHFW for their active participation and welcomed all the distinguished guests. He called for an interactive day proceedings that would bring out frontline messages to help all to proceed further to achieve the respective goals of improving access of health care to urban poor.

Improving Healthcare Delivery through Effective Distribution System
Mr Nitya Anand, Chairman RSF highlighted the paradoxical situation that we are living in at present. He said that while we are enjoying phenomenal economic and industrial development, the benefits of this are confined to a small segment of the society. This gap points out to the social inequity; the most visible form being in the Health Sector. Though the cities are endowed with well equipped hospitals with state of the art facilities, there are slums nearby who do not even enjoy basic health facilities and have not seen a trained doctor. He further added that although India manufactures 65% of world’s anti-tuberculosis drugs, yet it is home to 35% of world’s TB patients. He emphasized the need to accord greatest priority to the distribution system to improve access of drugs and health care services to the un-reached. He said that pharma industry could play a major role in extending services towards meeting their health needs.

He remarked that it is most appropriate and timely to have a Round Table Conference (RTC) on “Improving Access of Healthcare to the Urban Poor” since the Government is planning to have an Urban Health Mission soon. This therefore is the right platform to discuss the various issues on increasing the availability of health services to the urban poor and forward the recommendation to the concerned department so that these could be considered for incorporation in the work plan of the urban health mission.

Mr Anand extended his deep gratitude to the USAID and UHRC for supporting this conference and wished the RTC much success in being able to give practical shape to all the concerns on this important issue.

Integrated Approach to Better the Health Situation
Dr Robert Clay, Director Population Health and Nutrition USAID India, in his inaugural address emphasized the need of an integrated approach to fight this issue. He said that though there are a number of projects on water and sanitation, nutrition, maternal and child health that involve various stakeholders including government, parastatal agencies, NGOs and corporates, they operate with a lack of convergence, thereby losing out on the benefits of sharing resources, information and expertise and lead to duplication of efforts. Convergence of all programs working in slum communities is crucial for achieving maximum impact on the urban poor. He shared some of USAID’s experiences of working for urban poor health including Environmental Health Project in Indore and Agra, Jeevan Daan Program in Ahmedabad and the ‘Chotton Ki Asha’ program for child health in Delhi.

He congratulated the Government for its commitment towards a dedicated programme for healthcare of the urban poor in the form of National Urban Health Mission. He said that the Mission is indeed a very timely and much needed intervention. He wished the participants and the organizers a fruitful interaction and hoped that the deliberations would help enrich the knowledge about different national programs and policies and city level initiatives that are addressing different determinants of health so that there can be better integration. He further added that the perspective of slum community representatives would lend special significance and learning for all program professionals. He felt assured that this cross-learning would help strengthen all efforts towards improving access and ensure a healthier and happier future for the urban poor.

JNNURM: Ensuring Basic Services for Urban Poor
Dr. P.K Mohanty, Joint Secretary Ministry of Housing and Urban Poverty Alleviation (MoHUPA), briefed the audience on the flagship program of the GOI: Jawaharlal Nehru National Urban Renewal Mission (JNNURM). He explained that JNNURM is reform driven, fast track, planned development of identified cities that would improve availability and access of services to urban poor. The focus is on efficiency in urban infrastructure/services delivery mechanism, community participation and accountability of Urban Local Bodies (ULBs)/Parastatal agencies like State Public Work Department (SPWD) towards citizens. He emphasized the importance of addressing the issues of land tenure, housing, environmental condition that impinges upon the health of the poor than looking at symptoms of disease or what we call the burden of disease.

He further explained the approaches to be adopted for maximum utilization of JNNURM and related schemes of Urban Infrastructure Development Scheme for Small and Medium Towns (UIDSSMT) and Integrated Housing and Slum Development Program (IHSDP). He emphasized on the crucial role the urban local bodies are going to play in delivery of services to the urban poor since public health is a mandated function of municipal bodies as per the 12th schedule of the 74th Constitutional Amendment Act 1992. He stressed on the need to endow the municipality with power and develop their capacity to function in the most productive way.

He emphasized the need of mobilizing and empowering the community through Neighbourhood Groups and Committees and Community Development Societies. Community structures play a very important role in facilitating the process of healthcare delivery. Since poor need hand holding, public private people’s partnership (PPPP) involving the government, ULBs, NGOs, community groups is the need of the hour.

