101st Induction Course for IAS Officers Workshop on Urban Health

27th September, 2006

REPORT

Lal Bahadur Shastri National Academy for Administration (Govt. of India) Mussourie

Technical support: Urban Health Resource Centre, New Delhi

LIST OF ACRONYMS

AIDS Acquired Immune Deficiency Syndrome

ANM Auxiliary Nurse Midwife

BCC Behaviour Change Communication

BPL Below Poverty Line

CBO Community Based Organization

GOI Government of India

GOM Government of Maharashtra

HIV Human Immuno-deficiency Virus

ICDS Integrated Child Development Scheme

IEC Information Education and Communication

IMR Infant Mortality Rate

KIT Kolkata Improvement Trust

MHADA Maharashtra Housing and Area Development Authority MMR Maternal Mortality Rate

NGO Non Government Organization

RWA Resident Welfare Association

SIP Slum Improvement Program

VIPP Visualization in Participatory Programs

UHRC Urban Health Resource Centre

TABLE OF CONTENTS

Prologue

Acknowledgements

1. Background

2. Context setting

3. Discussion on the challenges and suggestion for improving health care delivery to the urban poor

4. Discussion on the initiatives of the states in urban health

5. Feedback

Annexes

i) Agenda

ii) Why urban? (presentation by Dr. Siddharth Agarwal, Urban Health Resource Centre)

iii) Outline for case study presentations

iv) Case study presentations

a. Agra

b. Shahdara North, Delhi

c. Indore

v) List of participants

vi) Feedback form

vii) Reference material

PROLOGUE

ACKNOWLEDGEMENTS

We are grateful to Mr. Chiranjeev Choudhary, Senior Deputy Director, Lal Bahadur Shastri National Academy for Administration for providing us an opportunity to conduct a session on urban health at the 101st Induction Course for IAS Officers. Mr. KK Pathak, who was the in-charge for the day, put in a lot of effort to help us conduct the session. We appreciate his cooperation and would like to thank him for his unconditional help. Ms. Arti Ahuja’s contribution to the session has also been invaluable. We take this opportunity to thank her for her support and guidance. Thanks are due to Dr. Sanjeev Kumar and Dr. S Kaushik (UHRC) for putting together the reference material for the session. Ms. Karishma Srivastava, Mr. Anuj Srivastava and Dr. Siddharth Agarwal (UHRC) need a special mention for organizing and conducting the session. Special thanks to Mr. S. Kukreja and Mr. Ajith Kumar (UHRC) who helped with the travel and logistics management. Mr. Ashish Kumar also needs a mention for his support with the maps.

This report has been prepared by Ms. Ayushi Agnihotri with inputs from Dr. Siddharth Agrawal, Ms Karishma Srivastava and Mr. Anuj Srivastava.

1. BACKGROUND

Urbanization: Urbanization is fast becoming the defining process in shaping the course of social transformation and ensuing development concerns in India. Of the total population of 1027 million, as on 1st March, 2001, 285 million lived in urban areas. The percentage decadal growth of population in urban areas was 31.2%; nearly double that of in rural areas (17.9%). An analysis of population growth trends between 1991 and 2001 shows that while India grew at an average annual growth rate of 2%, urban India grew at 3%, mega cities at 4% and slum populations rose by 5%. Projections by United Nations indicate that by 2030, India’s urban population will grow to 576 million and constitute 40% of its total population. In 2001, there were 35 ‘million plus’ cities and 393 cities with population above 100,000. It is estimated that the number of ‘million plus’ cities in India will grow to 51 by 2011 and 75 by 2021. In addition, there would be 500 large cities with population above 100,000 by 2021. Urban poverty: About 23.6 % of the urban population of India is living below the poverty line i.e., their per capita expenditure on consumption goods is less than Rs.454 per month. The benefits of urbanization have eluded this burgeoning 67 million urban poor population, living mostly in slums. Health of the urban poor: Studies reflect that the health of the urban poor is as bad as or worse than that of their rural counterparts. Of the 2 million births each year among the urban poor population in India, more than 50% of the deliveries occur at home, 1.1 million mothers do not receive adequate antenatal care, 1 million newborns are likely to be low birth weight and the initiation of breast feeding is likely to be delayed for about 1.6 million newborns. Neonatal, infant and under-5 mortality rates are considerably higher among the urban poor compared to the urban as well as national averages. More than half of India’s urban poor children are under weight and/or stunted. The reach and utilization of essential preventive health services by the urban poor is abysmal. The poor health indicators of the urban poor, a large section of our growing cities, need to be addressed on a priority basis. The health and productivity of this section of the

• The percentage decadal growth of population in urban areas was 31.2%; nearly double that of in rural areas (17.9%)

• Projections by United Nations indicate that by 2030, India’s urban population will grow to 576 million and constitute 40% of the total population.

• About 23.6 % of the urban population of India is living below the poverty line

• Studies reflect that the health of the urban poor is as bad as or worse than that of their rural counterparts

• The reach and utilization of essential preventive health services by the urban poor is abysmal.

population is also vital as they contribute substantially to the economic growth of the country. Urban Health Resource Centre, a Delhi based NGO, has been working with the Government and other key stakeholders to ensure better health for the urban poor. One of the key areas of work has been advocacy and sensitization along with capacity building of all the stakeholders including the community itself. UHRC facilitated a half day session at the ‘101st Induction Course for State Level Civil Service Officers’ at the Lal Bahadur Shastri Academy, the nodal body for training of Indian Administrative Services and other Civil Service officers.

