Public Private Partnership to Improve Health of Urban Poor in Agra

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1 Public Private Partnership to Improve Health of Urban Poor in Agra Introduction Agra, one of the important cities of Uttar Pradesh city is spread over an area of 140 sq. km. along the banks of the river Yamuna. The large scale migration from rural areas has led to the congestion in the city with very poor civic facilities. The total urban population of Agra is 1,331,339. Population density of Agra is 897 persons per square kilometer as compared to the Indian average of 324. According to the 1991 census, the sex ratio of the city is 852 females per 1000 males. Total of 8.41 lakh people live in slums, which is about 50% of the city s population. Primary health care in Agra is provided through 15 D-Type Health Centers (DTHCs). D- Type health Centers are providing maternal and child health and family welfare services to a population of 50,000. But due to substantial increase in the population of the city over time, each health center is now catering to a population of 70,000 to 100, 00. In such a situation it is quite evident that the existing primary health delivery system is inadequate to respond to the health needs of the burgeoning urban population, of which approximately 50% reside in slums or slum like conditions. Slum dwellers prefer to access private health facilities due to better attention/services or proximity of these services. Nature of Project- Public Private Partnership in various services is one of the preferred ways of reaching out to underserved communities all over the world. It is efficient way of combining Government resources with non government expertise. In this context of rapidly expanding reproductive health services to underserved urban areas, Government of India has designated Urban Health Resource Centre to develop samples urban health plan focusing on urban poor. This centre carried out detailed health analysis of Agra s low income settlements. After the request of Government of Uttar Pradesh, PPP model health centre was started by involving government officials, local NGOs and community. The main objective was to provide access to basic reproductive health facilities to people living in low income settlements. The whole concept is based on two following approaches: Approach 1 Under this the NGO partners provide reproductive health services. They provide OPD services to under served slum population. The urban health intervention in Agra involves establishing Urban Health Centre through partnership with local NGOs to provide reproductive health services in eight low-income settlements of the city, having a total population of about 86,000 in 44 slums. In the centre sterilization and other family planning services are provided at negligible cost to patients while for deliveries, operations and diagnostic tests patients are referred to Lady Lyall Government Hospital

2 Approach 2 Under this NGOs are covering 24 slums by mobilizing community and through outreach camps in these areas. Mainly RCH services are provided and the outreach team includes a doctor and community link volunteers and Mahila arogya samitis. Link Volunteers and MAS members identify the needy women in the community and motivate resistant women in the community to avail health services. They also identify and support special attention households. This is done where already Government health centre exists. This avoids duplication of services and also strengthens public health system. 80 Link Volunteers, each covering population 43 women s health groups promoted in 34 slums

3 Public Private Partnership- Urban Health Resource Centre is the coordinating agency for developing sample urban health plans focusing on urban poor. To improve health conditions among the urban poor of Agra, Urban Health Resource Center (UHRC) initiated an urban health program in partnership with the Government of Uttar Pradesh.The program partners with 3 local NGOs to provide reproductive health services in underserved slum communities in Agra.The three local NGOs are Family Planning Association of India (FPAI), Naujhil Integrated Rural Project for health and Development (NIRPHAD) and Shri Niroti Lal Buddhist Sansthan (SNBS). Involvement of Community- A key strategy of the program is the promotion of community collectives to enhance demand and utilization of health care. This also helps in furthering ownership of the program by the community. This is achieved through Community Link volunteers (CLVs) and Mahila Arogya Samitis (MAS) (Women s Health Groups). Community Link Volunteers are married women from same community. They are selected on the basis of attitude, capabilities, sincerity and willingness to serve

4 the community to which they belong. They act as a bridge between community and services. They track beneficiaries and they do a follow up on their health needs. They do counseling for women on various health issues. They motivate women and their family members on availing various health services. They refer cases to urban health centres. Mahila Aarogya Samitis (MAS) comprises of women members from the community who have keen interest on community issues and are able to work collectively. They are usually identified by Community Link volunteers. Both CLVs and MAS support outreach camps by ensuring women from target group attends these camps. Capacity building activities are undertaken by NGO functionaries once a month on RCH themes They manage community health fund for meeting health emergencies in the slums. The community has actively supported this project by starting a health fund. They contribute Rs 25 monthly and lend this money to women in need. 34 groups across 30 slums have collected a total of Rs. 45,500 for health purposes Agra, one of the important cities of Uttar Pradesh city is spread over an area of 140 sq. km. along the banks of the river Yamuna. The large scale migration from rural areas has led to the congestion in the city with very poor civic facilities. The total urban population of Agra is 1,331,339. Population density of Agra is 897 persons per square kilometer as

