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Maternal and NewbornHealth in Urban India
Save the Children, IndiaM a y 2 0 1 6
A Monograph based on Literature Review Exercise
Maternal and Newborn Health in Urban India
Save the Children, IndiaMay 2016
A Monograph based on Literature Review Exercise
Contents
Letter from Ministry of Health & Family Welfare 5
Message 6
Preface 7
Message from CEO 8
Acknowledgement 9
Acronyms 10
Executive Summary 12
Outline of the Report 15
I Introduction 16
II Methodology 20
III Findings 24
A. Service Delivery Mechanisms, Logistics and Supply-Chain Management 24
B. Governance 37
C. Human Resources 40
D. Financial Mechanisms 46
E. Health Infrastructure 49
F. Health Management & Information System (HMIS) 50
G. Community Interventions and Innovations 51
H. Innovative Approaches 57
IV Discussion and Conclusions 64
References 72
Annexure 1: Evidence tables of the literature reviewed 84
Annexure 2: Tables on citywise programmes, schemes and innovations 113
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ublic healthcare for the urban poor has lagged behind in India despite good intentions. It suffers from multiplicity of players, non-standardised structure and low investments. Above all, the rich-poor gap is Pstaggering. It has therefore been a challenge to systematically plan priority maternal-newborn health
(MNH) services in cities and towns. Not surprisingly, the National Urban Health Mission has lagged behind the National Rural Health Mission by almost a decade.
One reason for this state of affairs has been a relative lack of reliable information and program relevant research in urban MNH. Diversity and dynamics of urban health system make the available knowledge difficult to comprehend and apply. In this context, Saving Newborn Lives (SNL), Save the Children, has made a tremendous contribution by synthesising available literature and research in MNH in urban India.
This monograph is based on well-researched, painstaking review using robust methods. The credentials of the team are impeccable. The flow of the narrative (service delivery, infrastructure, human resources, etc.) follows the health system framework. Gaps and solutions are captured in precise text at the end of each chapter; and discussions and implications are well captured in the final chapter.
This review brings out several facets of urban MNH. Analytic insights into lack of community processes in urban areas in the report are most insightful. Equally, interesting is the capture of most innovations in MNH in cities. The need to design and test next generation primary care models for urban India is a clear priority. Overall scene of urban MNH cries out for more investment, better governance and coordination, and more research.
The recurring theme in the monograph is the paucity of actionable information and evidence. We need studies on urban MNH epidemiology and innovative interventions; we need implementation research to inform scale up of what is known to be effective; we need demonstration sites to showcase replicable models; and we need technical support teams to facilitate implementation and monitoring. The government, the Indian Council of Medical Research and the public health research community together have the responsibility to bridge the knowledge gap.
The monograph provides highly valuable inputs on MNH for the National Urban Health Mission. MNH and urban health stakeholders would gain immensely by insightful repository of information that this review provides.
A must read document for the public health community of India.
Dr. Vinod PaulProfessor & HeadDepartment of Paediatrics, AIIMS, New Delhi
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Message
Preface
ave the Children’s 2015 State of the World's Mothers Report, The Urban Disadvantage, brings into sharp focus the health inequities found within cities all over the world. Data from the report demonstrate that Swhile great progress has been made in reducing under-5 mortality globally, in about half of the cities where
data are available, the mortality gap between rich and poor children has grown. The poorest children, especially those living in urban slums, have alarmingly high risks of death. These inequalities also exist in cities in high-income countries such as Washington, DC, in the United States.
Given Save the Children's commitment to reaching the most disadvantaged children and families and the growing rates of global urbanization, we believe addressing the challenges surrounding improving health – especially maternal and newborn health – in poor urban areas is increasingly important. We are keen to understand the root causes of these inequalities and to learn from the experience of others about addressing the needs of children and families living in urban slums.
Save the Children's Saving Newborn Lives Program, supported by the Bill and Melinda Gates Foundation, is working actively with appropriate stakeholders and the National Health Mission to explore how the contextual factor differ in urban settings for maternal and newborn health service availability as well as care seeking behaviors. Who are the main service providers to poor urban dwellers? How are those services financed? Are they of sufficient quality to improve health outcomes? How have they targeted the most deprived and poorest families?
A key step in this learning agenda was to undertake a literature review to explore the rich array of programs already in existence in India. The results remind us of how much work has already been undertaken and the rich set of lessons that have emerged. However, it also is evident that most urban health programs have been pilot projects, covering relatively small populations within a fixed time period, and that successful pilots have yet to be scaled up to benefit large population groups. The challenge for India and other countries is to learn how to shape large-scale, well-funded,and sustainable programs such as India's National Health Missions to target services to those who need them the most in varied urban environments. Further, while future investments in urban health must come from government, we must also tap into the vibrant private and corporate sector and involve the service delivery systems of government, nonprofit, and commercial sectors, because everyone has an equal stake in the health and well being of India's women and children.
I would like to thank all of those involved in carrying out this important review and analysis as well as those who guided it. We appreciate the global leadership that India is providing for improving urban approaches to addressing the health of women and children.
Joy Riggs-PerlaDirector, Saving Newborn LivesSave the Children, USA
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Message from CEO
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rbanisation is often thought of as being beneficial for economic and social growth, which is what prompts rural populations to migrate to the cities for a better life and better prospects. Being the world's largest Udemocracy, the second most populous country (1.21 billion as per Census 2011) and the tenth largest
economy (with a Gross Domestic Product of US$ 1377.3 billion in 2009), India has undergone extraordinary socio-economic and demographic changes. In the past 30 years, the geographically-wide, densely-populated and enormously-varied Republic of India has made remarkable efforts in the field of health, including development of a strategic framework on RMNCH+A in 2013 and the recently launched National Health Mission with a sub-mission (NUHM) on Urban Health as a key component.
Save the Children's Saving Newborn Lives (SNL) programme works with governments and partners to put newborn health on global and national agendas. In India, the programme is working towards evidence-generation, consensus-building and supporting policy and programmatic processes on delivering Maternal and Newborn Health (MNH) in urban poor settings. As a part of this process, a need was felt to review both the published and the unpublished literature on mechanisms, programme platforms, service delivery systems, practices and innovations in MNH in the urban areas of India including, literature on scaling up pilots/ innovations and conceptual frameworks with a specific focus on the urban poor.
It is important that the MNH programmes, though variably existing in the urban space of India, gets a thorough prioritisation and reboot. The whole service delivery mechanism is not in place when it comes to most of the cities in the country. Ambiguity on the information, data, role of departments, leadership, personnel, supply chains and logistics continue to remain.
The findings of this review clearly reflect on the gaps in terms of current availability of health services to deliver MNH care along with the clearly defined paucity of service delivery platforms, governance and mechanisms inclusive of infrastructure, human resources, logistics, supply chain, partnerships and community, level efforts. It further draws our attention to the fact that the gaps with regard to the availability of literature and evidence from the research undertaken in all of the abovementioned aspects of health service delivery for MNH care should not be ignored.
At Save the Children, we consider that both the policy and programmatic efforts along with commitment of working towards the betterment of urban poor mothers and newborns should be augmented especially at this juncture, wherein the country is attempting to understand, develop and formalize the mechanisms for delivering health care to the urban poor mothers and newborns.
This review report affirms the overwhelming constraint of better availability of services for MNH care in urban areas and it distinctly provides a direction to future researchers and policy-makers as to what needs to be done to ensure that MNH care services are delivered to the urban poor.
Thomas ChandyCEO, Save the Children, India
Acknowledgements
eepest appreciation is expressed to all those who provided technical and moral support to complete the review of literature and subsequently this report. Special gratitude to Mr. Nikunj Dhal, erstwhile Joint DSecretary, Urban Health and ICT, Ministry of Health and Family Welfare (MoHFW), Government of
India (GOI); Dr. Rakesh Kumar, erstwhile Joint Secretary, Reproductive and Child Health, MoHFW, GOI; Dr. P. K. Prabhakar, Deputy Commissioner - Child Health, MoHFW, GOI; and Ms. Preeti Pant, Director, NHM (Urban), MoHFW, GOI whose continuous patronage and encouragement helped to put this comprehensive report together so as to provide insights to all of those who are keen to know more about maternal and newborn health care in urban poor settings in India.
The study team wishes to express gratitude to the members of national level Technical Advisory Group (TAG) for their suggestions guidance and insights during the whole process of the review exercise. Specific insights and understanding from Prof. Vinod Paul helped in the overall design and finalization of research questions. Inputs from Prof. N. K. Arora, Prof. Rajib Dasgupta, Dr. Sanjay Pandey and Mr. Gautam Chakraborty were extremely helpful and instrumental in finalizing this report. An especially strong appreciation goes to the officials of Municipal Corporations and associated public health teams of few municipal corporations that provided first hand information on the service delivery aspects.
Much appreciation is extended to the staff of Save the Children, USA especially Ms. Joy Riggs-Perla, Director - Saving Newborn Lives (SNL) Program; Dr. Stephen Wall, Senior Technical Advisor; Dr. Uzma Syed, Technical Advisor - Newborn Health; Dr. Lara Vaz, Senior Advisor - Monitoring & Evaluation; who guided the design of the study. A special thanks goes to Dr. Sudeep Singh Gadok, erstwhile Director of Programmes, Ms. DeepaliNath, Director, Knowledge Management and Mr. Prasann Thatte, Manager Research, Save the Children, India, for their untiring support and technical insights.
A special mention of THOT, the research agency, which helped assemble and assimilate the pertinent information and gave valuable suggestions throughout the study.
This study would not have been possible without the abundant support and guidance of the core team of SNL, India which was led by Dr. Rajesh Khanna, Technical Advisor – Newborn Health, Save the Children, India and Dr. Benazir Patil, Advisor – Urban Health, Save the Children, India. The guidance and appreciation of other colleagues are sincerely cherished.
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ANC Ante-Natal Care
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist
BEmOC Basic Emergency Obstetric Care
BPL Below Poverty Line
CEmOC Comprehensive Emergency Obstetric Care
CHC Community Health Centre
CSSM Child Survival and Safe Motherhood Programme
DCM District Community Mobiliser
DRC District Resource Centre
EmNC Emergency Newborn Care
EmOC Emergency Obstetric Care
EmONC Emergency Obstetric and Newborn Care
FBNC Facility-Based Newborn Care
FRU First Referral Unit
HBNC Home-Based Newborn Care
HMIS Health Management Information System
HR Human Resource
HRH Human Resources for Health
IAP Indian Academy of Paediatrics
IMNCI Integrated Management of Neo-natal and Childhood Illnesses
IMR Infant Mortality Rate
INAP India Newborn Action Plan
IPHS Indian Public Health Standards
IMCI Integrated Management of Childhood Illnesses
IMNCI Integrated Management of Newborn and Childhood Illnesses
JNNURM Jawaharlal Nehru National Urban Renewal Mission
JSSK Janani Shishu Suraksha Karyakram
JSY Janani Suraksha Yojana
KMC Kangaroo Mother Care
Acronyms
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MDG Millennium Development Goal
MNH Maternal Newborn Health
NFHS National Family Health Survey
NHM National Health Mission
NMR Neo-natal Mortality Rate
NRHM National Rural Health Mission
NUHM National Urban Health Mission
PHC Primary Health Centre
PPP Public Private Partnership
RCH Reproductive and Child Health
RBSK Rashtriya Bal Swasthya Karyakram
RKSK Rashtriya Kishore Swasthya Karyakram
RKS Rogi Kalyan Samiti
RMNCH+A Reproductive, Maternal, Newborn, Child and Adolescent Health
SBA Skilled Birth Attendant
SHG Self-Help Group
SN Staff Nurse
SNCU Special Newborn Care Units
SNEHA Society for Nutrition, Education and Health Action
SRS Sample Registration System
TAG Technical Advisory Group
TBA Trained Birth Attendant
U5MR Under-Five Mortality Rate
UNICEF United Nations Children's Fund
UPHC Urban Primary Health Centre
USHA Urban Social Health Activist
VHND Village Health & Nutrition Day
VHSC Village Health & Sanitation Committee
WASH Water Sanitation and Health
WHO World Health Organization
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ith rapid urbanisation, as in most Departments of Publ ic Heal th , Urban developing countries, public health Development, Medical Education, and the Wproblems in India are increasingly Municipal Corporations and the urban local
assuming an urban dimension. Largely viewed as bodies is a greater challenge. a rural society for many decades, the Government Save the Children's Saving Newborn Lives (SNL) of India's conception of primary healthcare was programme, supported by the Bill and Melinda
th almost entirely rural oriented. The 12 Five Year Gates Foundation is a globally recognised leader Plan, stated for the first time that urban expansion in newborn health and a respected voice in many will happen at a speed quite unlike anything that low-resource countries. Since its inception in the India has seen before and, if not well managed, this year 2000, SNL has worked to reach the world's inevitable increase in India's urban population most vulnerable newborns and help them survive
1will place enormous stress on the system . their first month of life. By working with Interestingly, it has been found that the health governments and partners to put newborn health services in urban areas often observe an “inverse on global and national agendas, SNL serves as a care law”: those in greatest need of care have the catalyst for action. To accomplish its goals, the poorest access to it. Despite the fact that few SNL programme works to develop, apply, governments have formulated urban health document and sustain packages of effective, policies that prioritise the poor, even when such evidence-based newborn care services and plans and programmes do exist , their practices at scale. SNL provides technical implementation is hampered by resource leadership, advocacy, and measurement support.
2 .shortages . In India, while the analysis of the The programme facilitates a cycle of evidence-NFHS-III data confirms the inequitable health generation, consensus-building, policy-
3status of the urban poor , a number of other formulation and-guidance, and programme 4studies have also concluded that the health of the implementation and learning.
urban poor is significantly worse than the health of Currently in its third phase (2013-2017) of the rest of the urban population and is often implementation, SNL in India is working toward comparable to health conditions in rural areas. generation of practical and feasible solutions for India contributes to 16% of the global maternal delivery of MNH services for the urban poor in deaths and around 27% of global newborn deaths. India. Reducing the burden of maternal and newborn For designing sensitive, responsive and relevant mortality and morbidity in urban poor settings urban health policy and action, it is important for today requires an expansion of effective Maternal planners and programme managers to understand and Newborn Health (MNH) care services and the context with regard to current systems and lowering the barriers to the use of such services, mechanisms, potential organisations and best especially availability and accessibility. practices, that can be leveraged and built upon to Addressing these barriers can substantially ensure urban institutional reforms and improved improve the utilisation of services, as well as governance for MNH in urban poor settings. In increase inequity in health outcomes. The launch order to address this need, SNL commissioned a of the National Urban Health Mission(NUHM) in study that reviewed the literature and looked at 2013 as a sub-mission of the National Health available secondary data on MNH in urban poor Mission(NHM) is being looked at as the very first settings. The study synthesised quality evidence step to tackle the needs of the urban poor. that identified opportunities and gaps in the health However, the lack of clarity on the ultimate system, looked into the factors affecting responsibility for providing public health services programming and service delivery; and reflected in urban areas, lack of demonstrated political will on potential strategies to help address specific to assume responsibility and accountability for MNH care needs of the urban poor in India.urban services, along with the absence of inter-
The review looked at both published and departmental coordination between the
Executive Summary
Maternal and Newborn Health in Urban India A report on literature review
1 th12 Five Year Plan: Approach paper on “The Challenges of Urbanisation in India”.
2http://www.unsystem.org/scn/archives/scnnews01/ch2.htm
3National Family Health Survey: Round III reveals that the childhood mortality indicators among the urban poor are higher compared to the urban averages – 72.7 vs. 51.9 for U5MR, 54.6 vs. 41.7 for IMR, and 36.8 vs. 28.7 for NMR.
4 Islam, Montgomery, and Taneja (2006); Montgomery and Hewett, (2005); Fotso, Ezeh, and Oronje (2008).
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Save the Children, India
unpublished literature on mechanisms, determinants of MNH and barriers in accessing programme platforms, service delivery systems, services, there is little information available on practices and innovations in MNH in the urban interventions and models that have worked to areas of India including literature on scaling up address these challenges. In exceptional cases, if MNH pilots/innovations and conceptual certain initiatives did work providing some frameworks with a specific focus on the urban piecemeal solutions, the sample size was either not poor. The search for evidence involved examining large enough for confidence of scalability or these of planning and implementation frameworks, case w e r e m o s t l y p r o j e c t - b a s e d i n i t i a t i v e s studies, reports, evaluation and impact implemented and managed by non-governmental assessment reports, strategic frameworks, reports agencies dependent on available resources.of different programmes and interventions, The review affirms the overwhelming constraint research studies, surveys, documents and articles. of better availability of services for MNH care in A total of 250 sources were identified and included urban areas. It further confirms two specific in the present review. aspects: first and foremost, there exists limited or This review report focuses on the evidence base insufficient and inadequate evidence on the pertaining to the status, major milestones, availability of services for MNH in urban areas problems and challenges with regard to the urban and, secondly, whatever evidence is available MNH in India, the existing supply side agencies shows an absence of any defined structures and and its linkages, and the existing financial mechanisms to deliver services for mothers and mechanisms and budgetary provisions for the newborns in urban poor settings. In the end, the urban MNH. review sets out suggestions not only in terms of
requirement of evidence on the aspects of service The findings of the review can be distinctly provision and service delivery mechanism in classified under two different pieces. The first urban settings but also reflects the need for piece reveals the gaps in terms of current undertaking rigorous research in the area of urban availability of health services to deliver MNH care maternal and newborn health which continues to along with the clearly defined paucity of service remain an untouched area of research and delivery platforms, governance and mechanisms learning.inclusive of infrastructure, human resources,
logistics, supply chain, partnerships and Though the study reflects that the evidence base community, level efforts. The second piece focuses with regard to the existence of specific policy on the gaps with regard to the availability of instruments for this purpose is still being literature and evidence from the research developed, nevertheless, it provides a direction to undertaken in all of the abovementioned aspects of future researchers and policy-makers as to what health service delivery for MNH care. needs to be done to ensure that MNH care services
are delivered to the urban poor.While maximum data is available mostly on social
Key Findings
l There is an overall lack of clarity with regard to the ultimate responsibility of providing health services and the information on service-provision mechanisms reveals that the health services, vary from city to city. While a few large cities such as Mumbai, Kolkata, and Chennai have used the Indian Population Project to focus on the health infrastructure establishment in urban slums, just a few large Municipal Corporations with good revenue resources have demarcated special resources to provide urban MNH services.
l There is no mechanism for a health worker to make community or home visits; thus; no holistic outreach and follow-up services are available for MNH.
l Referral services are available in corporation hospitals/ district hospitals/ medical college hospitals as well as in several private hospitals. There is no definite system of referral; no linkages between domiciliary, health centre and hospital; and no protocols for admissions to the primary, secondary and tertiary levels.
l Private health providers are the key players in the overall provisioning of services. Multiplicity of providers and lack of coordination among them has led to dysfunctional referral systems and a consequent overload on tertiary-care providers.
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l
been neglected, there are exceptions of larger metropolises such as Mumbai and Delhi that provide primary healthcare by means of dispensaries, health posts and maternity homes.
l The urban health posts (UHPs) are located mainly in big towns. Small towns continue to be deprived of these facilities.
l The findings of the NFHS-III reflect that the private sector is the main provider of healthcare for a majority of people living in urban areas and the main reason for non-utilisation of public facilities is the poor quality of care.
l The literature does not reflect on the aspects such as staffing mechanisms, training, job satisfaction, appraisals and career development of the staff engaged for MNH care.
l Very little information could be traced on details of the guidelines or protocols for the functioning of primary and secondary level healthcare systems or the logistics required for MNH.
l There is no information available on processes adopted for supply chain management, especially training procedures for staff at the primary and secondary levels to manage the supply chain for drugs & equipment and co-ordination with the blood banks & referral support.
l Lack of research in terms of availability and accessibility of services that may concern women living in urban slums comes across as a great deficiency. The existing literature also hints at the existence of private bodies. However, this does not extensively map the same.
l Various studies reflect on the lack of uniformity in delivery/provision of health services within and across cities. However, these hardly touch on the opportunities for the marginalised at the health service centres, especially for MNH.
l The evidence gathered from the National Health Systems Resource Centre’s (NHSRC) city-visit reports indicates a paucity of information on guidelines that govern the health service system and the detail on the facilities available for MNH.
l While some studies do mention the type of facilities providing MNH services which are accessible to the urban poor, it lacks analysis in terms of its functioning, efficiency, governance and monitoring mechanisms.
l Reliable and consistent information on health informatics is scarce. Little or no efforts have been made to conceptualise mechanisms or/and to capture disaggregated, discrete data on health service availability and its performance in relation to urban MNH across cities and states.
l The information from the Health Management Information System (HMIS) features largely around NRHM and the information available for urban and semi-urban places is abysmal. The websites of the National Institute of Health and Family Welfare (NIHFW), NHSRC and urban local bodies (ULBs) such as the Municipal Corporation of Delhi (MCD) mostly include information on communicable diseases, sanitation and hygiene.
l While a number of documents reflect on the role of State Health Departments, Municipal Corporations (MCs), Town Councils, and ULBs in the health sector in general, literature that examines the roles of these bodies in the provision of MNH service is very scanty.
l Very little and inconsistent information is available on financing patterns, the role of local bodies in budget planning, the process adopted for sustaining projects and the decision making in relation to the same across a majority of the cities, especially in urban and semi- urban locations. No information is available on the budgetary allocation process for maternal and newborn health except for some small-scale cash-transfer programmes that exist in various states.
While primary healthcare in urban areas which the poorest sections can easily approach has largely
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This report is organised into the following sections: -
Outline of the Report
Section III presents the findings with regard to each of the components reviewed, and has sub-sections on Service Delivery; Infrastructure; Human Resource; Logistics and Supply-Chain Management; Community-Level Inputs/Processes/Interventions; Governance Mechanisms and Leadership; Financing and Sustainability; Partnerships and Networks; and Inter-sectoral Coordination.
Annexure 1: Evidence tables of the literature reviewed.
Annexure 2: Tables on city-wise programmes, schemes and innovations.
Section I is the introduction that provides an overview of the growing urbanisation in the country, the global, and the Indian urban maternal and newborn health scenario.
Section II focuses on the methodology used in the review and the scope of the study, along with the research questions it intends to address.
Section IV summarises and discusses the results, assesses the strength and weakness of the evidence base, and provides conclusion.
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Background
The Urban Context
Being the world's largest democracy, the second most populous country (1.21 billion as per Census 2011) and the tenth largest economy (with a Gross Domestic Product of US$ 1377.3 billion in 2009), India has undergone extraordinary socio-economic and demographic changes. The population pyramid of India has evolved, with an increase in both the very young and the ageing population. An urbanisation process with megacities and expanded shanty-towns has witnessed a 4.6-fold increase between 1951 and 2001, compared to only a 2.8-fold increase in the total population.
For the past 30 years, the geographically-wide, densely-populated and enormously-varied Republic of India has made remarkable efforts in the field of health. The list of initiatives include the adoption of a
rd thNational Health Policy in 1983; the 73 and 74 Constitutional Amendments devolving power to local institutions in 1992; the National Nutrition Policy in 1993; the National Health Policy, the National Policy on Indian System of Medicine and Homoeopathy and Drug Policy in 2002; the introduction of simple health insurance schemes for the poor in 2003; the inclusion of health in the Common Minimum Programme of Government in 2004; the initiation of the National Rural Health Mission in 2005; the development of a strategic framework on RMNCH+A in 2013 and the recently launched National Health Mission with a sub-mission (NUHM) on Urban Health, as one of the key components.
While India accounts for 21% of the world's global burden of disease, and is home to the greatest burden of maternal, newborn and child deaths in the world, there has been a significant achievement with regard to reductions in the Infant Mortality Rate (IMR) from 83 per 1,000 live births in 1990 to 44 per 1,000 live births in 2011, and Maternal Mortality Ratio (MMR) from 570 per 100,000 live births in 1990 to 212 in 2007–2009. Achieving of Millennium Development Goals (MDGs) 4 (reduce child mortality) and 5 (improve maternal health) guided the efforts on ensuring the progress on both the supply and demand side and helped in expanding the availability of effective Maternal, Newnorn and Child Health (MNCH) care services. The most frequently occurring and formidable challenges of modernising the health system, reducing the high out-of-pocket expenditures, addressing the insufficiency &uneven distribution of staff, balancing the service provision (overwhelmingly in private hands) and its quality, and ensuring a better alignment of regulation with present-day needs, continue to remain.
India's urban growth has been described as following a '2-3-4-5' pattern: annual population growth of 52%, urban population growth of 3%, mega-city growth of 4% and slum population growth of 5% . The
urban population increased from 28.6 crore in 2001 to 37.7 crore in 2011. Urban Indians live across 7,935 6towns and cities, of which 468 have populations of at least 100,000 . Nearly 50% of the urban population
of India lives in just five states, namely, Maharashtra, Uttar Pradesh, Tamil Nadu, West Bengal and Andhra Pradesh. Uttar Pradesh, which has just 22% of its population living in urban areas, accounts for almost one-fourth of the total urban population of these five states, purely due to its population size.
Urbanisation is often thought of as being beneficial to economic and social growth and gains, which is what prompts rural populations to migrate to the cities for a better life and better prospects. However, most Indian cities do not have the requisite infrastructure to be able to provide the population with basic amenities such as health. This adversely affects the well-being and health of especially the urban poor. Unaccounted for populations such as the migrant workers and shifting definitions of areas of habitat such as slums, have led to the marginalisation of the urban poor, living alongside drivers of economic growth in India. Being in urban conditions does not provide any advantage to the urban poor.
I. Introduction
5 Source: p.2, Water and sanitation for Urban Poor: Expansion and exclusion? A Briefing Paper on Related Policies, published by Health of the Urban Poor (HUP) Programme, Population Foundation of India, (September 2012).
6 74 cities have been added to this list since Census 2001, which reflects a rapid increase.
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The urban poor are seen as a homogenous entity, which they are not. Such a broad definition leads to a greater marginalisation in the provision of basic amenities, because it does not take into account sections of the urban poor population which are excluded, illegal and unaccounted for. As a result, services and provisions do not take them into account and do not reach them. A broad view of the urban poor only plans for services to be delivered to slums, which themselves are not a constantly defined habitat; it also neglects other urban poor populations such as the homeless, migrant labourers, daily-wage workers, construction workers, rag-pickers, people who are institutionalised- male, female & transgender, sex workers and other groups who may not necessarily live in slums, but are socially, economically and
7geographically marginalised in cities .
Various studies have assessed and identified vulnerability factors amongst the slum population that need to be looked into while sketching an overall health programme for the urban population. These have been categorised as residential or habitat-based vulnerability; social vulnerabilities; and
8occupational vulnerabilities .
On the basis of the health burden, it has been found that the vulnerable populations face innumerable barriers, with respect to accessing the public health services, which results in an aversion to seeking care from health centres. Some of the key factors are: lack of comprehensive primary care service in public facilities; ill-timed consultation and long waiting hours; improper location of and long distances to public health services; and disrespectful behaviour by the health providers.
Health outcomes of newborns are shaped by biological factors. Further, the social, economic and cultural environment, make the task complex and demanding. Newborn health is inter-dependent on the health of mothers. Though India has been at the forefront of the global effort to reduce maternal &child mortality and morbidity, given its demographic and cultural diversity, it does face numerous challenges with significant rural-urban, poor-rich, gender, socio-economic and regional differences. Furthermore, maternal and newborn mortality varies considerably between states and regions. Various efforts have been made to address these multi-layered hurdles in achieving optimum MNH care in India. While the two path-breaking interventions, National Rural Health Mission (NRHM 2005) and RMNCH+A strategy (2013), provided unprecedented attention and resources for maternal and newborn health with a focus on rural India, the latter specifically focused on a paradigm shift in perspectives based on the continuum-of-care approach and health system strengthening.
Interventions under NRHM have definitely led to a noticeable increase in the utilisation of hospitals for childbirth, and have resulted in encouraging progress in reducing maternal and newborn mortality rates in rural areas faster than the urban. Thus, a growing realisation that there must now be a more focused approach toward urban MNH, specifically targeted toward the needs of the urban poor, has emerged in the last few years.
Over the years, various committees, such as the Bhore Committee 1946, Jungalwalla Committee 1967, Bajaj Committee 1996, Mashelkar Committee 2003 and the National Commission on Macro-economics and Health 2005 have suggested ways to strengthen the health sector. More significant for policy formulation has been the share of urban population to the total population, which has grown substantially from 1951 to 2011.
On the recommendations of the Krishnan Committee, under the revamping scheme in 1983, the Government established four types of UHPs across 10 states and union territories with a pre-condition of locating them inside or close to the slums. The main functions of the UHPs are to provide outreach, primary healthcare and family welfare as well as MCH services. In reality, however, limited outreach
Maternal and Newborn Health: The Indian Scenario
Health Structures in Urban India
7 Report and Recommendation of the Technical Resource Group for The National Urban Health Mission, MoHFW (2014).8 Report and Recommendation of the Technical Resource Group for The National Urban Health Mission, MoHFW (2014).
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activities are being undertaken by the UHPs. Due to the rapid growth of the urban population, efforts were made in the metropolitan cities of Chennai, Bengaluru, Kolkata, Hyderabad, Delhi and Mumbai for improving the healthcare delivery in the urban areas through the World Bank-supported India Population Project (IPP). Only the IPP cities are conducting some outreach activities as community link workers are employed to strengthen demand and access. Limited outreach activities through the provision of link volunteers under the RCH are visible in Indore, Agra, Ahmedabad and Surat.
thThe Government of India's 12 Five Year Plan builds on the National Rural Health Mission and converts it into a National Health Mission for the whole country. In doing so, it incorporates the developing National Urban Health Mission as a sub-mission.The NUHM aims to meet the healthcare needs of the urban population, with a focus on the urban poor, by making essential primary healthcare services available to them and reducing their out-of-pocket expenses for treatment. This will be achieved by strengthening the existing healthcare service delivery system, targeting the people living in slums, and converging with various schemes relating to the wider determinants of health (such as drinking water, sanitation, and school education), implemented by the Ministries of Urban Development, Housing and Urban Poverty Alleviation, Human Resource Development, and Women and Child Development.
The NUHM endeavours to achieve its goal specifically through a need-based, city-specific, urban healthcare system that will meet the diverse healthcare needs of the urban poor and other vulnerable sections, and through institutional mechanism and management systems to meet the health-related challenges of a rapidly growing urban population. In response to the needs for convergence and public health management, the NUHM envisions that every municipal corporation, municipality, notified area committee and town panchayat will be a planning unit in its own right, with its own approved norms for setting up health facilities. These urban local bodies will prioritise services for the urban poor (in both listed and unlisted slums) and for vulnerable groups, such as the homeless, rag-pickers, street children, rickshaw-pullers, construction and brick &lime kiln workers, and sex workers.
The NUHM is currently setting up well-identified, primary healthcare facilities for each segment of the target population that can be accessed conveniently. The UPHC will act as a common platform for availability of all services. Mechanisms of referrals should be operationalised to make the PHC effective; the PHC will also provide outreach services. This will be done by the female health worker, who will be provided mobility support for this purpose. Services will be universal in nature. Community participation will be encouraged by a community link volunteer (Urban ASHA). Creation of community-based institutions, such as Mahila Arogya Samiti (MAS) involving 50-100 households will empower women so that they can demand services.
National Urban Health Mission: The Most Recent Mandate
Structural and Human Resource Propositions of the NUHM
Proposition Serving
Urban Primary Health Centre
U-PHC
50,000 to
60,000 population
Urban Community Health Centre
U-CHC
250,000 to
360,000 population
Five to six U-PHCs in larger cities
Auxiliary Nurse Midwife
ANM
10,000 population
Accredited Social Health Activist
Urban Social Health Activist
ASHA
(USHA)
200 -
500 households
1,000 –
3,000 population
718 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
MNH in Urban Poor Settings
While half of India's population is expected to reside in urban areas by 2030, little is known about the appropriate delivery mechanisms or effective intervention strategies for the urban areas. Urban poor newborns are more vulnerable to many health problems as compared to the non-poor urban counterparts. Evidence from NFHS-III indicates that neo-natal mortality among the urban poor (NMR 37/1000 live births) is higher as compared to the urban average (NMR 29/1000 live births). Similarly, analysis of the NFHS-III (2005-2006) data shows that the NMR among the poorest 20 percent of the population is more than double the NMR of the richest 20 percent. The Urban Health Resource Centre looked at urban data from NFHS-III for 8 cities and found that women in the poorest quartile were substantially less likely to make at least three ante-natal care visits (54% compared with 83%) and to have a birth assisted by a health provider. Their children had higher under-five mortality rates, lower immunisation rates (40% compared with 65%) and higher proportions of stunting (54% compared with
933%) . It is important to note that, while data is available for MNH in urban India, reliable & disaggregated urban data or census data that include slums — focusing on the most vulnerable city-dwellers (often not counted)—is completely absent.
The challenges facing MNH for the urban poor in India are many. The inequities and social exclusions that plague the urban poor lead to inequities in accessing services and systems such as ANC care. The environment that the urban poor live in is not conducive for health and well-being, further aggravating their problems. The mandate for provision of municipal services is unclear when settlements are not notified and their residents do not have tenure, with implications for water supply and collection of waste. There is a lack of co-ordination and convergence between the relevant departments dealing with water and sanitation, housing, transport and health. Thus, the paper trail is sketchy, accountability is minimal, and transport is often the responsibility of the family. For maternal and newborn care, there is a lack of norms for service provision at different levels of health facility. No protocols exist for identifying women at risk and referring them for specialised care.