2. CONTEXT SETTING

In India, development efforts have been rural centred since independence. There has always been a general belief that the urban areas, with more advanced infrastructure and facilities, are better than rural areas as far as health care delivery is concerned. This understanding has led a large population living in underserved poor urban settlements to be abandoned by health care services which have laid greater emphasis on the rural dwellers. Also the misleading better health indicators have led to the strengthening of this belief. In order to set the agenda for greater emphasis of the health of this ‘invisible’ urban poor population, Dr. Siddharth Agarwal, Executive Director, UHRC, in his presentation highlighted the rapid rate of urbanization and prevailing poverty and precarious living conditions in urban slums. Bringing forth disparities in the health status of urban poor and rich in the cities, he stressed on the pressing need of increasing the reach of healthcare delivery to the urban poor and also to those who live in unrecognized settlements and therefore are eluded from basic facilities including health. While highlighting the challenges of healthcare delivery, he revealed that ‘invisibility’ of a large proportion of slums and social exclusion of urban poor restricts them from accessing healthcare services. According to him inadequate coverage by healthcare services and ICDS programme, low awareness among the margina lized population about health services and programmes and weak linkages between community and providers as well as lack of familial support and home-care for infants, cumulatively create a set of conditions that ails health of the urban poor. The presentation is annexed (Annex ii).

• In India development efforts have been largely rural centred.

• Various reasons have caused rapid urbanization in India over the past decade.

• This has led to the neglect of a large population, living in underserved poor urban settlements, by health care services.

• Misleading better health indicators have led to the strengthening of this belief.

• Invisibility of a large proportion of slums and social exclusion of urban poor restricts them from accessing healthcare services.

3. DISCUSSION ON THE CHALLENGES AND SUGGESTIONS FOR

IMPROVING THE HEALTH CARE DELIVERY TO URBAN POOR In this session the participants were asked to list the challenges in urban health care delivery on a VIPP card. On another VIPP card they were asked to list the possible suggestions to address these challenges. The responses of the participants are summarized below.

CHALLENGES SUGGESTIONS

Staff, infrastructure and supplies related

• Insufficient staff , infrastructure and supplies

• Untrained private health practitioners

• Inadequate number of health facilities

• Inconvenient timing at the health centre

• Lack of local health workers

Community related

• Growing slum population

• Low literacy

• Low response from community

• Community bias

• Lower priority to health

• Lack of acceptance, especially of family planning services in certain communities

Environment related

• Poor environmental health conditions –water supply and drainage

• Lack of toilet and garbage disposal mechanism

• High population density

Others

• Lack of political will

• Low use of technology such as software and computers for coordination

Staff, infrastructure and supplies related

• Appointment of new staff

• Set up new health facilities

• Up-gradation of existing facilities

Community related

• Provision of urban amenities in rural areas to arrest migration

• Sensitization of the general people for ensuring more respect for slum dwellers

• Door to door canvassing Environment related

• Low cost sanitation mechanism with little use of water

• Improve the housing and living conditions by shifting the slum population

• Increase the use of technology especially computers for making health services accessible

• Ensure proper disposal of syringes Others

• Greater political will to address health and well being concerns of slum dwellers.

• Develop city level urban health plans and make concerted efforts

• Involve the NGOs to bridge the critical gap between the administration and slum dwellers

4. DISCUSSION ON THE INITIATIVES OF THE STATES IN URBAN HEALTH a. Slum Redevelopment Programme in Karnataka Highlighting the slum development programme in Karnataka, Mr. K. Vishvakantha Reddy (Deputy Secretary, Housing Department, Karnataka Government), shared the following aspects of the Slum Redevelopment Program. • Joint development programme with a private developer in the slum in situ. • The developer builds multi-storeyed building wherein all slum dwellers are

accommodated. • The slum dwellers will get tenure rights. • The developer can exploit the area of his share for commercial purpose. • The developer will bear the cost of maintenance of the building. • The slum dwellers are satisfied as they do not have to shift from their present

location. • The local politicians also do not raise any hue and cry as they generally do in

case of relocation of slums. c. Slum Improvement Programme in Maharashtra Highlighting the slum improvement programme in Maharashtra, Mr. H. K. Jawale (Joint Commissioner of Sales Tax, Mumbai), emphasized the following aspects. • Slum Improvement Program (SIP) has been well implemented in urban areas

by GOM through Housing Department and Maharashtra Housing and Area Development Authority (MHADA).

• SIP was implemented in all notified slums in all Municipal Corporations and in Municipal Councils having population more than 50,000.

• 5 provisions have been made under the SIP Scheme. These are (1) Path (Road) (2) Water (tap) (3) Drainage (4) Toilet and (5) Electricity

• SIP has resulted in improvement of environmental conditions of slums. • In Mumbai, Dharavi Slum Improvement Program is being implemented. • Slum Redevelopment Scheme: under this scheme the slum dwellers are

rehabilitated by adopting a unique private-people partnership. The slum dwellers are temporarily relocated to some place and their original place of residence is developed by a private developer and the residents are provided an area of 250 sq.ft. free of cost and the remaining land is sold by the

developer. A number of slums have been upgraded in this manner in Mumbai.

• In Jalgaon, Maharashtra all slums had been redeveloped by the Municipal Council under the Slum Redevelopment Scheme.