Challenges hindering access of the urban poor to healthcare
Dr Siddharth Agarwal, Executive Director, UHRC gave his presentation on the limited access to healthcare services and barriers faced by the urban poor. He expressed his concern on the irony of the cities where slum dwellers in-spite of living in very close proximity to the state- of –the- art hospitals have little or no access to basic health facilities. He shared some key data based on NFHS 3 reanalysis that described poor access to health and environmental services resulting in poor maternal and child health outcomes among the urban poor. He further explained the barriers that limit access of healthcare. These barriers include illegality of slums that results in compromising their access to basic services like water, sanitation, entitlement cards (Targeted Public Distribution System, Janani Suraksha Yojana); their multi-dimensional vulnerability; sub-optimal primary health care services; lack of convergence and program experience; weak referral mechanism and weak community demand.

Expanding reach of health services to the urban poor in Delhi
Mr. Suyash Prakash, Mission Director, Delhi State Health Mission highlighted the challenges and the available opportunities to improve access to health services in Delhi. He said that no distinction should be made between rural and urban health mission in Delhi since the state is completely urbanized. He said that the biggest challenge to improve access of healthcare lies in the wide disparity of health indicators within the state owing to increasing in-migration. This dynamic status of the population makes it difficult to meet the growing health demands. Another challenge is proprietary issue due to unclear division of responsibility among ULB officials and state government. He mentioned that Delhi state has 2300 Accredited Social Health Activists (ASHAs). He stressed on the need to strengthen the secondary care system by strengthening municipal structures and utilizing Janani Suraksha Yojana (JSY) and Public Private Partnership (PPP) approach (Mamta Scheme) to combat the health demands. Two government non- functional super specialty hospitals in Delhi are being covered under PPP mode with private doctors.

National Urban Health Mission: Meeting the health challenges of urban population with a focus on urban poor
Mr. Pravir Krishn, Joint Secretary, Ministry of Health and Family Welfare (MoHFW), restated that urban poor have a severely restricted access despite their proximity to Urban Health facilities and are being ‘crowded out’ because of the inadequacy of the public health delivery system. He stated that the National Urban Health Mission (NUHM) aims to improve the health status of the urban poor particularly the slum dwellers and other disadvantaged sections by facilitating equitable access to quality health care through a revamped public health system. The main features of the mission include city specific planning based on spatial mapping of slums and slum-like habitations as well as existing health facilities to reach out to all urban poor clusters; rationalizing available manpower and resources and partnering with private providers and NGOs for filling gaps and improving access and quality of health services by regular outreach camps and referral services. Urban Social Health Activist (USHA) and Mahila Arogya Samitis (MAS) are envisaged to facilitate improved access to public and private health services at community level and instigate community risk pooling linked where feasible to insurance mechanism and providing smart cards to the family to ensure access to quality health care.

The mission also propose convergence with other departments right from planning stage, establishing synergies with programs having similar objectives like JNNURM, Swaran Jayanti Shehari Rozgar Yojana (SJSRY), and Integrated Child Development Services (ICDS) to optimize the outcomes. He said that Urban Local Bodies and Elected Representatives (ERs) would play a very important role in the operationalization of NUHM and therefore their capacity need to be strengthened so that responsibility of health care services could be vested upon them.

Session I: Strengthening Access of Primary Healthcare to the Urban Poor Experiences in improving access to health and nutrition care for urban poor – Dr Armida Fernandez SNEHA, Mumbai presented the learning of SNEHA’s City Initiative to Newborn Health (CINH) program, operational in Mumbai. The program execution was based on Appreciative Inquiry (AI) technique. The fundamental philosophy of AI is to target behaviour change in order to shift the focus from a problem oriented approach to a possibility oriented one through building on the existing capacities, strengths and intentions of the urban poor. The community is engaged in discussion to identify solutions to their health needs. On the other hand, quality perinatal care is provided to the pregnant mothers by upgrading the existing health posts to extend ANC and PNC services. The program provides clinical trainings in obstetric and neonatal services to health staff of BMC facilities; do mobilization of vital equipments through PPP; and establish regional referral link between maternity homes and peripheral hospitals. The combination of technical as well as behavior change leads to increased availability of necessary health services during pregnancy, better referral and monitoring system and overall positive attitude of the community towards availing health services and improved motivation and responsiveness of service providers towards the urban poor.