819Maternal and Newborn Health in Urban IndiaA report on literature review
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9 NFHS 3
Maternal and New Born Urban Health in Urban India A report of literature review and secondary data analysis
II. Methodology
Objectives of Review
Research Questions
Methodology
This review was undertaken to systematically identify and synthesize evidence from the available literature on the current status of maternal and newborn healthcare services in urban India, particularly with respect to specific components of the health systems and the urban poor population. Additionally, an attempt was made to identify innovations and case studies of the best practices, with reference to their potential for scaling-up. The exercise is expected to help in developing a compendium of relevant literature available on the maternal and newborn health services for the urban poor population in India. This would help the planners, programme managers and researchers in not only identifying the factors and gaps in information affecting delivery of MNH services for the urban poor population, but also plan and design future approaches/models for effective coverage of these services within the context of the NUHM.
a. What are the issues, problems and challenges with regard to urban MNH in India? Specifically with regard to: Service Delivery; Infrastructure; Human Resource; Logistics and Supply-Chain Management; Community-Level Inputs/Processes/Interventions; Governance Mechanisms and Leadership; Financing and Sustainability; Partnerships and Networks; and Inter-sectoral Co-ordination
b. Why do these problems and challenges exist; what are the specific reasons?
c. Which are the various supply-side agencies? What have been their successful interventions along and what are the existing linkages on the supply-side?
d. What are the financial mechanisms and budgetary provisions that exist for the urban MNH?
A systematic literature search was planned to identify evidence on the above-mentioned questions and specific criteria were defined for study selection. These criteria were: –
a) Population: All relevant studies available on maternal and newborn health services for the urban poor population. Studies on rural or peri-urban populations were not included.
b) Interventions: Any study pertaining to selected supply side parameters of health system for the delivery of maternal and newborn health services as given under the WHO framework was included. The parameters were: infrastructure, human resources, logistics & supply-chain management, community-level inputs/processes/interventions, governance mechanisms, financing, partnerships and networks and inter-sectoral coordination. There was no restriction regarding the source of funding for the intervention; that is, both public and private sector-funded initiatives/programmes were included.
c) Time period: Interventions and programmes that had been implemented and/or studied over the last 10 years were included.
The review aimed at focusing on interventions and programmes, which had been implemented in
20 Maternal and Newborn Health in Urban India A report on literature review
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Maternal and New Born Urban Health in Urban IndiaA report of literature review and secondary data analysis
sizeable urban poor populations, in order to lend themselves to scalability. However, as the review progressed, it became clear that there were very few studies available using the pre-defined criteria and, hence, the initial selection criteria were expanded to include:–
l All interventions and programmes on the delivery of maternal, newborn and child health services.
l All interventions and programmes for the urban poor population, irrespective of population size coverage.
Despite expanding the criteria, only limited literature was identified from the public domain. As a result, the search strategy was expanded to include not just grey literature from manual search and cross-referencing, but also literature identified by interviewing subject experts. Moreover, due to lack of sufficient and credible evidence available from the published studies, the design was modified from a systematic literature review to a narrative/descriptive and thematic review of available literature.
Three data sources were used to collate the evidence: 'computer/ internet-based search', 'manual research' and 'interviews with subject experts'. For the Internet-based search, a combination of free-text words and MeSH words were used to systematically search electronic databases. This process was supplemented by manual search of the grey literature (any unpublished thesis, project report, evaluation, survey etc.), the literature identified from cross-referencing and literature identified by subject experts during interview. Subject experts were interviewed telephonically and/ or in face-to-face meetings using an open-ended questionnaire. Based on their information, efforts were made to contact the local authorities, organisations and institutes concerned, so as to access the relevant literature.
All the studies identified through the search process were indexed for de-duplication and screening. Two review authors independently examined the titles, abstracts and keywords of electronic records according to the eligibility criteria. The results of this initial screening were cross-referenced between the two review authors, and full-text records obtained for all potentially relevant reports. Any disagreements between the two reviewers were resolved by discussion with the review supervisor. Altogether, 300+ sources, over 385 documents and 40+ experts were reached out, to collect the relevant information.
In addition to the above, secondary analysis of the existing data from the urban MNH programmes, processes and large-scale surveys in different parts of the country, was undertaken to substantiate the desk review findings.
The data collected was classified in a theme-based matrix, and further organised in an Evidence Table to tabulate the details of the key aspects that the articles covered .
10The Thematic Synthesis method was used to synthesise and analyse the findings. This enabled the review team to synthesise findings from multiple qualitative studies by identifying the recurring themes or issues in the primary literature, analysing these themes, and drawing conclusions in the review. The purpose of this method was to develop analytical themes through a descriptive synthesis and find explanations relevant to a particular review question. This method was developed to address specific review questions about the need, appropriateness and acceptability of interventions, as well as the effectiveness of the same. The entire process of the literature review is depicted below:–
Search Strategy
Data Collection and Analysis
10 ‘A guide to synthesising qualitative research for researchers undertaking health technology assessments and systematic reviews', Ring N., Ritchie K.,
Mandava L., Jepson R., NHS Quality Improvement, Scotland (2011).
21Maternal and Newborn Health in Urban IndiaA report on literature review
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Challenges and Limitations
Initially, the research was planned as a systematic literature research for relevant information, following standard methods of search and literature review. Hence, the inception report and research protocol that were developed, were in keeping with this methodology (Please see Annexures 1 and 2).
However, the research surmised that there was a significant shortage of specific information related to maternal and newborn health services in urban India especially for the urban poor population. This was further complicated by the absence of credible information available on the identified supply side parameters of the health system. More work seemed to have been done on the implementation and research on the demand side and the community accessibility perspective, primarily on the barriers (most commonly, social determinants) while accessing MNH care in the urban areas. Inadequacy also prevails in the innovations and best practices attempted in the areas identified for this exercise.
Moving toward specific health system parameters, information was available for some of these; such as community interventions, human resources and service delivery, where interventions and innovations have also been attempted. However, some of the other parameters; such as supply chain management, logistics, partnerships and inter-sectoral convergence were conspicuously absent with evidence. Moreover, the majority of the available literature was targeted at small population sizes, thereby reducing its application for scalability. Another key limitation was that, where there were interventions or innovations, many were either not documented or were documented inadequately, leaving a large information gap.
Most of the documents that could be accessed were reports, opinion documents and articles, and commentaries. Published studies with a large sample size and statistically significant results covering various sub-sections of the supply side were largely not available. The studies were found to be numerically and statistically insufficient in many sections. While there were some quantitative studies and qualitatively rich research reports, they were mostly for one or two themes, rather than for all the aspects. The researchers also had to face inaccessibility of critical and specific UMNH data, especially with regard to city public health systems & HMIS. An intense snowballing efforts did pave access to a few useful documents; however, they were not yet in the public domain and could not be referenced, as they couldn't be off-the-record insights. Most of the articles covered overlapping themes and therefore
22 Maternal and Newborn Health in Urban India A report on literature review
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Potentially relevant articles identifiedafter intense electronic search ~ 400
Articles included fromelectronic search ~ 300
Studies from electronicsearch retrieved for moredetailed evaluation ~230
Studies from electronicsearch excluded (after
evaluation of full text) fromreview with reason ~10
Relevant studies includedin the review ~ 220
Experts in field contacted forfeedback on protocol & provide
information for manual search + 40
Studies from manualsearch retrieved for moredetailed evaluation ~20
Studies from manualsearch excluded (after
evaluation of full text) fromreview with reason ~10
Relevant studies includedin the review ~ 10
Synthesis of all studies included in the review
LITERATURE REVIEW PROCESS
impeded segregation. At the same time, these articles did not provide very useful information on possible solutions on those overlapping and multiple themes.
THOT Consultants, a New Delhi-based social and healthcare communications and advocacy consultancy, was commissioned by the Saving Newborn Lives programme of Save the Children to synthesise quality evidence to identify opportunities and gaps in-the health system; factors affecting programming and service delivery; and potential strategies to address the specific MNH care needs of the urban poor in India.
Who has conducted the review?
23Maternal and Newborn Health in Urban IndiaA report on literature review
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A. Service Delivery Mechanisms, Logistics and Supply-Chain Management
Service Delivery Mechanism: The Basic Mandate
This section focuses on service delivery mechanisms for MNH, specifically the currently available health services and existing service delivery platforms in the urban areas. The literature reviewed in response to this research question was divided into three sub-sections: service delivery platforms, infrastructure, and logistics and supply-chain management. Though these appeared as three separate areas of enquiry at the very beginning of the study, insufficient or limited literature and inter-linkages between the three resulted in a combined section focusing on all three functional areas.
First and foremost, it is important to understand the definition of service delivery mechanism in general. According to the WHO framework, service delivery is one of the 6 core components or 'building blocks' that define health systems. All women need access to good quality maternal health services during pregnancy, delivery and in the post-partum period to ensure their health and that of their infants, irrespective of the status of their pregnancy. Hence, access to and utilisation of quality health services is
111213an important proximate determinant of maternal mortality . This includes the delivery of interventions to reduce neo-natal, infant, child and maternal mortality, and the burden of various preventable communicable diseases. Service provision or delivery is an immediate output of the inputs into the health system, such as the health workforce, procurement, and supplies and finances. Increased inputs should lead to improved service delivery and enhanced access to services. Ensuring availability and access to health services is one of the main functions of a health system. Such services should meet a minimum quality standard. Different terms such as access, utilisation, availability and coverage are
14often used interchangeably to reflect whether people are receiving the services they need .
Some key characteristics of a good service delivery, which are accepted as necessary in any well-functioning health system, are:
1. Comprehensiveness: A comprehensive range of health services is provided, appropriate to the needs of the target population, including preventive, curative, palliative and rehabilitative services and health promotion activities.
2. Accessibility: Services are directly and permanently accessible with no undue barriers of cost, language, culture or geography. Health services are close to the people, with a routine point of entry to the service network at primary care level (not at the specialist or in hospital level). Services may be provided in the home, the community, the workplace, or health facilities, as appropriate. Access is a broad term with different dimensions.
3. Coverage: Service delivery is designed so that all people in a defined target population are covered, i.e. the sick and the healthy, all income groups and all social groups.
4. Continuity: Service delivery is organised to provide an individual with continuity of care across the network of services, health conditions, levels of care, and over the life-cycle.
5. Quality: Health services are of high quality, i.e. they are effective, safe, centered on the patient's needs and are given in a timely fashion.
6. Person-centered/ Responsive: Services are organised around the person, not the disease or the
III. Findings
11Bhatia, J.C. (1993). Levels & Causes of Maternal Mortality in South India. Studies in Family Planning, 24(5), 310-318.
12 McCarthy,J., and Maine,D. (1992).A Framework for Analyzing the Determinants of Maternal Mortality:Studies in FamilyPlanning, 23(1), 23-33.13 Fauveau,V., Koenig M., Chakraborty, T., and Choudhary, A. (1988). Causes of Maternal Mortality in Rural Bangladesh; 1978, 1985. Bulletin of WHO, 66(5)
643-651.14
Tanahashi, T. (1978). Health Services Coverage and its Evaluation. Bulletin of the World Health Organization, 56:295–303.
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financing. Users perceive that health services are responsive and are acceptable to them. There is participation from the target population in the design and assessment of service delivery. People are partners in their own health care.
7. Coordination: Local area health service networks are actively coordinated, across types of provider, types of care, levels of service delivery, and for both routine and emergency preparedness.
8. Accountability and Efficiency: Health services are well managed so as to achieve the core elements described above, with a minimum wastage of resources. Managers are allocated the necessary authority to achieve planned objectives and held accountable for overall performance and results.
9. Availability refers to the physical access or reachability of services that meet a minimum standard. The latter often requires specification in terms of the elements of service delivery, such as basic equipment, drugs and commodities, health workforce (presence and training), and guidelines for treatment.
10. Affordability refers to the ability of the client to pay for the services.
11. Acceptability of the service predominantly has a socio-psychological dimension and is a pre-condition for quality.
The process of developing a healthcare delivery system in urban areas has not as yet received the desired attention. Unlike the rural health services, there have been no efforts to provide well-planned and an organised primary, secondary and tertiary care services in geographically delineated urban areas. As a result, in many areas primary health facilities are not available; the limited but the existing primary care services remain underutilised while there is over-crowding in most of the secondary and tertiary
15centres .
The Constitution of India mandates that primary healthcare in urban areas is the responsibility of the Urban Local Bodies (ULBs). As of now, the country has four types of urban health posts, A, B, C and D. The Urban Family Welfare Centres are also of three types, I, II and III. They differ mainly in staffing patterns and, accordingly, in the services provided. They are supposed to mainly provide integrated Reproductive and Child Health (RCH) care. According to the Report and Recommendations of the Technical Resource Group, National Urban Health Mission (TRG, NUHM), Ministry of Health and Family
16Welfare, 2014) , it identifies three broad institutional patterns from the perspective of which government 17takes primary responsibility for organising healthcare in the city .
In the first pattern, healthcare facilities are entirely provided by the state departments of health, with no involvement of the Urban Local Body (ULB). There is usually a Municipal Health Officer who is in-charge of a number of non-medical services relating to public health, but even this post is often vacant or lacks the necessary support staff and importance. This is the pattern in all urban areas of states such as Himachal Pradesh and Bihar, and in small towns (typically less than 2 lakh population) in almost all the states.
In the second pattern, a minority of care provision is by healthcare facilities under the ULB and this role is receding. Typically, it is usually a maternity hospital and a few UHPs/ dispensaries and sometimes a cadre of health volunteers who are under the ULB. For the main part, it is the district hospital or medical college hospital that provides the healthcare services and there may be some UHCs under the state government as well. Bhubaneswar is a typical example of this.
In the third pattern, most of the healthcare facilities are under the ULB, which looks after the medical and non-medical public health functions in an integrated manner. The state government may have a few
Health Service Delivery in Urban Areas
15 Planning Commission, Government of India ; Tenth Plan Document (2002-2007, Volume II)16
NUHM (2014). Report and Recommendation of Technical Resource Group for the National Urban Health Mission. New Delhi: Ministry of Health and Family Welfare, Government of India.
17 rd th th73 and 74 Constitutional Amendment Acts (12 Five Year Plan, 2012).
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facilities, usually medical college hospitals; but the rest of the functions are delivered effectively by the ULB. This is the pattern in all the major metros: Mumbai, Kolkata, Chennai, Bengaluru, Ahmedabad and Delhi, though in the last the state government too administers several facilities. Among the non-metros, Pimpri- Chinchwad Municipal Corporation, Visakhapatnam, Burdwan and Madurai show this pattern.
Primary care is being accessed at all the five levels: medical college hospitals, secondary care hospitals (two levels), primary care facilities and outreach services. In terms of the frequency of use, an inverse pyramid phenomenon works. The major proportion of curative primary care provision may be occurring at the medical colleges and the district hospitals, with the urban health centres and maternity homes catering to a much smaller proportion and almost no care being delivered at the outreach or community level for a major part of the population. This does not happen to such an extent in a rural setting, because of the distances. However, in urban areas, geographical distance is not a major barrier, and since services are more assured at a higher level, the poor prefer to go there.
The National Urban Health Mission aims to address the health concerns of the urban poor through facilitating equitable access to available health facilities by rationalising and strengthening of the existing capacity of health delivery for improving the health status of the urban poor. This is to be done in a manner to ensure that well-identified facilities are set up for each segment of the target population, which can be accessed conveniently.
The NUHM proposes a broad framework rationalising the available manpower and resources, improving access through a communitised risk-pooling mechanism and enhancing participation of the community in the planning and management of the health care service delivery by ensuring a community link volunteer (Accredited Social Health Activist-ASHA/Link Workers from other programmes such as the JNNURM, ICDS, etc.) and establishment of Mahila Arogya Samiti (MAS) and
Health Service Delivery System as provided in the NUHM Implementation Framework
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Public orempanelledSecondary/
Tertiary privateProviders
Urban Health Centre (One forabout 50,000 population - 20-30
thousand slum population)*
Strengthenedexisting Public
HealthCareFacility
EmpanelledPrivateService
providers
Community Outreach Service(Outreach points in government/ public domain Empanelled
private services provider)Urban Social Health Activist (200-500 HH)
Mahila Arogya Samiti (20-100 HH)
*This may be adapted flexibly based on spatial situation of the city
Refe
rral
PrimaryLevel HealthCare Facility
CommunityLevel
URBAN HEALTH DELIVERY SYSTEM
18Rogi Kalyan Samiti (RKS) , ensuring effective participation of urban local bodies and their capacitybuilding, along with key stakeholders, and by making special provision for inclusion of the most vulnerable amongst the poor, development of an e-enabled monitoring system. The quality of the services provided will be constantly monitored for improvement (IPHS/ Revised IPHS for Urban areas).
The framework states that all the services delivered under the urban health delivery system through the Urban-PHCs and Urban-CHCs will be universal in nature, whereas the outreach services will be targeted to the target groups (slum dwellers and other vulnerable groups). Unlike rural areas, sub-centres will not be set up in the urban areas, as distances and modes of transportation are much better. Outreach services will be provided through the Female Health Workers (FHWs), essentially ANMs with an induction training of three to six months, who will be headquartered at the Urban-PHCs. These ANMs will report at the U-PHC and then move to their respective areas for outreach services (including school health) on designated days. They will be provided with mobility support for providing outreach services. On other days, they will conduct Immunisation and ANC clinics at the U-PHC itself. Apart from these, quality antenatal care, including prevention and treatment of anaemia, institutional/safe delivery services, essential obstetric care, post-natal and neo-natal care is to be provided.
To further strengthen the delivery of services, the framework provides for cities to also periodically engage the services of specialist doctors to provide services at the U-PHC based on needs, on a reimbursement basis. The U-PHC can also serve as a collection centre for diagnostic tests in partnership with empanelled private diagnostic centres. Under the NUHM, a uniform healthcare service delivery mechanism with IPHS norms will be developed and the states would be encouraged to adopt these norms for the U-PHCs. Existing hospitals, including ULB maternity homes, state government hospitals and medical colleges, apart from private hospitals, will be empanelled/ accredited to act as referral points for different types of healthcare services; such as reproductive, maternal, newborn and child health.
Despite the supposed proximity of the urban poor to urban health facilities, their access to them is severely restricted. The lack of standards and norms for the urban health delivery system, when contrasted with the rural network, makes the urban poor more vulnerable and worse off than their rural counterpart. Many components of the NRHM cover urban areas as well. These include funding support for the Urban Health &Family Welfare Centres and Urban Health Posts, funding of National Health Programmes such as TB, immunisation, malaria, etc., urban health component of the Reproductive and Child Health Programmes (including support for the Janani Suraksha Yojana in urban areas), strengthening of health infrastructure such as District and Block level Hospitals, Maternity Centres under the NRHM etc. The only limitation has been the fact that norms for urban area primary health infrastructure were not part of the NRHM proposal, setting a limit to the support for basic health infrastructure in urban areas. Municipal Corporations, Municipalities, Notified Area Committees and Nagar (Town) Panchayats with their own distinctive normative were not units of planning under the NRHM.
One primary healthcare facility in an urban area caters to a much higher population as compared to the government norm of one centre for every 50,000 of the population. From the providers' perspective, service delivery in slums is an enormous challenge, given the large and sometimes mobile nature of the slum population. This leaves them with little scope for persuasion for appropriate behaviour with target families. In cities, particularly in the large ones, there is an over-emphasis on super-speciality care centres within the private sector, which are clearly out of the reach of the urban poor.
Currently available Service Delivery Platforms
18Rogi Kalyan Samiti (Patient Welfare Committee) / Hospital Management Committee is a simple yet effective management structure. This committee, which would be a registered society, acts as a group of trustees for the hospitals to manage the affairs of the hospital. It consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials from the Government sector who are responsible for the proper functioning and management of the Hospital / Community Health Centre / FRUs. RKS / HMS is free to prescribe, generate and use the funds with it as per its best judgement for smooth functioning and maintaining the quality of services.
19 NUHM framework: Table 17:1, Indicative Service Norms by Levels of Service Delivery. No. L 1907/1/2008-UH, Government of India. Ministry of Health & Family Welfare, Department of Health & Family Welfare.
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thThe ULBs, in line with the mandate of the 74 Amendment, manage the primary healthcare services. However, in many cities, such as Delhi, the urban local body, (that is the Municipal Corporation of Delhi (MCD), the New Delhi Municipal Corporation (NDMC), the Delhi Cantonment Board and other para-statal agencies)and the state government jointly provide primary healthcare services.
Two models of service delivery are seen to be prevalent in urban areas. In states such as Uttar Pradesh, Bihar and Madhya Pradesh, healthcare programmes are being planned and managed by the state government. The involvement of the Urban Local Bodies is limited to the provisioning of public health initiatives, such as sanitation, conservancy provision of potable water and fogging for malaria. In other states such as Karnataka, West Bengal, Tamil Nadu and Gujarat, healthcare programmes are being primarily planned and managed by the Urban Local Bodies. In some of the bigger municipal bodies, such as Ahmedabad, Chennai, Surat, Delhi and Mumbai the medical or health officers are employed by the local body, whereas in smaller bodies, the health officers are mostly on deputation from the state health department. Andhra Pradesh has completely outsourced its service delivery to NGOs in the newly created 191 urban health posts across 73 towns. The experimentation, it appears, has been quite satisfactory, with reduced cost.
Seven metropolitan cities, viz. Mumbai, New Delhi, Chennai, Kolkata, Hyderabad, Bengaluru and Ahmedabad, will be treated differently. These cities are expected to manage the NUHM directly through their municipal corporations. Funds will be transferred to them through the state health society on the basis of their PIPs approved by the Government of India.
Efforts were made in the metropolitan cities of Chennai, Bengaluru, Kolkata, Hyderabad, Delhi and Mumbai for improving the healthcare delivery through the WorldBank-supported IPP. Under the programme, 479 urban health posts, 85 maternity homes and 244 sub-centres were created in Mumbai and Chennai as part of the IPP-V and in Delhi, Bengaluru, Hyderabad and Kolkata as part of the IPP-VIII. In several the IPP-VIII cities, partnerships with profit or not-for-profit providers has helped in expanding services. Kolkata had the distinction of implementing the programme through the establishment of an effective partnership with private medical officers and specialists on a part-time basis, fee-sharing basis in different health facilities, resulting in ensuring community participation and enhancing the scope of fund generation.
The Municipal Corporation of Greater Mumbai (MCGM) has a network of teaching hospitals, general
Sub District Hospital
Hospital
1. Civil Hospital
Hospital
2. Attached to Media Collage
Hospital
3. Municipal Corporation
Hospital
4. ESIS
Maternal and Child HealthCenters/ Homes
Maternal and Child HealthCenters/ Homes
Maternal and Child HealthCenters/ Homes
Urban HealthPost/ Center
Urban HealthPost/ Center
Urban HealthPost/ Center
Urban HealthPost/ Center
Urban HealthPost/ Center
Tertiary Level
Primary Level(Managed by MunicipalCorporation Council)
Secondary Level(Managed by MC/
State Govt.)
PERI
URBAN
URBAN PUBLIC HEALTH STRUCTURE
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hospitals and maternity homes across Mumbai. In Kolkata, strong political ownership by elected representatives has played a positive role in the smooth implementation of the project and sustainability of the reforms introduced. Bengaluru and Kolkata have fully dedicated maternity homes in adequate numbers that facilitate better follow-up care. In Bengaluru, the management of health facilities has been handed over to the NGOs.
The following box reflects the different systems of urban healthcare present in India especially in the B-level cities or Tier II cities that are immediately next to the mega and metro, cities in the country. This gives an indication of the diversity of health delivery systems in urban India :
The Report and Recommendations of the TRG, NUHM, Ministry of Health and Family Welfare, 2014, notes that there is an inverse pyramid phenomenon when it comes to the organisation of healthcare services. The major proportion of curative primary care provision is occurring at the medical college and the district hospitals, with the UHC and maternity homes catering to a much smaller proportion, and almost no care occurring at the outreach of community level for a major part of the population. In rural settings, to some extent, it is the distances that disallow, such a pattern. But in most urban areas, geographical distance is not such a major barrier and since services are more assured at the higher site, the poor often prefer to go there. Another big issue in the organisation of primary care services is that primary healthcare in the urban setting is not population-based.
Typically, the urban peripheral facility, be it a health post or health centre, treats all those who come for
AgraIn 2004, the UHRC was designated by the Government of India as the coordinating agency for developing a sample health proposal for Agra city. The proposal was to guide the District Health Department as well as the Municipal Corporation to expand health services to the large urban poor population in the city. Based on the assessment, two approaches were followed, that clearly focused on: the involvement of NGOs to recruit and train Community Link Volunteers (CLVs), formulation of Mahila Arogya Samiti (MAS), and NGOs operating the Urban Health Centres, along with the facilitation of linkages between the community and the service providers
CoimbatoreThere are nearly 750 hospitals in and around Coimbatore with a capacity of 5,000 beds. The first healthcare centre in the city was started in 1909. In 1969, it was upgraded to the Coimbatore Medical College Hospital (CMCH). It is a government hospital with a bed strength of 1,020 and provides free healthcare. Including the CMCH, the corporation maintains 16 dispensaries and two maternity homes. The city also has many large multi-facility private hospitals. It remains the preferred healthcare destination for people from nearby districts and also from the neighbouring state of Kerala.
IndoreIn partnership with the Department of Public Health, the Municipal Corporation of Indore, the district administration, NGO partners and local communities, the Indore Urban Health City Demonstration Programme was initiated in March 2003. The programme operates with the objective of improving maternal as well as child health and nutrition among the slum dwellers. Two programme strategies, the demand-supply and linkage approach and multi-stakeholder ward coordination approach were developed in order to improve the health of slum-dwellers in a consultative manner.
PuneThePune Municipal Corporation has a robust health infrastructure comprising 34 OPD units,2 mobile healthcare units operated out of 11 urban health posts, 14 family welfare centres, one general hospital, two secondary hospitals, one special hospital for communicable diseases and one tertiary-care hospital.
LucknowHealth services in the city are provided by the Department of Medical, Health and Family Welfare, the Lucknow Municipal Corporation, the private sector, Railways Hospital, ESI Hospital & dispensaries and Cantonment Hospitals. Primary healthcare is provided through Tier I centres which include Urban Family Welfare Centres (UFWCs), urban RCH health, school health dispensary, medical care unit and urban RCH nodal unit.
Navi MumbaiInnovations in health infrastructure in 1992, led to the formation of a five-tier health system consisting of mobile clinics, 20 health posts, 4 maternity and child health hospitals (50-bedded), a general hospital and a super-speciality hospital. A total of 182 link workers were appointed by the NMMC under the RCH-II. Parallel to the RCH, Navi Mumbai rolled out the Sure Start Project and developed excellent mechanisms for maternal and newborn healthcare.
SuratIt has a four-tier system. The first tier comprises a link worker who provides home-based care and support. The second tier includes trained ANMs, trained doctors and visiting paediatricians at the UHCs. The third tier comprises maternity homes and the fourth tier consists of tertiary-care centres, the medical college hospital and civil hospital. Thus, most of the structure at the SMC is similar to the rural structure in Gujarat. The same administration and management pattern has been replicated in the urban areas.
Other Tier II or B-level cities: Key Features, Initiatives and Innovations
29Maternal and Newborn Health in Urban IndiaA report on literature review
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services; there isn't a priority responsibility for the health of the population in a defined catchment area. This lack of definition of a catchment area and the connection between the health centre to a given population base has a direct adverse consequence for reaching the vulnerable. Another consequence is that all outreach services are limited and this implies that those with latent illness or inadequate health-seeking behaviours are altogether missed.
Another pattern is that primary health services in most cities are restricted mostly to RCH services and, even within these, to family planning, immunisation and a limited quality of ante-natal care. This is a major reason for reliance on tertiary hospitals or private care providers. The NHRC reports from 31
20urban cities in India reflected that, despite being the key facility for providing RCH services in slum areas, post- natal care and newborn care have not been provided by most of these centres, as the ANMs deputed here are not trained to do so. Also, the weak referral mechanisms and poor facilities prevent them from being effective in primary healthcare provisioning. The primary health institutions should be managed by the local governments and ULBs/ PRIs in order to achieve decentralisation and enhance
rd th th 21local participation, as mandated in the 73 and 74 Constitutional Amendment Acts (XII Plan, 2012) .
The IPP- VIII completion report also states that multiplicity of agencies providing health services posed management and implementation problems in all the project cities.
In many urban areas the institution functions under a Municipal Health Officer, who should be a public health officer having qualifications for the same. In most of the states the healthcare centres are being taken over by the state department. So, the Municipal Health Officer often lacks his managerial leadership, which undermines both convergence and effective response if any disease breaks out (NHSRC, 2013).
According to the National Family Health Surveys (NFHS-III, 2006), maternal and child health has st nd remained an integral part of the family planning programme since the time of the 1 & 2 Five Year Plans
th (1951-56 and 1956-61). As part of the Minimum Needs Programme initiated during the 5 FiveYear Plan (1974-79), maternal health, child health and nutrition services were integrated with family planning services. In 1992-93, the Child Survival and Safe Motherhood Programme continued the process of integration by bringing together several key child-survival interventions with safe motherhood and family planning activities. In 1996, safe motherhood and child health services were incorporated into the Reproductive and Child Health (RCH) Programme.
22A brief review of the chapter on 'maternal health' in the NFHS-III report provides with details of the status of maternal health service and delivery platforms – ante-natal care services, assistance during child delivery and post-natal care services. The services and programmemes specific to urban maternal and neo-natal health cannot be found directly as it is integrated into the components of general health service system. According to the National Family Health Survey (NFHS-III) report on maternal healthcare services, there is a wide variation in the coverage and quality of antenatal care services, percentage of deliveries by trained professionals and the number of post-natal visits among the states and within the states, with considerable rural-urban differences.
Undoubtedly, India has experienced considerable improvement in accelerating coverage in MNCH care since the Millennium Declaration, 2000. However, the persistent inequity in access to maternal and newborn healthcare across different economic groups masks the average improvement in the majority of states. An important hurdle in addressing this issue has been the identification of the marginalised,
23deprived people who deserve special attention . Even the migratory nature of the population poses a
problem in the delivery of services. Similar concerns have also been raised in the IPP-VIII completion report which states the lack of homogeneity among slum residents, coming from the neighbouring
Limitations and Challenges in Expanding the Range of Services
20 Ahmedabad, Ambala, Aligarh, Bengaluru, Bardhaman, Bhopal, Bhubaneswar, Chennai, Delhi, Dhamtari, Gangtok, Guwahati, Indore, Jorhat, Kochi, Kolkata, Madurai, Mumbai, Muzaffarpur, Patna, Pimpri – Chinchwad, Pune, Raipur, Satara, Shimla, Trissur, Tumkur, Valsad, Villupurum, Vishakhapatnam, Viziangaram.
21Health Mission(NRHM) for the tweflth Five Year Plan (2012-2-17). New Delhi: Planning Commission, Government of India.22 NFHS-3. (2007). National Family Health Survey (NFHS-3), Volume I, (2005-2006). Mumbai, India: Indian Institute of Population Sciences (IIPS) and Macro
International.
30 Maternal and Newborn Health in Urban India A report on literature review
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states/countries to the large metropolitan cities, made planning and implementation of social mobilisation activities very challenging.
Limited budgetary allocation from the central and state governments is a hurdle. The current government health expenditure in India amounts to less than 1 per cent of the GDP (these account for less than 20 per cent of the overall health spending). Further, this ratio is not only low internationally but is even lower compared to our own past experience. This low spending on health and the dominance of private sources of financing make India unique. This reflects the very low priority that governments have
24accorded to the health sector (High Level Expert Group, 2011) .
Currently, the secondary level of care is provided by the District hospitals and their equivalents, like combined and base hospitals, while tertiary care is provided by the Medical Colleges. However, these are not linked to primary care institutions such as health posts or dispensaries. Consequently, patients approach tertiary hospitals for primary care, which could have been provided elsewhere. The emphasis should be on primary prevention, primary healthcare and secondary prevention, in that order. This
25approach would be cost-effective and optimise resources at all levels (WG NRHM,XII FYP, 2011) .
Primary healthcare in urban areas, where the poorest sections can easily approach it has largely been neglected. Larger metropolises such as Mumbai and Delhi provide primary healthcare by means of dispensaries, health posts and maternity homes. In Mumbai, a Public Health nurse usually heads them. They provide basic ante-natal care and primary healthcare through Community Health Volunteers. Maternity homes, headed by an MBBS Medical Officer, are meant for conducting normal deliveries and
26have support staff for the purpose .
27 A study aimed to find out different aspects and perspectives of a quality maternal care to bring about favourable changes to reach MDG-5, recommends that there is a strong need to improve both coverage & quality of maternal healthcare services with the special emphasis on early registration of pregnancy, percentage of deliveries attended to by skilled personnel, improvement in the consumption of IFA and the number of post-natal visits, in order to achieve the target sets in MDGs.