d. Rehabilitating poor leprosy patients, Ranchi, Jharkhand. Mr. Ravishankar Jaipuriar (Additional Secretary, Department of Health and Family Welfare, Government of Jharkhand) narrated that cured leprosy patients living under the ‘over-bridge’ on the main road of Ranchi, beg during the day and go back to their unhygienic dwellings in the evening. Though they have been cured of their illness, i.e. leprosy, yet they do not go back to their families because of two reasons: • Their family members will not take them back. • They find begging an easier way of livelihood. Efforts have been made to identify such patients staying in different parts of the state. Based on the findings of the survey rehabilitation would be planned. e. Improving living conditions of slum dwellers: Experience of KIT (erstwhile CIT) Mr. Sailendra Krishna Das (Additional District Magistrate & DLLRO, Murshidabad, West Bengal) informed that the Kolkata Improvement Trust (KIT) had undertaken construction of 6000 low cost houses in prime locations at Kolkata under the Basti Rehousing Scheme and SIHS in the early 60s and 70s. The scheme not only helped in overcoming the encroachment but also helped in improving the living conditions of the urban poor. f. Community participation and effective coordination: Clearing the encroachment Mr. N.S. Channappa Gowda (Chief Executive Officer, Zila Panchayat, Mysore), highlighted an instance where about 200 households were relocated from an area through which the proposed ring road in Shimoga city, Karnataka had to pass. All civic amenities were provided in the relocated area. The rehabilitation was effectively undertaken through people’s participation and active coordination of the city Municipal Council and Urban Development Authority. g. Community Health Insurance: Chaitanya Scheme Mr. N.S. Channappa Gowda (Chief Executive Officer, Zila Panchayat, Mysore) provided details of the Chaitanya Scheme of community health insurance. He informed that under the scheme a poor family can insure itself by paying a premium of Rs.350 per annum. Once the premium is paid they can avail the

medical benefit including heart surgery and the cost will be reimbursed by the Government. h. Waste collection and Segregation Mr. M Chandrasekaran (Public Department, Govt. of Tamil Nadu, Chennai) provided the details of Binless City Scheme which has found a citation by the Supreme Court of India. Based on the judgment, officers from Chandigarh visited the town to learn about the scheme. In this scheme door-to-door collection of solid waste is done in slums as well as non-slum colonies. The waste is segregated into bio-degradable and non-biodegradable waste with the help of an NGO. The bio-degradable waste is used for making compost which is sold as manure. The non-biodegradable waste (mostly plastic) is shredded and sold to an industry which can recycle it. He also informed that scientists have developed a technique of utilizing plastic waste for spreading over roads along with bitumen, which reduced the amount of bitumen required; thereby reducing costs. It also strengthens the road. In this process, the shredded plastic is sprinkled over the heated bitumen (at around 160-170 degree Centigrade). At this temperature, the plastic does not convert into vapour, which can be damaging to the environment, but forms a layer over the bitumen and sticks to it making the road surface stronger and more resistant to wear and tear.

Innovative health insurance scheme with potential for impacting health of the urban poor “Chiranjivi Yojana”: PPP initiative for improving health of the poor, Highlighting the efforts of the Gujarat government to reduce the MMR and IMR, Mr. P.R. Sompura, emphasized the following. • To reduce IMR, MMR and increase institutional deliveries, private

gynaecologists have been engaged. • A package of 100 deliveries costs about 1.87 lakhs, which includes

complicated deliveries and caesarean sections. • BPL families are the beneficiaries and receive benefit of the scheme. • Six districts have been covered on pilot basis since May 2006. • Such schemes should be introduced for urban poor.

5. GROUP WORK ON DEVELOPING A MODEL CITY PLAN USING THE

SITUATION ANALYSIS OF THE CITY

To make the participants conversant with the process of developing a city level urban health care delivery plan, a group work was organized. The outline for the group work is annexed (Annex iii). The participants were divided into 3 groups based on similarity in terms of health infrastructure at the city level and the slum situation. Three case studies of

the cities for which UHRC has developed city level urban health programmes were shared with the group. Each group selected one city and had one facilitator from UHRC who was familiar with the city. The groups were asked to analyse the situation in the cities on the following issues: A. Slum Situation in the City: Describing the current situation of the urban poor

in the city as well as suggesting the possible solutions to improve the situation.

B. Health Service delivery: Describing the current status, the gaps and challenges and the options to address these challenges.

C. Community- Service Provider linkage: Describing the state of the coordination between the service providers and the service recipients.

D. Management Mechanism: Under this section, the mechanism for management of the health services was to be analyzed indicating the flaws and the plausible next steps for rectifying the flaws.

E. Sustainability: Suggesting ways and means as to how the urban health programme can be sustained.

AGRA Slum situation There are overall 393 slums in Agra with a population of 8.41 lakh. 215 slums appear in official lists and 178 are unregistered. Of the 393 slums, 183 are most vulnerable and 173 moderately vulnerable as revealed by the slum assessment exercise carried out by UHRC. Factors owing to which slum dwellers are not able to access primary and secondary services

Insufficiency of health centers, non availability of staff and service providers, lack of awareness and motivation among the slum communities, long distances and inconvenient timing of the health services and erratic earnings of the slum dwellers were identified as the major reasons for the poor health of the slum dwellers. Approaches for developing complete understanding of urban poor clusters A complete understanding of the health situation of the urban slums was identified as an important approach to make health care delivery to the urban poor more effective. Interactive sessions with the slum dwellers, mapping of the slums and a survey, based on a few key indicators, were considered to be good approaches to develop an understanding of the slum situation. Identification of slum areas and their relocation to appropriate areas was also a suggestion which evolved during the session. Present gaps in services, challenges in service delivery and suggested options for improvement Due to inaccessibility and inconvenient timing of the health services, health scenario in the urban poor dwellings is unsatisfactory. The suggestions for rectifying the above were provision 24 hours health services, mobile health services as well as improving outreach health services. Appointment of sufficient staff for health care delivery is also an important step to ensure better health for the slum dwellers. Partnering with NGOs and other stakeholders to achieve the above ends was also discussed as an important option. Promotion of IEC and BCC activities in the slums could be a vital approach. Options and approaches to strengthen health services With 15 first tier facilities in Agra city of 1.6 million population, there is a need for 17 new urban health centers (UHCs). It was also important to ensure a strategic location of these centers to improve accessibility. Provision of specialist care, mobile dispensaries, health cards and initiation of IEC activities were the other options which evolved as pertinent steps towards up-gradation of health services to the urban poor.

