PUBLIC HEALTH FOUNDATION OF INDIA

Innovative Ways to Meet Health Challenges of Urban India

A White Paper
Radhika Arora, Sourav Neogi, Madhavi Misra September 2011

Acknowledgement
We thank John D. and Catherine T. MacArthur Foundation for their support towards this project. We also sincerely thank Professor J. K. Satia for his inputs and guidance towards the development of this white paper. We would like to acknowledge the contributions by Dr Sanghita Bhattacharya, Dr Raj Panda and Dr Sutapa B Neogi to this paper.

I. INTRODUCTION CONTEXT In the year 2000, countries across the world agreed to work towards a set of Millennium Development Goals (MDGs). For India, this meant reducing the maternal mortality ratio (MMR) to 109 per 100,000 live births and infant mortality rate (IMR) to 27 per 1000 live births (MDGs 4 & 5). At its current rate of progress, with an MMR of 254 (SRS 2006-09) and IMR of 50 (SRS, 2009), India is off-track towards achieving the targeted MDGs. In 2005, the Government of India launched the National Rural Health Mission (NRHM) to rejuvenate the health care delivery system towards improving the availability and access to quality health care services. The Mission enabled State Health Departments and NGOs working in the health sector to innovate programmes and strategies to tackle the problem of Indias high MMR and IMR rates. At the same time, civil society organizations with the support of donors also used innovative practices to improve MMR and IMR in the country. While there have been some improvements in the MMR and IMR rates in the country, the pace of decline isnt fast enough to meet the MDGs. One of the reasons for the uneven results in improved healthcare indicators across the world has been attributed to the inability of large-scale application of effective interventions, especially in areas such as maternal care (Cash, et al., 2011). An urgent need was felt to strengthen competencies by documenting the innovations in MCH and youth reproductive health which have been piloted in different parts of the country. Appropriate dissemination of these documented case studies would also aid State health personnel and NGOs to use existing knowledge to address health challenges.

THE STUDY It was in this context that a landscape analysis, to create a directory of innovative approaches towards improving maternal and newborn health in India, was undertaken by the Public Health Foundation of India (PHFI). The aim of creating such a database was to use the information to develop detailed audio-visual case studies of select innovations which indicated a potential for scaling-up. Many of these innovations including those under NRHM succeeded in providing promising results in addressing the health needs of the local populace.

A directory of 204 innovations addressing maternal, newborn and adolescent health, as well as family planning was compiled. Out of these 11 innovations specifically targeted urban populations (see Figure 1). This paper discusses four innovations from the directory which target urban populations to reduce maternal and infant mortality and improve youth and adolescent health, as well as discusses their potential for scale-up. These innovations are being documented as documentary films accompanied by print case studies as part of the study.

Figure 1 : Number of Innovations Addressing Maternal and Child Health in Urban and Rural India. Source: Developing Case Studies of Innovations in Public Health for Competency Strengthening and Advocacy. PHFI-MacArthur Foundation, 2011

II. STUDY METHODOLOGY The study began by compiling a database of innovations addressing maternal, child and youth reproductive health in India. The database was built using various sources of information, such as existing directories of innovations, contacting central and state Government bodies and health departments, non-government bodies and civil society initiatives. Internet searches, phone calls and leads from a number meetings, seminars and conferences have contributed towards additions to the directory. An expert committee on the project consisting of Government representatives, academicians, civil society and NGO members also contributed significantly towards adding innovations to the directory. Shortlisting innovations Of the 204 innovations listed in the directory, 41, innovations were selected and shortlisted for indepth documentation based on a selection criterion developed with the help of the expert committee. Each innovation in the directory was judged on its impact, portability, utility, uniqueness and cost effectiveness before selection for further review. For the purpose of audio-visual documentation, 22 innovations were selected out of the 41 innovations. This paper focuses on 4 of the 22 innovations which directly address maternal and child health and youth reproductive health in urban India.