At the primary healthcare level, Delhi has a network of 987 clinics and dispensaries through theDelhi Government, MCD, NDMC, Delhi Cantonment Board, Central agencies (CGHS, ESIC) and Railways. Under the IPP-VIII, several maternity homes, health centres and health posts have been opened and are
28being run by the MCD (PHRN, 2010) . Multiple state agencies are providing services. There is an overlapping of services and a lack of coordination among these agencies. Private health providers are the key players in the overall provisioning of services.
The Urban Resource Centres (URCs) are one of the steps taken in response to the needs of the urban poor living in the slums. States such as Andhra Pradesh built 192 urban slum health centres with aid from the World Bank. After the end of the project, the State is running the centres with its own finances (USAID,
292006) . Public-private partnership models are adopted in most of the urban cities to address the needs of the poor living in the slums. Involving NGOs focusing mainly on service delivery, community
Limited Budgetary Allocation
Limited Reach and Scope of Primary Healthcare
Unclear and Overlapping Roles and Responsibilities
23Singh, Prashant Kumar, Rai, Rajesh Kumar and Kumar Chandan (2013). Equity in maternal, newborn, and child healthcare coverage in India,Global Health
Action, 6: 22217 - http://dx.doi.org/10.3402/gha.v6i0.22217.24
HLEG Report on UHC. (2011). High Level Expert Group Report on Universal Health Coverage for India. New Delhi: Planning Commission.25 th th
WG Tertiary Care XII FYP(2011). Report of the Working Group on Tertiary Care Institutions for the 12 Five Year Plan. New Delhi: Planning
Commission.26 National Health Policy, 2002.27 Kansal, S., Akhtar, M.A. and Kumar, Alok (2011)T Maternal Health Care Services in an Urban Setting of Northern India, International Journal of
Current Research, Vol. 33, Issue, 6, Pp.284-286, June.28
PHRN. (2010). Public Health Resource Network: Issues in Public Health, Book 16. Delhi: Capital Printers.29
USAID, (2006). Review of Public-Private Partnerships Models, published by PAIMAN (Pakistan Initiative for Mothers and Newborns).
31Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
collaboration, behaviour change communication and needs assessment of the urban poor living in the slums is also one common response adopted by the Governments towards MNH services. However, lack of institutionalised linkages lead to lack of coordination and, therefore, of accountability.
Multiplicity of providers and lack of coordination among them has led to dysfunctional referral systems and a consequent overload on the tertiary care providers. Even in states where primary healthcare is managed by ULBs, and secondary and tertiary healthcare by the state, the referral chain is not functional
30(NUHM, 2012) .
Das Gupta (2005) reviewed the state of public health in India and found several conditions and factors responsible for the poor state of public health in India. Some of these conditions reflect the limitations of public health in contemporary India and most of its states.
The private sector is the main provider of healthcare for a majority of the people living in urban areas 31(NFHS-III, 2007) . Private doctors and private clinics are the most commonly accessed source of
healthcare. Use of private hospitals increases with increasing wealth quintiles. However, the poor also utilise the private sector more than the public sector (NFHS-III, 2007). A study done in Mumbai from 2005-2007 showed that 16 percent of the women still preferred home delivery, citing reasons such as
32custom and tradition, rapid progress of labour and fear of hospital staff .
33An article by Fernandez, A. and Osrin, D ., describes the critical first steps taken to revitalise the vast public health system of Mumbai city through the active participation of personnel from within the system. It focuses on one of two components of an ambitious action-research project aimed at improving the survival and health of newborn infants and mothers living in slum communities in Mumbai. The article mentions that while the public health infrastructure is impressive in Mumbai, there are weaknesses in its provision for mothers and infants, and that the special needs of newborn babies are not
adequately recognised or addressed. Several inter-related factors are responsible for this weakness.
Tertiary hospitals tend to be overburdened as sources of routine pre-natal and delivery care; maternity homes, specifically oriented to the management of routine deliveries, are underused; there is limited or
no provision of pre-natal and post-natal care at health posts; inter-sectoral linkages are weak and patterns of referral between institutions have not yet been systematised; there is a lack of standardisation of clinical and administrative protocols, particularly in terms of coherence across a range of healthcare institutions; care provider efficiency and morale are low; and the coverage of home-based care and
home-visit systems for the vulnerable, newborn period is generally poor.
Medicalisation has resulted into substantial proportions of the urban health budgets being used for expanding subsidised medical training, public sector employment for medical graduates and high-end tertiary medical services. All of which benefit the middle classes and detract from the provision of public and primary health services in urban slums that are important to address the healthcare needs of the urban poor.
Secondly, there are no major programmes focused on strengthening urban community processes. Another important issue faced (NHSRC reports), is weak institutional mechanisms of urban primary healthcare services with other government-run schemes responsible for health determinants related to sanitation, drinking water and environment, along with Integrated Child Development Services. There
Narrowing of Public Health
Medicalization of all Financial Resources
30NUHM. (2012). National Urban Health Mission, Framework for Implementation. New Delhi: Ministry of Health and Family Welfare, Government of India.
31 NFHS-3. (2007). National Family Health Survey (NFHS-3), Volume I, 2005-2006. Mumbai, India: Indian Institute of Population Sciences (IIPS) and Macro International.
32 More, Neena Shah, Alcock Glyn , Das, Sushmita , Bapat, Ujwala , Joshi, Wasundhara, and, Osrin David (2010) 'Spoilt for Choice? Cross-sectional study of Care-seeking for Health Problems During Pregnancy in Mumbai Slums', Global Public Health, First published on: 27 October 2010 (iFirst) DOI:10.1080/17441692.2010.520725
33 Fernandez A, Osrin D (2006). The City Initiative for Newborn Health. PLoS Med 3(9): e339.DOI: 10.1371/journal.pmed.0030339. Fernandez, A., and Osrin, D.
32 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
is also no coordination between the private caregivers and UHCs, which results in duplication of services in certain areas and complete lack of services in other areas.
Studying systems alone may not give us the required answer. A study on health-seeking behaviour with regard to newborn care in urban slums and villages of Anand, Gujarat, revealed wide socio-economic
34gaps between slums and villages . It revealed that the proximity of the slums to two multi-specialty hospitals and smaller private hospitals did not improve utilization of services. Urban slum dwellers are ignorant about their health needs and also lack a positive attitude for seeking healthcare. Acceptability of existing public health infrastructure in both the areas was poor in contrast to the studies undertaken
35earlier . Neonatal follow-up, and care for infants that required medical advice, was largely provided by unqualified professionals as high as 72% in the slum areas.
36Similarly, a multi-centric study also found that education of immediate healthcare providers and mothers in basic newborn care is a must in urban slums, as similar provisions exist in villages under various government efforts. The study also describes a wide gap in newborn practices in slums of a smaller town as compared to the surrounding villages, which had better practices than slums. Urban slum dwellers were 6 times less likely to seek care. Not seeking ANC and illiteracy were also associated with more home deliveries. Though, a single district study did pose its limitations, similar gaps between rural and urban health settings undoubtedly exist not only in the rest of the state Gujarat but in most other states of India.
Responsiveness of the health system to the service-seekers is an important factor that directly impacts health outcome. This involves providing culturally appropriate services with adequate clinical quality. The latter is determined by the availability, efficiency and quality of human resources as well as by the adequacy and regularity in supply of essential commodities such as pharmaceuticals, blood, fluids, contraceptives, and consumables. To ensure these outcomes, the health systems need to provide adequate financing through revenue generation, risk- pooling, and efforts to enhance efficiency through
37competitive purchasing of services from the private sector (World Bank, 2005) . It is an accepted fact that rapid urbanisation in India is characterised by the growing poor/non-poor divides in health and utilisation of the MCH services.
38A study on the utilisation of maternal health services among pregnant women in the slums of Delhi suggested that the awareness and accessibility of healthcare equipped with modern maternity facilities has a significant influence on the health-seeking behaviour of women. Since, it may not be possible to establish a health facility staffed with a doctor or a nurse in every slum area of each city, there is a need to increase awareness of the community about benefits of using modern maternity care at nearby health centres for better health outcomes.
The available logistics and supply chain management mechanisms have not taken into account the real needs of the community. A number of studies undertaken across cities to understand the health-seeking behaviours and existing patterns of accessibility reflect that the Urban Health Centres (UHCs) continue to remain underutilised due to lack of medicines, inadequate or inefficient health functionaries, leading
Health-Seeking Behaviours of the Urban Poor
Lack of Responsive Healthcare
Logistics and Supply-Chain Management
34 Archana S Nimbalkar, Vivek V Shukla, Ajay G Phatak and Somashekhar M Nimbalkar, 2013. 'Newborn Care Practices and Health Seeking Behaviour in Urban Slums and Villages of Anand, Gujarat', Indian Paediatrics, Volume 50__April 16.
35Gupta, M., Thakur, J.S., Kumar R. Reproductive and Child Health Inequities in Chandigarh Union Territory of India. 2008. Journal of Urban Health, 85:291-9
36Srivastava, N.M., Awasthi, S., Mishra, R. (2008).Neo-natal Morbidity and Care-seeking Behaviour in Urban Lucknow. Indian Paediatrics, 45:229-32
37 World Bank, (2005). Achieving the Millennium Development Goal of Improving Maternal Health: Determinants, Interventions and Challenges; Health, Nutrition and Population (HNP) Discussion Paper. Eds. Lule, Elizabeth,. Ramana,G.N.V., Oomman, Nandini, Epp,Joanne, Huntington, Dale And Rosen, James E., The International Bank for Reconstruction and Development / The World Bank.
38 Agarwal, Paras. Singh,M.M. Garg, Suneela (2007). Maternal Health-Care Utilisation among Women in an Urban Slum in Delhi, Indian Journal of Community Medicine Vol. 32, No. 3, July.
33Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
to a strong preference for private services, especially in the case of MNH services (NHSRC DATA 39BASE) .
The situation worsens as one moves to semi-urban locations. A study conducted in Murshidabad town of 40West Bengal reflects that deliveries are mostly attended to by unskilled personnel. Factors such as
distance, connectivity and availability of infrastructural facilities play a predominant role in the 41underutilisation of maternal and newborn healthcare services . Dealing with a large number of
populations in most of the sub-centres increases the work pressure on the ANMs and affects the quality of work. Other infrastructural problems and logistical challenges such as the availability of life saving medicines and vaccines at the health centres compel them to go to private doctors. Nevertheless, the issues of affordability for seeking treatment and childbirth at the facility cost eventually results in
42women giving birth at home without any trained assistance .
In terms of logistics, major gaps were revealed in both the process of review of literature, as well as the issues pertaining to execution of the programme. The prime issue with the litertature available is that a very minor portion of the information deals specifically with the aspects of urban maternal newborn care and is eligible for dicussion on this topic. Some of the existing literature discusses the lack of trust from the communities, with respect to the system. From the literature reviewed, it is evident that the existing resources are underutilised, mainly due to under-staffed facilities and non-availability of services. Moreover, there is also a dearth of literature that focuses on protocols and guidelines with regard to the functioning of primary and secondary level healthcare systems and logistics, specfically for maternal and newborn health in urban spaces.
The insufficiency of logistics and supply chain management surfaces sharply from the data obtained 43through these studies . Inadequate ratio of health functionaries versus the population it is catering to,
lack of equipment and of trained personnel, are some of the shortfalls when one discusses Bhubaneswar city (NHSRC DATA BASE). Most of the ANMs and AWWs largely involved in the delivery of services, lack adequate training. The special programmes, such as JSSK and JSY, are not functioning well enough and provision of MNH services is restricted to immunisation and educating women for institutional delivery (NHSRC DATA BASE). The supply of medicines is inadequate to meet the demands of the people at the community level. To cover a population of nearly 30,000, medicines worth Rs. 6,000 are provided to each urban slum health centre every month. Apart from this, Rs. 5,000 is provided to buy the essential medicines to meet the need of OPD or outreach camps or emergencies; these funds are highly
44inadequate to meet the demand, both at the OPD and outreach camps .
Lack of information on processes adopted for supply chain management, training of staff at primary and secondary-level care, supply chain for drugs and equipment, availability of blood through blood banks and referral support for MNH care reflects a massive gap in secondary literature and calls for research on the availability and accessibility factors that concern pregnant mothers and newborns living in urban slums. The existing literature also hints at the existence of private bodies; however, it does not extensively map the same.
Convergence in the health sector occurs broadly at two levels: one is at the policy level and the other at the functional level. The matter of convergence at the level of policy- making, planning, and framing of
45programmes and schemes is very important for designing better implementation strategies (GOI, 2014) . At a functional level, convergence occurs at different levels via actions by various players, including health department officials and community health workers. Various actions are to be performed by
Convergence and Coordination: The Need of the Hour
39NHSRC DATA BASE (2014): City Study Reports.
40Shodhganga (2013),”Maternal and Child Healthcare Service in West Bengal – a Comparative Study”
41Shodhganga (2013),”Maternal and Child Healthcare Service in West Bengal – a Comparative Study”
42Devasenapathy, N., et al (2014)”Why Women Choose to Give Birthat Home: a Situational Analysis from Urban Slums of Delhi”,British Medical Journal,Downloaded from bmjopen.bmj.com on, September 27 2014 - Published by group.bmj.com
43NHSRC Database.
44 Bhubaneswar city report, NHSRC Database.45 GOI(2014), Understanding Urban Health : An Analysis of Secondary Literature and Data
34 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
46 GOI (2014), Reaching Health Care to the Unreached : Making the Urban Health Mission Work for the Urban Poor
47 Ibid GOI ( 2014), Understanding Urban Health: An Analysis of Secondary Literature and Data. 48
GOI( 2014), Reaching Health Care to the Unreached: Making the Urban Health Mission Work for the Urban Poor.49 GOI ( 2014) Reaching Health Care to the Unreached: Making the Urban Health Mission Work for the Urban Poor.50 Bannerjee M, Sharma D (2007) Exchange for the Maternal and Child healthCommunity Consolidated Reply. 51Ibid Bannerjee, M, Sharma D( 2007).
52 NHSRC data base ( 2014, Pune city report ).53 Acharya A, Paul MacNamee (2009),”Assessing Gujarat's Chiranjeevi' Scheme” Economic and Political Weekly.54 Ibid Acharya A, Paul MacNamee (2009),”55 Ibid Bannerjee M, Sharma D( 2007).56 Ibid Bannerjee M, Sharma D( 2007).57 GOI (2013) January 2013, A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India. For healthy
mother and child.58 GOI (2013), “NUHM, Implementation framework
59 Ibid Bannerjee, M., and Sharma D( 2007)
different departments in provisioning of health services by collective action (where the goal is set or defined) and different stakeholders engage in a coordinated, inter-departmental effort to achieve the
46broad goals (GOI, 2014)
An urban health programme focusing on the needs of mothers and newborns needs to promote both 47inter-sectoral as well as intra-sectoral convergence (GOI, 2014) . The required actions include
convergence with Ministries; such as the Ministry of Urban Development, Housing and Poverty Alleviation, Ministry of Women and Child Development, Ministry of Human Resource Development
48and core departments such as the Ministry of Health and Family Welfare(GOI, 2014) . The Health of the Urban Poor Project (HUP) by the Population Foundation of India (PFI), emphasises the creation of a common platform for the various relevant programmes and departments, to improve the provision of
49urban health services (GOI, 2014) .
There have been some efforts made at mission convergence across the metropolitan cities in the country 50(Bannerjee, Sharma, 2007) . One of the functional examples can be found in Delhi. The Government of
Delhi created 'Samajik Suvidha Sangam', registered as a society, setting an example for mission 51convergence in the National Capital (Bannerjee, Sharma, 2007) . Similarly, “Mahila Milan” was
successful in the design, building and management of toilet blocks in Pune. Further, the Pune Municipal Corporation set a good example through a participatory approach, as it provided an alternative housing solution in the densely populated urban slums, to address the socio-economic determinants of health
52(NHSRC Data base) . Gujarat also designed a scheme based on public-private partnership (Chiranjeevi Yojana) that aims to increase institutional deliveries in partnership with private nursing
53homes(Acharya, MacNamee, 2009) . However, the challenges still continue, with a majority of obstetricians and gynaecologists not registering for this scheme and also not many private nursing
54homes located in remote areas opting to be a partner .
The mission convergence in the urban slums emphasises tackling the unsanitary, unhealthy environment and the socio-economic conditions of the poor, as major challenges to attaining better
55health standards (Bannerjee, Sharma, 2007) . In this regard, the mission recommends a framework for pro-active partnership with NGOs/civil society groups for strengthening the preventive and health
56promotion activities at the community level (Bannerjee, Sharma, 2007) .
Given the current urban provider landscape and consumer preferences, for any scheme such as the RMNCH+A to provide universal comprehensive public healthcare, it must be supplemented through
57contracting accredited private providers, organisations and NGOs (GOI, 2013) . There are many programmes that have been successfully launched with inter-sectoral coordination, for example, the National Vector-Borne Disease Control Programme (NVBDCP), National AIDS Control Society
58(NACO), AYUSH, and now the NUHM, (GOI, 2013) . The most critical aspect of all these programmes is to follow a holistic approach to achieve the target goals. The synergy between all these partner agencies and governments, both at the central and state levels, plays a pivotal role.
In Delhi, a few NGOs have successfully engaged the community to improve service delivery. In Andhra Pradesh, the government has used decentralised monitoring and implementation systems along with people's participation, to provide basic primary healthcare and family welfare services to the urban
59poor . Across and within states, the arrangements for the governance of each of the services and the
35Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
Key Findings :
l Unclear responsibility of providing health services, unlike that of rural areas.
l Resources are geared to provide curative care.
l The urban healthcare system is focused on secondary and tertiary care with little or no focus on primary care.
l Urban Health Posts/ Centres (UHPs/UHCs) mainly provide three types of services: Regular (including preventive, curative, IEC activities and training), seasonal (pre-monsoon and monsoon-related activities) and disaster relief (in specific areas in the country).
l Few larger Municipal Corporations with good revenue resources such as Surat, Navi Mumbai, Pune and Pimpri-Chinchwad, have demarcated special resources to provide urban health services.
l There is no definite system of referral; no linkages between domiciliary, health centre and hospital; and no defined protocols for admissions to primary, secondary and tertiary levels.
l The unorganised urban poor have no relationship with healthcare providers and, therefore, mostly access expensive private healthcare, often at the expense of nutrition and other basic necessities.
mechanisms provided for the urban slum population are very different, so the effectiveness of co-ordination between them also varies widely.
S. No.
Intervention/ Implementing Organisation
City/State Inference
2 Mukhyamantri
Swasthya Yojana
Dhamtari
3 Mahila Arogyam
Samiti (MAS)
Pune Tackle issues of maternal and newborn healthcare through
spreading awareness and assisting the beneficiaries in availing
of
ANC and institutional delivery in healthcare centers
4
Chiranjeevi Scheme
Municipal
Corporation
Launched
in 2006
The scheme based on public - private partnership (Chiranjeevi
Yojana) that aims to increase institutional deliveries in
partnership with private nursing homes
1 Urban Health
Units, Kolkata
Municipal
Corporation
Kolkata Key features of the programme are the Honorary Health
Workers (HHW), the Sub - Centres and th e Health
Administrative Units (HAU). Although the programme has
Reproductive and Child Health as its core, its only focus seems
to be on assisting delivery for pregnant women and
immunisation
36 Maternal and Newborn Health in Urban India A report on literature review
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B. Governance
Governance Mechanisms in Urban Health
60In their recent book, Drèze and Sen call for a public welfare system that works better for the millions of people living in destitution. They question the pitiable investments in health and education made by the Indian government and pertinently ask- 'what difference does it make to lift millions above some notional poverty line, if they still lack the basics for a decent quality of life'. The NRHM is widely acknowledged as an outcome of the grassroots pressure generated by India's vibrant democracy, which
61is capable of influencing government policy in pro-poor directions . Over the past few decades, popular movements, non-governmental organisations and other forms of grass roots mobilisation have emerged as local and supra-local forces that have buffered, accelerated, ameliorated and even challenged the
62state's shifting development agendas . Rather than understanding policies as instructions flowing down from above, policy implementation should be understood as practices that must be situated in the
63broader domains of knowledge and power in which they are embedded .
At this juncture, it is important to study the objectives of the NRHM. The NRHM aimed at architectural correction of the rural health service system and laid great significance on reducing maternal and child mortality through a systematic approach of tracking pregnant women, care during pregnancy,
64institutional or assisted delivery, and educating communities in new born care . The triad of ASHA, ANM and AWW are entrusted with the responsibility of acting as a catalyst for ensuring change in
65knowledge, attitude and practices of the community with relation to motherhood and newborn care . The Primary Health Centres and sub-centres are bound to follow specific operational guidelines to
66manage assisted delivery as well as newborn care corners . However, the challenges of urban health are much more complex, with an unequal access to healthcare facilities. The structure of the city is diverse in nature, with unequal living conditions and inequitable access to basic resources such as water,
67sanitation, and food . As far as availability is concerned, an ample number of outlets (both government-68run and private) exist in the city . The expansion of private bodies in the city has transformed health into
a commodity—making it inaccessible for a majority of the population, specifically for the urban poor.
The urban local bodies, state health departments and other social welfare departments are at the core of 69governance systems in the city . Although as a policy, management of MNH care needs to be paid
70attention to, so as to reduce the proportion of maternal and newborn deaths , it is an irony that the Municipal Corporation, (the basic unit of local governance in cities) is presently playing a minimal role as
71far as providing of MNH care is concerned . A perusal of the city visit reports by the NHSRC experts conducted across 31 cities, suggests that most of the Municipal Corporations have been restricting
72themselves to public health engineering .
One of the reports clearly says: “They mainly have the responsibility regarding water and sanitation. Only a single person, who is designated as a Health Officer in the Municipal Corporation, has the responsibility with regards to health. His responsibility is looking after the cleanliness of the drains, dealing with dog bite cases/rabies prevention. There is some fund allocation for insecticide sprayed
73.mosquito nets and people are provided with the same.” (NHSRC-Data base)
60 Jean Drèze & Amartya Sen, An Uncertain Glory: India and its Contradictions, Princeton University Press, (2013)61 Chatterjee P. “Lineages of Political Society: Studies in Postcolonial Democracy”. New York, NY: Columbia University Press (2011)
Sen, A. ( 1999). “Development as Freedom”. Oxford: Oxford University Press.6 Ray, R., Katzenstein, M.F., (2005)Social Movements in India: Poverty, Power, and Politics (Rowman and Littlefield Publishers, USA)63 ., Roalkvam S. (2013) Health Governance in India: Citizenship as Situated Practice, Good Public Health. 2014 Sep 14; 9(8): 910–926.
Published online 2014 Aug 18. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166913/)64 MOHFW (2011), Guidelines on Newborn Care.65 MOHFW (2006), Guidelines for ASHA.66 MOHFW( 2011) Guidelines on Newborn Care.67
GOI (2014), Reaching Healthcare to the Unreached: Making the Urban Health Mission Work for the Urban Poor.68
Baru (2000), “Privatisation and Corporatisation” http://www.indiaseminar.com/2000/489/489%20baru.htm69 Ibid, NHSRC ( 2014).70
Ibid GOI ( 2014).71
Ibid GOI ( 2014).72 NHSRC data base ( city reports ) .73 NHSRC Data base ( 2014 ) City report.
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There exists some evidence on certain activities related to health carried out by the Municipal Corporations across a few large towns and metropolitan cities such as Mumbai, Pune and Surat; however, health per se is run in a piece-meal approach, with MNH holding a small segment in the entire
74system . The reports for cities such as Kolkata and Madurai show the presence of a system within their Municipal Corporations for the delivery of healthcare. There is an initiative from the Kolkata Municipal Corporation for running of primary healthcare and secondary healthcare services and Medical Education. It runs 144 Ward Health Units (WHUs) in the vicinity of urban poor settings. It has launched an Urban Health Programme in 2002 with key features of Honorary Health Workers (HHW), the Sub-Centres and the Health Administrative Units (HAU). Although the programme has Reproductive and Child Health as its core, its only focus seems to be on assisting delivery for pregnant women and immunisation. Moreover, the facilities available in terms of drugs and equipment are also very limited.
Some of the other urban local bodies studied by the NHSRC field teams, such as those in Madurai, Bhubaneshwar, Gangtok and Ambala are apparently also not very proactive when it comes to providing
75maternal and newborn healthcare . There are a few facilities such as maternity homes and hospitals that are run by corporations. However, these lack any special focus on maternal and newborn health and the corporations seem much more focused on the prevention of communicable diseases, solid waste
76management and drainage systems . Urban Health Centres with an ANM stationed for registration of pregnant mothers and immunisation do exist in very few cities. However, many of the community members interviewed reported that they do not prefer the services offered at these urban health centres. In the Dhamtatri district of Chhattisgarh, the maternal and newborn health system was somewhat strengthened with the recruitment of additional urban ANMs and larger involvement of Anganwadi workers for maternal, newborn and child health services under the Mukhyamantri Shahari Swasthya
77Yojana .
The governance mechanisms also lack adequate norms of standardisation as far as logistics and supply 78chain management are concerned . At present, the urban MNH care programmes do not operate under
79one uniform umbrella . Secondly, there are no major programmes that are focused on strengthening urban community processes. There is also no coordination between the private caregivers and UHCs,
80which results in the duplication of services in certain areas and a complete lack of services in other areas .
Governance also has a crucial role in bringing accountability and transparency in the health systems as well as in the effectiveness of programmes implemented on the ground. While it maybe difficult to correlate health governance directly with health outcomes, there are processes that can be measured for good governance (such as community participation in the decision-making process). In recent times, the
81role of governance in monitoring and evaluation has also gained recognition and acknowledgement .
The role of State Health Departments, Municipal Corporations (MCs), Town Councils and ULBs is immense; however, the existing literature does not delve deeper into the roles of these bodies in the provisioning of services related to MNH. As this process of review of literature has already revealed, there is a comparative abundance of information on other public health issues and very little on urban MNH in relation to governance (specifically with regard to the role of MCs). As large cities contain a lot of diversity in their social fabric, the provisioning of services is recommended to be consistent with the cultural ethos and felt needs of the community. The health authorities here have to not only play the role of a service provider but also create innovations to address diverse issues of the heterogeneous, marginalised and poor urban population.
The literature available also lacks a detailed analysis ofthe roles of various departments in providing services to the urban mothers and newborns,except for a few examples wherein PPP models are functioning in coordination with NGOs or other private providers/bodies.
74 NHSRC Data base ( 2014), City reports Mumbai, Surat , Pune.75 NHSRC Data base ( 2014) , Bhubaneshwar, Gangtok, Ambala.76
Ibid NHSRC ( 2014).77
NHSRC Database, Dhamtari.78Ibid GOI ( 2014).79
Ibid GOI ( 2014).80
Ibid NHSRC Database ( 2014), city reports.81 SOIN (2014).
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The governance issue is acute when it comes to implementation and execution. The local self-governance mechanism is not connected to the grassroots and there is immense distrust of the quality and efficiency of the services provided by them. Indeed, the structures of the corporations are mostly non-functional, with very few health services available.
Key Findings:
l Lack of clarity with regard to the specific tasks to be undertaken for maternal and newborn care at Municipal Corporation level.
l No coordination between the private caregivers and UHCs, resulting in the duplication of services in certain areas and a complete lack of services in other areas.
l Governance mechanisms also lack adequate norms of standardisation as far as logistics and supply chain management is concerned.
l Absence of programmes that are focused on strengthening urban community processes.
l Municipal Corporation facilities that exist, lack special focus on maternal and newborn health.
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C. Human Resources
Staffing Mechanisms
thIn the early 20 century, industrialised countries halved their maternal mortality by providing professional midwifery care at childbirth, and in the 1950s, improving access to hospitals further reduced maternal mortality. A similar picture has been generated by various studies in India, where increased access to skilled attendance at birth with the back-up of a well-functioning health system has resulted in a
82markedly decreased maternal mortality (Graham, W., Bell, JS., and Bullough, CHW., 2001) .Based on these experiences, long-term initiatives and efforts to provide skilled professional care at birth are believed to be the way forward when aiming at addressing maternal mortality. The consensus on the importance of skilled attendance at delivery is also reflected in the MDGs, where the proportion of births attended by skilled health personnel is considered to be a key indicator for the MDG-5 of improving maternal health and reducing maternal mortality.
Unfortunately, in India, with an uneven distribution of overall workforce, the scenario reflects asymmetry in the distribution of health professionals. India also faces difficulties in producing, recruiting and retaining health professionals. Insufficient number of medical schools, low salaries of the existing health workforce, poor working conditions, lack of supervision, low morale, low motivation and lack of infrastructure are the other prominent causes of losing them, for which they tend to migrate to
83wealthier countries (Lehmann, U., Dieleman, M., Martineau, T., 2008) . To overcome the failure of providing birthing women with skilled attendance, the country had to invest in training Traditional Birth Attendants (TBAs) under the NRHM and in schemes like Janani Suraksha Yojana. (Berer, M.,
842003) .
The shortage of emergency obstetric services over the last decade has attracted substantial attention. In response to this situation, the government and health organisations have been addressing the challenges related to human resources for health (HRH) planning and management, that deal with both coverage and equity aspects. There is an increasing body of evidence that documents bold initiatives and innovative actions that allow for improved efficiency in using existing human resources, including team approaches to the delivery of intervention, multi-tasking, task-shifting and sharing increased involvement of communities in responding to different health needs etc. However, most of these innovative approaches have been implemented as pilots or time-limited projects, with negligible evidence of success at scale.
As the review reveals, the Human Resource for Health (HRH) function faces a diverse set of issues and challenges from both the internal and external environment. Global competition, technological advancement, changing profile of employees, skill shortages, retention, downsizing and outsourcing are some of the most common HRH challenges. In order to effectively meet these challenges, HRH has to play different roles, as proposed by different scholars. The following section also focuses on the identified gaps, lessons learned, and recommendations that emerge from studies and implementation experiences of HRH interventions for better maternal and newborn health outcomes.
A report on the Surat Municipal Corporation (SMC) reflects that the NUHM norms will take some time to come into universal practice. Currently, the SMC is following its own norms with regard to the UHCs and the number of link workers is as per the RCH recommendations. The UHCs were set up on the basis of rural PHC standards and cater to 100,000 population per UHC. The staffing plan is also as per the PHC pattern; hence the UHC staff is much more than what is recommended in the NUHM guidelines. A broader challenge faced by the SMC is with regard to the constantly expanding municipal limits and the
82 Graham, W., Bell JS, Bullough CHW. 2001. Can skilled attendance at delivery reduce maternal mortality in developing countries? Safe motherhood strategies: A review of the evidence, 17:97–130.
83 Lehmann, U., Dieleman, M., Martineau, T., (2008). Staffing remote rural areas in middle and low-income countries: A literature review of attraction and retention. BMC health services research. 8(1):19.
84 Berer M (2003). Traditional birth attendants in developing countries cannot be expected to carry out HIV/AIDS prevention and treatment activities.Reproductive Health Matters. 11(22):36-39.
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new villages consequently getting merged in the SMC. Also, no formal 'handing over' process of these new areas has been designed or institutionalised for transfer of authority from the rural to the urban functionaries. Apart from this, there exists an Urban Health Training Centre in Surat (the only one in the
85entire state of Gujarat), however, no clear guidelines or modules exist on training for MNH care .
86A case study by Padmanaban et al. 2009 in Tamil Nadu, reviewed available literature and secondary data that were drawn from various national surveys and service statistics compiled by the State Government. The study reflects that the state has become one of the top performers in the country in terms of maternal health- with its MMR now at 90 (2007)- as compared to other states, while the overall efforts focused on improvement in: availability of human resources; drugs and supplies; management capacity; monitoring of health services and analysis of maternal deaths. Major challenges still remain in improving the quality of infrastructure and services in rural and peri-urban areas for maternal and newborn health.
87According to the World Bank (2010) , human resources for maternal and newborn health are limited, with only 0.6 physicians per 1,000 population but nurses and midwives are slightly more common, at 1.27 per 1,000 population. A study conducted by the Urban Health Resource Center (UHRC) in collaboration with the Johns Hopkins Bloomberg School of Public Health, USA and Chhatrapati Shahuji Maharaj Medical University, Lucknow assessed the status of maternal, neonatal, child and reproductive
88health in the urban slums of Meerut city in Uttar Pradesh . The study used both qualitative and quantitative methods. The household survey from October 2007 to March 2008, covered 15,025 women who had a live or stillbirth in the preceding three years. Referred to as “recently delivered
89women”(RDW), these were drawn from 44,888 households across 45 slums within the city . The scope of the survey was very similar to the District Level Health Survey (DLHS)/ National Family Health Survey (NFHS), except that the study collected more detailed information on newborn care and was adapted to capture information specific to the urban slum context. The study found that capacity- building of the existing health and paramedical staff on essential newborn care practices, (including cord care, thermal protection, detection of danger signs and timely treatment of the newborn)needs to be a regular event. The staff should be trained at the facility and community level to follow recommended guidelines under
90the Integrated Management of Newborn and Childhood Illnesses (IMNCI) . Since only 0.5% of the mothers in the study availed of newborn care from a public health facility, due to inhibitions related to the attitude of the staffs there is a need to sensitise the health service providers on communicating compassionately with the poor to help the latter overcome their reservations of availing of services at the public health facilities.