Community-service provider linkage Considering the poor community-service provider linkages, up-grading the existing system was considered an important option. Provision of staff, infrastructure, equipment and laboratory services evolved as important next steps. A situation specific health delivery system, followed by community mobilization with help from Self Help Groups evolved as an important strategy. Management mechanisms Due to the current segmented approach, effective management and coordination of the services was not achieved. It was realized that coordination along with convergent community action and a target based approach was important to achieve greater efficiency in health care delivery. Regular monitoring of targets was important to assess success and decide the future course of action. Organization of health awareness camps was also discussed as an important next step. Inter-sectoral coordination Currently insufficient, inter-sectoral coordination could be achieved through creation of a committee with representatives from all the stakeholder groups. Integration of services of departments such as the ICDS, water supply and sanitation is imperative for the same. Sustainability Proactive compassionate approach rather than a reactive approach was recommended for ensuring sustainability of the program. A Ward level committee in each slum cluster and a beneficiaries committee at the slum level would help ensure accountability of the key stakeholders and therefore infuse them with a feeling of responsibility. Group medical insurance, saving schemes and credit linked programs would help ensure greater financial security for the people. Encouraging partnerships with NGOs and other private providers came up as an important option. Introduction of housing programs and other related schemes such as Shram daan were also suggested. Mobilization of funds from the government, Urban Local Bodies, industrialists, NGOs and other funding bodies was considered important for ensuring sustainability of the program. Discouraging slum growth also came up as an important option.

SHAHDARA NORTH Slum Situation & Urban Poor Cluster According to the official lists the total slum population is 2,36,000 whereas identification through slum survey reveals that the approximate slum population is 21 lakhs living in 181 urban poor habitations. Access to Health Care Services: Challenges The main challenges identified are poor approach as well as the low community awareness and demand. Inadequacy of health facilities as well as effective referral mechanism is also an important challenge. Approaches to understand urban poor cluster A slum survey and regular updation of the slum list was identified as an important approach to better understand the urban poor clusters. Health Service Delivery: Existing situation Almost eight lakh population of Shahdara North does not have a dedicated first tier service. There is a mal-distribution of the health facilities with greater numbers in a concentrated area and lack of coverage in others. There are two second tier hospitals in the area and four maternity homes. Dearth of staff leaves some areas under-served. Outreach services are inadequate. Suggested options: Health Care Delivery: First Tier At the first tier level there is a felt need of 15 new facilities. Therefore provision of these would be helpful in reaching the urban poor with health services. Also convergence of services of the Government of National Capital Territory of Delhi and Municipal Corporation of Delhi is important for more effective healthcare delivery. Suggested options: Health Care Delivery: Second Tier Up-gradation of the existent second tier health facilities as well as establishment of newer facilities in partnership with charitable and private health care providers is a vital approach.

Community Service provider linkage The linkage between the community and the providers is not effective. The, Resident Welfare Association (RWA), link volunteers, NGOs and elected representatives should help strengthen this linkage. Management Mechanism The overlapping authorities and services due to lack of coordination among the various service providers and other stakeholders has led to ineffective health care delivery. It is imperative that coordination among all stakeholders be ensured. This could be made possible through a ward level committee involving the key stakeholders. Inter-sectoral Coordination Coordination among all the stakeholders should be achieved through establishment of various coordination committees such as the State level committee headed by the Principal Secretary (Health). This is important to ensure overall improvement in the health of the people whereby all the departments put in a concerted effort. Sustainability To ensure sustainability of the approaches, it is important to ensure regular monitoring and feedback at all levels of healthcare delivery as well as the community. Nominal user charges could be levied for provision of services. Integration of various programs to achieve coordination is important for effectiveness of the approaches. INDORE Slum Situation The city has 540 slums with 430 accounted for in official slum lists. The total urban slum population of the city is 7 lakhs. With most of the present slums located around the cloth mills, the slums are growing in other parts of the city as well. 153 slums, based on a slum vulnerability assessment exercise, are most to moderately vulnerable; with poor health indicators and services. Challenges The low sensitivity of the government to the needs of the slum population leads to poor reach of health services in these areas. Ignorance of the community also leads to poor demand of health services as well as the practice of sub-optimal health behaviors. Also the highly priced private secondary health services is out of reach of the poor urban slum dwellers.

Approach for understanding slum situation in a city Understanding the situation of the slums in terms of their current situation, their needs as well as the challenges faced by the health care providers and the community is important. This could be done organizing slum visits would be an important approach. It is important to map all the listed as well as the unlisted slums with the current facilities marked on the maps. This would help in targeting as well as better planning for health care delivery. Health Services in the City With only 23 Primary Health Centers, the primary level health services in the city are inadequate. Also the insufficiency of staff and equipment at the facilities makes the situation worse. This compounded with poor motivation of the health providers, long distance of the health facilities and poor referral linkages has caused further deterioration in the health of the poor slum dwellers. The private facilities too are highly priced and therefore unaffordable for the poor urban slum dwellers. Suggestions The existing health facilities should be upgraded, whereas, newer facilities should be established where the need is felt. Regular outreach services help ensure greater turn-over. Equipping the community with information about the existent government schemes for aiding health care delivery such as the Prasav Hetu Parivahan Yojana, Deen Dayal Antyodaya Upchar Yojana and Janani Suraksha Yojana is an important approach to create demand. Suitability of the timing of the health centers should be ensured. Community-Service provider Linkage: Current scenario and suggestions Dearth of community level functionaries to mobilize and create demand among the slum dwellers is a great handicap of the health system. By appointing more community level functionaries such as the ANMs or mobilizing groups from the community itself would help create demand and make people more aware of not only the existing health schemes but also the optimal health practices. Building capacity of the slum communities bears fruitful results and helps improve the health situation. Addressing other related issues such as water, sanitation, gender inequity and social evils such as alcoholism would help improve the situation in the slums. IEC activities should also be promoted for information dissemination.

