Strengthening Functional Community-Provider Linkages: Lessons from the Indore Urban Health Programme
Agarwal S, Satyavada A, Patra P, Kumar R. Strengthening functional community-provider linkages: lessons from the Indore urban health programme. Glob Public Health 2008; 3:308-25.
29 Pages Posted: 9 Jun 2016 Last revised: 16 Jun 2016
Date Written: June 15, 2008
The National Sample Survey Organisation (NSSO 2001) estimates that 67 million people (24% of the country’s total urban population) are poor. This estimate is based on the official urban consumption expenditure poverty line of INR454 (approximately US$11) per capita per month, a questionable measure since INR454 is sufficient only to meet basic food requirements and ignores other requirements, such as health care. According to the Census of India, about 43 million of India’s urban citizens live in slums (Office of the Registrar General and Census Commissioner 2001b). However, even this estimate does not reflect the real magnitude of urban slum populations, for it fails to capture ‘unaccounted’ for and unrecognized squatter settlements and other populations residing in inner city areas, pavements, constructions sites, urban fringes, etc.
Overcrowded slums communicable diseases, such as tuberculosis, acute respiratory infections, diarrhea, and worm infestations, are exacerbated in the absence of adequate water sanitation and timely medical help, while vaccine-preventable diseases, such as measles, pertussis (whooping cough), and diphtheria, spread more rapidly among their typically under-immunized populations. Although, in aggregate, Indian women in cities and their children have better health outcomes, findings from the dis-aggregated 1998-1999 National Family Health Survey 2 (NFHS-2) data by economic groups reveal that mortality rates for neonates, infants, and those under 5 years old are considerably higher among the urban poor as compared to overall national averages. More than half of India’s urban poor children (0-3 years old) suffer from malnutrition. In most states, malnutrition rates among urban poor children are far higher than those among children living in rural areas.
Weak linkages between health providers and slum communities hinder the improvement of health services for India’s urban poor. To address this issue, an urban health programme is based on evolved through three processes: urban health situation analysis of the city, slum identification, and plotting and vulnerability assessment, before culminating in consultative programme planning with active involvement of slum communities. Based on the planning, the program implemented two approaches in Indore city, Madhya Pradesh, the demand-supply linkage approach and ward coordination approach.
The first of the two approaches is based on the premise that building social capital, i.e. norms and networks within a community facilitating collective action, helps improve the demand and supply of health services for the urban poor. The latter focuses on encouraging local stakeholders to function in a coordinated manner to ensure better health service coverage in under served slum areas. Findings suggest that the programme has enhanced utilization of services among Indore’s slum communities and helped improve immunization coverage and other maternal and child health indicators.
Data from a baseline survey (October-November 2003) and an independent evaluation study in March 2006 suggest a substantial increase in institutional deliveries, exclusive breastfeeding, and immunization rates, for both pregnant women and children in the slums where the demand supply and linkage approach is being implemented.
Through these coordinated efforts in Ward 5 from May 2003 through April 2006 a total of 204 camps (primarily for childhood immunization) were organized, covering 28 under served slums (population of 35,000), both by the DPH and by an NGO that runs an ICDS project and has its own trained health worker.
Lessons: i) In particular, use of UHP preparatory phase tools, i.e. techniques regarding situation analysis, slum most better understand the local context, develop ownership of the programme, and effectively implement programming in underserved slum areas. It also helps in identifying the most vulnerable pockets, which are often not included in the official municipal corporation slum lists and, therefore, are unable to avail themselves of, and have access to, public health services.
ii) To sustain the ward coordination approach, the WCC must remain active, and thus bring convergence of resources lead to synergistic efforts, better resource utilization, and improved outcomes in health service coverage and utilization. This approach is effective in slum clusters where a few ‘go-getters’, or urban health champions who can continuously stimulate WCC action. At times, such support has been lacking in Indore. It has been necessary to provide continued outside support and facilitation to ensure that the stakeholder coordination mechanism remains functional and active, which is unsustainable.
iii) It is important for any urban health programme to identify an appropriate implementation mechanism that strengthens community networks and builds functional links between slum communities and health care providers.
iv) An important achievement of the demand-supply and linkage approach has been the evolution of slum CBOs as a potent institutional mechanism for implementing slum health and development programmes. CBO members function as role models, empower slum families to adopt behaviours, avail themselves of services, and negotiate for other slum development programmes.
When adapting similar mechanisms in other developing country cities, the key is to select a mechanism that will both involve and strengthen the capacities of existing local, particularly slum level, groups or networks during planning and implementation.
Keywords: Slums, India, Vulnerability assessment, social capital, health, demand-supply linkage approach, ward coordination approach, community-based organization, cluster coordination team
JEL Classification: D1, D10, I00, I1, I10, I12, I18, I19, I3, I30, I31, N35, O18, R00, R10, R19
Suggested Citation: Suggested Citation