The study also showed that 40% of the home deliveries in the slums were conducted by untrained local dais. It also highlighted that majority of the newborns received post-natal check-up and treatment from unqualified practitioners. The study recommended that there is an urgent need to complement the efforts to encourage hospital deliveries with training and competence enhancement of slum level dais and local private practitioners to provide essential newborn care. It suggested that they should be skilled enough to identify the signs of common acute conditions & complications, provide timely initial treatment and appropriate referral.
Another facility level study found that the availability of an adequate number of doctors and nurses is critical for providing quality appropriate newborn care. Besides staff numbers, the skills and the
85 Benazir Patil (2014). A brief report on urban newborn sub-group as a part of India Newborn Action Plan. Save the Children, India.86 Padmanaban P, Raman PS, Mavalankar DV (2009). Innovations and challenges in reducing maternal mortality in Tamil Nadu, India. Journal of Health,
Population and Nutrition.2009; 27(2):202.87 World Bank. (2010). World Development Indicators. Washington DC.88 Meerut was selected for the study, in view of the presence of a large urban slum population (highest among cities in Uttar Pradesh). Situation analysis of
the slums revealed the existence of unlisted slums, pockets of underserved slum population and underutilizsation of the existing health services.89
The indexed women were the ones who had a live birth during the last 36 months preceding the survey.90Under the Reproductive and Child Health(RCH II) programme of the GOI, the Integrated Management of Newborn and Childhood Illnesses (IMNCI) package has been adapted from WHO/UNICEF's Integrated Management of Childhood Illnesses (IMCI). Since newborn care is an important issue for bringing down the infant mortality rate in India, this aspect has been included in the package adapted by India. This package includes interventions for the care of newborns and young infants (infants under 2 months) by keeping the child warm, initiation of breastfeeding immediately after birth and counselling for exclusive breast feeding and non-use of pre-lacteal feeds, cord, skin and eye care, recognition of illness in newborns and management and/or referral, immunisation and home visits in the post-natal period.
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motivation level of caregiving personnel are prime prerequisites, since it has been estimated that the odds of mortality of newborns admitted in Special Newborn Care Units (SNCUs) increase significantly when one nurse cares for more than 1.7 newborns. Paediatric staff ratios are obviously inversely related to mortality rates. While nurses are critical at all levels of care, the availability of neonatologists is also very important, especially for those units providing higher levels of sophisticated care, (such as ventilation) and for the survival of low-birth-weight babies. In the authors' assessment, it was noted that three out of the eight units studied had less number of nurses than the recommended nurse: bed ratio of 1:1.2 and 3 had fewer doctors than the recommended doctor : bed ratio of 1:4. Nurses appeared to play a crucial role in improving newborn survival in these units – the mortality rate across the units dropped with improved nurse:bed ratios. Units with poor ratios had worse outcomes, as expected, and almost 15% of the variation in neonatal mortality rates across the units could be explained due to the factor of nurse:bed ratio. The number of doctors, though an important factor, did not appear to directly influence the NMR as compared to the number of trained nursing staff allocated.
A recent study by Sumit Malhotra et al, (2014), assessed all facilities for the availability of trained personnel in the labour room or operation theatre in the Nagaur and Chhattarpur districts of India. A competency assessment of healthcare providers in ENC was conducted with a total of 38 healthcare providers, 19 each from Nagaur and Chhattarpur districts. Among them, 14 were doctors (9 specialists and 5 general-duty medical officers), and 24 providers belonged to nursing staff categories (15 staff nurses, 9 ANMs). The individual domainand category-wise average scores revealed that, in most of the domains, knowledge and skill scores were found to be higher or similar in doctors when compared with nursing staff, except for skill domains relating to preparation at birth and breast feeding, where the nursing staff scored higher than doctors. The results in different domains were based on the grading of knowledge and skills into three categories. The majority of the providers scored only moderately satisfactory scores for most of the knowledge domains, except Kangaroo Mother Care (KMC) and breast-feeding, where it was largely satisfactory. The skill scores for all domains were predominantly non-satisfactory.
A useful study on the role of informal providers in healthcare delivery by the Centre for Health Market Innovations (CHMI) discussed the role of informal providers (IPs) that comprises a plethora of independent and largely unregulated healthcare practitioners. They are a vital source of care for many in the lower and middle - income countries, comprising over 50% of healthcare workers in India and close to 96% in rural Bangladesh, according to some estimates. They are utilised for a wide variety of health interventions and often represent the first point of care for patients, particularly for the urban poor. Although they are heavily utilised, IPs pose a number of significant challenges. They generally have little formally recognised training and usually operate outside the purview of the regulatory authority; hence, the quality of care is not well understood with respect to urban maternal newborn health. Despite these challenges, IPs represent a large component of the private health sector and routinely fill the human resource gaps in formal healthcare provision.
l Task-shifting: Lowering the Bar from Paediatricians to Graduate Doctors
In Gujarat, to combat the shortage of paediatricians for newborn care, the state government launched a short course on “Emergency Newborn Care for Medical Officers” (EmNC) for graduate medical officers. The duration of the course is 120 days, out of which 30 days are spent in an FRU or district hospital,
Training and Skill-sets
Role of Informal Providers
Innovations and Interventions
Sutapa Bandyopadhyay Neogi, Sumit Malhotra, Sanjay Zodpey and Pavitra Mohan (2011). Challenges in scaling-up of special- care newborn units- Lessons from India, Indian Paediatrics, Volume 48, December 17, pp 931-935
Sumit Malhotra, Sanjay P. Zodpey, Aishwarya L. Vidyasagaran, Kavya Sharma, Sunil S. Raj, Sutapa B. Neogi, Garima Pathak, Abhay Saraf (2014). Assessment of Essential Newborn Care Services In Secondary-Level Facilities From Two Districts of India, Journal of Health Population Nutrition, March 32(1): 130-141
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managing newborn babies. The nomination is based on an undertaking sought by the state government that, after training, the medical officers will be posted in one of the pre-identified FRUs or CHCs. An online course has also been rolled out on FBNC and medical graduates working in SNCUs can undergo training through these courses.
l From Nurses to Nursing Aides and Yashoda
Nurses perform both specialised and unspecialised functions. In Purulia district in West Bengal, in order to partly overcome the severe shortage of trained nurses for SCNU, newborn nursing aides were engaged. Local young women with 10 to 12 years of school education were given hands-on training for six months, followed by a six-month internship at a SNCU. Yashoda, a facility-based ASHA, was introduced in NIPI districts in 2008, as an innovative pilot effort to improve the quality of newborn and related maternal care in those district hospital maternity wards which had a high delivery load. They performed simple housekeeping functions and took care of newborns, under the supervision of trained nurses. Assessment by external experts suggested that they had acquired reasonable levels of skills and their involvement freed up the time of the limited number of trained nurses for more specialised functions.
l Slum-based Health Volunteers
The Meerut study by the Urban Health Resource Centre (UHRC) also found that slum-based health volunteers are the crucial agents for influencing community health behaviours, for providing home-based health advice and for building linkages of the community to health facilities. Therefore, a key programme component should be appropriate training, with regular refreshers, as well as supportive supervision of these workers in newborn care. This would enable them to inform the community of correct care practices and also to detect newborns with high-risk of hypothermia and other complications, and refer them to timely and appropriate medical care. The study reflected that slum-based health volunteers not only created a demand for the services in the slums but were also instrumental in facilitating the provision of existing benefits such as the Janani Suraksha Yojana and encouraging the women to deliver at a facility. This helped in building linkages with affordable public/private facilities for appropriate treatment and timely referral. Similar approaches have been proposed in the NUHM framework.
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44 Maternal and Newborn Health in Urban India A report on literature review
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Innovations in Human Resources
S. No.
Name of the Programme
Place Where Functional
Status of the Programme
Inferences
1.
Short course on “Emergency Newborn Care for Medical Officers” (EmNC) for graduate medical officers
Gujarat
undergo training through these courses
The duration of the course is 120 days, out of which 30 days are spent in an FRU or district hospital, managing newborns. The nomination is based on an undertaking sought by the state government that,
after
training, the medical officers will be posted in one of the pre-identified FRUs or CHCs. An online course has also been rolled out on FBNC and medical graduates working in SNCUs can
.
2.
Yashoda
Purulia District, West Bengal
2008
To partly overcome the severe shortage of trained nurses for SCNU, newborn nursing aides were engaged. Local young women with 10 to 12 years of school education were givenhands-on training for six months, followed by a six-month internship at an
SNCU. They performed simple housekeeping functions and took care of newborns, under the supervision of trained nurses. Assessment by external experts suggested that they had acquired reasonable levels of skills and their involvement freed up the time of the limited number of trained nurses for more specialised functions.
3. Slum-based Health Vounteers
Lucknow, U.P.
Crucial agents for influencing community health behaviours, for providing home-based health advice and for building linkages of the community to health facilities. Slum-based health volunteers can create a demand for the services in the slums.The volunteers were also instrumental in facilitating the provision of existing benefits such as theJanani Suraksha Yojana and encouraging
the women to deliver at a facility. Similar approaches have been proposed in the Government of India’s National Urban Health Mission (NUHM). Thus, these volunteers can be forced
multipliers and be very instrumental in helping the screened pregnant mothers
& newborns reach the right facilities at the right time.
Key Findings :
l No publications were found regarding the individual outcomes of components, such as the shortage of human resource, lack of staff motivation, appraisals, workplace safety and career development on urban maternal and newborn healthcare.
l Availability, retention and training of skilled birth attendants was a major issue. It was seen that in most places doctors and midwives were not available at the time they were most needed, i.e. at night.
l Professional qualification does not necessarily mean that the provider is actually skilled.
l Little information was available regarding the efficacy of the midwife training programme.
l No study was found on the financial component addressing the budget allocation for salaries and allowances, education &training and HRH expenditure data.
l Migration of skilled birth attendants is one of the main causes of workforce crisis.
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D. Financial Mechanisms
With the advent of stronger private entities in the area of health service provision, the aspect of overall 93health financing in India needs to be looked at critically (GOI, 2008) . Although the idea of “health for
all” has been restated in many of the committee reports, since the days of the Bhore Committee, it is a 94relatively low priority in our national economic planning . The expenditure incurred on health in the
context of budgetary allocation is rather dismal in developing nations, with India standing much lower 95 thin rank (GOI, 2006) . In the 12 Five Year Plan, the health allocation of budgets was increased by about
25% (the base was the total GDP) and states were encouraged to enhance the outlays for health in their 96annual plans as well (GOI, 2014) . The analysis of recent programmes indicates that the concerns
regarding financial management continue to prevail, as obstacles such as governance; transparency and accountability hinder appropriate utilisation of the funds allocated.
There is a lack of clarity on the proportion of funds specifically designated for maternal and newborn health in urban areas in the overall health budget of the city corporation. In recent times, for the country, however, there has been an increase of funds for a broad range of reproductive and child health-related aspects, from 5,288 crore in Phase- I (1997-1998 to 2003-04) to 40,000 crore in Phase- II (covering 2005-06 to
972009-2010) . There is indeed an increase in the funding process with many donor organisations entering into the picture, yet ensuring quality maternal and newborn care services has remained a problem owing to confusion at the stage of implementation, inability to absorb more funds and health workers' discomfort with spending because of their lack of experience with identifying funding priorities and
98managing money . Corruption has also remained at the core of non-utilisation of the money that has 99been reserved for health-related action (Singh et al, 2006) .
Moreover, many of the primary and secondary care services are considered to be free, the mixture of public-private creates a precarious situation as quality care is only seen to be promised by the private
100bodies . The scenario, hence, is a cause of a big concern for the urban poor pregnant women and their newborns, since it usually saddles their breadwinners with the burden of high out-of-pocket
101expenditure (Singh et al, 2006) . As far as the health of the mother and newborn are concerned, the financing of the same is again limited and almost restricted to the cash transfer policy for institutional
102delivery . The utility of such a cash transfer policy run by various states has remained problematic as the sheer incentive mechanism to generate demands for institutional delivery, does not encompass a holistic approach to handle issues of inadequate health infrastructure, especially for essential emergency obstetric-newborn care; wrong cultural attitudes (that professional pre-natal, intra-natal, post-natal and neo-natal care are unnecessary); provider bias and discrimination against women belonging to
103marginalised groups and a chronic scarcity of domain specialists .
Secondly, the financial allocation for maternal and newborn care is dependent on the state budgetary allocations through its different units. To begin with, the expenditure to be incurred on maternal and newborn healthcare has very little space in the health planning of the family. One of the major findings of a study conducted indicates that, although health-seeking amongst urban women is better than in rural
104 105India , the realistic expenditure is surely far higher when it comes to the urban poor .
93 thGOI (2008): 11 Five Year Plan of India, Health and Family Welfare and Ayush” http://planningcommission.nic.in/plans/planrel/fiveyr/11th/11_v2/11th_vol2.pdf
94Mukherjee, S., Singh, A and Chandra R(2013): Maternity or Catastrophe: “A study of Household Expenditure on Maternal Healthcare in India Maternity care in India
95 GOI, 2006, Government Health Expenditure in India: A Benchmark Study” Economic Research Foundation.96 GOI, 2014, “ Report on Health Nutrition and Family Welfare “(http://planningcommission.gov.in/sectors/index.php?sectors).97 Mukherjee, S., Singh, A. and Chandra, R. (2013): Maternity or Catastrophe: “A Study of Household Expenditure on Maternal Healthcare in India
Maternity care in India98
Singh S et al (2009) “Barriers to Safe Motherhood in India” www.guttmacher.org99
Ibid Singh, S. et al ( 2009).100
Ibid Singh, S. et al ( 2009).101 Ibid Singh, S. et al ( 2009).102 Ibid Singh, S. et al ( 2009).103
Ibid Singh, S. et al ( 2009).104
Jogdand, K.S., Yerpude, P., Jogdand, M. (2013): A Perception of Maternal Mortality among Women in an Urban Slum Area of South India. International Journal of Recent Trends in Science And Technology.
105Mukherjee, S. Singh, A. Chandra R(2013) : Maternity or Catastrophe: “A study of household expenditure on maternal healthcare in India
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The possibility of impoverishment after obtaining maternal and newborn care is much higher amongst the educated section of women. This counterintuitive study indicates that women with middle-level education were 33% less likely to enter into poverty due to out-of-pocket (OOP) maternal healthcare expenditure in urban areas, whereas women with higher education were more likely (76% for rural and
10687% for urban) to be impoverished by out-of- pocket expenditure (Mukherjee, Singh, Chandra,2013) . The percentage of impoverishment due to out-of-pocket expenditure is also lower amongst the socially backward sections, by approximately 99% and 98%, for women belonging to the schedule castes (SCs) and schedule tribes (STs) respectively, as compared to women belonging to the 'others' caste category in
107urban areas . Certain studies also indicate that, in the urban scenario, home birth comes across as an 108easier and viable option for the poorer sections of the society .
Furthermore, the role of the Municipal Corporations (MCs) and Urban Local Bodies (ULBs) in decentralised budgetary planning for MNH care is neither detailed nor fully enshrined in the current
109NUHM guidelines(NUHM, 2013) . A perusal of the city-level data has details of food, sanitation and money dispersed to its dispensaries but lacksspecific details on MNH expenditure. Moreover, in recent times, many of the cities have concentrated primarily on the aspect of introducing schemes through
110public-private partnerships (PPP) . Cities located in the state of Gujarat have been one of the important examples of those that have adopted many such schemes for ensuring affordable MNH care (Database,
111NHSRC) .
l Janani Suraksha Yojana (JSY)
Under this scheme, the main aim of the NHRM is to reduce maternal and neo-natal mortality rate by incentivising institutional delivery for the mothers falling in the category of below poverty line (BPL), SC and ST, about 8 to 12 weeks prior to the delivery. It is also available to those residing in peri-urban areas as per the NUHM TRG report,usually this area comprises migrants and marginalised populations.
l Chiranjeevi Yojana (CY)
Under this scheme, poor women are provided free delivery services by the hospitals of both government andprivate sectors and the obstetricians are paid a flat rate of Rs. 2,800/- (twenty eight hundred rupees) per normal delivery, payable upon conducting every batch of 100 deliveries.
l Bal Sakha Yojana (BSY)
Under this scheme, the costs of neonatal care are exempted for BPL mothers who give birth to live babies. All participating paediatricians are paid a flat rate of Rs. 1,300/- (thirteen hundred rupees) per live newborn and the obstetricians are also paid a lump sum of Rs. 30,000 (thirty thousand rupees) in case of a minimum 48 hours of hospital stay, for a batch of every 100 newborns treated.
l Kasturba Poshan Sahay Yojana (KPSY)
Under this scheme, Rs. 700/- (seven hundred rupees) are paid to pregnant women on three occasions, i.e. at the time of registration for ANC, for institutional delivery in government hospitals and for immunisation of newborns in government hospitals.
Ahmedabad Municipal Corporation in Gujarat also started a public-private partnership in collaboration with the Red Cross Society, where a thalassemia test costs Rs.185/- (one hundred and eighty five rupees)
112at a subsidised rate, as the same costs up to Rs.500/- (five hundred rupees) at other private hospitals . It is noteworthy that, though cash assistance has been counted as a great measure, criticisms of the
Public-Private Partnerships
106 Ibid Mukherjee, S. Singh, A.and Chandra, R. ( 2013)107 Ibid Mukherjee, S.,Singh, A. and Chandra, R. ( 2013)108
Ibid Jogdand, K. S., Yerpude, P.and Jogdand, M. (2013)109 NUHM( 2014), Executive summary of Technical Resource Group, for National Urban Health Mission.110 NHSRC, City Study Report, Ahmedabad111
Ibid Database NHSRC.112Ibid Database NHSRC.
47Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
Chiranjeevi experience in Gujarat show that it may have lacked foresight regarding issues such as 113transportation cost, distances to fair-quality institutions, etc. in its budget planning . Another thesis
study reiterates that a major drawback in every programme designed for healthcare, including MNH care, is that vast sums of money are being invested without sufficient attention being paid to the key management aspects such as the training of human resources and capacity-building of the government health departments to mentor their officials efficiently for counseling, check-ups, institutional delivery
114and operating available modern diagnostic tools(Shodhganga, 2013) . Hence, this study suggests major concentration on such issues, both while designing programmes and allocating budgets to the respective
115programme (Shodhganga, 2013) .
116Sambhav Voucher Scheme (http://futuresgroup.com/files/publications) is another innovative way to harness the resources of the private sector, as well as increase access to quality healthcare services through public-private partnerships (PPP). This approach involves the Government paying private providers for maternal health services rendered to those below poverty line (BPL). It 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). This is potentially useful in urban areas, where there is a strong presence of the private sector, giving the urban poor an opportunity to avail of quality maternal health services from private hospitals covered under the scheme, thereby improving their access to maternal-newborn healthcare services, assuming proper regulation
117(http://futuresgroup.com/files/publications) .
113 Acharya, A. and McNamee, M. (2009) ,”Assessing Gujarat Chiranjeevi Scheme”,Economic & Political Weekly.114Shodhganga (2013), “Maternal and Child Healthcare Service in West Bengal – a Comparative Study, Conclusion.115
Ibid Shodhganga ( 2013).116
http://futuresgroup.com/files/publications117Ibid http://futuresgroup.com/files/publications
Key Findings :
l There is an absence of adequate information on financing patterns, the role of local bodies in budget planning and the process adopted for sustaining projects across cities.
l The budgetary allocation is also not segregated for maternal and newborn health, creating an ambiguous state of the evidence.
l Health financing in India needs revisiting, most importantly, taking in view both the demand and the supply side of the maternal newborn care service.
l As far as execution is concerned, there is an urgent need to ensure timely allo-cation and release of earmarked budgets. There are cash transfer programmes that exist in various states.
48 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
E. Health Infrastructure
Present Situation
Transport Facilities
Adequate infrastructure, including sufficient space, functional equipments, transport facilities and special care divisions such as ICUs, are some of the key requirements for providing health services. While discussing MNH, one needs to look into the aspects of space and the basic instruments used for ante-natal, intra-natal, post-natal and newborn care. Tables shared in the Annexure- 2 provide an overview of the status of infrastructure for MNH care in some cities across the country. These cities were assessed as a part of the NHSRC assessment done by the Technical Resource Group (TRG) team. The cities and towns were selected randomly with no specific criteria.
The situation pertaining to infrastructure across the states is very grave. As reflected from the city reports the majority of the health service facilities are managed out of rented apartments. Most of the urban health centres lack facilities of transport and specialised care for the mothers and newborns. Although in a few of the city reports, it has been clearly mentioned that the building provided for primary and secondary care services was inadequate, the information available on the status of the building is unclear. The reports of the metro cities reveal that the available diagnostics facilities are not sufficient and the special newborn care units, as well as emergency obstetric care, were found to be operating in just a few
118cities .
An important aspect that deters connecting pregnant women to health facilities is lack of transport. Although the facilities are well connected through public transport in many metro and bigger cities, transportation, along with communication, continues to remain a challenge in smaller towns.
118City Analysis Reports of the TRG, (2013).
49Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
S.
No.
Programme/
Scheme
Place
Status
Inferences
1.
Janani
Suraksha Yojana (JSY)
Ahmedabad
2005
Under this scheme, the main aim of the NHRM is to reduce maternal and
neonatal mortality rate by incentivizing institutional delivery and Rs.500/-
(five hundred
rupees) areto
be paid to those below poverty line
(BPL), SC and ST women, about 8 to 12 weeks prior to the delivery. It is
also available to those residing in peri-urban areas;usually this area
comprises migrants and marginalised populations, as per the NUHM
TRG report.
2.
Chiranjeevi
Yojana (CY)
Ahmedabad
2006
Under this well-publicised and well-published scheme, the poor women
are provided free delivery services by the hospitals of both government
& private sectors, and the obstetricians are paid a flat rate of Rs.2,800/- (twenty eight hundredrupees) per normal delivery, payable onconducting every batch of 100 deliveries.
3. Kasturba Poshan
Sahay Yojana (KPSY)
Ahmedabad
2002-03 Under this scheme, Rs.700 (seven hundred rupees) arepaid to pregnant women on three occasions, i.e. at the time of registration for ANC, for
institutional delivery in government hospitals and their newborns’ immunisation in government hospitals.
4
Bal Sakha Yojana (BSY)
Ahmedabad
2008
Under this scheme, the costs of neonatal care are exempted for BPL mothers who give birth to live babies. All participating paediatricians are
paid a flat rate of Rs.1,300/-
(rupees thirteen hundred
rupees ) per live
newborn and the obstetricians are also paid a lump sum of Rs.30,000/-
(thirty thousand rupees ) in case of a minimum 48 hours of hospital stay,
for a batch of every 100 newborns treated.
5
Sambhav Voucher
Scheme
2005
It is an innovative way to harness the resources of the private sector, as well as increase access to quality healthcare services through public-
private partnerships (PPP). This approach involves the Government-
paying private providers for maternal health services rendered to those
below poverty line (BPL).
Preference for Private Facilities
Lack of Comprehensive Approach
F. Health Management & Information System (HMIS)
In many cities, the public health facilities are charging a user fee, resulting in disinterest of the urban poor in accessing public health systems and preferring treatment at private clinics. The fact remains that the public health system lacks trained personnel and the scenario is worse when it comes to handling diagnostic equipment. In a few of the city reports there are discussions on the availability of equipment; however, there is a dearth of human resource to manage the same.
As reflected from the reports, the healthcare system available in the country is neither sufficient nor comprehensive when it comes to mothers and newborn babies. The UHCs are not functional and the referral system in effective in just a few of the cities, such as in Sikkim. Although the situation and the design of healthcare varies from one city to another based on population size, the need for a planned and systematic effort toward provision of maternal and newborn care holds true to every urban space; especially when one looks at the number of urban slums, it surely raises a question on the adequacy of infrastructure.
The HMIS is essential for an analysis of the existing health scenario. However, both the infrastructure available for health provision in urban settings, (specifically for the poorer sections) and the HMIS, remain abysmal. The reporting of the same is unstructured and needs revamping. The review process for HMIS techniques related to maternal and newborn health care found lacunae in the information management system. The Municipal Corporations and other urban local bodies provide hardly any detailed reporting and analysis for the cities. The MoHFW, in its report, also identifies the loopholes in reporting systems that prevail across the various states at each level of service delivery.
Although Delhi, being the capital of the country, reports of a functional HMIS system, many of the Municipal Corporations in various states of the country seem to be facing issues such as lack of training or absence of management of data. The HMIS implies a system that helps in the management and maintenance of data and the storing of information, on the basis of which one can analyse performance of health units right from the level of sub-centre. As per the protocol given in the NRHM (now part of the NHM), the HMIS process needs to be facility-based (compulsory reporting at every unit of facility) and conducted in monthly, quarterly and annual mode (http://mohfw.nic.in/). However, the overarching problem in the management of HMIS process across the various states is rooted in the inability of the health functionaries to report data in the prescribed format on time. Most of the UHCs are managed without basic facilities such as functional computers (www.nhsrcindia.org). The Project Implementation Plan (PIP) available with the NUHM indicates that every city needs to have a budget and a plan in place for delivering of health services. However, the information on health informatics related to the overall arena of reproductive and child health remains confusing. As mentioned in one of the PIPs, the monetary allocation to the HMIS is 70 lakh rupees (Rs. 70,00,000/-) (http://nrhm.gov.in/nrhm). In the process of review, efforts have been made to have access to guidelines and detailed reporting through the HMIS for the NUHM (on the websites of the NIHFW & NHSRC) and the information on the same is either not accessible or absent with regard to RCH in the NUHM.
Key Findings :
l The existing literature does not provide sufficient information on the aspects of bed: population ratio, status of buildings, drug and device-supply chains, inventories and also the list of equipment available in each of the cities where the field visits/studies have been conducted.
l Most of the services are housed in old and dilapidated buildings as well as in rental arrangements and lack the necessary infrastructure.
50 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
The Central Bureau of Health Intelligence deals with information on health; however, most of it pertains to communicable and non-communicable diseases. The engagement of the CBHI in maternal health could be seen in the training of health personnel on various indicators (maternal morbidity, maternal
119mortality, immunisation rate etc.) of RCH . The MCD (Municipal Corporation of Delhi) website of Delhi, however, holds a mechanism of tracking children for immunisation and also assessment of the nutritional status of children. An online tracking system prevails that provides detailed information on the vaccination schedule and centres of vaccination (mcwis/detail.php). It also contains components of health education pertaining to care during pregnancy. There is, however, no information available on morbidity during pregnancy and childbirth.
In a chapter on health informatics (www.nhsrcindia.org), the NHSRC has identified the problems associated with information on human resources, health management, geographical information system and mobile-related services. It further details that the informatics currently used are not following any common mechanisms, lack of common terminology is hindering the creation of a uniform method of information management. Most of the informatics is now developed on the basis of silos, causing redundancy and ambiguity in the information shared (www.nhsrcindia.org).
To conclude, it can be stated that the aspect of health management in the urban context needs thorough revamping and a uniform mechanism that captures systematic information on the facilities available for overall RCH.
The Alma Ata declaration, 1978 brought the essence of community involvement in healthcare planning 120(Alma Ata, 1978) . The major aspect that was put into its core was of self-reliance of communities in the
planning phase of healthcare. The same spirit was also seen in the five-year planning process of India 121with the introduction of community health volunteers. The declaration of Alma Ata (1978) strongly
argued for the significance of social determinants of health and that the community, the best stakeholder, to ensure accountability of the health service system.
However, the essence of community self-reliance was lost in the efforts when the country got engaged in 122selective healthcare, and “Health For All” (Das, 2014) has remained an “elusive goal”. In the current
format of healthcare provisioning, the services to urban mothers and newborns involve the community 123only in terms of mobilisation, with very little participation in the overall planning (Das, 2014) . The
urban healthcare systems for MNH care are advancing with an attitude of correcting healthcare systems in the cities, for the urban poor, and therefore, the learnings from the NRHM ought to be kept in mind
124(NUHM, 2014) .The framework for the NUHM has envisaged ensuring a protective ambit for the mother and newborn and the ideas of community participation surely have to find a place in the same, as it will pose a bigger challenge owing to the densely populated nature of the urban slums and also
125heterogeneity in their backgrounds and way of life (NUHM, 2014)
G. Community Interventions and Innovations
Key Findings :
l The HMIS process that should have indicated the morbidity and mortality issues pertaining to the UMNH is not visible.
l Secondly, as indicated in the reporting formats of MoHFW (a report of various districts within a state), the training required for the health personnel —at the level of PHCs, CHCs and even district hospitals—for maintaining and managing the HMIS is immense.
119 (http://cbhidghs.nic.in/)120 Alma Ata declaration (1978), http://www.who.int/, The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of
September in 1978, to promote and protect health for all.121 Ibid Alma Ata declaration (1978), http://www.who.int/122 Das , .(2014),” Community Participation in Health Care Management in India: Need and Potentials”; India Infrastructure Report 2014.123 Ibid Das, A. (2014).124
NUHM(2014), Executive Summary of Technical Resource Group, for National Urban Health Mission.125
Idid NUHM(2014).
51Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
Suggested Framework of the NUHM
Community Interventions and Innovations
The current framework of the NUHM entails the need fora community-based healthcare system, considering the fact that urban areas need a comprehensive system; a single ASHA, as in the rural areas,
126would not be able to tackle the aspects of organising healthcare(NUHM, 2014) . The most common observation across all cities and states is that there is really no major programme in place that is focused on strengthening urban community processes. A further challenge is that in settlements of the urban
127poor, there are fewer organic communities than what one may find in villages (NUHM, 2014) . Avillage is much divided by caste and gender inequalities, but is a stable social identity and also holds a stronger
128social capital(NUHM, 2014) . In cities, however, there is a paucity of structured systems as far as social functioning is concerned and many of the residents living in an urban context are devoid of care owing to
129their migratory status and absence of a large, family support (NUHM, 2014) . So is the case of women living in such a social fabric, they have access to very few support systems during and after pregnancy. Hence, the urban programme needs to keep this context in mind while designing guidelines for MNH
130care (NUHM, 2014) .
The range of services currently offered by urban ASHAs or other Community Health Workers, to the extent that they are in position, is largely limited to the promotion of immunisation, antenatal care and
131family planning (GOI, 2013) . The studies conducted across cities point to the fact that the reach of the ASHA to the vulnerable population is limited, since she has neither been equipped by mandate nor been
132trained to focus on the felt health needs of these marginalised groups (GOI, 2013) . The reach of the ASHA to the marginalized communities is critical, particularly in view of the fact that the NUHM lays substantial emphasis on reaching the invisibles; especially the destitute, the homeless and the
133marginalised (GOI, 2013) .
For bottom-up planning to occur, a community worker operating in isolation is insufficient 134(www.ifrc.org) . She needs a group of people - a community collective - who can support the process of
local planning, given their knowledge of and familiarity with their community and their environments, 135and their interest in positive outcomes (www.ifrc.org) . The proposed Mahila Arogya Samiti (MAS)
under the NUHM is composed of about 15-20 persons, drawn from a neighbourhood cluster (NUHM, 1362014) . The Kudumbashree model in Kerala has useful lessons on how to make this committee more
137representative by drawing one committee member from each cluster of 10 to 20 houses, (NUHM2014) . Promotion of public-private partnerships is required for capacity building, training and building of skills of the health workers and agencies who work on management, monitoring and implementation of
138health programmes (NUHM, 2014) .
The NUHM can adopt and adapt from various community healthcare interventions that have been running across the country. These initiatives are localised and much adapted to the life style of the community they address. A series of experiments has already been conducted for training the existing community with adequate information and hands-on skills for the management of reproductive health issues. A table containing some of the promising community interventions and innovations is shared in Annexure- 2.
126 Ibid NUHM (2014).127 Ibid NUHM (2014).128 Ibid, NUHM (2014).129 Ibid NUHM (2014).
133IbidGOI (2013).
134www.ifrc.org Maternal, Newborn and Child Health Framework, International Federation of Red Cross and Red Crescent Societies.135Ibidwww.ifrc.org136
Ibid NUHM ( 2014).137
Ibid NUHM( 2014).138Ibid NUHM (2014).
130Ibid 14 NUHM (2014).
131GOI (2013), Mission Work for the Urban Poor, Report of the Technical Resource Group, Urban Health Mission.
132Ibid GOI (2013).
52 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
A study conducted on Home-Based Newborn Care (HBNC) in the district of Gadchiroli, comprised of women health workers who undertook home visits on a regular basis, collected information on, and observed and examined mothers and newborns, checked the weight of the newborn every week and treated illnesses such as pneumonia. Other than that, the health workers were also trained in treating
139neo-natal illnesses through home-based sepsis management (Bang et al, 1999) . This intervention was replicated in the urban areas of Maharashtra and, later, in five other states, under the aegis of Project
140Ankur (NIPCCD, 2008) . The project focused primarily on building capacity of community-level mobilisers, training of trainers, creating a process to register pregnant women, providing care and also record cases of each newborn. It accorded high importance to attending to neonates right after birth, and
141in monitoring and recording deaths and still-births (NIPCCD, 2008) . The programme also undertook a stringent process of evaluating its training component through reviewing deliverables set for the community mobiliser. This project could not be scaled up to the national level and ended after the pilot
142phase itself. (NIPCCD, 2008)
The identified gap of absence in care-giving has been incorporated in many other schemes developed in recent times. A programme under the Norway-India Partnership Initiative (NIPI) named Yashoda was initiated in 2008 with the main objective to improve the quality of maternal and neonatal care in health
143facilities (http://www.oneindia.com) . The programme was inspired by the concept of legendary Yashoda, the foster mother of Lord Krishna, and “the idea is to give the love and care to the newborns the
144way Yashoda did to Lord Krishna” (http://www.oneindia.com) . This programme has been greatly 145effective in the selected districts of India (Varghese et al, 2014) .Under this programme, the Yashodas
were placed in health facilities where deliveries take place on a regular basis, and their main work was to give care to these pregnant women in the form of counselling on immunisation, breast feeding, family
146planning, and danger signs during pregnancy and newborn care (Varghese et al, 2014) . This programme helped in increasing the support, care and respect given to the expectant mothers and their families. It was found that there was a 50% increase in women who followed immediate breast feeding
147after undergoing Caesarean section in the intervention facilities (Varghese et al, 2014) . It also resulted in four to five times increase in postnatal check-ups in the intervention facilities as compared to the control facilities.