Management Mechanism: Existing Health Systems/gaps and suggestions for improvement The lack of coordination and accountability in the current system has led to a poor management of the health and basic services. Coordination within the various departments with defined responsibility and accountability is important. Training of program managers for monitoring as well as organizing regular monitoring and review meetings is an imperative step which would help assess the current status and plan for future action and modify the existing programs based on the review. Appointing an Urban Health Program Officer on contractual basis would be helpful for achieving day to day coordination. Inter-sectoral Convergence Partnership and coordination among various departments and development programs such as health, education, sanitation, slum development, nutrition programs would help in convergence of resources and efforts for more effectively planned health care delivery. This could be done by creating a Ward level committee headed by the Ward Councilor There should be proactive efforts to partner with private/corporate sector to share equipment, hospital services and other resources Sustainability Institutionalizing government initiatives and establishing user’s committee with slum representatives and elected Ward representatives would be an important step towards ensuring the sustainability of the initiatives. The District Rogi Kalyan Samiti earmarking funds for slum health and harnessing financial assistance from GoI, state government, Municipal Corporations, Rogi Kalyan Samiti or local donors would help garner financial resources for sustainability.

6. PARTICIPANTS’ FEEDBACK ON THE SESSION ON URBAN HEALTH

The participants' overall reaction to the session on Urban Health was overwhelmingly positive, with many suggesting that a full day should be devoted for such sessions. The summary of feedback below is based on filled feedback forms from 36 participants.

a. Contribution of the session to help broaden and deepen understanding on urban health

All, except one participant, mentioned that the session helped broaden and deepen their understanding on urban health. The presentations, case studies, group work and its presentations and the reference material provided contributed immensely to exercise their thoughts on urban health and further understand urban poor issues.

b. Adequacy of time allotted for the session Majority of the participants (22) mentioned that more time should have been allotted for the session. The participants felt that more time devoted for discussions on the subject of urban slums would evolve other new ways and means to mitigate the problems of the slum dwellers and better coverage on all aspects. One of the participants mentioned that time should have been used more economically

c. Expansion of content for relevance and usefulness to administrators

There were varied responses on the content of the workshop. Some participants felt that the existing course structure was appropriate. They highlighted the following strengths of the content.

• Group study and presentations improved relevance • Action provoking • Opportunity in the form of syndicate groups for discussing case studies

was adequate to generate understanding on urban health programming. Besides the above strengths of the content of the workshop, a few suggestions to make it more succinct were pointed. They are the following:

• More information on topics such as solid waste management • Comparative study between urban and rural scenario • Provisions for urban poor under different Acts and schemes of

local/state/GoI • Urban administrative structure/system of different states • Empirical study of few upcoming cities to have proper proactive

approach towards urban health • Status of drinking water supply in slum areas • Correlation between women literacy and family health indicators of slum

dwellers

• More information on best practices/ success stories of slum improvement schemes/ urban health programs implemented in the country as well as globally

• Public private partnership initiatives • Approaches for up-gradation of health facilities, • Effective use of RTI Act 2005 by slum dwellers • Possible options to protect slum dwellers indulged in hazardous jobs • The participants also felt that a visit to any Municipal Corporation such

as Delhi or slum visits and interactions with slum dwellers would also be meaningful.

d. Topics on which participants would like to receive more detailed information While one participant mentioned that the information provided is exhaustive, most other participants indicated that they would like to get detailed information on the same topics that they suggested to be included in the course content to make it more relevant to Administrators. Some areas/topics not mentioned above were (i) Data on IMR, MMR, civil legislation of birth and death, epidemics for slum areas to have focused targets for improvements, (ii) Converting used plastic bags and any used plastic goods into good public use, (iii) Ways and means for controlling the growth of slums may be taught; the details of slums at various places and remedial measures to discourage further growth of slums, (iv) Trends on current scenario in India and developing nations about non-metro urban poor, (v) Existing schemes in the health sectors , (vi) CD showing pre-project &post-project situation in a successful slum development project, (vii) Some lectures on international organizations which are involved in funding education and health related programs for urban poor, and (viii) Community health issues like HIV/AIDS other and issues related to urban health in slum areas, and safe motherhood, livelihood of slum dwellers and family planning interventions in slum areas. e. Application of approaches in respective states/cities Almost all participants’ responses indicated that they were geared up to apply learnings from the session in their respective states/cities. Two participants mentioned not having any slums in their state but they found the session very informative and useful should the state encounter growth of slums in future. Following are the approaches, participants mentioned, they would apply in their respective states/cities. Awareness building among slum dwellers through public-private partnerships,, SHG approach, involvement of stakeholders including the community, promotion of community leaders, empowering slum dwellers to improve the public health scenario through improved extension services.

• Inter-sectoral coordination/Coordination committees, and funds and activity convergence; effective committee formation with borough chairman/councilor as chairman.

Overall comments on the workshop ‘The workshop has created awareness and sensitized all the administrators on how to address the urban health problem which might have an impact on the population at large’. ‘Informative, case study group discussion were good, more time should be allotted, more information and data, comparative facts and figures of slum areas of main cities of every states’. ‘Immensely useful; Growing urbanization - so more concerted efforts needs to be exercised’ ‘Good job done by UHRC team within available time’ ‘Excellently outstanding and deserves appreciation. Hats off to the learned resource persons’. ‘Well organized. The reading material however should have been given at least a day ahead of the date of the workshop.’ ‘Very good, an eye opener, gave lot of insights for handling urban health programmes’. We have been amazingly sensitized to problems of health of slum dwellers of cities in the country” “So far I had the focus on rural health only, only this time I heard the term “UHC”; despite Municipal Corporation, municipal support, the slum dwellers need more attention”

• Better informed and participatory planning (involving all key stakeholders including the community) and strict monitoring for successful operation of schemes in urban areas

• Continuous monitoring of health indicators in the slums • Solid waste management, underground drainage system, provision of

basic amenities like water and sanitation. • Participatory approach for mapping of slums, identification of slums and

problems faced by them. • Creation of a sustainable social security system . • Improving health service delivery to urban poor by organizing the

multiple health care providers under one umbrella and stepping up efforts to provide more preventive and curative services even in remote and difficult to reach areas. Provision of mobile facilities would be useful.