III. ISSUE OF URBANIZATION AND ITS IMPACT Urban population across the world is growing rapidly. In a projection done in 2005 by the United Nations, it was estimated that more than half of the population in developing countries will be living in urban areas. From 2000 to 2030, the world's urban population is projected to grow at an average annual rate of 1.8 percent, nearly double the rate expected for the total population (United Nations, 2005). Population growth will be particularly rapid in urban areas of less developed regions, averaging 2.3 percent per year during this period; almost all of the world's population growth is expected to take place in urban areas of less developed regions. Globally, the level of urbanization is expected to rise from 50 percent in 2008 to 70 percent in 2050 according to a UN Population Division report (2005). In India, the Planning Commission estimates the below poverty line (BPL) population in urban India comprises of 25.7 percent of the urban population (2004 -05). According to the NFHS-3 (Report on Health and Living Conditions in Eight Indian Cities, 2009) this rapid population growth in urban areas has caused a host of serious problems, including overcrowding, degradation of the environment, the development of slums, disparities in living conditions and access to services, thereby increasing the vulnerability of urban populations, particularly the urban poor, to diseases and poor health. Poor people in urban areas of developing countries face a daily struggle to meet their basic needs for shelter, food, water, education, and health. The Government authorities are hard pressed to cope with this 'new urban revolution', in light of the explosive growth of cities. Given the problems caused by rapid urbanization and migration to urban areas, in developing countries such as India, addressing maternal and newborn health along with youth health is imperative to improve health indicators. Effective dissemination and advocacy are one of the elements of an effective scale-up strategy (ExpandNet Framework for Scaling-up, Cash, et al, 2011). Through audio-visual documentation along with detailed print material of these examples of successful innovations in the areas of maternal, newborn and youth health, the study hopes to disseminate the findings to a larger audience which

would include medical and public health professionals as well as policy makers in the next phase of the study. The next section explores four initiatives from the PHFI study that have the potential to be further replicated nationally to meet the needs of the urban poor in terms of maternal and child health and improve health of youth and adolescents.

IV. ADDRESSING MATERNAL AND NEWBORN HEALTH IN INDIA THROUGH INNOVATIONS a). Sambhav Voucher scheme under PPP initiative Improving Access to Healthcare Services for the Urban Poor In India, lack of wide-scale use of formal health insurance, inadequate social safety nets and public health facilities lead to high out-of-pocket (OOP) expenditure on health, often making healthcare services inaccessible to the poor (Roy et al., 2007). In addition, public sector spending is low on health services and this result in over-dependence on private sector for accessing health services (Rao et al., 2005). The private sector contributes to 78.5 percent of the total health care expenditure, with out-of-pocket expenditures contributing to over 71.12 percent of the total sources of funds towards accessing health care (National Health Accounts, 2004-05). Initiatives through public private partnerships (PPP), such as the Sambhav Voucher Scheme are an innovative way to harness the resources of the private sector, as well as, increase access to quality healthcare services. The innovative approach involves the Government paying private providers for maternal health services rendered to those below the poverty line. Where implemented, State Governments have empanelled private hospitals to provide institutional deliveries free of charge to the poor. This is especially useful in urban areas, where there is a strong presence of private sector, giving the urban poor the opportunity to avail quality maternal health services from private hospitals under the scheme, thereby improving their access to healthcare services in the case of maternal health. The Sambhav Voucher Scheme was created under the Innovations in Family Planning Services (IFPS) project, along with the Government of India (GOI) and the United States Agency for International Development (USAID). The Sambhav voucher scheme has been documented through this project in the state of Uttarakhand where this PPP intervention is a part of a mainstream approach to improve reproductive health care. The goal of the voucher scheme is to reduce inequities in reproductive health care by enabling access to services, while empowering the below poverty line (BPL) population to choose their own provider. The model is set to reduce financial barriers in accessing health, and by default, increase BPL use of private hospitals. An overview of the services the scheme offers are: antenatal care (ANC), post natal care (PNC), new born care, sterilization, oral contraceptive pills, condoms, IUCDs, institutional deliveries including complications. Initial response to the scheme during our interactions with beneficiaries as part of the documentation process indicated a sense of empowerment among the recipients of the vouchers. For most, this was the first time they had the resources and option to access private health services; using vouchers, instead of BPL cards further enhanced the experience of utilizing private healthcare facilities.