'Mamta', an organisation that works on health aspects in Delhi and the National Capital Region (NCR), 148experimented with a group of community-based health educators(Mamta, 2003) . It initiated a YFHS
centre (called “Friends”) in the community of Tigri and its function was to connect adolescents to referral clinics, providing them counselling facility, laboratory and dispensary by building linkages (Mamta,
1492003) . It also started a programme called 'The 10K Club - a club for the health and development of the poorest' which focuses on improving the quality of maternal and newborn health by eliminating poverty through proper mobilisation of the local community and other partners (NGOs). The Regional Resource Centre of Mamta has focused extensively on training, capacity-building and enhancing technical knowledge amongst various NGOs committees and panchayat members across Punjab, Haryana and
150Chandigarh (RRC Mamta, 2011) . This has helped in enhancing the capacity and knowledge of the staff, leading to an increase in the number of women registering pregnancy and availing of health check- ups at
151regular intervals (RRC Mamta, 2011)
152 The NGO, Saath (Annual Report, 2013) located in Gujarat had developed similar programmes with the
139Ibid Bang, A. et al(1999)
140NIPCCD( 2008), DCWC Research Bulletin, Vol. xii.
141Ibid NIPCCD( 2008).142Ibid NIPCCD( 2008).143
http://www.oneindia.com144Ibid http://www.oneindia.com145Verghese, B.et al ( 2014) ”Fostering maternal and newborn care in India the Yashoda way: does this improve maternal and newborn care practices during
institutional delivery?”
http://www.ncbi.nlm.nih.gov/pubmed/24454718146Ibid Verghese, B.et al ( 2014)147
Ibid Verghese, B.et al ( 2014)148
Annual Report (2003) Mamta Organisation 149
Ibid Annual Report (2003) Mamta organisation150
RRC ( 2013), Biannual Report Mamta.151
Ibid RRC( 2013).152Saath ( 2013), Annual Report.
53Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
idea of empowering community level health workers and also establishing a system of constant monitoring and follow-up ofcases of pregnancy and child birth. The maternal and child survival programme titled Jeevan Daan began in the year 2004 in association with Ahmedabad Municipal
153Corporation and Saath International (Annual Report, 2013) . It aimed to reduce infant mortality and morbidity by focusing its efforts on five key technical interventions that are major causes for infant mortality, namely: Pneumonia Case Management; Control of Diarrhoeal Diseases; Nutrition/Immediate Breastfeeding; Expanded Programme on immunisation and Maternal & Newborn Care.
Under the maternal health programme, Saath organised fortnightly camps that addressed the concerns 154of sexual and reproductive health aspects (Saath, Annual Report,2013) . It was diligently accompanied
by constant visits to the homes along with street meetings for reducing myths associated with pregnancy and newborn care. The behaviour and attitude of the women living in the targeted areas did see a shift. The number of women availing the services of ante-natal care (ANC), post-natal care (PNC) and also taking better care of nutritional requirements during pregnancy, increased significantly.Apart from the fact that most of the women in the community are devoid of good care during pregnancy, the absence of adequate referral systems stands as a hurdle in ensuring the survival of mothers and newborn babies.
SNEHA, an organisation working in the field of newborn health in Mumbai aimed at establishing an 155improved referral system for maternal and newborn care (http://www.snehamumbai.org/) .In the
first year of the project, workshops were organised, bringing together health providers from different levels of service and action groups were formed which met on a monthly basis. These action groups created a database of existing facilities for maternal and neonatal services, using a self-assessment tool
156(http://www.snehamumbai.org/) . They standardised technical and administrative protocols and ante-natal-neonatal services were also introduced at the health posts, which formed the primary centre at the slums. Besides the participatory approach, 'appreciative inquiry'— a behavioural methodology—was used to empower health providers in the public system and to bring about the change they envisioned in their respective facilities.
Sure Start, an urban maternal and newborn health project implemented by PATH in Maharashtra, revealed that the urban poor face problems due to poor accessibility, weak outreach and inadequate referral systems. Social exclusion, inadequate knowledge and absence of assistance at secondary and tertiary hospitals added to the existing challenges. The main objectives of Sure Start were to generate demand through enhanced individual, household and community mobilisation on the one hand and to strengthen institutional capabilities in order to improve maternal and newborn health in urban areas
157(www.path.org/publications) on the other hand. Sure Start was implemented through partnerships in seven Municipal Corporations of Greater Mumbai, Navi Mumbai, Nagpur, Pune, Malegaon, Nanded
158and Solapur in Maharashtra(www.path.org/publications) . The key strategies comprised: Need-based BCC; Mobilising community groups; Leveraging available resources; and developing collaborations with the local Municipal Corporations, professional bodies, community-based organisations and academic institutions.
To implement all these strategies in every city, a Common Minimum Programme (CMP) was designed; in addition to the CMP, each of the cities tested an approach or a model with an aim to create a safety net for MNH. PPP, convergence, community-based health insurance, emergency health funds, creation of quality-of-care norms, and empowering the self-help groups were some of the approaches that were
159tested in seven cities (www.path.org/publications) .
Quality-of-Care Model, Mumbai: The main objective of this model was to provide care to pregnant mothers and newborns by ensuring availability, accessibility, appropriateness and acceptability of public and private health services. It also aimed at establishing new antenatal, postnatal clinics and community centres.
153Saath( 2013), Annual Report.
154Ibid Saath, Annual Report (2013).
155Ibid http://www.snehamumbai.org
156Ibid http://www.snehamumbai.org
157Ibid www.path.org/publications158Ibid www.path.org/publications, 159
Ibid www.path.org/publications
54 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
160 http://www.surestartdata.com Sure Start in Maharashtra, India.
Public-Private Partnership (PPP) Model, Navi Mumbai: This model ensured provision of ANC/PNC and newborn health services through special clinics organised every week at the UHCs. Paediatricians and gynaecologists from the professional bodies such as the IAP and NMOGS attended these clinics under the special partnerships worked out for this project. Under this model, a total of 26,823 pregnant women were examined in 131 clinics and 2,728 cases were sent to special clinics.
The Convergence Model, Pune: The main aim of this model was to create awareness about HIV amongst pregnant women and create a link between Integrated Counselling and Testing Centres and establishing committees such as MOMS (Monitoring of Maternal and Newborn Status). This committee functions by providing health services to mothers who are affected by HIV, with the help of Municipal Corporation & public health facilities. The MOMS committees strictly monitored the families of pregnant women for ensuring ante-natal check-ups, post-natal care and newborn care. It has well incorporated mothers, mothers-in-law and link workers, AWWs to act as a pressure group on families that are not adopting safe health practices for the care of mother and newborns
160(http://www.surestartdata.com/) .
Emergency Health Funds (EHF) Model, Nagpur: The EHF is a financial mechanism which helps in providing health services to mothers and newborns at affordable rates. To attain these objectives, prepaid cards were developed after a thorough assessment of the needs of the community. Nearly 1,160 families have benefited under this EHF model so far and the funds helped in meeting the cost of delivery and treatment of newborns.
Quality of Care Model, Malegaon: Under this model, capacity building of Municipal Corporation staff and participation andmobilization of communities for high quality health services was targeted. Meetings on the quality of care norms in two health posts having an alliance with the Malegaon Municipal Corporation were organized on a regular basis but the major limitation was a lack of trained manpower for providing health services and sustaining this process.
The Volunteerism Model, Solapur: The main objective of this model was to mobilise the community of Solapur by using volunteers to enhance maternal and newborn health services. The model was a success and was accepted by the Solapur Municipal Corporation as a strategy for further improvement. Formulation of a network of 170 Self-Help Groups (SHGs) with adequate knowledge on MNH care was the key aspect.
The Community-Based Health Insurance (CBHI) Model, Nanded: Introduction of service providers' network and a community-based health insurance mechanism known as “Apni Sehat” was introduced in the targeted slum areas of Nanded city. Itensured the availability of funds for the poor slum-dwellerswhocould not meet the cost of institutional deliveries and antenatal care check-ups.
The role of Corporate Social Responsibility (CSR) has also been outlined in some of the interventions across the country. Biocon Foundation reiterated the strategy of first assessing the community needs and then establishing a package of health education amongst expectant mothers targeted through self-help groups. They adopted community awareness and a participatory approach in which they closely associated with the women self-help groups. They also organised workshops for mothers and community members on issues such as malnutrition.
55Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
Key Findings :
l
l
There is no nationalised and overarching programme focused on strengthening urban community processes for MNH care.
The literature does not address why many of these interventions were not expanded at a larger scale and there is also a lack of understanding as to why so many of these have failed to address the challenges of MNH care in India.
56 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
S.
No.
Pro
gram
me
/ Age
ncy
Sta
te/C
ity
Sta
tus
Infe
renc
e
1
Mam
ta
Del
hi (
NC
R)
Pre-
2003
The
10K
Clu
b
-
a cl
ub
for
the
heal
th &
dev
elop
men
t of
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poo
rest
’ whi
ch f
ocus
es o
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prov
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the
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ity
of m
ater
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and
bor
n
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lth
by e
limin
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thro
ugh
pro
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mob
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tion
of
the
loca
l com
mu
nity
and
oth
er p
artn
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(NG
Os)
.
A f
unc
tion
al R
egio
nal
Res
ourc
e C
entr
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that
tra
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NG
Os
and
Pan
chay
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embe
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cros
s Pu
njab
, Har
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and
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nd
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ts t
o re
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ass
ocia
ted
wit
h pr
egna
ncy
an
2
Saat
h
Ah
med
abad
, G
uja
rat
2005
1. J
eeva
n D
aan
Mat
erna
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Chi
ld S
urv
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pro
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:–
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ase
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) Nu
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ded
prog
ram
me
on im
mu
nisa
tion
e) M
ater
nal
and
New
born
Car
e.
2. A
ngan
wad
i cen
tres
func
tion
al in
23
war
ds
that
cat
er to
neo
nata
l hea
lth
and
pre
gnan
t wom
en.
3. A
n R
CH
pro
gram
me,
whi
ch
is a
ligne
d w
ith
the
conc
ept o
f car
egiv
ing
and
ind
ulg
es li
nk w
orke
rs fo
r ho
me
visi
ts.
* T
he
d
new
born
car
e.
3
SNEH
A
Mu
mba
i
Cre
atio
n of
an
impr
oved
ref
erra
l sys
tem
thr
ough
the
fol
low
ing
pro
cess
:-
a.
Bri
ngin
g to
get
her h
ealt
h p
rovi
der
s fr
om d
iffer
ent
leve
ls o
f se
rvic
e an
d t
he f
orm
ula
tion
of
acti
on g
roup
s
b
.
The
se a
ctio
n gr
oup
s cr
eate
d a
dat
abas
e of
exi
stin
g fa
cilit
ies
for
MN
H s
ervi
ces,
usi
ng a
sel
f-as
sess
men
t to
ol
c.
The
y st
and
ardi
sed
tech
nica
l an
d ad
min
istr
ativ
e p
roto
cols
for
pro
vid
ing
MN
H s
ervi
ces .
4
A
nku
r
Mah
aras
htra
2000
(P
ilot
p
roje
ct)
1.
Bui
ldin
g ca
paci
ties
of
com
mu
nity
an
d le
vel m
obili
sers
th
e
trai
ning
of t
rain
ers.
2.
Cre
atin
g a
proc
ess
to r
egis
ter
pre
gnan
t w
omen
, giv
e
care
and
als
o re
cord
cas
es o
f ea
ch n
ewbo
rn. I
t gav
e hi
gh im
port
ance
to
mon
itor
ing
and
rec
ord
ing
dea
ths
and
sti
llbir
ths.
3.
A s
trin
gen
t p
roce
ss o
f ev
alu
atin
g it
s tr
aini
ng c
omp
onen
t th
rou
gh r
evie
win
g de
live
rabl
es s
et fo
r the
co
mm
uni
ty m
obil
iser
.
5
Yas
hod
a
Sele
cted
d
istr
icts
2007
Yas
hod
a ha
s be
en c
ruci
al in
trai
ning
com
mun
ity-
leve
l wor
ker
s fo
r fo
ster
car
e of
neo
nate
s.
6
Sure
Sta
rt
M
um
bai
2006
-
2012
Q
ual
ity
of C
are
ensu
red
thr
ough
ava
ilab
ilit
y,
acce
ssib
ility
, ap
pro
pri
aten
ess
and
acc
epta
bilit
y of
pub
lic
&
pri
vate
hea
lth
serv
ices
.
Nav
i
Mu
mba
i
2006
-
2012
Publ
ic-P
riva
te P
artn
ersh
ip (
PPP
) wit
h th
e p
rofe
ssio
nal
bod
ies.
Pune
2006
-
2012
Con
verg
ence
of M
NH
and
HIV
/A
IDS
Nag
pur
2006
-
2012
EH
F ex
tend
ed t
hrou
gh p
rep
aid
car
ds a
nd h
ealt
h in
sura
nce
mec
hani
sms.
Mal
egao
n ,
2006
-
2012
Inte
rfac
e of
ser
vice
see
kers
and
ser
vice
pro
vid
ers
at th
e Q
OC
mee
tin
gs h
eld
at th
e M
aleg
aon
Mun
icip
al C
orpo
rati
on.
Sola
pur
2006
-
2012
Mob
ili s
e th
e co
mm
uni
ty o
f Sol
apu
r by
usi
ng v
olu
ntee
rs to
enh
ance
mat
ern
al a
nd
neon
atal
hea
lth
serv
ices
.
Nan
ded
2006
-
2012
Intr
oduc
tion
of
a se
rvic
e p
rovi
der
s’ n
etw
ork
and
com
mu
nity
- bas
ed h
ealt
h in
sura
nce
calle
d ‘A
pni
Seh
at’.
57Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
H. Innovative Approaches
Innovation is essential to keep pace with the shifting demographics of a country undergoing rapid economic and social changes, such as India. Without the initiatives of the state government in strengthening the health system, innovations cannot achieve their desired outcome. This section delves into the various innovations that have successfully dealt with the complex issues of decaying public health infrastructure, scarcity of human resources and other relevant factors; which can possibly be adapted to develop a nationalised programme for maternal and newborn care in the urban Indian context.
l Strengthened Health Systems
A dedicated public health cadre under the Directorate of Health Services in Tamil Nadu, has three key 161directorates, which are organisationally equal, under the Health Secretary. (Gupta et al.2010) . The
Directorate has trained public health managers, who are promoted to the Directorate after years of experience in planning and overseeing public health services in both rural and urban areas. Thus, one of the reasons why Tamil Nadu is able to achieve relatively good health statistics, even in urban maternal and newborn care, is its strength in implementation—which is reinforced by a dedicated public health workforce that is appropriately trained and has the relevant experience.
l Greater Budgetary Allocation for MNH
A good example of prioritised budgetary allocation is Muthulakshmi Reddy Maternal Assistance Scheme. In India, most of the states are providing Janani Suraksha Yojana (a Centre- sponsored scheme) money to the mothers who deliver in a recognised health facility. In Tamil Nadu, the state has launched a separate state-funded scheme of Conditional Cash Transfer (CCT) for institutional delivery, i.e. the Muthulakshmi Reddy Maternal Assistance Scheme, introduced in 1989, much before the JSY (introduced in the year 2007, October). It started by offering a cash incentive of Rs. 500/- to each pregnant woman. The scheme was initially run by the Social Welfare Department and subsequently handed over to the Health Department. This particular amount was meant to compensate pregnant women for wage losses during pregnancy. Subsequently, the amount was increased to Rs. 2,000/- and then to Rs. 6,000/-. This amount was recently raised to Rs. 12,000/- per pregnancy and is paid by the government for the first two live births. Apart from wage-loss compensation, another purpose of giving the money is to provide additional nutrition to the mother to prevent anaemia and low-birth-weight babies. This scheme is only meant for Below Poverty Line (BPL) families (Padmanaban et al 2009).
l Health System Innovations
The Tamil Nadu Medical Service Corporation (TNMSC) was set up in 1995 with the primary objective to ensure ready availability of all essential medicines at all the government health facilities. The government of Tamil Nadu adopted a streamlined procedure for its procurement, storage and distribution. The list of nearly 900 drugs was reduced to 240 drugs as per the WHO's model list of essential drugs, accounting for around 90% of the budget outlay for the purpose, leaving other drugs of smaller quantities to be purchased locally by the institutions from out of the remaining 10% of the budget. This innovation has improved availability of drugs in nearly 2,000 government medical
162institutions throughout the state .
l Maternal Death Review (MDR)
MDR is an important strategy to improve the quality of obstetric care and reduce maternal mortality and morbidity. It provides detailed information on various factors at the facility, district, community, regional & national levels and the information can be used to adopt measures to fill the gaps in service
161Gupta, M., Desikachari, B.R., Shukla, R., Somananthan, T.V., Padmanaban, P. and Datta, K.K. (2010). 'Special Article: How Might India's Public Health Systems Be Strengthened? Lessons from Tamil Nadu', Economic & Political Weekly, XIV (10).
162Padmanaban, P., Raman, P. and Mavalankar, D. (2009). Innovations and Challenges in Reducing Maternal Mortality in Tamil Nadu, India', Health Population Nutrition, 27(2): 202-19. International Centre for Diarrhoeal Disease Research, Bangladesh.
163(Government of India, 2010) . Government of Tamil Nadu started compulsory audits of all maternal deaths occurring in the state since 1994. Sensitisation workshops were organised among the health functionaries on the importance of reporting maternal death. The system became fully established when the government of Tamil Nadu issued an order in 2004, stating that all maternal deaths should be audited. The reporting of the maternal death itself is the first important step, because many times people do not even report maternal death cases. The state mandates that each maternal death be reported to the Maternal and Child Health Commissioner, within 24 hours of occurrence, through a telegram or FAX, irrespective of the place of death – public facility or private nursing home or during the time of transit. Multiple sources of reporting are also encouraged, to avoid missing out on any incidents and lapses. Maternal deaths are reported by ANMs, the medical officer posted at the periphery, from the First Referral Unit (FRU), non-government hospitals, district public health nurses and Deputy Director of Health Services. Investigations of maternal deaths are carried out through community-based maternal reviews (verbal autopsy) and facility-based maternal death reviews/clinical audits.
Iron Sucrose Injections
Iron Deficiency Anaemia (IDA) is responsible for 95% of anaemia during pregnancy. Over the past years, various oral, intramuscular and intravenous preparations of iron have been used for correction of IDA in expectant mothers. However, they are associated with significant side effects and it is not possible to achieve the target rise in haemoglobin (Hb) level, in a limited period, when the mother is approaching term.
Iron sucrose injection was approved by the United States of America Food and Drug Administration(USFDA) in November 2000. The recommended schedule is to administer 100 mg intravenously over five minutes, once or thrice weekly, until 1,000 mg has been administered. The rate of administration should not exceed 20 mg per minute. A test dose is also not required and is at the
164physician's discretion (Silverstien and Rodgers 2004) . Iron sucrose complex achieves a relatively satisfactory level when used in severely anaemic, iron- deficient, pregnant women. A Few state governments in India are conducting initial research on it and the state governments of Bihar, Uttar Pradesh, Karnataka, Tamil Nadu, Maharashtra and Chattisgarh have allocated resources in their Programme Implementation Plans (PIP) for procurement of iron sucrose, for making it available in all primary healthcare settings. The decision to include it has been based on evidence obtained from very small observational studies and on the experience of clinicians who have been using it. Of the above-mentioned states, Tamil Nadu has implemented the administration of IV iron sucrose in primary
165healthcare settings since 2009 (Srinivasan and Ayyanar 2010) .
The documents sourced from the CHMI (www.healthinnovations.org) profile more than 220 programmes that harness private providers to deliver Maternal, Newborn, and Child Healthcare (MNCH) in Low and Middle-Income Countries (LMICs). The CHMI profiles programmes that use innovative delivery and financing mechanisms to improve access, quality or affordability of healthcare for the poor including clinical social franchises, vouchers for safe deliveries, and high-volume/ low-cost maternity hospitals. The overview of the market-based activities in MNCH programmes highlights that over 70% of the CHMI's MNCH programmes are concentrated in South Asia and East Africa and 58% are private and not-for-profit models. The volume of services delivered by the private sector is estimated to be quite high with considerable experimentation with new approaches and models for care. Social franchising, micro-insurance and vouchers are the most commonly applied approaches and have some
l Technological Innovations
l Innovative Approaches by the Centre for Health Market Innovations (CHMI)
58 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
163 Government of India. 2010. Maternal Death Review: Guidebook Maternal Health Division, Ministry of Health and Family Welfare, Government of India.164 Silverstien, S.B. and Rodgers, G.M. (2004). 'Parental Iron Therapy Options', Department of Pharmacy Services and Departments of Medicine and Pathology,
University of Utah Health Sciences Center, Salt Lake, Utah.thTrends in maternal mortality: 1990 to 2013, http://data.unicef.org/, accessed on 28 March , 2015.
165Srinivasan, A.K. and Ayyanar. (2010). 'Intravenous Iron Sucrose Complex Therapy for Iron Deficiency Anaemia in the Pregnant Women'. Published in Compendium of Scientific Papers presented in TNPHCON 2010&2011 and ICONHSS 2010. Department of Health and Preventive Medicine, Dharmapuri District, Tamil Nadu.
evidence of impact such as increased utilisation, improved pro-poor targeting and reduced out-of-pocket spending. More research is, however, needed on the effects on quality, affordability and accessibility.
Innovative use of technology and the development of high-volume, low-cost clinics is becoming more common, particularly to improve operations and processes of care, change patient behaviour and increase access to affordable, quality services. However, evidence on the impact and effectiveness of these models on urban MNCH outcomes is limited.
Launched in the year 2006, this is a national mobile hospital programme, catering to the underprivileged children and women in remote rural areas and urban slums, using primarily volunteer physicians and nurses. Smile-on-Wheels operates in several locations across India—Chhattisgarh, Delhi, Maharashtra, Odisha, Tamil Nadu and Uttarakhand—reaching nearly 750,000 people in 249 villages and urban slums. Three more units are being added in Ahmedabad, Hyderabad, and Lucknow. Implemented by the Smile
166Foundation , a not-for-profit organisation working in education and healthcare for underprivileged children across India, it operates in the areas where governmental healthcare facilities are scarce, non-existent or non-functional. The mobile vans delivering healthcare at a nominal cost to the community are staffed by specialised medical personnel and are equipped with an x-ray machine, electrocardiogram machine, basic pathological services for blood and urine tests, ante-natal and post-natal services, and an out-patient department for common ailments. The staff performs routine medical examinations, distributes condoms and oral contraceptive pills, and transports severely ill cases to super-specialty clinics. The team also carries out awareness activities on health and hygiene to encourage health-seeking behaviour, focusing equally on preventive and promotive healthcare, including home-based care. The project receives deep community support through a cadre of health volunteers who provide health education, provide counseling and serve as depots for family planning kits, oral rehydration salts, iron tablets etc.
Launched in the year 2002, this is a health programme providing a wide range of targeted medical services to the most vulnerable segments of society through innovative service delivery and risk- pooling. The NICE Foundation operates in Andhra Pradesh and Rajasthan with plans to expand to other states. It is a registered charitable trust based in Hyderabad that designs and implements all health programmes in partnership with state governments, the private sector and civil societies. The NICE Foundation's programmes are financed through public funding sources (including state governments and the central government) and through private donations from individuals and grant-making organisations.
NICE Foundation's Institute for the Newborn: The Institute for the Newborn is a first-of-its-kind specialised institute providing affordable international-quality neonatal care to all segments of society, using a cross-subsidisation model to benefit the poorest. Located in Hyderabad, it is the largest of its kind in South Asia and the institute is a 120-bed facility that networks with all the maternity hospitals in the city and provides neonatal care and referral care to high-risk newborns. The institute runs several 24/7 mobile intensive care units, staffed by a dedicated newborn transport team, that have peri-natal links with its existing government maternity hospitals, private nursing homes and non-governmental organisations. The institute and its clinical care teams also conduct training and research in various areas of neonatology.
Founded in 2005, LHPL is a for-profit, high-volume, low-cost hospital providing quality and affordable
l Innovative Service Delivery by the Smile-on-Wheels Programme in India
l Innovative Service Delivery and Risk Pooling by the NICE Foundation, India
l Life Spring Hospitals Private Limited (LHPL)
59Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
166 The Smile Foundation partners with local organisations in each state to run Smile-on-Wheels, including: Ambuja Cement Foundation (Roorkee, Uttaranchal), Berojgar Mahila Sewa Samiti (Bhilai, Chhattisgarh), Operation Blessing India (Delhi), Orissa Institute of Medical Research and Health Services (Cuttack, Odisha), and Sevadham Trust (Pune, Maharashtra). The Smile Foundation receives funding from several domestic and international partner organisations.
healthcare to women and children from lower income households across India. LHPL operates six hospitals serving 23,000 patients, with plans to scale up to 140 hospitals by 2014 in Andhra Pradesh, Karnataka and Maharashtra. Jointly operated by Hindustan Latex Limited and the Acumen Fund, it is a for-profit hospital operated with a 50/50 equity partnership.
LHPL addresses maternal and child healthcare in India through a chain of high-quality, small private hospitals (20–25 beds) that offer efficient, affordable customised care to its customers (“guests”). Its strategy is to provide services at the lowest possible cost, focusing on the working-class poor in high-population-density urban areas. LHPL's niche is standardisation of processes and specialised provision of maternal and child services, including ante-natal care, post-natal care, deliveries, family planning services, medical termination of pregnancy, paediatric care (including immunisation), diagnostics and pharmacy services. To maintain self-sustainability while serving low-income customers, LHPL applies internal cross-subsidisation, with service rates based on the type of accommodation and not on the quality of service. Under this model, hospitals are expected to become profitable within 21 months and to further reduce costs for services; LHPL is developing relationships with several government-sponsored voucher and insurance schemes (such as the Janani Suraksha Yojana).
Customer Relationship Management: LHPL has developed a unique protocol for customer care, Life Spring CARES (courteous, attentive, respectful, enthusiastic and safe), which all hospital employees are required to observe. To ensure high-quality service, client surveys and discussions with customers are used to obtain feedback which is fed into the operational system to improve overall service.
High-quality services: LHPL provides high-quality services at a low cost by leveraging information technology (they are now setting up a data centre to link all their hospitals) and working with the national and international medical equipment vendors to negotiate better prices for equipment through economies of scale.
Launched in 2005, Arogya Raksha Yojana (ARY) is a health micro-insurance scheme providing affordable, high-quality healthcare for the underserved in rural and urban areas of the Indian state of Karnataka through an accessible provider network of private hospitals and clinics supported by leading doctors and surgeons. ARY insures 70,000 people across seven districts of Karnataka. The programme is a joint project between the Biocon Foundation (the foundation of Biocon Pharmaceuticals Ltd.) and Narayana Hrudayalaya Hospital. Several independent rural service providers support them. The risk is covered by ICICI Lombard and funding for the programme is provided through the Arogya Raksha Yojana Trust.
ARY leverages the expertise of the commercial insurer to provide retail insurance to workers in the informal sector in non-rural areas by bearing the risk and undertaking all insurance administration. Local ARY clinics (run by the Biocon Foundation) create a presence in local communities and provide care to both the insured as well as the uninsured, reduce the costs of insurance claims by providing good primary healthcare (thus reducing rates of hospitalisation for surgical procedures). ARY benefits are comprehensive and include free outpatient consultation; generic medicines at special rates from Biocare pharmacies; diagnostic tests at discounted rates at network hospitals, at Biocare Clinics and approved diagnostic centres; hospitalisation (not leading to surgery) and surgical treatment for more than 1,600 types of surgeries. ARY offers health insurance to workers in the informal sector in the slums of Bangalore (India's third-largest city), who are reached through micro-finance organisations and community-based organisations. In places where no strong community institutions exist, ARY sets up enrolment booths for a limited time each year.
Established in 2005, CY is a government-organised, quality-driven voucher programme contracting private obstetricians and gynaecologists to provide delivery services to women who live below the poverty line to reduce the maternal and newborn mortality rates. Initially launched in five poor districts
l Risk-Pooling by Leveraging Commercial Experience for Social Benefits
l Chiranjeevi Yojana (CY): Contracting the Private Sector
60 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
of the state of Gujarat, it was later extended to the entire state, with 892 participating providers who have performed 294,635 safe deliveries per data sourced. Established by the government of Gujarat with support from the Indian Institute of Management, (Ahmedabad) and Sewa Rural–Jhagadia and facilitation by GTZ, it is financed by the Government of Gujarat, with support from the Central Government under the National Rural Health Mission.
The CY was created to significantly reduce maternal and infant mortality by harnessing the existing private sector and encouraging it to provide delivery and emergency obstetric care at no cost to families living below the poverty line. Under the scheme, the government contracts private providers that volunteer to render their services by signing a memorandum of understanding with the district administration. In return, they receive an advance payment to commence services and are compensated at about US$4,500 per 100 deliveries (normal, Caesarean, or with other complications). Any qualified private provider with basic facilities, such as labour and operating rooms and access to blood and anaesthetists can enroll in the programme after a thorough orientation. The CY beneficiaries are enrolled through their family health workers but the scheme uses the existing cards issued to families living below the poverty line (BPL) by the Rural Development Department of the State Government. In the first six months since the launch of the scheme, each provider performed 116 deliveries on average. The institutional delivery rate has apparently increased to more than 81% from an about 54.7% in 2005–06. The CY's long-term goal was to achieve an institutional delivery rate of 95% by 2012.
Benefits Package: The CY uses demand-side financing to provide families living below the poverty line with access to a comprehensive benefits package that covers both direct and indirect costs, including free delivery (with no condition exclusions), free medicines after delivery and transport reimbursement. In addition, as a thoughtful gesture, it offers support to the attendant in exchange for lost wages. The payment method and formula encourages providers to reach a certain volume of work, avoid complicated transaction costs and create a disincentive for unnecessary Caesarian sections. The provider compensation package is designed to account for all potential complications during delivery (estimated at approximately 15% of cases).
Contract Management: The CY's district management authorities require participating doctors to maintain a case file for each patient they serve. Weekly records of the deliveries conducted by the providers are submitted to the local authorities and the Block (sub-district) Health Officer, who regularly visits beneficiaries to monitor service quality and address grievances. Payment to providers is also made through block health officers based on instructions from district authorities. All districts send a monthly report to state authorities for review and feedback.
l Engagement of Community-Level Media: Community Radio
Dissemination of information has been one of the major components of maternal and child health programmes in India. Media campaigns can act as an effective mode to transfer information on good
167health behaviours and services available for the issue concerned (southasia.oneworld.net) . Community radio has been designed on many occasions for passing information to a larger audience in our past healthcare programmes. The Annamalai University started its community radio called Putholi with the intention of addressing the issue of stigma associated with HIV/AIDS. This resulted in success
168and the radio station was awarded as well in recent times (southasia.oneworld.net) . The intervention can surely be extended to maternal and newborn healthcare in urban communities. This can be usedwell as a tool to spread information on home-based neonatal care and, in fact, toward creating an environment within communities for building a support system for ensuring safety of the mother and
169the newborn(southasia.oneworld.net) .
61Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
167Ibid southasia.oneworld.net
168 Ibid southasia.oneworld.net169 Ibid southasia.oneworld.net
Conclusion
To conclude, the innovations that have been able to cater to the needs of communities dwell primarily on the principles of ensuring affordability, accessibility and availability. In the urban Indian context, where the diversity is wide and a subsidised healthcare system is still not present universally, the innovations of effective health finance (low-cost clinic, e-finance) discussed above can prove to be useful. Secondly, as the heterogeneity aspect and absence of social capital adds to the challenges in urban areas, the need to create safer cocoons of care for mothers and newborns through the involvement of NGOs, hospitals and local governance is a must.
62 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
Key Findings :
l The innovations have been designed to address the issues of infrastructural decay, crunch in human resource, depleting finance in health, high-cost treatment processes; however, the best practices of these innovations have not been tested on a large scale for maternal and newborn health.
l There is a dearth of literature on how the learnings from the innovations can be used to create integrated models for a national-level programme.
63Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
Promising Innovations in Maternal & Newborn Health in India
1.
Muthulakshmi Reddy
Maternal Assistance
Scheme
Tamil Nadu
Introduced
in 1989
State-funded Scheme of Conditional Cash Transfer (CCT) for institutional
delivery. It started by offering a cash incentive of Rs.500/-
to each pregnant
woman. The scheme was initially run by the Social Welfare department and
subsequently handed over to the health department. This particular amount was
meant to compensate pregnant women for wage losses during pregnancy.