• Sensitization of service providers, government, as well as NGOs • Involving all the key stakeholders in the process of slum development

and rehabilitation to infuse them with a sense of ownership and responsibility.

• Improving the overall conditions in the slums by making available more education and job opportunities for urban slum dwellers.

Annex i 101st Induction Course for IAS Officers

Workshop on Urban Health Lal Bhadur Shastri National Academy for Administration, Mussoorie

Round of introductions [11.30 to 12 noon] With your name, please mention one aspect of public health or deve lopment that you wish to improve as an administrator Presentation on Why Urban [12 noon to 12.10] Broader group discussion on urban health programming respective states and key challenges [12.10 to 12.45] What has been the focused effort on urban health in your respective states and one key challenge in implementing urban health programmes Case Study Discussion: [12.45 to 1.45] Each group is requested to analyse the situation in the assigned city based on the short report and the map with respect to the following aspects.

A. Slum Situation in the City: 1. Current Slum Situation in the City:

a. Number and population of under-served slums and urban poor clusters in the city

b. Factors owing to which urban poor are not able to access a) primary and ii) secondary services

2. What approaches will be effective for developing a complete understanding of urban poor clusters in a city?

B. Health Service delivery: a. First Tier (Primary level)services b. 2nd Tier Services c. Referral linkages d. Regular Outreach services for vulnerable slums of the city

1. Current Situation: What are the present gaps in services and challenges in service

delivery: (e.g. facilities concentrated in certain areas, lack of manpower and health infrastructure, poorly defined catchment areas for health posts, clus ters or uner-served or un-served population)

2. Suggested Options and approaches to strengthen health services: What can be the approaches for a) strengthening services and b) addressing Gaps. Is there a role for PPP, NGO involvement

C. Community- Service Provider linkage and Capacity of slum community to

access service and improve health 1. Current Situation and challenges 2. Suggested Options for strengthening linkages of slum community with health

services

D. Management Mechanism: 1. Current Situation and Gaps

a. What are the present challenges and issues with respect to the management of the urban health program in the city?

2. Suggested Options for setting up efficient management mechanism for an effective urban health program

b. What can be the ways to strengthen the program management: i. To improve accountability

ii. To ensure outcome based health program to reach the underserved iii. To strengthen management capacity at the city level

c. Suggest options to effectively involve the Urban Local Bodies in the management of the health care delivery system in the context of the 74th Amendment.

E. Inter Sectoral Coordination 1. Current Situation and Gaps

a. What are the existing Intersectoral coordination forums / committees in the city?

b. Is the existing mechanism able to adequately facilitate Intersectoral convergence to ensure required services to the urban poor

3. Suggest options for more effective Intersectoral coordination at city and ward / UHC level.

F. Sustainability

a. Kindly suggest ways and means as to how the urban health programme can be sustained

b. Programmes from which funds can be dovetailed for urban health

Suggestions and Steps for energizing urban health programmes in your respective states and Cities

Preparation of Group Work Outputs [2.15 to 3.15 pm] Presentations by three sub-groups (10 min each) and discussion

[3.15 to 4.15]

Concluding remarks/feedback from participants [4.15-4.30]

Annex ii

Annex iii

Suggested Outline for Case Study Discussion Each group is requested to analyze the situation in the assigned city based on the short report and the map with respect to the following aspects.

G. Slum Situation in the City: 1. Current Situation in the City:

a. Number and population of under-served slums and urban poor clusters in the city

b. Factors owing to which urban poor are not able to access a) primary and ii) secondary services

2. Suggested Options and approaches to improve health services for the urban poor: • Please identify the program related challenges with respect toa the above • Please suggest approaches to address these challenges in terms of planning

and implementation.

H. Health Service delivery: a. First Tier (Primary level)services b. 2nd Tier Services c. Referral linkages d. Regular Outreach services for vulnerable slums of the city

3. Current Situation: What are the present gaps in services and challenges in service

delivery 4. Suggested Options and approaches to strengthen health services: What can be the

approaches for a) strengthening services and b) addressing Gaps. Is there a role for PPP, NGO involvement

I. Community- Service Provider linkage and Capacity of slum community to

access service and improve health 4. Current Situation and challenges 5. Suggested Options for strengthening linkages of slum community with health

services J. Management Mechanism: 1. Current Situation and Gaps

a. What are the present challenges and issues with respect to the management of the urban health program in the city?

2. Suggested Options for setting up efficient management mechanism for an effective urban health program

b. What can be the ways to strengthen the program management: i. To improve accountability

ii. To ensure outcome based health program to reach the underserved iii. To strengthen management capacity at the city level

c. Suggest options to effectively involve the Urban Local Bodies in the management of the health care delivery system in the context of the 74th Amendment.

K. INTER SECTORAL COORDINATION 1. Current Situation and Gaps

a. What are the existing Intersectoral coordination forums / committees in the city?

b. Is the existing mechanism able to adequately facilitate Intersectoral convergence to ensure required services to the urban poor

6. Suggest options for more effective Intersectoral coordination at city and ward / UHC level.

L. Sustainability

a. Kindly suggest ways and means as to how the urban health programme can be sustained

b. Programmes from which funds can be dovetailed for urban health

M. Suggest options and mechanism for partnership with private/ charitable and NGOs for strengthening service delivery and community capacity

Steps at the State and City level: Key Priority actions

Annex iv a

Annex iv b

.