Role of Urban Local Bodies (ULBs) in improving delivery of healthcare and nutrition – Dr. Sneha Palnitkar, Director, AIILSG emphasized on the role of ULBs to enhance access to basic services in the urban centre under 74th Constitutional Amendment Act. She pointed out that though the responsibility lies with the ULBs, adequate resources, mandates and competencies have not been transferred to them. She further expressed her concern regarding health service delivery to urban poor and said that acute resource crunch of ULBs and lack of qualified/trained personnel to handle community health situation leads to low priority of health services in a large number of cities mostly in Empowered Action Group (EAG) states. She concluded by giving a road map for cities and ULBs to better the access by strengthening urban health infrastructure in ULBs, relocation of health care facilities within or close to slums, increased outreach services, strong community linkages and referral system, improved MIS for urban primary healthcare in ULBs and involvement of municipal elected members for institutional sustainability. She reiterated that elected ward level representatives are best suited to identify access related problems at micro level and provide appropriate solutions.

Spatial Mapping of slum clusters, health centres and other resources for effective planning, improving access and monitoring Urban Health Care programs – Mr Tapas Ghatak, Kolkata Metropolitan Development Authority (KMDA), emphasized on the need of efficient and inclusive planning to extend reach of healthcare services to the poor in Kolkata Municipal Corporation (KMC) through Geographic Information System (GIS). The project prepared a database of all existing health infrastructure in municipalities followed by GIS mapping. Analysis showed that most of the available facilities were concentrated in bigger towns and small municipalities were dependent on rural infrastructure located in municipal areas that resulted in limited access and poor availability of facilities for urban poor. This led to revelation of various factors responsible for poor health outcomes and wide variation in health awareness among slums. Upgrading the existing facilities and building adequate infrastructure (UHCs) in the vicinity of slums would definitely boost the access to these services.

Role of Basti-based groups in promoting access to improved healthcare – sharing of experiences from community initiatives – Dr R.S Bakshi, Ranbaxy Community Healthcare Society (RCHS), New Delhi talked about community groups functioning as ‘motivation groups’ for the under-served to raise demand along with operating as ‘pressure groups’ to improve availability and quality of healthcare services in close proximity. Dr Bakshi shared the program experience of forming Basti based groups in Dewas, MP. These groups are formed of different categories – women, adolescent girls, adolescent boys, breastfeeding support groups, health committees, community health volunteers, anganwadi workers, etc. Each group is given clear responsibilities and set of duties that they follow. The mobile health team of RCHS provides technical inputs and monitors these groups.

Mr Prabhat Jha, UHRC Indore pointed out that the community organizations in Indore are instrumental in the entire program planning, identifying the hidden and unlisted poverty clusters, generating health services demand at the community level, building linkages between the community and service providers by conducting outreach camps, developing partnerships and negotiating with government, district health society and private service providers, networking with the ward level agencies and demanding quality health services. These groups have also formed health funds to address any medical emergency related to pregnancy which are repaid once they receive the JSY incentive. They also ensure entitlement of community like providing BPL cards through which they can access schemes like TPDS, JSY, Deendayal Upadhyay Scheme, etc.

Role of private sector in enhancing access to maternal and child health care for the urban poor – Mr. Balaji Utla, Satyam Foundation, Hyderabad shared the experience of the Foundation in extending reach of healthcare services to the urban poor. The program uses the existing Urban Health Posts (UHPs) in slum areas to run clinics for the poor with their own staff after the usual working hours of the public health facilities. These clinics operational in the evenings in 4 UHPs cater to the health needs of daily wagers, domestic helpers, petty shopkeepers without affecting their daily earnings. Another innovation is the comprehensive coverage of Medical, Police and Fire emergencies through Public-Private Partnership that the government of Andhra Pradesh has recognized as Emergency Management and Research Institute (EMRI). In Andhra Pradesh and Gujarat, the number 108 is used as the centralized helpline for these emergencies. 502 ambulances are operational covering entire Andhra Pradesh and 80 ambulances in Gujarat

Panel Discussion on “Inter and Intra Sectoral Coordination and Convergence for Ensuring Access to Primary Health care for the Urban Poor”
The panel discussion was moderated by Dr R. Srinivasan, Ex. Health Secretary, GOI and Dr Siddharth Agarwal, UHRC, New Delhi. The panelists included Dr. Monica Rana, NRHM, Delhi; Dr S.K Kapoor, St. Stephens Hospital, Delhi; Ms. Sanghmitra, Health Officer, Brihat Bengaluru Mahanagar Palike, Bangaluru; Dr Monica Jain, Private Sector Health Provider, Indore; Mr M.G Shekhar, National Slum Dwellers Federation, Mumbai; Ms. Sapna Alanse and Ms. Anita Rathore, Representatives from Slum Community, Indore.