Subsequently,
the amount was increased to Rs.2,000/-
and then to Rs.6,000/-.
This amount was recently raised to Rs.12,000 per pregnancy and is paid by the
government for the first two live births. Apart from wage-loss compensation,
another purpose of giving the money is to provide additional nutrition to the
mother to prevent anaemia
and low birthweight babies. This scheme is only
meant for below poverty line (BPL) families.
2.
Three Staff Nurse Model:
24x7 functional PHCs
Tamil Nadu
Between
2001-2006
This innovation
ensures safe delivery services in a PHC to pregnant women, at
the onset of labour pains, at any time of the day or night.
3.
Technological
Innovations - Iron
Sucrose Injections
Tamil Nadu
2009
Iron sucrose is an iron hydroxide sucrose complex in water. It is administered by
intravenous (IV) injection or infusion. The recommended schedule is to
administer 100 mg intravenously over five minutes, once or thrice weekly, until
1,000 mg has been administered. The rate of administration should not exceed 20
mg per minute. A test dose is also not required and is at the physician’s
discretion. Iron sucrose complex achieves a relatively satisfactory level when used
in severely anaemic iron-deficient pregnant women. 4. Non-Pneumatic Anti -
Shock Garment (NASG)
Tamil Nadu The Government of Tamil Nadu has incorporated the use of the NASG into its
protocols for active management of the third stage of labourand routinely trains
staff at all levels for its use. The NASG is now also being kept in all 108
Emergency Management and Research Institute (EMRI) ambulances in Tamil
Nadu. 5. Raksha Project Bihar, Rajasthan,
Tamil Nadu
To implement the ‘Continuum of Care’ philosophy and, within that, introduce the
NASG.
6. Development of Embrace
Baby -Warmer
Bengaluru,
Karnataka
2011 The current form of the baby-warmer was also being used as a transport device.
Here, if the LBW baby is required to be transported intra-hospital or inter-hospital
for any laboratory checks or referrals, the baby-warmer might be used to keep the
baby warm. It is seen to be a suitable alternative which is easy to use and cost-
effective. 7. Smile-on- Wheels
Programme
Chhattisgarh,
Delhi,Maharashtr
a, Odisha, Tamil
Nadu,
Uttarakhand,
Ahmedabad,
Hyderabad,
Lucknow
2006 Focusing on women and children, Smile-on-Wheels is a national, multi-centric
mobile hospital programme that provides medical care to rural and semi-rural
areas and urban slums where governmental healthcare facilities are scarce, non-
existent or non-functional. Provide both preventive and curative services to those
in need, including outpatient, ante-natal and post-natal services, identification of
difficult pregnancies and referral for institutional care, immunisation for mothers
and children, minor surgery, blood pressure examinations, electrocardiograms,
first aid, iron folic acid tablets, vitamin A prophylaxis and treatment of
malnutrition.
8. Innovative Service
Delivery and Risk-
Pooling by-NICE
Foundation, India
Andhra Pradesh
and Rajasthan
2002 It runs two health programmes in Andhra Pradesh - the School Newborn
Healthcare Plan, the Tribal Reproductive Newborn Health Programme and also
operates the specialised Institute for the Newborn, Hyderabad, which provides
neonatal care and conducts training and research. The School Newborn
Healthcare Plan has been replicated in three districts of Rajasthan and further
rollout is planned in the state.
9. Innovative Service
Delivery by Life Spring
Hospitals Private
Limited (LHPL)
Andhra Pradesh,
Karnataka, and
Maharashtra
2005 Specialised provision of maternal and child services, including ante-natal care,
post-natal care, deliveries, family planning services, medical termination of
pregnancy, paediatric care (including immunisation), diagnostics and pharmacy
services.
10.
Arogya Raksha Yojana
(ARY)
Karnataka 2005 Health micro-insurance scheme providing affordable, high-quality healthcare for
the underserved in rural and urban areas of the Indian state of Karnataka,
through an accessible provider network of private hospitals and clinics supported
by leading doctors and surgeons.
11
. Chiranjeevi Yojana (CY) Gujarat 2005 This is a government-organised, quality-driven voucher programme contracting
private obstetricians and gynaecologists to provide delivery services to women
who live below the poverty line to reduce the maternal and newborn mortality
rates.
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Summary of Findings
Irregularities and complications during pregnancy, child-birth and post-natal period are the leading causes of death and disability among women of reproductive age and newborn babies & infants in developing countries. Providing healthcare services, especially maternal and newborn care, is increasingly understood to be a dynamic system of entitlement and obligations among people, communities, providers and governments. However, the paradox in a country like India is that while the global community still concentrates on efforts to attain health-related Millennium Development Goals (MDGs) based on national strategies to reach high and equitable coverage of health services, the provision of health services, though absolutely necessary, is insufficient and unstructured in urban areas. Thus, on the one hand, the quality of treatment and care provided by the health system in rural areas does become complementary to the global efforts to reach and maintain coverage of health services, the pregnant mother and her newborn from the vulnerable sections of urban settings still struggle for the availability and accessibility of public health services. This only proves that on the other hand, the straightforward indicators for measurement in urban areas are, first and foremost, about the provision of services because unlike its rural counterpart there is no envisaged Primary Health Centre with its planned network in urban slums. Moreover, administration of health services through multiple health authorities, which are not effectively organised, has resulted in duplication of services in some
170.areas and non- existence of health services in other areas
The urban poor are at the interface between underdevelopment and industrialisation. Urban health in the slums presents serious public health concerns and challenges; predominant among them is maternal and newborn health and mortality. Although urban mortality statistics are comparatively better than the rural, there is a wide disparity between the settled urban population and the marginalised slum-dwellers. Hence, the existing urban statistics do not give a true representation of urban slums. Vulnerable urban communities continue to be poorly served. Though this is a result of “service” barriers, it is also a product of inter-related variables, such as poverty, inequitable distribution of primary healthcare services, poor referral systems, vertical programming and attitudinal & management challenges. Understanding how policies and programmes can address both service and demand-side barriers is a central question today.
With the growing urbanisation of poverty—with almost one out of four poor persons living in urban slums—the available indicators for the urban poor compare unfavourably with both the urban and national averages. There is a widespread awareness of the issue in research literature and a growing need for significant increase in research in this area has been felt for the last one decade. The findings of this review also spell out this need reasonably well as the evidence available is relatively meagre. The findings of the review can be distinctly classified under two different pieces. The first piece reveals the gaps in terms of the current availability of health services to deliver maternal and newborn healthcare along with the clearly defined paucity of service-delivery platforms, governance and mechanisms— inclusive of infrastructure, human resources, logistics, supply chain, partnerships and community-level efforts. The second piece focuses on the gaps with regard to the availability of literature and evidence from the research undertaken in all of the above-mentioned aspects of health service delivery for maternal and newborn healthcare.
The conclusions from this review are based on very peculiar findings that dwell largely on the following key facts. While maximum data is available mostly on social determinants of maternal and newborn health and barriers in accessing services, there is little information available on interventions and models that have worked to address these challenges. In exceptional cases certain initiatives did work, providing some piece-meal solutions, then first, the sample size of these interventions was not large enough for confidence of scalability and second, these were mostly project-based initiatives
IV. Discussion and Conclusions
170 Armida Fernandez, Jayshree Mondkar and Sheila Mathai. Urban Slum-Specific Issues in Neo-natal Survival, Indian Paediatrics(2003); 40:1161-1166.
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implemented and managed by non-governmental agencies. Thus, the review sets out suggestions not only in terms of requirement of evidence on the aspects of the service-provision and service-delivery mechanism in urban settings but also reflects the need for undertaking rigorous research in the area of urban maternal and newborn health which continues to remain an untouched area of research and learning.
Although not much information can be derived from the literature review on the status of maternal and newborn health services in urban India, oflate there are a few stand-alone initiatives that are being undertaken in different parts of the country to strengthen the health service delivery mechanism. The most specific initiativethat is being implemented uniformly across the entire country is the National
thUrban Health Mission (NUHM). The Government of India's 12 Five Year Plan built on the National Rural Health Mission and converted it into a National Health Mission (NHM) for the whole country. In doing so, it incorporated the developing of the National Urban Health Mission as a sub-mission of the NHM.
The information on the overall lack of clarity with regard to the ultimate responsibility of providing health services in urban areas as it is in rural areas is most well covered. The information on service provision mechanisms reveal that the health services vary from city to city, while a few large cities (such as Mumbai, Kolkata and Chennai) have used the Indian Population Project to focus on health infrastructure establishment in urban slums, only a few large Municipal Corporations with good revenue resources like Surat, have demarcated special resources to provide urban MNH services. In addition, the lack of demonstrated political will to assume responsibility and accountability for urban services, as well as the absence of inter-departmental coordination between the Departments of Public Health, Urban Development, Medical Education, the Municipal Corporations and the local bodies have made matters worse.
A number of studies reveal that the resources invested in urban healthcare deal primarily with curative services; urban health posts/centres (UHPs/UHCs) mainly provide three types of services: regular (including preventive, curative, IEC activities and training), seasonal (pre-monsoon and monsoon-related activities) and disaster management; and the urban healthcare system is focused on secondary and tertiary care, and not on comprehensive promotion, preventive and primary-level services. There is no mechanism for a health worker to make community or home visits and, thus, no holistic outreach and follow-up services are available. A link worker or community health volunteer has been appointed in a few cities that are effectively implementing the NRHM (Urban Component) and RCH-II project. The main role of the link worker is family welfare, maternal and child health, immunisation, health education and demand generation.
Referral services are available in corporation hospitals/district hospitals/medical college hospitals as well as several private hospitals. There is no definite system of referral; no linkages between domiciliary, health centre and hospital; and no protocols for admissions to primary, secondary and tertiary levels. Currently, secondary level of care is provided by District Hospitals and their equivalents(such as combined and base hospitals) while tertiary care is provided by Medical Colleges. However, these are not linked to primary care institutions such as health posts or dispensaries. Consequently, patients approach tertiary hospitals for primary care which could have been provided elsewhere. This is a major reason for their high workload; challenging adequate quality.
A number of policy documents reviewed, reveal that by and large, the service delivery structure and mechanisms in the urban areas continue to be rudderless with a complete lack of clarity on roles and responsibilities vis-à-vis the rural areas, where the district administration is structured and responsible for service provision. Multiple state agencies are providing services. There is anoverlapping of services and lack of coordination among these agencies. Private health providers are the key players in the overall provisioning of services. Multiplicity of providers and lack of coordination among them has led to dysfunctional referral systems and a consequent overload on tertiarycare providers. Even in states where primary healthcare is managed by ULBs and secondary & tertiary healthcare by the state, the referral chain is not functional (NUHM, 2012).
While primary healthcare in urban areas (where the poorest sections can easily approach has largely
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been neglected, there are exceptions of larger metropolises such as Mumbai and Delhi that provide primary healthcare by means of dispensaries, health posts and maternity homes. Health posts have been established under the India Population Project, e.g. in Mumbai basic ante-natal care and primary healthcare is provided through Community Health Volunteers and maternity homes, headed by an MBBS Medical Officer; these are meant for conducting normal deliveries and have support staff for this purpose. Similarly, at the primary healthcare level, Delhi has a network of 987 clinics and dispensaries through the Delhi Government, MCD, NDMC and Delhi Cantonment Board and central agencies though the CGHS, ESIC and Railways. (PHRN, 2010).
The UHPs, however, are located mainly in the big towns. Small towns continue to be deprived of these facilities. Though the UHPs are expected to carry out the same activities as the PHCs, their sanctioned staff strength is less. NUHM aims to meet the healthcare needs of the urban population, with a focus on the urban poor, by making available to them essential primary healthcare services and reducing their out-of-pocket expenses for treatment. This will be achieved by strengthening the existing healthcare service delivery system, targeting the marginalised and the people living in slums, and converging with various schemes relating to wider determinants of health (such as drinking water, sanitation and school education) implemented by the Ministries of Urban Development, Housing and Urban Poverty Alleviation, Human Resource Development, and Women and Child Development.
The urban poor are a diverse group of vulnerable populations, such as the homeless, rag-pickers, street children, rickshaw-pullers, construction, brick &lime kiln workers, sex workers and temporary migrants. They do not have stability, lack family support structures and are from varied cultures. Very few documents reflect the responsiveness to the needs of the poorest and the most vulnerable. While the availability of a large number of for-profit and not-for profit private providers encourages them to access private care more than the public facilities, they can hardly form any relationship with healthcare providers. The National Health Policy (2002) states that the public health facilities (with their poor infrastructure and inconvenient timings) are least accessed by the poorer populations and this has a serious implication for increased out-of-pocket payments for accessing private healthcare at the cost of items such as basic nutrition. The findings of the NFHS-III reflect that the private sector is the main provider of healthcare for a majority of the people living in urban areas. Use of private hospitals increases with increasing wealth quintiles. However, the poor also utilise the private sector more than the public sector. The main reason for non-utilisation of public facilities is the poor quality of care.
Studies on the availability of human resources reflect retention and training of the skilled birth attendants as the key bottleneck. Professional qualification does not necessarily mean that the provider is actually skilled. These also reflect the gaps identified in the guidelines on care and practices during pregnancy and the non-availability of doctors and midwives at the time they are most needed, i.e. at night. None of the studies reflect aspects such as staffing mechanisms, training, job satisfaction, appraisals, workplace safety and career development of the staff engaged for urban maternal and newborn healthcare.
Very little information could be traced on details of the guidelines or protocols for the functioning of primary and secondary level healthcare systems or the logistics required for maternal and newborn health in urban spaces. There is no information available on processes adopted for supply chain management, especially training procedures for staff at the primary and secondary level, to manage the supply chain of drugs and equipment and coordination with the blood banks and referral support. Lack of research in terms of availability and accessibility of services that may concern women living in urban slums comes across as a great deficiency. The existing literature also hints at the existence of private bodies however, does not extensively map the same.
Various studies reflect the lack of uniformity in delivery/provision of health services within and across cities. However, these hardly touch upon the opportunities for the marginalised at the health service centres, especially for MNH. The evidence gathered from the NHSRC 31-city-visit reports indicate a paucity of information on guidelines that govern the health service system and the details on facilities available for maternal and newborn health. The existing literature does not provide sufficient information on the aspects of bed: population ratio, status of buildings, drug and device supply-chains, inventories and also a list of the equipment available in each of the cities where the field visits/studies
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were conducted. While some studies do mention the type of facilities providing MNH services, which are accessible to the urban poor, they lacks analysis in terms their functioning, efficiency, governance and monitoring mechanisms.
Reliable and consistent information on health informatics is scarce. Little or no efforts have been made to conceptualise mechanisms or/and to capture disaggregated, discrete data on health service availability and its performance in relation to urban MNH across cities and states. The information from HMIS features largely around NRHM and the information available for urban and semi-urban places isabysmal. The websites of the NIHFW, NHSRC, CBHI and ULBs such as MCD, mostly include information on communicable diseases and sanitation and hygiene. The reporting formats of MoHFW on various districts within a state reflect the training required for the health personnel at the level of PHCs, CHCs and even in District Hospitals for maintaining and managing HMIS. Reports of a few city corporations such as Delhi and Mumbai reflect on the adequate reporting system that undertakes necessary actions for training, creation of tracking sheets and monitoring of planned activities.
While a number of documents reflect on the role of State Health Departments, Municipal Corporations (MCs), Town Councils and ULBs in the health sector in general, there is very scanty literature that examine the roles of these bodies in provision of services related to maternal and newborn health. Abundant information is available on other public health issues and the role of Municipal Corporations in managing these. With specific reference to convergence, very little literature is available on the coordination that exists between various departments at the city level. A couple of studies discuss the Public-Private Partnership model that functions in coordination with the NGOs or other private providers/bodies. Scantily available literature on the ULBs reflects the immense distrust on the quality and efficiency of the services provided and talks about the non-functionality of the few available facilities.
Very little and inconsistent information is available on financing patterns, the role of local bodies in budget planning, the process adopted for sustaining projects and the decision-making in relation to the same, across a majority of the cities, especially in the urban and semi-urban locations. No information is available on the budgetary allocation process for maternal and newborn health except for some small-scale cash-transfer programmes that exist in various states.
Despite emerging evidence on the challenges and issues faced by a rapidly urbanising India, knowledge on, and availability of, information for understanding the health situation of urban poor mothers and newborns continues to remain insufficient and inadequate. This review examined the evidence on maternal and newborn health in the urban poor environments specifically with regard to the opportunities and gaps in the health system, factors affecting programming and service delivery, and potential strategies that address specific MNH care needs of the urban poor in India. Apparently, the evidence has significantly improved in quantity and quality over the past few decades, but it remains patchy in terms of geography, issues and methods. Broad generalisations are difficult to make, both state-wise and for the different cities specifically.
First and foremost, MNH care calls for a dire necessity of public health services, specifically the primary level care for mothers and newborns in all the urban areas of the country; this is logically followed by the requirement of easy accessibility and its affordability by the urban poor. While the absence of defined and structured primary healthcare in urban areas directly affects the health of the mothers and babies, its indirect impact is seen in the coping strategies and care-seeking behaviours that households adopt in response to their circumstances. Additionally, the evidence also suggests that poor households often face a state of confusion when it comes to dealing with MNH situations. Confusion about their access to peri-natal healthcare services mirrors the confusion of the services themselves – why should a tertiary
171hospital routinely deliver preventive care? Needless to say, social and cultural barriers are more common in slums where healthcare services are not reachable.
Discussion
171 Bhaumik, (2012).
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Strengths and Weaknesses of the Evidence Base
This section assesses the strengths and weaknesses of the evidence base with regard to each of the four 172research questions presented during the review . Two general weaknesses in the available data are
discussed first. Firstly, this review of literature on MNH care in urban poor settings has revealed a lack of substantial and robust evidence on the availability of services associated with ante-natal, intra-natal, peri-natal and post-natal care for pregnant mothers and their newborns. Most of the studies located, examine the differences and diversities of service provision in the rural and urban areas in a comparative mode. Accurate and reliable findings on the specific service-delivery structures and platforms, their uniformity across the country, the proposed models by several committees and commissions and its actual implementation, are fairly limited. Further, in the literature available there is virtually very little or no coverage identified on the nitty-gritty of a functional health system, particularly aspects such as human resources, logistics, supply chain management and financing mechanisms. The lack of these data represents a critical gap in the evidence base.
A second weakness in the reviewed literature communicates on the generality of the write-ups, articles and documents, wherein all are trying to touch upon all the aspects of urban health. There are limited number of studies and research documents that talk exclusively about maternal and newborn health in a stand-alone manner rather than considering everything under the broader garb of reproductive and child health. While the evidence base with regard to MNH in the country is strong, with several good quality studies from different states, there are very few that are urban with a handful of these focusing on the urban poor. Another challenging area is the absence of uniformity in terms of pre-requisite and anticipated services in the light of the newly rolled-out NUHM which, nevertheless, is in a nascent stage, plagued by challenges of the very acceptance of proposed uniform structures.
The evidence base on the issues regarding maternal and newborn health in urban India is of better quality because a number of research studies, peer-reviewed articles, projects and programmes have narrated the problems and challenges faced by the urban poor. The results of several studies that are reviewed, although reliable, are somewhat compromised by the want of disaggregated data that can clarify the difference between slum versus non-slum, poor versus non-poor, and long standing residents versus recently migrated populations, in the urban locations.
On the reasons for the existing problems and challenges, the prevalent evidence-base is of medium quality. Examining challenges in relation to the provision of MNH services—that can help assess the situation and suggest solutions—has important limitations. What is obtained is essentially a snapshot of the problems and challenges that have existed for long in some of the larger cities and are now emerging rapidly in most of the cities. This, however, does not capture all the potentially valid reasons for this distressing situation.
The evidence base with regard to third research question on various supply side agencies, the successful interventions along and the existing linkages on supply side is varying for all the three aspects. Insufficient data is available on establishment of outreach services and their effectiveness. Few studies mention mass media campaigns and community education as standalone interventions, though many interventions use the delivery platform of community, including clinical interventions. Many of these community-based interventions reflect a great rate of success but are way beyond scalability because the population covered is minuscule. The studies reviewed also reflect that the state governments and city corporations often collaborate with NGOs & CBOs as satellite nodes linked with larger central offices as a structural arrangement for community outreach programmes.
Evidence is available on overall urban governance that reflect gaps and challenges but lacks reflections on urban health governance, with a complete absence on governance for MNH programmes. Data also reflects generic information on the desirability of inter-sectoral coordination but lacks evidence on any specific coordination beyond the ICDS programme.
172 a. What are the issues with regard to urban MNH? b. Why do these issues exist- what are the reasons? c. Who are the various supplyside agencies and what have their successful Interventions been along and what are the existing linkages on the supply side? d. What are the financial mechanisms/financial availability/budgetary provisions that exist for urban MNH?
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The evidence-base on financial mechanisms/financial availability/budgetary provisions that exist for urban MNH is largely scarce. However, secondary data from a number of Municipal Corporations reflect the expenditure incurred on reproductive and child health services of which MNH is one of the core areas. Robust information is available from two specific documents (the NUHM framework and the Technical Resource Group's report on Urban Health), as these incorporate inferences and recommendations of various committees and sub-committees that worked during the phase of the
th12 Five Year Plan. Once again however, the information provides a broader spectrum of expenditure, budgets and finances in the urban areas and cities but does not specifically reflect the disaggregated information on financial mechanisms for MNH.
There are studies that focus on the evaluation of mechanisms established for JSY, JSSK, RBSK, RSBY and Chiranjeevi Yojana; however, there is very little coverage for urban areas. Some evidence on social franchising, micro-insurance and voucher schemes does exist in terms of its impacts such as increased utilization, improved pro-poor targeting and perceived reduced out-of-pocket spending. However, none of the studies focuses on the quality, affordability and accessibility of the services targeted by these vouchers and scheme.
The overwhelming constraint on better availability of services for MNH care in urban areas is starkly visible. The findings presented in this review suggest two specific aspects: first and foremost, there exists very poor evidence on availability of services for MNH in urban areas and, secondly, there exist no defined structures for MNH services for the urban poor. Similarly, the evidence base is relatively weak with regard to the existence of specific policy instruments. Nevertheless, the following tentative conclusions may be reached with regard to what direction researchers and policy-makers should take in order to ensure that MNH care services are delivered to the urban poor.
The possible solutions vis-à-vis the conclusions stated can be mapped from the perspective of the AAAQ (Availability, Accessibility, Affordability and Quality) framework that was laid out in the terms of reference and the initial study protocol under the following sub-heads.
a. Physical Infrastructure
The need of the hour is certainly to conduct an extensive research on finding the gaps in the existing health structure for MNH care in terms of: number and type of facilities available for urban mother and newborns; the status of infrastructure in the urban centre (as in the few cases where information was available, the health facilities were running in rented spaces, poorly designed, or dilapidated structures); presence of basic facilities such as x–ray, ultrasound, labs and other essential equipment; SNCU and emergency obstetric care units; and suitably equipped transport facilities for pregnant women.
a. Responsive, Sensitive and Standardised Mechanisms
Setting up of standards for institutions for providing primary healthcare and making them accountable to the local government and, in turn, to the citizens, are vital aspects that need attention. The process of providing managerial oversight to UHCs needs to be defined by strengthening primary care services, which means allocating more resources to them and creating a well-defined referral system for secondary and tertiary care. The urban poor are a diverse group of migrants and 'outsiders', mainly from rural areas. They endure tough working conditions and have a poor health status. They have an unsteady relationship with service providers, unlike other city-dwellers. Consequently, any planning for them needs to take this diversity into account. This city-specific planning would require micro-planning by the ULBs. Therefore, urban health centres must be built in adequate numbers to ensure
Policy Recommendations and Areas of Future Research
Availability
Accessibility
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universal access to slum populations. Urban health posts must be distributed evenly to avoid concentration of facilities in a few cities, or in parts of a city.
b. Effective Outreach
Most of the resources under the NUHM should be allocated for outreach work. Corporations should be strongly encouraged to appoint an ASHA/USHA for every 2,000 population. Effective outreach depends primarily on these link workers.
c. Functional Referral Chain
There is a need of strengthening the referral system as well as managing the issue of variable distance from the health service system. The placement of the health service system within the localities of the urban poor as well as the need of transport facilities must be urgently considered. The tertiary care institutions can provide better quality of specialised care, if the primary level institutions are efficient, and the referral chain is functional. This requires strengthening of the primary and secondary levels of care and a functional referral linkage, with an emphasis on primary prevention, primary healthcare and secondary prevention (WG NRHM,XII FYP, 2011).
a. Financing Mechanisms
Research in the field of cost-effective methods of sustainable financing needs to be looked at by the state health departments, donors and NGOs. There should be a sense of urgency and prioritisation in the entire planning process and a dedicated, focused plan of action for urban marginalised maternal and newborn care. The provisioning of funds should be timely and regular to ensure smooth, round-the-clock functioning of the urban, maternal and newborn health services. There should be a detailed study on the needs of the target urban communities before designing any financial plan.
a. Policy Guidelines
Guidelines that will strictly govern the UMNH facilities at the primary and secondary healthcare centre need to be formulated. Evidence-based effective interventions need to be clearly defined for each level of service delivery. Policy decisions should take into account the specific contexts of the city, as well as the needs of various population groups.
b. Effective Monitoring and Reporting Systems
There is a need to establish an effective monitoring system as the provisioning of services for the urban poor is almost redundant in the space provided. As some of the city reports indicated, in many of the facilities,the absence of trained personnel was an evident issue. There is a need to recruit and trainboth community level workers as well as engage trained professionals to manage the equipment.
c. Incorporating Learning from NRHM
Implementation of NUHM must incorporate lessons learnt through NRHM. Policy decisions need to be taken to address the overt focus on curative services, poor public health and hygiene, problems of pollution, collapsing public healthcare facilities, unregulated private sector expansion in healthcare and the lack of ethics and self-regulation amongst medical professionals. Policy documents must clarify responsible who is the authority to for urban health, after reorganising the public health administration in urban local bodies. There should be uniformity in the basic structure and services, such as sanitation, electricity, waiting rooms and laboratories.
d. Human Resource Planning
Task-shifting and lowering the bar, especially capacitating the graduate doctors to provide essential
Affordability
Quality
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newborn care will make a difference. Successful experiments to that effect have been undertaken in states like Gujarat. Involvement of paramedics such as the Yashodas in West Bengal, could be another strategy to support the nurses in the facilities, as the involvement paramedics freed the limited number of nurses for more specialised functions. It is equally important to attract, retain and motivate human resources that are involved in providing special care to newborns. By providing improved work conditions, higher remuneration and recognition of their work in public, the state government of Madhya Pradesh and UNICEF have been able to attract and retain paediatricians and nurses for the special-care newborn units.
Further, the need for a multi-sectoral approach for maternal and newborn health should be emphasised; which includes training of staff, their employment, retention and improved management systems in formal healthcare. The training and education programmes implemented by some of the countries, which improved maternal mortality, need to be taken on alarger scale and implemented. Government, partners, stakeholders and donors need to work together to suit the needs of the urban poor in managing emergency obstetric care and decreasing maternal mortality. More studies need to be conducted focusing on the other HRH management system components, such as supervision, partnership and proper HRH information system development, and their impact on the maternal and newborn healthcare in urban areas.
e. Standardised Service Delivery Protocols
A standard protocol that mandates the existing health service system in the cities to ensure timely care for pregnant mothers and newborns. Research on the current of urban health service delivery mechanisms, from a demand-side perspective is expressly needed.
f. Governance Mechanisms
It is time to strongly underline the roles of local bodies and also ensure convergence within various departments. Special provision that dwells on a bottom-up approach and mandatorily engages the community in the decision-making for UMNH systems. The governance system should also look into the aspects of involvement of the CBOs, training of home-based caregivers, strengthening of services for EOC-ENC, training of link workers for home-based care and facility-based professionals in essential newborn care.
To conclude, it is important that the maternal and newborn health programmes, though variably existing in the urban space of India, gets a thorough prioritisation and reboot. The whole service delivery mechanism, adopted along with the NUHM guidelines, is not in place when it comes to most of the cities in the country. Ambiguity on the information, data, role of departments, leadership, personnel, supply chains andlogistics continues to remain. Most facilities remain under utilised due to an inefficient mechanism of functioning. Extensive research needs to be conducted on the social fabric and the needs of diverse urban target populations. The local bodies that have been eluding or excluded from the key responsibilities; need to create a comprehensive bottom-up plan for urban mothers and newborns. In this case, the community-based interventions (discussed in the chapter for innovations) that have taken place across the country, can be taken as a base for designing & extending a programme that caters to the issues of availability, accessibility, affordability and sustainability of quality-assured services.
A final recommendation for future research is conceptual rather than methodological. Future researchers should make a greater effort to examine the associated linkages with maternal and newborn healthcare in urban poor settings, which are areas that have hitherto received less attention than the other aspects of health. While it is acknowledged that data on MNH care provided outside the formal health sector is more difficult to collect, the lack of such data is critical in settings where a majority of residents live in vulnerable conditions. This reinforces the need to undertake research on the existing health systems and service delivery mechanisms for the urban poor so as to ensure the establishment and management of appropriate mechanisms in the coming years.
1. Agarwal, Paras, M.M. Singh, Suneela Garg (2007), Maternal Health-Care Utilisation among Women in an Urban Slum in Delhi, Indian Journal of Community Medicine Vol. 32, No. 3, July.
2. Archana S. Nimbalkar, Vivek V. Shukla, Ajay G Phatak and Somashekhar M Nimbalkar, (2013). 'Newborn Care Practices and Health Seeking Behaviour in Urban Slums and Villages of Anand, Gujarat', Indian Paediatrics, Vol. 50, April 16.
3. Becker, S., H.P. David, H.G. Ronald, G. Connie and E.B. Robert, (1993), 'The Determinants of Use of Maternal and Newborn Health Services in Metro Cebu, the Philippines', Health Transition Review, 3 (1): 77-89.
4. Bhatia, J.C. and J. Cleland,( 1995), 'Determinants of Maternal Care in a Region of South India', Health Transition Review, 5(2): 127-42.
5. Bhatia, J.C. (1993), Levels & Causes of Maternal Mortalityin South India. Studies in FamilyPlanning, 24(5), 310-318.
6. Campbell, O.M., Graham W.J. (2006), Lancet Maternal Survival Series Steering Group. Strategies for Reducing Maternal Mortality: Getting on with what works. Lancet; 368:1284-99.
7. Chakraborty, N., M.A. Islam, R.I. Chowdhury, W. Bari and H.H. Akhter, (2003), 'Determinants of the Use of Maternal Health Services in Rural Bangladesh', Health Promotion International, 18 (4): 327-37.
8. Das, N.P., V.K. Mishra and P.K. Saha, (2001), 'Does Community Access Affect the Use of Health and Family Welfare Services in Rural India?' National Family Health Survey Subjects Reports, Number 18.
9. Das Gupta M., (2005) Public Health in India: An Overview. Development Research Group, World Bank Policy Research Working Paper 3787, The World Bank, Dec. 2005.
10. Fauveau,V., Koenig, M., Chakraborty, T., and Choudhary, A.(1988), Causes of Maternal Mortality in RuralBangladesh; 1978, 1985. Bulletin of WHO, 66(5) 643-651.
11. Fernandez, A. Osrin, D. (2006), The City Initiative for Newborn Health. PLoS Med 3(9): e339.DOI: 10.1371/journal.pmed.0030339.
12. Health Mission(NRHM) for the Tweflth Five Year Plan (2012-2-17). New Delhi: Planning Commission, Government of India.
13. High Level Expert Group Report on Universal Health Coverage, 2011, [online] available at http://planningcommission.nic.in/reports/genrep/rep_uhc0812.pdf
14. HLEG Report on UHC. (2011). High Level Expert Group Report on Universal Health Coverage for India. New Delhi: Planning Commission.
15. Kansal, S., Akhtar, M.A. and Kumar Alok (2011), The Maternal Health Care Services in an Urban Setting of Northern India, International Journal of Current Research, Vol. 33, Issue, 6, Pp.284-286, June.
References
72 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
16. Kotecha, P.V. (2009) Maternal Health Services – Quality of Care: Uttar Pradesh Scenario Anaemia Control as a Context: Solution Exchange for MCH Community, Newsletter Safe –Motherhood Special, April.
17. Kumar, A.and Singh, A. (2013), Decomposing the Gap in Childhood Undernutrition between Poor and Non–Poor in Urban India , 2005–06. PLoS ONE 8(5) : e64972. doi:10.1371/journal.pone.0064972.
18. Lee, S.H. and Mason, A. (2005), Mother's education, learning-by-doing, and newborn healthcare in rural India. Comparative Education Review 49:434–551.
19. McCarthy,J., Maine,D. (1992), A FrameWork for Analysing the Determinants of Maternal Mortality . Studies in Family Planning, 23(1), 23-33.
20. More, NeenaShah ,Alcock, Glyn , Das, Sushmita , Bapat, Ujwala , Joshi, Wasundhara and Osrin,David(2010), 'Spoilt for choice? Cross-sectional study of care-seeking for health problems during pregnancy in Mumbai slums', Global Public Health, First published on: 27 October 2010 (iFirst) DOI:10.1080/17441692.2010.520725.