Annex iv c

Annexure v: LIST OF PARTICIPANTS

S.No. Participant’s name/present posting Address

Telephone numbers office/residence/fax/mobile

and e-mail

1

G.G. Saxena, General Manager (Personnel), Prasar Bharati Corporation, (Ministry of I&B), PTI Building, 2nd Floor, Parliament Street, New Delhi-1100001

D-1434, 3rd Floor, East of Kailash, New Delhi-1100065

011-23352543 (O) 011-26414106 (R) 9810603010 (M) ggsaxena@gmail.com

2

S.P. Dixit, Collector & District Magistrate , DIU-362520

Government House & Collector’s Residence, DIU

02875-252111/252444 (O) 02875-252222/252176 (R) 02875-252333(F) 9824460377(M)

3

Dr. B S Banerjee, Secretary, Rural Development, Panchayat & Cooperative, Civil Secretariat, Itanagar-791111 Arunachal Pradesh

102, Circuit House, Itanagar-791111 (Arunachal Pradesh)

0360-2212451 (O) 0360-2292715 (R) 0360-2212451 (F) 9436040022/9868281006(M) drbsbanerjee@hotmail.com drbsbanerjee@yahoo.co.in

4

B. Pertin, Secretary, Urban Development and Housing, Government of Arunachal Pradesh, Itanangar (Arunachal Pradesh)

Vivek Vihar, VIP Colony, Itanagar-791111 (Arunachal Pardesh)

0360-2214236 (O) 0360-2292715 (R) 094360775 (M) 09436040980 (M)

5

Hage Bhatt, Deputy Commissioner , Changlang District, Changlang Arunachal Pradesh

Deputy Commissioner’s Residence, Changlang District, Changlang Arunachal Pradesh

03808-222221 (O) 03808-222224 (R) 03808-222226 (F) 9436057001 (M)

6

TT Gamdik, Director (RR&DM) Govt. of Arunachal Pradesh, Itanagar

Vivek Vihar, Qtr. 11 Type V, Itanagar Arunachal Pradesh

0360-2212282 (O) 0360-2290778 (R) 9436042710 (M)

7

Shri. M Jagan Mohan, Joint Collector, Vizianagaram Andhra Pradesh

Flat no. 205, Keerthi, Kuteer Apartments, Himayatnagar, Lane no. 16, Hyderabad

08922-276902 (O) 040-23262919 (R) 9441272277 (M)

8 B. Ramaiah, Joint Collector,

0861-2331644 (O) 0861-2331724 (R)

Nellore Andhra Pradesh

0861-2331839 (F) 9849904052 (M)

9

RN Sharma, Secretary, Environment & Forest, Government of Assam, Dispur, Assam

Alok Path, Lichubagan, Khamapara, Guwahati-22

03612260784 (O) 03612360426 (R) 9435403772 (M)

10

Hemenga K Sharma, Dy. Commissioner, Govt. of Assam, Kokrajhar Assam

Dy. Commissioner’s Residence, Korakjhar

03661-270741 (O) 03661-270740 (R) 9435027330 (M)

11

A B Md Eunus, Director, Industries and Commerce Department, Govt. of Assam, Dispur

Durgasarobar, Guwahati-781009

0361-2550242 (O) 0361-2541929 (R)

12

Freeman Kharlyngdoh, Deputy Commissioner, East Garo Hills District, Williamnagar Meghalaya

Mawlai Kynton, Massar, Block C, Shillong-793001, Meghalaya

03658-220226 (O) 0364-2550226 (R) 09436102305

13

Lawanda Diengdoh (Smt.) Director, Social Welfare Department, Government of Meghalaya, Shilong, Meghalaya.

Malk I, Kharmalk I Shillong-793001 Meghalaya

2225187 (Telefax) 2210652 (R) 9236103818 (M)

14

Renilla D. Marak (Smt) Deputy Commissioner, South Garo Hills District, Baghmara Megahalaya

Matchakolgre, PO Araimile, Jura, West Garo Hills-794102

03639-222292 (O) 03639-222226 (R) 03651-233720 (Tura) 9436111044 (M)

15

DH Brahmbhatt, Collector, Panchmahals, Godhra-389001, Gujarat

Collector and DM Bungalow, Godhra Panchmahals.

02672-242800 (O) 02672-242900 (R) 09427306217 (M) collector-pan@gujarat.gov.in

16

RS Patel, Joint Secretary, Government of Gujarat, Revenue Department, Sachivalaya, Gandhinagar.

41, Bhagwat Bungalows, S. Ghiehway, Gota, Ahmedabad.

079-23251527 (O) 079-2774275 (R) 9427622195 (M)

17 DG Jhalavadia, Collector and DM 02692-242871 (O)

Collector, Anand, Gujarat

Bungalow, Imra Road, Anand, Gujarat

02692-261000 (R) 02692-241575 (F) 9427306203 (M) collector-nd@gujarat.gov.in

18

PR Sompura, District Development Officer, Banaskantha-Palanpur, Gujarat

D.D.O’s Bungalow, Palanpur

02742-254060 (O) 02742-253029 (R) 02742-252063 (F) 9426515222 (M) p-r-sompuraias@yahoo.com ddo-ban@gujarat.gov.in

19

AK Garyali, Joint Financial Commissioner (Revenue), Govt. of Jammu & Kashmir, Srinagar, Jammu

E-7, Bahu Apartments, Panama Chowk, Jammu (J&K)

2430461 (O) 9419101728 (M)

20

Yedullah, Special Secretary, Finance Department, Govt. of Jammu and Kashmir, Srinagar.

Shah Anwar Colony, By Pass West, Hyderpur-190014

0194-2950160 (O) 0194-2442965 (R) 09419002368 (M) yedullah@gmail.com

21

Sahajanand Sharma, Special Secretary cum Director, Employment and Training, Govt. of Jharkhand, Ranchi.

778, Sector II, HEC Colony, Dhurwa, Ranchi.