Following are the issues raised during the discussion along with pertinent opinions
Definition of Urban Poor – It was strongly opined that urban poor should not be defined based on their income or consumption pattern. Although slums are a manifestation of urban poverty, all people living in these settlements may not be poor. From programmatic point of view, urban poor or vulnerable sections should include those who do not enjoy security of tenure and have limited access to services like health, water, sanitation, housing, education, and employment. It is also important to identify more vulnerable groups in a city like pavement dwellers, construction workers, waste pickers, beggars, street children, etc . This was opined to ensure that no needy family gets missed out.
Role of Elected Representatives (ERs) in providing basic services to urban poor – There is an urgent need to build capacity and skills of ERs to be able to identify existing vulnerabilities of their ward whether it is water supply, population to toilet ratio, sanitation condition or garbage collection. They can then represent their ward needs/gaps in ward committee or general body meetings. Government programs like JNNURM or NUHM and NGOs or technical agencies can conduct such training programs for ERs. Though experience has shown that ERs do support health initiatives in the form of providing space for camps, conducting GIS mapping, monitoring the services provided in public hospitals, etc it would be a good check on their performance if a pre-post survey is conducted to analyze the improvement in the access to services during their tenure. ERs can also draw on their power to negotiate with private practitioners to improve the access to health services in their wards. NGOs and ERs synergize to extend the facilities to all residents of their ward.
Primary care services to be made more responsive to the needs of the poor – The first most important step taken towards being responsive to the growing needs of urban poor is that public sector has realized its shortcomings. To increase the access of urban poor to quality healthcare, it is essential to do GIS mapping for facility assessment followed by reviewing the services provided in those facilities. The existing primary health care services provide different types of facilities/services/infrastructure/staffing pattern with no set standard as far as delivery of services is concerned.

For optimal and responsive primary health care services, there is a need to have an effective OPD with adequate supplies, basic diagnostic facilities, regular outreach services to vulnerable clusters and linkage mechanism with slum community.