b). Adolescent clinics - Initiatives towards improving youth health in urban areas Young people, between the ages of 10 and 24 years, account for almost 30% of Indias population with the majority of them between the ages of 10-14 year (Dr Rajesh Metha, 2011). For adolescents, the transformation from childhood to adulthood, the physical and mental development brought on by puberty, along with restricted access to information, presents a range of challenges that makes them vulnerable to misinformation and leave them at an increased risk of contracting RTI/STIs, including HIV/AIDS, tobacco and alcohol abuse, sexual violence, reproductive and sexual health issues among other things. For young people living in urban areas, especially those from a lower socio-economic background, the problems are exacerbated by their living conditions and lack of access to correct information. It was realized that while specialized care exist for children up to the age of 12 years and adults, there was a lack of targeted care for one of the most vulnerable age groups (Dr Rajesh Mehta, 2011) - that of adolescents. The needs of the adolescent population extend beyond clinical services towards psychosocial care and access to information. The first adolescent friendly health services were created in the form of adolescent clinics a concept which was already in existence in other parts of the world. The Safdarjung Hospital Adolescent Healthcare Network (SHAHN) was one of the first attempts by the Government of India, with support of the World Health Organization towards creating an adolescent clinic in the country. The physical setting of the clinic ensures access to referrals and counselling by medical professionals from other departments: gynaecology, psychiatry etc. Similar clinics were established in other tertiary care hospitals in urban areas in other parts of the country. NGOs such as Mamta, with technical and financial support from donors such as SIDA run more a localized adolescent healthcare center in the urban slum of Tigri in Delhi. The clinic, called Friends Clinic focuses on the needs of the local youth population provides clinical and counselling services. Catering to a specific socio-economic clientele the clinic also provides a space for young people to gather, meet and explore a world beyond theirs. A mix-of the above two types of adolescent clinics are the Anwesha Clinics of West Bengal which are operated at the block level and provide primary healthcare services, along with counselling and psychosocial support through their clinics and outreach services to middle-schools in more remote areas. The adolescent clinics are not operated on a daily basis; the establishment of the clinics is supported by outreach initiatives to help generate awareness and create demand for utilization of these services. Interactions with young people utilizing services at the Friends Clinic and Anwesha Clinic highlight the difference that these adolescent clinics have made to their lives. For many the clinics have provided access to clinical and reproductive health services as well as information services which were previously almost completely inaccessible to young people. The clinics have also created awareness among the society on the importance of reproductive, sexual health bringing about a larger social change.

c). Life Spring and Merry Gold Hospitals A low cost, high quality Maternal Health service in urban India In most of urban India, public hospitals are overburdened and space in delivery rooms is limited, affecting the quality of care. Besides quality of healthcare services and patient satisfaction, a womans right to privacy is often not taken into consideration. High costs make private healthcare facilities out of reach for the urban poor, often pushing those who can afford some private healthcare services into poverty. Healthcare infrastructure in cities of urban India has not been able to keep pace with the fast growing urban population and its requirements, especially in terms of affordable health care. With this background, Hindustan Latex Family Planning Promotion Trust (HLFPPT) with support from the Acumen Fund, set up the first low cost, high quality hospital for maternal health called Life Spring at Hyderabad in 2005. Since then, Life Spring has opened nine such facilities in and around the city of Hyderabad. Life Springs business model of low cost and high quality care has been discussed widely. Small innovative system changes help to reduce costs, such as nurses doubling up as receptionists as well as administrators, gynaecologists which work as consultants and not full time doctors. Life Spring hospitals refer all complicated cases at the very beginning and depends entirely on the EMRI ambulance facility in time of need, thus reducing costs of maintaining its own ambulances. Each Life Spring hospital caters to the community within its 5-7 km radius and is usually in established in rented accommodation such that no cost on capital infrastructure is uncured (Mr Anant Kumar, 2011). Multi-speciality hospitals Hyderabad charge upto Rs. 80,000/ per delivery, however the cost at LifeSpring are nearly one tenth, where the most expensive rate is of Rs 9,000/ for a five day stay in hospital after a caesarean section for delivery. The regular delivery charges are approximately Rs 4,000/ which include two-day stay at hospital. Merry Gold Hospitals, set up by HLLFPPT, is another similar example which has seen the setup of nearly 70 district level franchised hospitals and 700 merry silver clinics in Uttar Pradesh. Here, the franchised hospital is provided with branding facility and outreach workers who bring patients from catchment area to the hospitals and the hospital cannot charge more than the specified, subsidized amount from the patients. The cost for regular delivery is Rs 1,999/ and that of a caesarean section is Rs 6,999/.

d). Quality Assurance Programmes (QAP) Underlying all innovations to improve quality of care The issue of quality underlies all innovations addressing maternal and child health in urban areas that are being discussed in this paper. Quality interventions are especially relevant in the context of the current policy focus on improving maternal and child health in India through incentives encouraging institutional deliveries, which resulted in an increase in institutional deliveries from 40.7% in 2005-06 (NFHS-3) to 72.9% in 2009-10 (UNICEF, 2009). The rise in numbers of institutional deliveries led to challenges in the quality of care at healthcare facilities. Quality of care includes three elements (Donabedian, Hulton et al.) 1. Structure: This includes physical and human resources, covering issues of infrastructure, equipment as well as ensuring adequate numbers of qualified personnel 2. Process: This would include competency and efficiency of care 3. Outcome: This would be the resulting outcomes measured by clinical outcomes (such as reduction in mortality figures) as well as level of satisfaction with care One innovation being documented in-depth as part of this project is the Quality Assurance Programme (QAP) which focuses specifically on the issue of quality in the context of maternal and newborn health services in public facilities in some states in India. The innovation, implemented in 6