0651-2491424 (O) 9431916592, 9421107369 (M)

22

Kanhaiya Pandey, Additional Secretary, Planning and Development Department, Govt. of Jharkhand, Ranch

D6/18 (New), Doranda, Ranchi.

0651-2490653 (O) 0651-2490617 (F) 9431337833 (M)

23

Ravishankar Jaipuriar, Additional Secretary, Department of Health and Family Welfare, Govt. of Jharkhand, Ranchi

E-4, ATI Quarters, Meurs Road, Ranchi.

0651-2490649 (O) 9431157036 (R) 0651-2490314 (F) rsjaipuriar@yahoo.co.in

24

NS Chanappa Gowda, Chief Executive Officer, Zila Panchayat, Mysore District, Mysore

No. 658, 11th Cross 7th Main Micro- layout, BTM IInd Stage, Bangalore-560076

0821-2330316 (O) 0821-2330513 (R) 9845655554 (M) cgwda@yahoo.com

25 Dr, V Chandrasekar, Deputy 08262-230401 (O)

Deputy Commissioner & DM, Chickmanglur District.

Commissioner’s Bungalow. Chickmanglur District.

08262-230402 (R) 9880200117 (M) dcckmlr@sancharnet.in

26

K. Vishwanatha Reddy, Deputy Secretary, Housing Department, Karnataka Government Secretariat, Room no. 208, IInd Floor, Vikasa Soudha, Dr. Ambedkar Veedhi, Bangalore-560001

No. 3 A, Walker Lane, Richmond Town, Bangalore-560025

080-22255878/22034501/22034502 (O) 080-22276699 (R) 080-22253718 (F) kv_reddy53@yahoo.co.in

27

S Dayashankar, Joint Commissioner of Commercial Taxes (Intellligence), South Zone, Vanijya Therige Karyalaya-2, Near National Games Village, 80 Feet Road, Viveknagar Post, Koramangala, Bangalore-560047

S. Dayashankar, House No. L-70 XIth Sector, 95th B Main, 10th Cross, LIC Colony, Jeevan Bheemanagar, Hal IIIrd Stage, Bangalore

080-25704971 080-25273469 (R) 9880112200 (M) jcctintsz@yahoo.com

28

Shivanand Dubey, Collector, Shajapur (Madhya Pradesh)

Collector’s Residence, Shajapur.

07364-226500 (O) 07364-228600 (R) 9425084444

29

MH Sawant, Dy. Secretary, Deptt. of Agriculture, Govt. of Maharashtra, Mumbai

Ch. Shivaji Corp. Housing Society, CS No. 270/B/1, Shivaji Nagar, Pune-411016

22025963 (O) 25674128 (R) 9881371957 (M)

30

HK Jawale, Joint Commissioner of Sales Tax, Enforcement Division-B, MS, Room No. 504, 5th Floor, Vikrikar Bhawan, Mazgaon, Mumbai-400010

8, Kedar Babubhai Chinoi Road, Behind LIC Building, Churchgate, Mumbai-400020

022-23732468 (O) 022-22886454 (R) 9819788388 (M)

31

M. Chandrashekharan, Public Department, Govt of Tamil Nadu, Chennai

33, Duraisamy, Naikar Street, Dharampuri, Tamil Nadu-636702

9443773710 (R)

32

V. Chandrasekharan, Deputy Secretary, Environment and Forest Department, Secretariat, Chennai.

Plot No. 38, Mahatama Gandhi Street, VGN IV Phase, VGN Nagar, Nulumbur, Chennai-50

25671042 (O) 65377678 (R) 9444174485 (M)

33 VM Xavier Chrisso Flat No. B-1, Door 044-28583323

Nayagam, Additional Director of Agriculture, Govt. of Tamil Nadu, Cheepauk, Chennai-5

No. 9 & 10, Santhome High Road, Mylapore, Chennai-4

044-28544730 044-24661122 (R) 9894685111 (M) xaviernayakam@yahoo.com

34

Abhijeet Chaudhuri, Member Secretary and Project Director, Sundarban Development Board, Department of Sundarban Affairs, Mayukh, 1st Floor, Bidhannagar, Kolkata-700091

HA-333/4, Salt Lake City, Sector III, Kolkata-97

033-23344252 (O) 033-23584300 (R) 9433021032 (M)

35

Sailendra Krishna Das, Additional District Magistrate & DLLRO, Murshidabad, West Bengal.

12 K, Samar Sarani, Kolkata-700002

03482-251173 (O) 033-25580347 (R) 9831542867 (M) 03482-251173 (F)

36

Smt. Sharmishtha Ghosh, Additional District Magistrate, Murshidabad, West Bengal.

6/2, Rajghat Lane, Ganga Villa, PO Serampore, District Hooghli

03482-250389 (O) 03482-251550 (R) 033-26623092 (R) 03482-261800 (F) 9434859728 (M)

37

Uday Shankar Nandi, Additional District Magistrate, Bankura, West Bengal

18/7 SP Colony (W), Plot No. 195 (1st Floor), Block J, N. Alipore, Kolkata-53

03242-250355 (O) 033-24007589 (R) 03242-250795 (F) 9474142052 (M) nandy-uday@rediffmail.com

Annex vi

Urban Health Workshop Feedback Form 1. How has the session helped broaden and deepen your understanding on Urban

Health? _______________________________________________________________________ _______________________________________________________________________ 2. Should more time have been allocated to the session? 3. What else in your opinion should be included in the content to make the session

more relevant to you as an administrator? _______________________________________________________________________ _______________________________________________________________________ 4. Kindly let us know any topic on which you would like to receive more detailed

information? _______________________________________________________________________ _______________________________________________________________________ 5. Please mention two key items/approaches which you would apply in your

States/cities? _______________________________________________________________________ _______________________________________________________________________ 6. Overall comments regarding the workshop for Urban Health Programming _______________________________________________________________________ _______________________________________________________________________