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 India’s population has followed a 2-3-4-5 paradigm over the last decade: growth of the total population at 2 percent, the urban population at 3 percent, larger cities at 4 percent and slum populations at 5 percent. Given this rapid increase, particularly within larger cities and slum communities, there is a growing recognition of the need to plan for the nutrition and health vulnerabilities of the urban poor. Slum populations in India rank among the poorest, most under-serviced and, consequently, most vulnerable groups in terms of health. They are further compromised by the often unauthorized status of localities, the poor environmental conditions within them, and the wide spread heterogeneity in demographic characteristics in their populations, magnified by large scale migration. Problems with housing, sanitation, pollution, and physical space, as well as access to water, electricity and health services, make communities more susceptible to ill health. While the lack of specific data on the health status in urban slums tends to mask the magnitude of the problem and the inequalities between localities, available health indicators for the urban poor compare unfavourably against both the respective rural and national averages. In contrast to rural areas, however, the extremely poor health and nutrition outcomes in urban contexts such as Mumbai, India’s most populous city, persist even with the existence of geographically accessible health infrastructure and services. Although urban India has a relatively strong health and nutrition infrastructure - with public sector investments coming from central, state and local bodies as well as a vast private sector - vulnerable urban communities continue to be poorly served. This is not only the result of under-provision: existing public infrastructure is often sub-optimally utilised. Rather, it is the product of a range of interrelated factors such as underdevelopment, inequitable distribution of primary healthcare services, poor referral systems, inadequate inter-sectoral and private sector linkages, vertical programming, human resource rationalisation, attitudinal and management challenges, inappropriateness and inefficiency of data management systems and psychological barriers to access. This mesh of influences also includes socio-economic and cultural determinants, such as caring practices, the status of women and women's work, the nature of livelihoods, and food-security, in addition to social capital related to community participation and environmental factors..
This scenario calls for better understanding of and planning for vulnerabilities at various levels. Research has revealed the need to prioritise strategies that -
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Work at the community-level to change key household practices and health seeking behaviours.
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Facilitate the municipal system – the primary healthcare service provider for the poor in the city – to re-orient and strengthen maternal and child health services provided through slum health posts.
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Rationalise care uptake and quality across maternity homes, peripheral hospitals and tertiary hospitals. The systemic interventions therefore depend on participation from a range of facilities and health service providers including administrators, clinicians, medical doctors, public health nurses, auxiliary nurse midwives, multipurpose workers and community health volunteers.
The City Initiative for Newborn Health (CINH),
is an action research study aimed to lower maternal and newborn
morbidity and neonatal mortality among underprivileged slum communities
in Mumbai through health systems strengthening as well as community-based
strategies. Established in 2004, the project is spread over 24 slum
clusters across 6 wards of the city, with an active surveillance
system covering a population of 400,000 approximately. CINH is a
collaboration with the Society for Nutrition, Education and Health
Action (SNEHA), the Municipal Corporation of Greater Mumbai and
the UCL Centre for International Health and Development. SNEHA,
an NGO based out of Dharavi, familiar to many as one of Mumbai’s
oldest slum areas, was founded by the retired former dean of Sion
Hospital, one of Mumbai’s three large municipal tertiary and
teaching hospitals, and has grown into a team with backgrounds in
clinical medicine, paediatrics, obstetrics, anaesthetics, public
health and social work. With personal histories of work within municipal
hospitals, SNEHA’s leadership has a deep understanding of
the municipal health system, its constraints and capacity for change.
As a result, SNEHA is uniquely positioned as an NGO to work on strengthening
municipal facilities and providers to improve the quality of essential
maternal and child health services available to vulnerable slum
populations in the city. The UCL Centre for International Health
and Development is the primary collaborator in research within the
project.
CINH’s approach to improving the quality of municipal health
services is driven by a belief that motivation, participation and
performance in public systems can be transformed if the focus is
shifted from a problem-orientated approach to a possibility-oriented
one. It has therefore used Appreciate Inquiry techniques in facilitating
the formation of Action Groups bringing together cadres of health
care providers – doctors, administrators, nurses and paramedical
staff – in a non-hierarchical setting. The Action Groups in
turn have taken the lead in conducting situational analyses, strategic
planning, implementation and reviews in areas such as facilities
upgradation, human resource development and training. They have
also undertaken the development and implementation of administrative
and clinical protocols for appropriate maternal and neonatal referral
between different levels of health facilities.
The three complementary sets of components
in the project include the following
The main purpose of this intervention is to improve maternal
and neonatal health in vulnerable urban communities through a process
of participatory action cycles with community based women's groups.
The groups primarily include young married women, family members,
members of CBOs, health workers and local opinion formers. A facilitator
guides the group to discuss issues on the identification of maternal
and neonatal problems, identification of possible solutions, planning,
implementing and monitoring these solutions, and sharing information
with others.
The main purpose of this intervention is to increase
the availability and quality of decentralised antenatal, postnatal,
and neonatal services at the primary healthcare facilities. Catalysing
action group formation and discussions among MCGM staff, participatory
workshops with personnel from selected health posts, NGO representatives,
professionals and research institutions. Establishment of antenatal
and postnatal services at the health posts, implementation of a
comprehensive IEC strategy, and strengthening of the monitoring
system are expected outcomes of this intervention.
The main purpose of this intervention is to
work with municipal health service providers to achieve continuous
quality improvement for maternal and neonatal services at maternity
homes and hospitals. Through action group work on clinical and administrative
protocols, it is expected to achieve better availability of health
services, appropriateness of services, and continuous quality improvement.
Research has been a core component of CINH. The project began with a descriptive vulnerability assessment undertaken to understand the maternity practices and care-seeking in Dharavi. The key findings of the study indicated specific gaps in quality of care, minimal dietary or occupational concessions to pregnancy, late registration, late ultrasound (of questionable purpose), and late attendance for delivery. Discussions about these issues pointed to a number of determinants, such as a lack of awareness of a need for earlier registration and a preference for visiting tertiary institutions where clinics were crowded. Inappropriate health behaviours, child caring practices, and maternal care during and after pregnancy were common. These findings helped inform the interventions of the project. Besides formative research, evaluation is another integral aspect of CINH and a variety of quantitative and qualitative methodological tools are being used to study the impact of the intervention strategies on distal, proximate and process outcomes. In the community, these include improvements in home care for pregnancy, mothers and newborn infants. At health facilities, they include provision of good quality maternal and newborn care services. Both of these impacts are expected to increase uptake of services and improvements in maternal and newborn health status.
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