state of West Bengal, was initiated as a pilot programme in 2007 by the GTZ (now Deutsche Gesellschaft fr Internationale Zusammenarbeit). At the time, the program focused on covering issues of quality at primary and secondary healthcare facilities such as improving bio-medical waste management and improving administrative processes. The pilot programme resulted in improved ANC check-ups, reduced infection, and better hygiene maintenance among other improvements. The Government of West Bengal under the guidance of Ministry of Health and Family Welfare/ NHSRC is now in the process of scaling-up the program across public hospitals in West Bengal. While the project in West Bengal is in its first Phase of implementation, a similar initiative at the Puri District Hospital in the State of Orissa was completed recently. Based on the results of the intervention at the Puri District Hospital it was realized that quality assurance programs which aim to improve the overall functioning of health facilities in terms of infrastructure, equipment, human resources and also ensure that the process of providing care is as per as standard norms, if implemented well can lead to good clinical outcomes.

V. CONCLUSION AND RECOMMENDATIONS The innovations discussed in this paper showed successful results in their pilot phases and have been subsequently replicated in other settings with context specific modifications to the initial model. The four innovations discussed here may be used as examples of innovations which were successful in the areas of their implementation and later taken forward with relevant changes to be implanted in other settings. Dissemination of documentation using the correct tools such as training, technical sessions and policy dialogues should be used with the correct audiences. Often, lessons learnt from successful innovations get lost because not enough focus is laid on advocating and supporting scaling-up of the intervention. Scaling-up of successful innovations has been recommended as one of the ways to accelerate efforts towards achieving health and development goals. This paper recommends looking at different ways of scaling-up the innovations addressing urban health needs, specifically maternal health. For effective scale up, advocacy is a useful tool especially with policy makers and programme implementers. Innovating is essential to keep pace with the changing demographics of a country undergoing rapid economic and social change such as India. It is only through due recognition of successful initiatives in the areas of health, that innovative approaches to improving healthcare for the masses will be given the right environment to germinate and grow. This white paper is our attempt to lay emphasis on the importance of thorough documentation and scale-up of successful innovative practices.

References Adolescent Fact File, Available at http://www.who.int/features/factfiles/adolescent_health/ en/index.html Based on unpublished results from field work conducted in 2011 Cash et al., From One to Many: Scaling-Up Health programmes in Low Income Countries, (Dhaka: The University Press Limited, 2011) Cash et al., From One to Many: Scaling-Up Health programmes in Low Income Countries, (Dhaka: The University Press Limited, 2011) Central Bureau of Health Intelligence, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Available at http://cbhidghs.nic.in/ Accessed on 23 September 2011 IIPS & Macro International, National Family Health Survey 3. Volume II. Mumbai: IIPS; 2007. Interview with Dr Rajesh Mehta WHO-SEARO Unpublished transcriptions of interviews from field research, 2011 Interview with Mr Anant Kumar, Life Spring Hospitals Unpublished transcriptions of interviews from field research, 2011 Kakoli Roy and David Hill Howard, Equity in out-of-pocket payments for hospital care: Evidence from India, Health Policy Volume 80, Issue 2 (2007), Pages 297-307 Millennium Development Goals, Available at http://www.un.org/millenniumgoals/ accessed on 23 September 2011 National Family Health Survey (NFHS-3), Health and Living Conditions in Eight Indian Cities. Ministry of Health and Family Welfare, Government of India 2005-06 National Health Accounts Section232_1261.htm 2004-05. Available at http://www.whoindia.org/en/Section2/

Percentage of population below poverty line, Planning Commission 2004 -05. Available at http://planningcommission.nic.in/data/datatable/1705/final_40.pdf Quality of Care Framework, based on Donabedian, Hulton et al. & Institute of Medicine Rao, et al. (2005), Financing of Health in India. Financing and Delivery of Health Care Services in India, New Delhi: National Commission on Macroeconomics and Health, Ministry of Health & Family Welfare, Government of India UNICEF, Coverage Evaluation Survey. National fact sheet, New Delhi: UNICEF India Country Office; 2009. United Nations Population Fund (UNFPA), State of World Population 2007, Unleashing the Potential of Urban Growth, (New York: UNFPA, 2007) United Nations, World Urbanization Prospects: The 2005 Revision, (New York: United Nations Population Division, 2005)

About PHFI - The Public Health Foundation of India (PHFI) is a public private partnership and was set up in 2005. PHFI is a response to redress the limited institutional capacity in India for strengthening training, research and policy development in the area of Public Health. For further information please contact Madhavi Misra (Senior Research Fellow PHFI, madhavi.misra@phfi.org , Phone - +91 11 49566000, Extn 6071.