These services are controlled by multiple agencies with lack of coordination among them. Some prominent steps are planned to be taken under NUHM to ensure maximum reach of services to the underserved in Delhi. One such effort in this direction is the seed Primary Urban Health Centres (PUHCs) manned by a doctor, 2 ANMs, 1 lab technician and 1 project manager. Another initiative is PPP in diagnostics. Private health facilities would be accredited to provide services to patients getting referred from dispensaries/PUHCs. In order to maximize ANC check-ups and universalize institutional deliveries, existing maternity homes are being strengthened and MOU signed with private nursing homes under ‘Mamta Scheme’. Conducting OPD services and outreach camps to provide immunization, ANC examinations, referral services etc can surely improve the access to health services.
Private health providers expand services to urban poor – Private hospitals and practitioners play an important role in delivering basic health care services to the urban poor. This underserved section prefers private doctors close to their dwelling for ANC check-ups and approach government facilities for deliveries. Strong and clear accountability between government facilities and private providers not only increases the avenues for the urban poor to avail services but also assure quality care at affordable cost. Private Doctors with the help of ANMs provide domiciliary services when required. In some municipalities vaccines and treatment boxes under DOTS are provided to private medical practitioners to be able to reach out to the concerned. Another example is where private hospital in Delhi runs mobile clinic or sends an ambulance to take the pregnant mothers to the outreach camps to get their ANC free of cost or at nominal user charges. Link workers or Basti groups also play a vital role in ensuring that all in need are being catered to. These workers are not only motivated to encourage the pregnant women but are also trained to monitor their pregnancies and conduct sessions with them using IEC material. Private Doctors in collaboration with NGOs and CBOs in Indore also provide health cards to pregnant women that facilitate their institutional deliveries in government set-ups. Health fund in Indore and Agra is another innovation initiated for easy availability of funds to access private services in case of health emergencies. The community group save minimal amount depending upon their socio-economic status that they lend to cover health exigencies like pregnancy. The amount is returned over a period of 1-3 months or once the pregnant lady receives the JSY incentive.
What motivates private doctors to take up these initiatives? Private providers have to overcome a lot of challenges including resentment from the women for undergoing ANC check-ups and getting registered for institutional deliveries. But it is a matter of personal choice and motivation not to give up. There is immense satisfaction in serving the poor especially when outcome of all the efforts is improved maternal and child health indicators. Also it is possible for the private doctors to adapt to people’s tendencies. If the private providers are able to respect these tendencies they are in a position to hold a structure that enhances service delivery and acceptability by the poor. But all private doctors do not follow similar school of thoughts. Therefore for many the incentive to work for under served community could be the assured amount of 1 lac every month under NRHM.
Approaches and mechanisms for convergence – To cater to the ever- increasing population of the country and more so of urban poor, the time has come to work together without any threat to individual identity. To reach out to maximum, convergence is the only solution overcoming the concept of vertical programs. Three approaches to convergence were discussed that includes inter- programmatic, inter- agency and inter-sectoral. Inter- programmatic convergence includes programs which are not directly under the umbrella of the mission but that need to converge with since they impact the health outcomes of the population like National AIDS Control program. Under inter- agency convergence, for eg. in Delhi, agencies like Delhi government, NIHFW, MAMC, UHRC are coming together to identify and list standard services to be provided under PUHCs that includes preventive and curative services, national programs, basic lab facilities, referral services, etc. District Health Societies are being formed that do not represent MCD, NDMC or Delhi government but it is a group of people who are representing the people and the agencies together in a body. It is important to converge with departments that impact the health of the poor in some way. Inter-sectoral convergence between JNNURM, ICDS, school health program or water & sanitation program, etc is going to be included in the mission Project Implementation Plan (PIP) from this year. Also Ward Coordination Committees operational in Indore work to develop linkages among various stakeholders including health department, urban development department, ICDS, municipal bodies, NGOs, and private providers for building up synergy in several activities that improves the quality of services.
Facilitating collectivization of slum community into groups – The first step is to initiate dialogue with some active community members to understand their issues and concerns. This is followed by motivating them to believe in themselves and the power of unity. Initially people come together in large numbers out of curiosity or their own personal motives. But only few committed individuals take the lead to inspire people to work together towards improving their quality of life. It requires continuous motivation and zeal to carry forward the good work whether it is persistently pursuing the local bodies to resolve the sanitation situation or meeting the emergency needs of a pregnant lady. It is the outcome of the united effort that stimulates them to carry on. In heterogeneous slums, it is important to respect the differences based on religion, caste or economic status. The approaches could be different but the goal is to improve the quality of life. When the social capital of working together becomes strong, the negotiating power increases and they are able to negotiate for water, roads, health and entitlements like PDS cards.

The panel discussion concluded by Dr R Srinivasan reiterating the necessary emphasis on addressing the multi- needs of the urban poor whether it is survival, discrimination based on caste, religion and gender or employment/livelihood. The communities come together and form small groups to address their local micro issues whether it is related to water, sanitation or housing. It is important to operate through them. It was felt that there is an urgent need to create genuine decentralization among local units for all issues. Local bodies/leaders must be given responsibility to improve access of services and empowered to influence decisions at local level. Another important observation was emphasizing on the running cost of any facility being provided to the urban poor. It is important to understand that low cost living is a great advantage for the poor and solutions that involve higher cost transformation are not sustainable. Therefore, solutions for urban poor must be affordable by them in the long run. It was also strongly felt that NUHM has a lot of potential and to harness it, convergence and partnership between government, NGOs and private sector is essential.

Valedictory Remarks: Dr Khapde, Deputy Commissioner Infrastructure Division and Immunization, MoHFW gave the valedictory remarks. He commented on the timeliness of this conference since NUHM is soon going to be operational. He mentioned that NUHM stresses on the need for PPP since public health facilities are facing a lot of pressure due to increasing population. He further elucidated that NUHM would require strengthening of ULBs, identification and capacity building of (USHAs), utilization of Rogi Kalyan Samitis and existing programs like JSY and inter-sectoral convergence. He further remarked that an III –tier system of health service delivery with one UHP covering a population of 5000 at I tier and hospitals/nursing homes/corporation at II and III tier needs to be strengthened. He mentioned that NUHM would have flexibility for need based planning and utilization of resources.

Vote of Thanks: Dr S Kaushik, UHRC extended the vote of thanks to RSF, GOI, and USAID, all panelists, participants and UHRC team for successful execution of the conference.