21. National Family Health Survey 2005-2006 (NFHS-III), Mumbai: Ministry of Health & Family Welfare, (Government of India) and International Institute for Population Sciences, 2006.
22. National Urban Health Mission (2010) National Urban Health Mission Draft. Urban Health Division, Ministry of Health and Family Welfare, Government of India, New Delhi. http://mohfw.nic.in/NRHM/Documents/Urban_Health/UH_Framework_Final.pdf.
rdAccessed on 23 June 2012.
23. Navaneetham, K. and A. Dharmalingam, (2002), 'Utilization of Maternal Health Services in Southern India', Social Science and Medicine, 55: 1849 – 69.
24. New York, Family Care International, 1998, p.4 (Safe Motherhood Fact Sheet).
25. NFHS-III. (2007). National Family Health Survey (NFHS-III), Vol., 2005-2006. Mumbai, India: Indian Institute of Population Sciences (IIPS) and Macro International.
26. NHP (2002). National Health Policy. New Delhi: Ministry of Health and Family Welfare.
27. NRHM (2005). Mission Document,National Rural Health Mission. New Delhi: Ministry of Health and Family Welfare, Government of India.
28. NUHM (2012). National Urban Health Mission, Framework for Implementation. New Delhi: Ministry of Health and Family Welfare, Government of India.
29. PHRN (2010). Public Health Resource Network: Issues in Public Health, Book 16. Delhi: Capital Printers.
30. Prashant Kumar Singh, Rajesh Kumar Rai and Chandan Kumar (2013). Equity in maternal, newborn, and newborn healthcarecoverage in India,Global Health Action, 6: 22217 - http://dx.doi.org/10.3402/gha.v6i0.22217
31. Raha, S. (2010, December). Institutional Arrangements in providing Urban Health Services:Current Context and the possible way forward. India Health Beat:Supporting Evidence-based Policies and Implementation, 4 (3).
73Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
32. Shenghelia, B. et al (2003). Beyond access and utilization: Defining and measuring health system coverage in Health Systems Performance Assessment: Debates Methods and Empiricism. Edited by C.J.L. Murray and D.B. Evans. Geneva, World Health Organization, 221-235
33. Singh A., Arora A.K. ( 2007). The Changing Profile of Pregnant Women and Quality of Antenatal Care in Rural North India. Indian Journal of Community Medicine; 32:135-6.
34. Sunil, T.S., S. Rajaram and L.K. Zottareli, (2006), 'Do individual and Programme Factors Matter in the Utilization of Maternal Care Services in Rural India? A Theoretical Approach', Social Science and Medicine, 62: 1943-57.
35. Tanahashi, T. (1978), Health services coverage and its evaluation. Bulletin of the World Health Organization, 56:295–303.
36. USAID (2006), Review of Public-Private Partnerships Models, published by PAIMAN (Pakistan Initiative for Mothers and Newborns).
37. Van de Poel, E., Speybroeck, N. (2009), Decomposing malnutrition inequalitiesbetween Scheduled Castes and Tribes and the remaining Indian population. Ethnicity and Health 14(3):271–287.
th38. WG Tertiary Care XII FYP (2011), Report of the Working Group on Tertiary Care Institutions for ththe 12 Five Year Plan. New Delhi: Planning Commission.
39. WHO (2008), Service delivery: Toolkit on monitoring health systems strengthening.
40. World Bank (2005). Achieving the Millennium Development Goal of Improving Maternal Health: Determinants, Interventions and Challenges; Health, Nutrition and Population (HNP) Discussion Paper. Eds. Elizabeth Lule, G.N.V. Ramana, Nandini Oomman, Joanne Epp, Dale Huntington And James E. Rosen, The International Bank for Reconstruction and Development / The World Bank.
th th41. XII Plan (2012), Report of the Steering Committee on Health: XII Five Year Plan. New Delhi: Health Division, Planning Commission, Government of India.
42. Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies, WHO (2010).
43. A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India, Ministry of Health and Family Welfare (2013).
44. Acting on the Call: Ending preventable child and maternal deaths (June 2014) Ministries of Urban Development, Housing and Urban Poverty Alleviation, Human Resource Development, and Women and Child Development.
45. NHSRC (2014), “City study Report, Mumbai”.
46. NHSRC (2014), “City Study Report, Bhubaneshwar”
47. NHSRC (2014), “City Study Report, Dhamtari ”.
48. NHSRC (2014), “City Study Report, Pune”.
74 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
49. NHSRC (2014) “City Study Report, Dhamtari”.
50. NHSRC (2014), “City Study Report, Kolkata”.
51. NHSRC (2014), “City Study Report,Ambala”.
52. NHSRC (2014), “City Study Report, Aligarh”.
53. NHSRC (2014), “City Study Report, Raipur”.
54. NHSRC (2014) “City Study Report Bhopal”.
55. INAP (2014), “Save the Children”
56. GOI (2014), “Executive Summary, Technical Resource Group”.
57. GOI (2014), Understanding Urban Health:An Analysis of Secondary Literature and Data.
58. GOI (2014), Reaching Health Care to the Unreached: Making the Urban Health Mission Work for the Urban Poor.
59. Devasenapathy, N. et al (2014),”Why women choose to give birthat home: a situational analysis from urban slums of Delhi”,British Medical Journal,Downloaded from bmjopen.bmj.com on
th27 Sept. 2014. - Published by group.bmj.com
60. Mahajan, S. and Sharma, B. (2014),”Utilization of Maternal and Newborn Healthcare Services by Primigravida Females in Urban and Rural Areas of India”, Hindawi Publishing Corporation ISRN Preventive Medicine.
61. GOI (2013), “NUHM, Implementation framework”.
62. NHSRC (2013), “Terms of reference of 31 city field reports”.
63. GOI (2013) January 2013, A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India. For healthy mother and child.
64. Pahwa, P. Sood, A. (2013), “Existing practices and barriers to access of MCH services – a case study of residential urban slums of district Mohali, Punjab”, India, vol. 2
65. Chandwani, H. and Padhiyar, N., (2013) “Utilization of Maternal Health Care Services in an Urban Slum of Gujarat, India”, Electronic Physician, Vol. 5.
66. Shodhganga (2013),”Maternal and newborn healthcare service in West Bengal – a comparative study”.
67. Bapat, U. et al(2012),”Stillbirths and newborn deaths in slum settlements in Mumbai, India: a prospective verbal autopsy study” Bio Med Central.
th68. MOHFW (2011), Guidelines on Newborn Care” accessed on 30 November 2014 http://rajswasthya.nic.in/FBNC%20Guidelines.pdf
69. Arora, R., Neogi, S., Misra, M. (2011), Innovative Ways to Meet Health Challenges of Urban
75Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
India, A White Paper, Public Health Foundation of India (PHFI).
70. Acharya, A. and Paul MacNamee (2009),”Assessing Gujarat's Chiranjeevi' Scheme” Economic and Political Weekly, Vol. XlIV.
71. Bannerjee, M., Sharma, D., (2007), Exchange for the Maternal and Newborn Health Community Consolidated Reply.
72. MoHFW (2006), Guideline for ASHA.
73. Premi, M.K., (2001), “The Missing Girl Child”, Economic and Political Weekly, Vol XXXVI.
74. Baru (2000), “Privatisation and Corporatisation” http:// www.indiaseminar.com/ nd2000/489/489%20baru.htm, accessed on 22 Nov, 2014.
75. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166913/.
76. Glob Public Health (2014) Sept. 14; 9(8): 910–926.
77. Chatterjee, P., Lineages of Political Society: Studies in Postcolonial Democracy. New York, NY: Columbia University Press; 2011
78. Sen, A., (1999) Development as Freedom. Oxford: Oxford University Press.
79. Ray, R., and Katzenstein, M.F., (2005), Social Movements in India: Poverty, Power, and Politics (Rowman and Littlefield Publishers, USA).
80. NHSRC (2014), “City Study Report, Mumbai”.
81. NHSRC (2014), “City Study Report, Bhubaneswar,”.
82. NHSRC (2014), “City Study Report, Dhamtari ”.
83. NHSRC (2014), “City Study Report, Pune”.
84. NHSRC (2014) “City Study Report, Dhamtari”.
85. NHSRC (2014), “City Study Report, Kolkata”.
86. NHSRC (2014), “City Study Report,Ambala”.
87. NHSRC (2014), “City Study Report, Aligarh”.
88. NHSRC (2014), “City Study Report, Raipur”.
89. NHSRC (2014) “City Study Report, Bhopal”.
90. INAP (2014), “Save the Children”.
91. GOI (2014), “Executive Summary, Technical Resource Group”.
92. GOI (2014), Understanding Urban Health-An Analysis of Secondary Literature and Data.
76 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
93. GOI (2014), Reaching Healthcare to the Unreached: Making the Urban Health Mission Work for the Urban Poor.
94. Devasenapathy, N. et al (2014)“Why women choose to give birthat home: a situational analysis from urban slums of Delhi”,British Medical Journal.Downloaded from bmjopen.bmj.com on Sept. 27, (2014) - Published by group.bmj.com
95. Mahajan, S. and Sharma, B. (2014), “Utilization of Maternal and Newborn Healthcare Services by Primigravida Females in Urban and Rural Areas of India”, Hindawi Publishing Corporation ISRN Preventive Medicine.
96. GOI (2013), “NUHM, Implementation Framework”.
97. NHSRC (2013), “Terms of reference of 31 city field reports”.
98. GOI (2013) January 2013, A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India. For healthy mother and child.
99. Pahwa, P. Sood, A. (2013), “Existing practices and barriers to access of MCH services – a case study of residential urban slums of district Mohali, Punjab”, India, Vol. 2.
100. Chandwani, H. and Padhiyar, N., (2013)“Utilisation of Maternal Health Care Services in an Urban Slum of Gujarat, India”, Electronic Physician, Vol. 5.
101. Shodhganga (2013),”Maternal and Newborn Healthcare Service in West Bengal – a Comparative Study”.
102. Bapat, U. et al(2012),”Stillbirths and Newborn Deaths in Slum Settlements in Mumbai, India: a prospective verbal autopsy study” Bio Med Central.
th103. MOHFW (2011), Guidelines on New Born Care” accessed on 30 November 2014 http://rajswasthya.nic.in/FBNC%20Guidelines.pdf
104. Arora R , Neogi S, Misra M (2011), Innovative Ways to Meet Health Challenges of Urban India, A White Paper, Public Health Foundation of India (PHFI).
105. Acharya A, Paul MacNamee (2009),”Assessing Gujarat's 'Chiranjeevi' Scheme” Economic and Political Weekly, Vol. XlIV.
106. Bannerjee, M., Sharma, D. (2007), Exchange for the Maternal and Newborn Health Community Consolidated Reply.
107. MoHFW (2006), Guideline for ASHA.
108. Premi, M.K., (2001), “The Missing Girl Child”. Economic and Political Weekly, Vol. XXXVI.
109. Baru (2000), “Privatisation and Corporatisation” http://www.indiaseminar.com/ nd2000/489/489%20baru.htm, accessed on 22 Nov. 2014.
110. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166913/
111. Glob Public Health. 14Sep2014; 9(8): 910–926.
77Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
112. Chatterjee, P., Lineages of political society: Studies in postcolonial democracy. New York, NY: Columbia University Press; 2011.
113. Sen, A. (1999), Development as freedom. Oxford: Oxford University Press
114. Ray, R., Katzenstein, M.F., (2005)Social Movements in India: Poverty, Power, and Politics (Rowman and Littlefield Publishers, USA).
115. Benazir Patil (2014), India Newborn Action Plan, A brief report on urban component, Save the Children, India.P
116. Berer, M. (2003), Traditional birth attendants in developing countries cannot be expected to carry out HIV/AIDS prevention and treatment activities. Reproductive Health Matters. 11(22):36-39.
117. Chen, L., Evans, T., Anand, S., et al (2004), Human resources for health: overcoming the crisis. The Lancet. 364(9449): 1984-1990.
118. George, A., & Iyer, A., (2013), Unfree markets: Socially-embedded informal health providers in northern Karnataka, India Social Science & Medicine, http://dx.doi.org/10.1016/ j.socscimed.2013.01.022
119. Graham, W., Bell, J.S., Bullough, C.H.W. (2001), Can skilled attendance at delivery reduce maternal mortality in developing countries? Safe motherhood strategies: A review of the evidence, 17:97–130. OL
120. Iyengar, K., Iyengar, S.D. (2009), Emergency obstetric care and referral: experience of two midwife-led health centres in rural Rajasthan, India. Reproductive Health Matters ;17(33):9-20.
121. Kirigia, J.M., Gbary, A.R., Muthuri, L.K., Nyoni,J., Seddoh, A. (2006), The cost of health professionals' brain drain in Kenya. BMC health services research. 6(1):89.
122. Lehmann, U., Dieleman, M., Martineau, T., (2008), Staffing remote rural areas in middle and low-income countries: A literature review of attraction and retention. BMC Health Services Research. 8(1):19.
123. Padmanaban, P., Raman P.S..0, Mavalankar, D.V. (2009), Innovations and challenges in reducing maternal mortality in Tamil Nadu, India. Journal of Health, Population and Nutrition (2009);27(2):202.
124. Rasch, V. (2007), Maternal death and the millennium development goals. Danish Medical Bulletin; 54(2):167-169.
125. Silvia Paruzzolo, Rekha Mehra, Aslihan Kes, Charles Ashbaugh (2010) Targeting Poverty And Gender Inequality to Improve Maternal Health, International Center for Research on Women (ICRW).
126. Simwaka, B.N., Theobald, S., Amekudzi, Y.P., and Tolhurst, R., (2005), Meeting millennium development goals 3 and 5. British Medical Journal. 331(7519): 708.
127. Sumit Malhotra, Sanjay P., Zodpey, Aishwarya L., Vidyasagaran, Kavya Sharma, Sunil S. Raj, Sutapa B. Neogi, Garima Pathak andAbhay Saraf, (2014). Assessment of Essential Newborn Care Services In Secondary-Level Facilities From Two Districts of India, Journal of Health
78 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
Population Nutrition, March 32(1): 130-141.
128. Sutapa Bandyopadhyay Neogi, Sumit Malhotra, Sanjay Zodpey and Pavitra Mohan (2011), Challenges in scaling up of special care newborn units- Lessons from India, Indian Paediatrics, Vol. 48, December 17, pp 931-935.
129. Sutapa Bandyopadhyay Neogi, Sumit Malhotra, Sanjay Zodpey and Pavitra Mohan, (2012). Does Facility-Based Newborn Care Improve Neonatal Outcomes? A Review of Evidence, Indian
thPaediatrics, Vol. 49, 16 August, pp. 651-658.
130. World Bank. (2010). World Development Indicators. Washington DC. SH
131. Zulfiqar A. Bhutta, Zohra S. Lassi, Nadia Mansoor. Systematic Review on Human Resources for Health Interventions to Improve Maternal Health Outcomes: Evidence from Developing Countries, Division of Women & Newborn Health, The Aga Khan University.
132. NHSRC, City Study Report, Ahmedabad.
133. GOI, (2014), “Report on Health Nutrition and Family Welfare “(http:// ndplanningcommission.gov.in/sectors/index.php?sectors=hea) accessed on 22 Sept. 2014.
134. Mukherjee, S. Singh, A. and Chandra, R. ( 2013),Maternity or catastrophe: “A study of household expenditure on maternal healthcare in India Maternity care in India”
thhttp://dx.doi.org/10.4236/health.2013.51015, accessed on 20 Sept 2014.
135. Shodhganga (2013), “Maternal and newborn healthcare service in West Bengal – a comparative study, Conclusion”.
136. Jogdand, K.S., Yerpude, P., Jogdand, M., (2013), A Perception of Maternal Mortality among Women in an Urban Slum Area of South India, International Journal of Recent Trends in Science And Technology.
137. Singh, Susheela et al (2009) “Barriers to Safe Motherhood in India”, www.guttmacher.org thaccessed on 20 Sept. 2014.
138. Acharya, A. and McNamee, M., (2009),“Assessing Gujarat Chiranjeevi Scheme”, Economic & Political Weekly, Vol 4.
th139. GOI (2008): 11 Five Year Plan of India, Health and Family Welfare and Ayush” http://planningcommission.nic.in/plans/planrel/fiveyr/11th/11_v2/11th_vol2.pdf
thaccessed on 24 Sept. 2014.
140. GOI( 2006).“Government Health Expenditure in India: A Benchmark Study” Economic Research Foundation.
141. Sambhav Voucher Scheme (2012) http://futuresgroup.com/ files/publications/ thSambhav_Voucher_Scheme_Report.pdf, accessed on 10 December 2014.
142. NHSRC draft report, Ambala.
143. NHSRC draft report, Bardhaman .
79Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
144. NHSRC draft report, Bhopal.
145. NHSRC draft report, Bhubaneshwar.
146. NHSRC draft report, Dhamtari.
147. NHSRC draft report, Sikkim.
148. NHSRC draft report, Kolkata.
149. NHSRC draft report, Chennai.
150. NHSRC draft report, Muzaffarpur.
151. NHSRC draft report, Ahmedabad.
152. NHSRC draft report, Bangalore.
153. NHSRC draft report, Guwahati.
154. NHSRC draft report, Jorhat.
155. NHSRC draft report, Valsad.
156. NHSRC draft report, Aligarh.
157. NHSRC draft report, Mumbai.
158. NHSRC draft report, Pimpri.
159. NHSRC draft report, Pune.
160. NHSRC draft report, Raipur.
161. Bang, A. et al(1999)“Effect of home-based neo-natal care and management of sepsis on neo-natal mortality: field trial in rural India” , Lancet Vol.354.
162. Aggarwal, S. and Bhanot, A., (2005)“Neonatal Care and Transport Among the Urban Poor:Challenges and Options”, Journal of Neonatology, Vol. 19.
163. Community-led approach among urban poor in maternal and neonatal health http://www.surestartdata.com, accessed Dec. 2014.
164. A Case Study of Public-Private Partnership in Newborn healthcare at Dinajpur, Bangladesh, http://healthmarketinnovations.org/, accessed Dec.2014.
165. Alma Ata declaration (1978), http://www.who.int/, accessed Dec. 2014,
166. NUHM( 2014), Executive summary of Technical Resource Group, for National Urban Health Mission,.
167. Annual Report (2003) Mamta organisation.
80 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
168. RRC ( 2013), Biannual report, Mamta.
169. Annual Report (2012- 13) Saath, Ahmedabad.
st170. Sure Start, Helping mothers and newborn thrive, , accessed on 1 Dec. 2014.
171. Ensuring the health and safety of mothers and newborns in India through behaviour change, stwww.path.org/publications, accessed on 1 Dec. 2014
st172. Sure Start in Maharashtra, India, www.surestartdata.com, accessed on 1 Dec.2014.
st173. Sure start, small steps big leap, www.path.org/publications, accessed 1 Dec.2014.
st174. Maternal and newborn health, http://www.snehamumbai.org/, accessed on 1 Dec. 2014.
nd175. Yashoda Programme, http://www.oneindia.com, accessed on 12 Feb.2015.
176. Verghese B et al ( 2014) ”Fostering maternal and newborn care in India the Yashoda
177. way: does this improve maternal and newborn care practices during institutional delivery?”
178. http://www.ncbi.nlm.nih.gov/pubmed/24454718, accessed on 1st Dec. 2014.
179. Das , A. ( 2014),” Community participation in Healthcare Management in India: need and potentials”; India Infrastructure Report 2014.
180. MIHF, GOI (February, 2014), Reaching Health Care to the Unreached: Making the Urban Health Mission Work for the Urban Poor, Report of the Technical Resource Group, Urban Health Mission.
181. MIHF,GOI, (January 2013), A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health(RMNCH+A) in India. For healthy mother and child.
182. Maternal, newborn and newborn health framework, International Federation of Red Cross and Red Crescent Societies,www.ifrc.org, accessed on 1 December , 2014
183. No.L.19017/1/2008-UH (2013), GOI, Ministry of Health & Family Welfare , Framework for implementation
185. Bang, A. et al (1999), “Effect of home-based neonatal care and management of sepsis on neo-natal mortality: field trial in rural India” , Lancet,Vol.354.
186. Putholi, the community radio http://www.newindianexpress.com/Accessed in Nov.2014.
187. A Case Study of Public-Private Partnership in Newborn healthcare at Dinajpur, Bangladesh, http://healthmarketinnovations.org/, accessed in Dec.2014.
188. Making Mobile Phones Work for Women with Fistula: The M-PESA Experience in Kenya and Tanzania , http://www.fistulacare.org/ Accessed in Nov. 2014.
184. NIPCCD( 2008), DCWC Research Bulletin, Vol. xii.
81Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
189. Lewis, T., et al (2012)“E-health in low- and middle-income countries:findings fromthe Center for Health Market Innovations”, Bulletin World HealthOrganisation
190. Innovations of Life Spring Hospital, www.lifespring.in, accessed on Nov., 2014
191. Shodhganga (2013),Recommendation and Conclusions, Home Care Services and Development Perspective – A Study on Customer Perception and Acceptability In the Urban Parts of India.
192. India's National Community Radio Awards-2014 presented, southasia.oneworld.net, accessed on Nov.2014.
193. Centre for Health Market Innovations (2013), Innovations in Privately Delivered Maternal, Newborn and Newborn Health: Exploring the Evidence Behind Emerging Practices. Health innovations.org Draft, August
194. Government of India (2010), Maternal Death Review: Guidebook, Maternal Health Division, Ministry of Health and Family Welfare, Government of India.
195. Gupta, M., Desikachari, B.R., Shukla, R., Somananthan, T.V., Padmanaban, P. and Datta, K.K. (2010), 'Special Article: How Might India's Public Health Systems Be Strengthened? Lessons from Tamil Nadu', Economic &Political Weekly, XIV (10).
196. Gupta, M., Desikachari, B.R., Somananthan, T.V., and Padmanaban, P. (2009). 'How to Improve Public Health Systems: Lessons from Tamil Nadu', Policy Research Working Paper 5073. World Bank Development Research Group, Human Development and Public Services Team.
197. Jamison, D.T., Breman,J.G., Measham, A.R., et al. (2006). Priorities in Health.
198. Washington, DC: World Bank. Available at http://www.ncbi.nlm.nih.gov/ books/NBK10265/pdf/ch7.pdf.
199. Padmanaban, P., Raman, P. and Mavalankar, D. (2009), Innovations and Challenges in Reducing Maternal Mortality in Tamil Nadu, India', Health Population Nutrition, 27(2): 202-19. International Centre for Diarrhoeal Disease Research, Bangladesh.
200. Silverstien, S.B. and Rodgers, G.M. (2004), 'Parental Iron Therapy Options', Department
202. SOIN (2014), State of India's Newborn, report Save the Children.
203. Trends in maternal mortality: 1990 to 2013, http://data.unicef.org/, accessed on th28 March, 2015.
204. NIPCCD( 2008), DCWC Research Bulletin, Vol. xii.
205. Vijay, V.S. (2011), 'Policy Note on Health and Family Welfare 2011-2012'. Health and Family Welfare Department, Government of Tamil Nadu.
of Pharmacy Services and Departments of Medicine and Pathology, University of Utah Health Sciences Center, Salt Lake, Utah.
201. Srinivasan, A.K. and Ayyanar. (2010), 'Intravenous Iron Sucrose Complex Therapy for Iron Deficiency Anaemia in the Pregnant Women'. Published in Compendium of Scientific Papers presented in TNPHCON 2010&2011 and ICONHSS 2010. Department of Health and Preventive Medicine, Dharmapuri District, Tamil Nadu.
82 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
206. www.arogyarakshayojana.org
207. www.lifespringhospitals.com
208. www.nicefoundation.in
209. www.smilefoundationindia.org
210. http://nrhm.gov.in/ state PIP, accessed in Dec. 2014.
211. https://nrhm-mis.nic.in, HMIS report on states, accessed in Dec.2014.
212. mcwis/detail.php, MCD information on maternal and newborn health, Delhi, accessed in Dec2014.
213. http://www.cbhidghs.nic.in/, accessed in Dec. 2014.
214. www.nhsrc.org, accessed in Dec.2014.
215. accessed in Dec.2014.
216. http://cbhidghs.nic.in/, accessed in Dec. 20
83Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
Annex
ure
- 1:
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e w
ere
the
mai
n re
ason
s fo
r n
ot u
tili
zin
g h
ealt
h c
are
faci
liti
es
and
serv
ices
by
wom
en r
esid
ing
in u
rban
slu
m a
reas
of
dist
rict
Moh
ali,
Pun
jab.
4
A S
trat
egic
App
roac
h t
o R
epro
duct
ive,
Mat
ern
al,
New
born
, Ch
ild
& A
dole
scen
t H
ealt
h
(RM
NC
H+
A)
in I
ndi
a
Min
istr
y of
Hea
lth
& F
amil
y W
elfa
re, G
oI, 2
013
Min
istr
y of
Hea
lth
& F
amil
y W
elfa
re, G
oI, 2
013
Str
ateg
y D
ocum
ent
Ser
vice
del
iver
y,
com
mun
ity
enga
gem
ent,
m
onit
orin
g &
in
form
atio
n
syst
em,
sect
oral
co
nve
rgen
ce.
Lif
e cy
cle
lin
ked
mat
ern
al a
nd
chil
d h
ealt
h c
are
serv
ices
hel
p to
bet
ter
ad
dres
s th
e ev
olvi
ng
nee
ds o
f w
omen
an
d ch
ildr
en.
5
Mat
ern
ity
or c
atas
trop
he
-
A s
tudy
of
hou
seh
old
expe
ndi
ture
on
mat
ern
al h
ealt
h c
are
in I
ndi
a
Sar
adiy
a M
ukh
erje
e, A
dity
a S
ingh
, Rak
esh
C
han
dra
Hea
lth
, V
ol 5
, 201
3
Stu
dy r
epor
t Fi
nan
cin
g T
his
stu
dy f
oun
d th
at t
he
urba
n h
ouse
hol
d m
ater
nal
ex
pen
ditu
re i
s tw
ice
that
of
rura
l ex
pen
ditu
re, l
eadi
ng
to i
mpo
veri
shm
ent.
6
A S
tudy
on
Uti
liza
tion
of
Mat
ern
al S
ervi
ces
in
Urb
an S
lum
s of
Ban
galo
re
Ran
gan
ath
T.S
an
d P
oorn
ima
C
Res
earc
h a
rtic
le
Ser
vice
del
iver
y T
o ac
hie
ve M
DG
-5, u
rban
slu
ms
nee
d im
prov
emen
t, a
s sl
um i
ndi
cato
rs a
re b
elow
urb
an a
vera
ge.
T
her
e is
poo
r ut
iliz
atio
n o
f m
ater
nal
ser
vice
s. A
war
enes
s is
nee
ded
in
84 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Inte
rnat
ion
al J
ou
rnal
of
Bas
ic a
nd A
pp
lied
M
edic
al S
cien
ces,
Vo
l 1
, 2
011
sl
um
s by
IEC
act
ivit
ies
7
AS
HA
s n
ot
eno
ugh
to
del
iver
H
ealt
hca
re t
o u
rban
po
or
S
on
al M
ath
aru
D
ow
n T
o E
arth
, 20
12
Op
inio
n a
rtic
le
Co
mm
un
ity
inte
rven
tio
ns,
se
rvic
e del
iver
y
Th
e A
SH
As
mo
del
sho
uld
be
repl
icat
ed i
n u
rban
m
ater
nal
hea
lth
car
e se
rvic
e del
iver
y
8
Ass
essi
ng
Gu
jara
t’s
‘C
hir
anje
evi’ S
chem
e
Ak
ash
Ach
arya
, P
aul
McN
amee
E
con
om
ic &
Po
liti
cal
Wee
kly
, n
ov
ember
28
, 2
00
9
vo
l x
liv
no
48
Co
mm
enta
ry
Ser
vic
e D
eliv
ery
Th
e ar
ticl
e sa
ys t
hat
th
e C
hir
anje
evi
Yoj
ana
aim
s ro
re
mov
e fi
nan
cial
bar
rier
s fo
r p
oo
r w
om
en t
o a
cces
s p
riv
ate
pro
vid
ers
but
sin
ce m
ost
of
them
tak
e o
nly
‘sa
fe
case
s’,
it d
efea
ts t
he
pu
rpo
se o
f ac
cess
ing
pro
vid
ers
in
com
pli
cati
on
s.
9
Bar
rier
s to
Saf
e M
oth
erh
oo
d i
n I
ndia
S
ush
eela
Sin
gh,
Lis
a R
emez
, U
sha
Ram
, A
nn
M.
Mo
ore
an
d S
uze
tte
Aud
am
Gu
ttm
ach
er
Inst
itu
te, 2
00
9
Rep
ort
S
erv
ice
Del
iver
y T
he
rep
ort
pro
vid
es a
des
crip
tive
ov
ervi
ew o
f m
ater
nal
h
ealt
h i
n I
nd
ia a
nd
hig
hli
ghts
th
e cu
rren
t st
atu
s o
f an
d
rece
nt
tren
ds
in g
aps
in t
he
rece
ipt
of m
ater
nal
hea
lth
ca
re an
d a
ssoci
ated
fac
tors
.
10
H
ealt
h o
f th
e U
rban
Po
or
–
Po
pu
lati
on
F
ou
nd
atio
n o
f In
dia
(HU
P-P
FI)
Pu
ne
Cit
y P
roje
ct
Po
pu
lati
on
Fo
un
dat
ion
of
Ind
ia
Po
pu
lati
on
Fo
un
dat
ion
of
Ind
ia, 2
014
Cit
y re
po
rt
Urb
an h
ealt
h T
he
rep
ort
is
bas
ed o
n a
Pu
ne
city
vis
it b
y th
e H
UP
-P
FI
team
, w
hic
h l
oo
ked
at
var
iou
s d
eter
min
ants
an
d
hu
rdle
s in
mat
ern
al h
ealt
hca
re d
eliv
ery
and
acce
ss.
11
In
dia
New
bo
rn A
ctio
n P
lan
, M
inis
try
of H
ealt
h &
F
amil
y W
elfa
re, G
ov
t o
f In
dia
, 20
14
S
trat
egy
do
cum
ent
New
bo
rn h
ealt
h T
his
str
ateg
y do
cum
ent
anal
ysis
th
e cu
rren
t sc
enar
io
wit
h r
espec
t to
new
bo
rn h
ealt
h i
n I
nd
ia a
nd
lays
do
wn
a
fram
ewo
rk t
o b
ette
r ad
dre
ss t
he
nee
ds
of
new
bo
rn
hea
lth
care
. 1
2
Th
e M
ille
nn
ium
Dev
elo
pmen
t G
oal
s R
epo
rt,
Un
ited
Nat
ion
s, 2
01
4
Sta
tus
rep
ort
M
DG
4&
5 T
his
is
a re
port
on
th
e st
atu
s o
f M
DG
4&
5 i
n v
ario
us
par
ts o
f th
e w
orl
d in
20
13.
1
3
Gro
wth
par
amet
ers
at b
irth
of
bab
ies
bo
rn i
n
Gam
pah
a di
stri
ct, S
ri L
ank
a an
d f
acto
rs
infl
uen
cin
g th
em; P
riya
nth
a J.
Per
era,
Nay
om
i R
anat
hu
nga
, M
eran
thi
P.
Fer
nan
do,
Tan
ia D
. W
arn
aku
lasu
riya
, R
ajit
ha
A.
Wic
krem
asin
ghe
Ori
gin
al
rese
arch
d
ocu
men
t
Infa
nt
mo
rtal
ity
Th
is r
esea
rch
lo
ok
s at
th
e gr
ow
th p
aram
eter
s fo
r re
cord
ing
the
dev
elo
pm
ent
of
infa
nts
in
Sri
Lan
ka.
14
D
istr
ict
pla
nn
ing
too
l fo
r m
ater
nal
an
d n
ewb
orn
h
ealt
h s
trat
egy
imple
men
tati
on
; W
HO
R
eso
urc
e G
uid
e P
lan
nin
g an
d im
ple
men
tati
on
, p
rogr
am
Pro
vid
es n
atio
nal
an
d d
istr
ict
hea
lth
man
ager
s /
pla
nn
ers
wit
h p
ract
ical
res
ou
rces
fo
r th
e p
lan
nin
g an
d im
ple
men
tati
on
of
Mat
ern
al a
nd
New
bo
rn H
ealt
h
85Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
m
anag
emen
t, dis
tric
t le
vel
M
ater
nal
an
d
New
born
Hea
lth
(M
NH
) se
rvic
es
(MN
H)
serv
ices
tow
ards
mak
ing
pre
gnan
cy s
afer
. It
is
a an
d p
ract
ical
tool
for
anyo
ne
wh
o i
s re
spon
sible
for
M
NH
pro
gram
me
man
agem
ent
and
all
stak
ehold
ers
at
dis
tric
t le
vel
. It
in
cludes
a t
ech
nic
al o
ver
vie
w o
n
pre
val
ence
an
d c
ause
s of
mat
ern
al a
nd n
ewborn
dea
th
and d
isab
ilit
y; h
igh
ligh
ts s
trat
egic
dir
ecti
on
s fo
r im
pro
vin
g m
ater
nal
an
d n
ewborn
hea
lth
an
d t
he
key
10 s
teps
requ
ired
for
the
pro
pose
d dis
tric
t pla
nn
ing
fram
ework
for
MN
H.