5 compared to the Indian average of 324. According to the 1991 census, the sex ratio of the city is 852 females per 1000 males. Total of 8.41 lakh people live in slums, which is about 50% of the city s population. Primary health care in Agra is provided through 15 D-Type Health Centers (DTHCs). D- Type health Centers are providing maternal and child health and family welfare services to a population of 50,000. But due to substantial increase in the population of the city over time, each health center is now catering to a population of 70,000 to 100, 00. In such a situation it is quite evident that the existing primary health delivery system is inadequate to respond to the health needs of the burgeoning urban population, of which approximately 50% reside in slums or slum like conditions. Slum dwellers prefer to access private health facilities due to better attention/services or proximity of these services. Nature of Project- Public Private Partnership in various services is one of the preferred ways of reaching out to underserved communities all over the world. It is efficient way of combining Government resources with non government expertise. In this context of rapidly expanding reproductive health services to underserved urban areas, Government of India has designated Urban Health Resource Centre to develop samples urban health plan focusing on urban poor. This centre carried out detailed health analysis of Agra s low income settlements. After the request of Government of Uttar Pradesh, PPP model health centre was started by involving government officials, local NGOs and community. The main objective was to provide access to basic reproductive health facilities to people living in low income settlements. The whole concept is based on two following approaches: Approach 1 Under this the NGO partners provide reproductive health services. They provide OPD services to under served slum population. The urban health intervention in Agra involves establishing Urban Health Centre through partnership with local NGOs to provide reproductive health services in eight low-income settlements of the city, having a total population of about 86,000 in 44 slums. In the centre sterilization and other family planning services are provided at negligible cost to patients while for deliveries, operations and diagnostic tests patients are referred to Lady Lyall Government Hospital Approach 2 Under this NGOs are covering 24 slums by mobilizing community and through outreach camps in these areas. Mainly RCH services are provided and the outreach team includes a doctor and community link volunteers and Mahila arogya samitis. Link Volunteers and MAS members identify the needy women in the community and motivate resistant women in the community to avail health services. They also identify and support special

6 attention households. This is done where already Government health centre exists. This avoids duplication of services and also strengthens public health system. 80 Link Volunteers, each covering population 43 women s health groups promoted in 34 slums Public Private Partnership- Urban Health Resource Centre is the coordinating agency for developing sample urban health plans focusing on urban poor. To improve health conditions among the urban poor of Agra, Urban Health Resource Center (UHRC) initiated an urban health program in partnership with the Government of Uttar Pradesh.The program partners with 3 local NGOs to provide reproductive health services in underserved slum communities in Agra.The three local NGOs are Family Planning Association of India (FPAI), Naujhil Integrated Rural Project for health and Development (NIRPHAD) and Shri Niroti Lal Buddhist Sansthan (SNBS). Involvement of Community- A key strategy of the program is the promotion of community collectives to enhance demand and utilization of health care. This also helps in furthering ownership of the program by the community. This is achieved through Community Link volunteers (CLVs) and Mahila Arogya Samitis (MAS) (Women s Health Groups). Community Link Volunteers are married women from same community. They are selected on the basis of attitude, capabilities, sincerity and willingness to serve the community to which they belong. They act as a bridge between community and services. They track beneficiaries and they do a follow up on their health needs. They do counseling for women on various health issues. They motivate women and their family members on availing various health services. They refer cases to urban health centres. Mahila Aarogya Samitis (MAS) comprises of women members from the community who have keen interest on community issues and are able to work collectively. They are usually identified by Community Link volunteers. Both CLVs and MAS support outreach camps by ensuring women from target group attends these camps. Capacity building activities are undertaken by NGO functionaries once a month on RCH themes They manage community health fund for meeting health emergencies in the slums. The community has actively supported this project by starting a health fund. They contribute Rs 25 monthly and lend this money to women in need. 34 groups across 30 slums have collected a total of Rs. 45,500 for health purpose

7 Role of Government - The government co ordinates with the local NGOs to provide support.it provides monthly stock of vaccines and essential medicines. The Health official conducts periodic visits and gives suggestions to improve the working conditions. Accountalibility- All stakeholders like NGO, community members, government officials and UHRC representatives were engaged in various consultations to assess the need situation. They were involved in decision making. A selection committee comprising government officials and UHRC representatives assessed capacities of potential partners and after comprehensively checking their past experience the NGOs were selected. Government of Uttar Pradesh has requested UHRC to be the key facilitator in operationalizing further such initiatives. Achievements 1. Service delivery has considerably improved amongst the urban poor particularly women and children in under served communities. 2. There is increase in institutional deliveries, immunization coverage levels and improved management of obstetric emergencies and provision of basic curative care. 3. Capacity building of community is promoted to achieve progressive improvement in not just health practices but also sanitation and overall empowerment.

8 Sustainability The project is sustainable as long as there is interest on the side of the Government and the non state partner can arrange funds to run the health centers. Sustainability also depends on the participation of the community. Unless and until community does not have full faith and trust in the service provider, such initiatives fail to deliver effectively over the period of time. Strengths- The main strength of the initiative is community partnership in the overall health service delivery. People were not treated as simply passive recipients of services but were active principlas who demanded services. This was done through their capacity building. This in true sense empowered people. Weakness - There was limited ownership of the initiative amongst the government officials. The MOU and other agreements were signed by the government officials and Urban Health resource Centre. But still Government officials were very reluctant in claiming that this project was their own initiative. They admitted that the project is doing well but do not wanted to be named. Unless Government takes an upper hand in administering such new Public Private Partnerships initiative, they will lose their purpose and objective. Replicability- The program has good potential to be replicated in other parts of Uttar Pradesh. This is in itself model for Uttar Pradesh Government for PPP activities. Lessons Learned Before the implementation of Public Private Initiative extensive consultations with community to secure their support is must. Area of Improvement There should be proper agreement between the government and service providers specifying their respective roles and responsibilities, especially with regard to the areas to be covered, payments, supplies, reporting etc. All the parties should stay committed to their respective roles otherwise such initiatives can be killed inspite of being useful to the poor people. Contact Person Mr Siddharth Aggarwal Project Location- Urban Health Centre,Trans Yamuna Colony, Agra.

9 Contact Address - Delhi Office Urban Health Resource Centre B-7/122-A, Safdarjung Enclave New Delhi Ph: / 21 Fax: Agra Office Urban Health Resource Centre - Agra 73-B, Surya Nagar (1st floor) Civil Lines, Khandari Road Agra Ph: Fax :

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