15
Id
enti
fyin
g, C
ateg
ori
zin
g, a
nd
Eval
uat
ing
Hea
lth
C
are
Eff
icie
ncy
Mea
sure
s; E
liza
bet
h A
. M
cGly
nn
, P
aul
G.
Sh
ekel
le, S
usa
n C
hen
, D
ana
P. G
old
man
, Jo
hn
A. R
om
ley,
Pet
er S
. H
uss
ey, H
an d
e V
ries
, M
arga
ret
C. W
ang,
Mar
tha
J. T
imm
er, Ja
son
C
arte
r, C
arlo
Tri
nga
le, R
obe
rta
M.
Sh
anm
an
Res
earc
h r
eport
H
ealt
hca
re
effi
cien
cy
Pre
sen
t cr
iter
ia f
or
eval
uati
ng
hea
lth
car
e ef
fici
ency
m
easu
res,
an
d dis
cuss
to w
hat
deg
ree
exis
tin
g m
easu
res
mee
t th
ese
crit
eria
.
16
U
rban
izat
ion
, Urb
an P
ove
rty
and H
ealt
h o
f th
e U
rban
Poor:
Sta
tus,
Ch
alle
nge
s an
d t
he
Way
Forw
ard;
Sid
dh
arth
Aga
rwal
, A
ravin
da
Sat
yavad
a,
S.
Kau
shik
an
d R
ajee
v K
umar
+
Art
icle
U
rban
hea
lth
Th
is p
aper
an
alyz
es t
he
asso
ciat
ion
bet
wee
n u
rban
pover
ty a
nd h
ealt
h o
f th
e urb
an p
oor
in
In
dia
. T
he
hea
lth
sit
uat
ion
am
on
g th
e urb
an p
oor
is d
escr
ibed
on
th
e ba
sis
of t
he
anal
ysis
of
the
NFH
S-2
dat
a by
econ
om
ic s
tatu
s. T
he
pap
er a
lso o
utl
ines
som
e of
the
chal
len
ges
in i
mpro
vin
g h
ealt
h o
utc
om
es o
f th
e urb
an
poor
and t
he
pote
nti
al o
per
atio
nal
solu
tion
s to
addre
ss
such
ch
alle
nge
s. 17
T
he
Sta
te o
f th
e W
orl
d's
Mid
wif
ery,
2011 –
D
eliv
erin
g
Hea
lth
, S
avin
g L
ives
; U
NFP
A
An
nual
Rep
ort
S
kil
led
bir
th
atte
nda
nts
, qual
ity
mat
ern
al
hea
lth
ser
vic
es
Pro
vid
es t
he
firs
t co
mpr
ehen
sive
anal
ysis
of
mid
wif
ery
serv
ices
an
d i
ssues
in
coun
trie
s w
her
e th
e n
eeds
are
grea
test
. T
he
report
pro
vides
new
in
form
atio
n a
nd
dat
a ga
ther
ed f
rom
58 c
oun
trie
s in
all
reg
ion
s of
the
worl
d.
Its
anal
ysis
con
firm
s th
at t
he
wor
ld l
acks
som
e 350
,000
skil
led m
idw
ives
--
112,0
00 i
n t
he
nee
die
st 3
8 co
un
trie
s su
rvey
ed -
-
to f
ull
y m
eet
the
nee
ds
of
wom
en
aroun
d th
e w
orl
d. T
he
report
explo
res
a ra
nge
of
issu
es
rela
ted t
o b
uild
ing
up t
his
key
hea
lth
work
forc
e.
18
R
each
ing
Hea
lth
Car
e to
th
e U
nre
ach
ed: M
akin
g th
e U
rban
Hea
lth
Mis
sion
Work
for
the
Urb
an
TR
G r
eport
U
rban
hea
lth
, urb
an p
oor
A T
ech
nic
al R
esourc
e G
roup (
TR
G)
on
Nat
ion
al
Urb
an H
ealt
h M
issi
on
was
con
stit
ute
d b
ased
on
‘Ter
ms
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
86 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
P
oor;
MoH
FW
of
Ref
eren
ce’ i
ssued
by
Min
istr
y of
Hea
lth
& F
amil
y W
elfa
re, G
ovt
of
India
. T
her
e w
ere
four
Work
ing
Gro
ups
un
der
th
e T
RG
. T
hes
e ar
e th
e ‘R
eport
an
d
Rec
om
men
dati
on
s’ f
or
NU
HM
subm
itte
d b
y N
HS
RC
19
S
yste
mat
ic R
evie
w o
n H
um
an R
esourc
es f
or
Hea
lth
In
terv
enti
on
s to
Im
pro
ve
Mat
ern
al H
ealt
h
Outc
om
es: E
vid
ence
fro
m D
evel
opi
ng
Coun
trie
s;
Zulf
iqar
A. B
hutt
a, Z
oh
ra S
. L
assi
an
d N
adia
M
anso
or
Rev
iew
rep
ort
H
RH
, m
ater
nal
h
ealt
h T
his
rev
iew
focu
ses
on
th
e im
pact
of H
RH
in
terv
enti
on
s on
hea
lth
car
e pro
fess
ion
als
def
ined
as
skil
led b
irth
att
endan
ts t
o d
ecre
ase
mat
ern
al m
ort
alit
y an
d m
orb
idit
y. I
t der
ives
les
son
s, g
aps
and
reco
mm
enda
tion
s bas
ed o
n t
he
studi
es c
on
duct
ed o
n
HR
H i
mpl
emen
tati
on
s in
dev
elopin
g co
un
trie
s.
20
U
rban
Hea
lth
-
Th
e E
mer
gin
g S
oci
al I
mper
ativ
e For
India
In
Th
e N
ew M
ille
nn
ium
; S
. A
garw
al,
K.
Sri
vas
tava
Rev
iew
art
icle
U
rban
hea
lth
n
eeds
Th
is a
rtic
le l
ooke
d a
t an
d l
iste
d o
ut
the
spec
ial
nee
ds
of
urb
an h
ealt
hca
re, gi
ven
th
e div
ersi
ty i
n p
opul
atio
n
an n
eeds,
as
wel
l as
th
e pro
ble
ms
that
wer
e un
ique
to
urb
an h
ealt
h. It
th
en g
oes
on
to
sugg
est
som
e poss
ible
so
luti
on
s to
th
e id
enti
fied
pro
blem
s.
21
M
ater
nal
an
d N
ewborn
Hea
lth
Toolk
it;
MoH
FW
G
uid
elin
es
docu
men
t M
CH
res
ourc
e gu
de
Pro
vid
es su
pport
an
d g
uid
ance
to p
oli
cym
aker
s,
pro
gram
me
off
icer
s, a
nd
man
ager
s to
est
abli
sh h
ealt
h
faci
liti
es p
rovid
ing
qual
ity
m
ater
nal
an
d n
eon
atal
se
rvic
es.
22
M
ater
nal
Mort
alit
y:
An
In
dica
tor
of
Inte
rsec
tin
g In
equal
itie
s; M
abel
Bia
nco
, S
usa
nn
a M
oore
D
ebat
es a
nd
rese
arch
fi
ndin
gs a
rtic
le
Mat
ern
al
mort
alit
y, s
ocio
-ec
on
omic
fa
ctors
, ge
nde
r eq
ual
ity
Gen
der
in
equal
ity,
pove
rty
and d
ispar
itie
s in
wom
en’s
an
d g
irls
’ acc
ess
to h
ealt
h, ed
uca
tion
an
d i
nco
me
as
wel
l as
soci
o-c
ult
ura
l st
atus
are
all
key
fac
tors
th
at
impac
t m
ater
nal
hea
lth
. B
ased
on
mon
itori
ng
dev
elope
d i
n A
fric
a, A
sia
Pac
ific
an
d L
atin
Am
eric
a an
d t
he
Car
ibbe
an, div
erse
Sex
ual
an
d R
epro
duct
ive
Hea
lth
an
d R
igh
ts n
etw
ork
s, i
ncl
udi
ng
those
work
ing
on
HIV
, re
sear
ched
th
e li
nkag
es b
etw
een
MD
G 5
an
d
MD
Gs
3 an
d 6
. It
was
aff
irm
ed t
hat
th
e on
ly w
ay t
o
impro
ve
mat
ern
al h
ealt
h i
s by
buil
din
g an
d
stre
ngt
hen
ing
a co
mpr
ehen
sive
appro
ach
th
at
inco
rpora
tes
cross
-cutt
ing
issu
es o
f ge
nder
equa
lity
an
d
wom
en’s
an
d g
irls
’ educa
tion
an
d e
mpow
erm
ent,
el
imin
atio
n o
f ea
rly
mar
riag
e, p
over
ty a
llev
iati
on
, ac
cess
to s
exual
an
d r
epro
duct
ive
hea
lth
com
modi
ties
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
87Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
cover
ed
and s
ervic
es i
ncl
udin
g sa
fe a
bort
ion
, H
IV p
reve
nti
on
an
d d
eliv
ery
hea
lth
car
e. 23
M
ater
nal
an
d N
ewborn
Car
e P
ract
ices
Am
on
g th
e U
rban
Poor
in I
ndore
, In
dia
: G
aps,
rea
son
s an
d
pote
nti
al p
rogr
am o
pti
on
s
Res
earc
h r
eport
M
ater
nal
an
d
new
born
soci
al
pra
ctic
es
Th
is r
eport
des
crib
es m
ater
nal
-new
born
car
e pra
ctic
es
and c
are
of
infa
nts
age
d 2
-4 m
on
ths
(fee
din
g pra
ctic
es,
morb
idit
y st
atus,
im
mun
izat
ion
sta
tus
and n
utr
itio
nal
st
atus)
in
urb
an s
lum
dw
elli
ngs
of
Indore
cit
y, M
adya
P
rades
h (
India
). A
lso d
iscu
ssed
in
th
is r
eport
, ar
e re
ason
s fo
r fo
llow
ing
thes
e pra
ctic
es, w
hat
fac
ilit
ates
an
d w
hat
hin
der
s fo
llow
ing
opt
imal
pra
ctic
es a
nd
pote
nti
al p
rogr
am o
pti
on
s fo
r th
eir
impro
vem
ent.
24
E
xam
inin
g th
e “U
rban
A
dva
nta
ge”
in M
ater
nal
H
ealt
h C
are
in D
evel
opin
g C
oun
trie
s; Z
oe¨
M
atth
ews,
Am
os
Ch
ann
on
, S
arah
Nea
l, D
avid
O
srin
, N
yovan
i M
adis
e, W
illi
am S
ton
es
Poli
cy a
rtic
le
Urb
an m
ater
nal
h
ealt
h T
his
Pol
icy
Foru
m a
rtic
le i
nves
tiga
tes
the
“urb
an
advan
tage
” to
det
erm
ine
w
het
her
th
e ur
ban
poor
in a
ra
nge
of
dif
fere
nt
coun
trie
s re
ally
do
hav
e an
adva
nta
ge
over
rura
l popula
tion
s in
hea
lth
an
d a
cces
s to
ser
vic
es.
It a
lso q
uan
tifi
es t
he
gap b
etw
een
th
e urb
an p
oor
and
oth
er r
esid
ents
of
tow
ns
and c
itie
s.
25
R
educ
ing
Neo
nat
al M
ort
alit
y in
In
dia:
Cri
tica
l R
ole
of A
cces
s to
Em
erge
ncy
Obst
etri
c C
are;
R
amm
oh
an, Iq
bal
K, A
wofe
so N
.
Art
icle
N
eon
atal
hea
lth
; fa
cili
ties
an
d
serv
ices
Addre
ssin
g th
e m
ain
cau
ses
of
neo
nat
al d
eath
s in
In
dia
--pre
term
del
iver
ies,
asp
hyx
ia, a
nd s
epsi
s--r
equir
es
adeq
uac
y of
spec
iali
sed w
ork
forc
e an
d f
acil
itie
s fo
r del
iver
y an
d n
eon
atal
in
ten
sive
car
e an
d e
asy
acce
ss b
y m
oth
ers
and n
eon
ates
. T
he
slow
dec
lin
e in
neo
nat
al
dea
th r
ates
ref
lect
s a
lim
ited
att
enti
on
to
fact
ors
, w
hic
h
con
trib
ute
to
neo
nat
al d
eath
s. T
he
subopti
mal
qual
ity
and c
over
age
of
Em
erge
ncy
Obst
etri
c C
are
faci
liti
es i
n
India
req
uir
e ur
gen
t at
ten
tion
.
26
A
n A
sses
smen
t of
th
e Q
ual
ity
of
Pri
mar
y H
ealt
h
Car
e in
In
dia
; T
imoth
y P
ow
ell-
Jack
son
, A
rnab
A
char
ya, an
d A
nn
e M
ills
Spec
ial
arti
cle
Qual
ity
of
PH
C T
her
e is
lim
ited
evid
ence
on
th
e qual
ity
of
pri
mar
y h
ealt
h c
are
pro
vis
ion
in
In
dia
. U
sin
g dat
a on
th
e av
aila
bil
ity
of
inputs
fro
m a
nat
ion
ally
rep
rese
nta
tive
su
rvey
of
pri
mar
y h
ealt
h c
entr
es, a
com
posi
te m
easu
re
of
stru
ctura
l qu
alit
y of
car
e fo
r pri
mar
y h
ealt
h c
entr
es
was
dev
eloped
wit
h a
vie
w t
o ex
amin
e it
s ge
ogra
ph
ical
var
iati
on
, as
soci
atio
ns
wit
h m
ort
alit
y an
d h
ealt
hca
re
uti
lisa
tion
, an
d th
e det
erm
inan
ts o
f bet
ter
qua
lity
, gi
vin
g par
ticu
lar
atte
nti
on
to t
he
role
of
man
agem
ent.
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
88 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
Th
e m
ean
qual
ity
score
was
52%
, w
ith
lar
ge d
iffe
ren
ces
acro
ss r
egio
ns,
sta
tes
and d
istr
icts
. Q
ual
ity
of
care
was
th
e w
ors
t an
d t
he
var
iati
on
gre
ates
t in
sta
tes
des
ign
ated
by
the
gover
nm
ent
as l
ow
per
form
ing.
Good
man
agem
ent
pra
ctic
es i
n a
fac
ilit
y w
ere
hig
hly
co
rrel
ated
wit
h b
ette
r qual
ity
of
care
. T
he
maj
ori
ty o
f pri
mar
y h
ealt
h f
acil
itie
s in
In
dia
fal
l fa
r sh
ort
of
gover
nm
ent
min
imum
sta
ndar
ds,
in
par
t ex
pla
inin
g w
hy
most
peo
ple
in
rura
l ar
eas
use
pri
vat
e pro
vid
ers
for
outp
atie
nt
care
. Futu
re r
esea
rch
sh
ould
explo
re t
he
causa
l re
lati
on
ship
bet
wee
n m
anag
emen
t pra
ctic
es,
qual
ity
of
care
an
d p
atie
nt
outc
om
es.
27
S
oci
al I
nfr
astr
uct
ure
: U
rban
Hea
lth
An
d
Educa
tion
; L
avee
sh B
han
dar
i
Art
icle
In
fras
truct
ure
, se
rvic
es
Both
for
educa
tion
as
wel
l as
th
e urb
an h
ealt
h c
are,
it
is p
oor
del
iver
y of
the
serv
ices
th
at h
as e
xac
erbat
ed t
he
con
sequen
ces
of
poor
infr
astr
uct
ure
. B
oth
are
sy
mpto
ms
of
fail
ure
of
the
inst
ituti
on
al s
et-u
p i
n
del
iver
ing
wh
at t
hey
set
out
to d
o a
nd i
mpro
vem
ents
ca
n b
e bro
ugh
t ab
out
by
alte
rin
g th
e del
iver
y an
d
inst
ituti
on
al m
ech
anis
m.
28
S
oci
al I
nfr
astr
uct
ure
; D
DA
A
rtic
le
Str
ateg
ies
for
hea
lth
rel
ated
in
fras
truct
ure
in
D
elh
i
Th
e qual
ity
of
life
in
an
y urb
an c
entr
e dep
ends
upon
th
e av
aila
bil
ity
of
and a
cces
sibil
ity
to q
ual
ity
soci
al
infr
astr
uct
ure
. S
oci
al i
nfr
astr
uct
ure
can
be
looked
at
in
term
s of
the
faci
liti
es i
ndic
ated
in
th
e C
ity
Lev
el
Mas
ter
Pla
n, an
d C
om
mun
ity
Fac
ilit
ies,
wh
ich
are
in
dic
ated
at
the
layo
ut
pla
n l
evel
in
var
ious
use
zon
es.
Th
e pro
pose
d P
lan
nin
g n
orm
s an
d d
evel
opm
ent
con
trols
an
d c
on
dit
ion
s in
res
pec
t of
var
ious
soci
al
infr
astr
uct
ure
fac
ilit
ies
are
bro
ugh
t out
in t
he
arti
cle.
29
Is
sues
In
Soci
al I
nfr
astr
uct
ure
: P
ubli
c H
ealt
h
Infr
astr
uct
ure
in
Mum
bai
; M
um
bai
T
ran
sform
atio
n S
upport
Un
it
Vis
ion
docu
men
t
Soci
al
infr
astr
uct
ure
in
M
um
bai
V
isio
n M
um
bai
docu
men
t ta
rget
s at
hea
lth
an
d
educa
tion
as
the
key
are
as o
f im
pro
vem
ent
for
soci
al
infr
astr
uct
ure
wh
ich
would
lea
d t
o b
ette
r
qual
ity
of
life
fo
r th
e co
mm
on
cit
izen
of
Mum
bai
. In
ord
er t
o
tran
sform
Mum
bai
in
to a
cit
y w
ith
glo
bal
ly c
om
par
able
in
fras
truct
ure
an
d o
ffer
a c
om
fort
able
qual
ity
of
life
,
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
89Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
ther
e is
a n
eed t
o i
den
tify
th
e pro
ble
ms
and c
om
e up
wit
h a
str
ateg
y to
rea
ch o
ur
goal
s. F
irst
rep
ort
of
the
Ch
ief
Min
iste
r’s
Tas
k f
orc
e se
eks
to i
mpro
ve
ph
ysic
al
and s
oci
al i
nfr
astr
uct
ure
in
Mum
bai
wh
ere
del
iver
y of
soci
al s
ervic
es w
ill
be
upgr
aded
to w
orl
d c
lass
lev
els.
T
his
would
req
uir
e dra
stic
im
pro
vem
ent
in t
he
infr
astr
uct
ure
for
hea
lth
an
d e
duca
tion
i.e
. im
pro
vem
ent
in g
over
nm
ent
run
hosp
ital
s an
d s
chools
w
hic
h c
ater
to t
he
com
mon
man
.
30
In
novat
ive
Way
s to
Mee
t H
ealt
h C
hal
len
ges
of
Urb
an I
ndia
; R
adh
ika
Aro
ra,
Soura
v N
eogi
, M
adh
avi
Mis
ra
An
alys
is a
rtic
le
Inn
ovat
ion
s in
m
ater
nal
an
d
new
born
hea
lth
A l
andsc
ape
anal
ysis
, to
cre
ate
a dir
ecto
ry o
f in
novat
ive
appro
ach
es t
ow
ards
impro
vin
g m
ater
nal
an
d n
ewborn
hea
lth
in
In
dia
, w
as u
nder
taken
by
the
Publi
c H
ealt
h F
oun
dat
ion
of
India
(P
HFI)
. T
he
aim
of
crea
tin
g su
ch a
dat
abas
e w
as t
o u
se t
he
info
rmat
ion
to
dev
elop d
etai
led a
udio
-vis
ual
cas
e st
udie
s of
sele
ct
inn
ovat
ion
s w
hic
h i
ndic
ated
a p
ote
nti
al f
or
scal
ing-
up.
Man
y of
thes
e in
novat
ion
s in
cludin
g th
ose
un
der
N
RH
M s
ucc
eeded
in
pro
vid
ing
pro
mis
ing
resu
lts
in
addre
ssin
g th
e h
ealt
h n
eeds
of
the
loca
l popula
ce. A
dir
ecto
ry o
f 204 i
nn
ovat
ion
s ad
dre
ssin
g m
ater
nal
, n
ewborn
an
d a
dole
scen
t h
ealt
h, as
wel
l as
fam
ily
pla
nn
ing
was
com
pil
ed. O
ut
of
thes
e 11 i
nn
ovat
ion
s sp
ecif
ical
ly t
arge
ted u
rban
popula
tion
s. T
his
pap
er
dis
cuss
es f
our
inn
ovat
ion
s fr
om
th
e dir
ecto
ry,
w
hic
h
targ
et u
rban
popula
tion
s to
red
uce
mat
ern
al a
nd i
nfa
nt
mort
alit
y an
d i
mpro
ve
youth
an
d a
dole
scen
t h
ealt
h, as
w
ell
as d
iscu
sses
th
eir
pote
nti
al f
or
scal
e-up.
31
T
arge
tin
g P
over
ty A
nd G
ender
In
equal
ity
To
Impro
ve
Mat
ern
al H
ealt
h;
Sil
via
Par
uzz
olo
, R
ekh
a M
ehra
, A
slih
an K
es,
Ch
arle
s A
shbau
gh
Rep
ort
G
ender
an
d
mat
ern
al h
ealt
h
Th
is p
aper
arg
ues
th
at i
n o
rder
to s
ust
ain
ably
red
uce
M
MR
an
d i
mpro
ve
the
over
all
life
ch
ance
s of
poor
moth
ers,
poli
cy a
nd p
rogr
ams
nee
d, as
a m
atte
r of
urg
ency
, to
add
ress
tw
o i
nte
rrel
ated
, ro
ot
cause
s of
m
ater
nal
dea
th: pover
ty, w
hic
h c
reat
es t
he
con
dit
ion
s fo
r in
adeq
uat
e, i
nac
cess
ible
an
d c
ost
ly m
ater
nal
hea
lth
se
rvic
es i
n p
oor
and u
nder
serv
ed a
reas
, an
d g
ender
n
orm
s th
at t
end t
o p
rivil
ege
the
wel
l-bei
ng
of
m
en a
nd
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
90 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
boys
at
the
expen
se o
f w
om
en a
nd g
irls
, le
adin
g to
w
om
en’s
lac
k o
f ec
on
om
ic opti
on
s an
d l
ack o
f au
ton
omy.
Th
is p
aper
exa
min
es t
he
way
s in
wh
ich
pover
ty a
nd g
ender
in
equal
ity
impac
t m
ater
nal
m
ort
alit
y by
crea
tin
g ba
rrie
rs t
o m
ater
nal
hea
lth
care
ac
cess
an
d u
tili
zati
on
. It
als
o a
nal
yzes
str
ateg
ies
des
ign
ed t
o i
ncr
ease
uti
liza
tion
to i
den
tify
bes
t pra
ctic
es.
32
T
ran
slat
ing
Res
earc
h F
indin
gs I
nto
Hea
lth
Poli
cy;
Dav
is P
, H
owden
-Ch
apm
an P
.
Pap
er
Hea
lth
res
earc
h
hea
lth
poli
cy
Evid
ence
of
the
infl
uen
ce o
f re
sear
ch o
n h
ealt
h p
oli
cy
is p
arad
oxic
al. W
hil
e th
ere
is s
can
t ev
iden
ce t
hat
re
sear
ch h
as h
ad a
ny
impac
t on
th
e dir
ecti
on
or
imple
men
tati
on
of
wid
espre
ad h
ealt
h r
eform
s, r
esea
rch
on
evi
den
ce-b
ased
med
icin
e h
as d
ram
atic
ally
in
crea
sed, de
spit
e li
mit
ed e
vid
ence
th
at i
t h
as a
ffec
ted
clin
ical
pra
ctic
e. T
hes
e dev
elopm
ents
hav
e oc
curr
ed i
n
the
con
text
of a
gen
eral
dec
lin
e in
sta
te i
nte
rven
tion
an
d p
rovis
ion
an
d a
post
-mode
rn q
ues
tion
ing
of
rese
arch
ers'
auth
ori
ty. M
odel
s of
the
rela
tion
ship
bet
wee
n r
esea
rch
an
d p
oli
cy r
ange
fro
m o
ne
wh
ere
empir
ical
res
earc
h r
atio
nal
ly i
nfo
rms
dec
isio
n-m
akin
g,
thro
ugh
res
earc
h i
ncr
emen
tall
y af
fect
ing
pol
icy,
to a
n
"en
ligh
ten
men
t" o
r "i
nfi
ltra
tion
" m
ode
l, w
hic
h m
ay
oper
ate
on
a c
on
ceptu
al l
evel
. H
ealt
h r
esea
rch
th
at
con
trib
ute
s to
lar
ge-s
cale
soci
o-p
oli
tica
l ch
ange
may
re
quir
e m
ore
met
hodolo
gica
l plu
rali
sm a
nd g
reat
er
focu
s on
key
in
stit
uti
on
al s
truc
ture
s.
33
S
tren
gth
enin
g M
ater
nal
an
d C
hil
d ca
re, N
utr
itio
n
& H
ealt
h i
n U
rban
Set
tin
gs; N
IPC
CD
S
um
mar
y R
eport
IC
DS
, urb
an
mat
ern
al a
nd
chil
d h
ealt
h
Th
is i
s a
report
of
a tw
o
day
work
shop o
rgan
ised
by
the
Min
istr
y of
Wom
en a
nd C
hil
d D
evel
opm
ent
(MW
CD
) on
18th
an
d 1
9th
July
201
2 a
t N
IPC
CD
. T
he
obje
ctiv
e of
the
work
shop
was
to u
nde
rsta
nd t
he
chal
len
ges
in
imple
men
tati
on
of
ICD
S i
n u
rban
set
tin
gs a
nd t
o ev
olv
e st
rate
gies
fro
m c
ross
lea
rnin
g.
34
N
eon
atal
Hea
lth
in
In
dia
; C
om
mon
Hea
lth
P
rese
nta
tion
N
eon
atal
su
rviv
al
Stu
dy
of
chil
dbir
th p
ract
ices
in
Raj
asth
an a
nd
appro
ach
es f
or
neo
nat
al s
urv
ival
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
91Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
35
C
ity
Init
iati
ve
for
new
born
hea
lth
, M
umbai
: O
ver
vie
w a
nd P
roto
col;
Arm
ida
Fer
nan
dez
A
rtic
le
Hum
an r
esourc
es
Th
is a
rtic
le d
escr
ibes
th
e cr
itic
al f
irst
ste
ps
taken
to
revit
aliz
e th
e va
st p
ubli
c h
ealt
h s
yste
m o
f M
um
bai
Cit
y th
rough
th
e ac
tive
par
tici
pat
ion
of
per
son
nel
fro
m
wit
hin
th
e sy
stem
. It
foc
use
s on
on
e of
two c
om
pon
ents
of
an a
mbit
ious
acti
on
-res
earc
h p
roje
ct a
imed
at
impro
vin
g th
e su
rviv
al a
nd
hea
lth
of
new
born
in
fan
ts
and m
oth
ers
livi
ng
in s
lum
com
mun
itie
s in
Mum
bai
.
36
S
cali
ng
up M
ater
nal
, N
ewborn
an
d C
hil
d H
ealt
h
Inte
rven
tion
s: T
he
Nee
d fo
r S
trat
egie
s to
Rea
ch
the
Urb
an P
oor;
Rober
t B
lack
Pre
sen
tati
on
S
trat
egie
s fo
r m
ater
nal
an
d
new
born
hea
lth
Burd
en o
f dis
ease
in
moth
ers,
new
born
an
d c
hil
dren
gl
obal
ly a
nd i
n I
ndia
. E
vid
ence
bas
ed i
nte
rven
tion
s th
at s
ave
live
s. G
ran
d c
hal
len
ges
for
impro
vin
g outc
omes
37
S
ugg
este
d U
rban
Hea
lth
Post
Model
an
d S
ure
S
tart
Mah
aras
htr
a Fra
mew
ork
; P
AT
H
Str
ateg
y docu
men
t M
odel
for
mat
ern
al a
nd
new
born
hea
lth
in
terv
enti
on
Th
is d
ocu
men
t pre
sen
ts a
sugg
este
d m
odel
for
urb
an
inte
rven
tion
in
mat
ern
al a
nd n
ewborn
hea
lth
aft
er t
he
succ
essf
ul
imple
men
tati
on
of
th
e S
ure
Sta
rt p
roje
ct i
n
urb
an s
lum
s of
Mah
aras
htr
a, I
ndia
. In
add
itio
n, th
e docu
men
t pro
vid
es a
dia
gram
mat
ic r
epre
sen
tati
on
of
the
stra
tegy
an
d a
ppro
ach
adopte
d b
y S
ure
Sta
rt i
n
Mah
aras
htr
a fo
r dem
and g
ener
atio
n a
nd
syst
em
lin
kag
es.
38
S
ure
Sta
rt i
n M
ahar
ash
tra,
In
dia
; P
AT
H
Pro
ject
su
mm
ary
docu
men
t
Inn
ovat
ion
s A
sn
apsh
ot
of
the
Sure
Sta
rt i
nit
iati
ve,
a s
even
-yea
r pro
ject
to i
mpro
ve
birt
h o
utc
om
es a
nd
ensu
re t
he
hea
lth
of m
oth
ers
and n
ewborn
s in
sev
en c
itie
s of
Mah
aras
htr
a, I
ndi
a. T
his
doc
um
ent
pre
sen
ts
a co
nci
se
over
view
of
the
impro
vem
ents
in
mat
ern
al a
nd h
ealt
h
pra
ctic
es i
n t
he
inte
rven
tion
are
as.
39
S
ure
Sta
rt:
En
suri
ng
the
Hea
lth
an
d S
afet
y of
Moth
ers
and N
ewborn
s in
In
dia
Th
rough
B
ehav
ior
Ch
ange
an
d C
om
mun
ity
Act
ion
; P
AT
H
Fac
t sh
eet
Com
mun
ity
bas
ed
inte
rven
tion
s
Th
is f
act
shee
t outl
ines
com
mun
ity-
bas
ed
inte
rven
tion
s th
at e
xpan
ded
acc
ess
to s
kil
led b
irth
at
ten
dan
ts, es
tabli
shed
support
gro
ups
for
wom
en, an
d in
troduc
ed c
om
mun
icat
ion
s ap
pro
ach
es t
o c
han
ge
beh
avio
rs.
41
S
ure
Sta
rt: H
elpin
g M
oth
ers
and
New
born
s T
hri
ve;
PA
TH
Fac
t sh
eet
Com
mun
ity
acti
on
Sure
Sta
rt i
s an
in
itia
tive
in
ten
ded
to c
atal
yze
sust
ain
able
im
pro
vem
ents
in
mat
ern
al a
nd n
ewborn
h
ealt
h t
hro
ugh
eff
ecti
ve
com
mun
ity
acti
on
in
sel
ecte
d
dis
tric
ts o
f U
ttar
Pra
des
h a
nd
urb
an s
ites
of
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
92 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
M
ahar
ash
tra,
In
dia.
Th
e S
ure
Sta
rt p
roje
ct h
as b
een
des
ign
ed t
o c
ompl
emen
t an
d su
pport
th
e G
ove
rnm
ent
of
Indi
a’s
com
mit
men
t to
im
pro
vin
g m
ater
nal
an
d n
ewborn
hea
lth
. T
his
fac
t sh
eet
gives
an
over
all
pic
ture
an
d p
rogr
ess
of
the
pro
ject
to d
ate.
42
S
ure
Sta
rt:
Sav
ing
Liv
es o
f M
oth
ers
and N
ewborn
s in
Mah
aras
htr
a: C
ity-
Spec
ific
In
terv
enti
on
M
odel
s; P
AT
H
Str
ateg
y docu
men
t M
odel
s fo
r qual
ity
care
an
d
med
ical
as
sist
ance
Th
is d
ocu
men
t su
mm
ariz
es t
he
model
s em
plo
yed b
y S
ure
Sta
rt i
n u
rban
slu
m a
reas
of
Mah
aras
htr
a, I
ndia
,
to
ensu
re g
ood-q
ual
ity
care
an
d m
edic
al a
ssis
tan
ce t
o
expec
tan
t m
oth
ers
and n
ewborn
s: v
olu
nte
eris
m,
publi
c-pri
vat
e par
tner
ship
, qua
lity
of
care
, co
mm
un
ity-
bas
ed h
ealt
h i
nsu
ran
ce, co
nver
gen
ce o
f m
ater
nal
an
d
new
born
hea
lth
an
d H
IV s
ervic
es, an
d a
n e
mer
gen
cy
hea
lth
fun
d an
d p
repai
d c
ard.
43
T
read
ing
a N
ew P
ath
: S
tori
es F
rom
th
e S
ure
Sta
rt
Pro
ject
in
Utt
ar P
rades
h;
PA
TH
R
eport
H
ealt
h w
ork
ers
Th
is r
eport
sh
ow
s h
ow
hea
lth
work
ers
in U
ttar
Pra
desh
off
ered
in
form
atio
n, pra
ctic
al s
olu
tion
s, a
nd e
moti
on
al
support
, en
abli
ng
wom
en t
o ta
ke
char
ge o
f th
eir
hea
lth
an
d t
hat
of
thei
r n
ewborn
s.
44
E
ffec
t of
hom
e-bas
ed n
eon
atal
car
e an
d
man
agem
ent
of
sepsi
s on
neo
nat
al m
ort
alit
y: f
ield
tr
ial
in r
ura
l In
dia
; B
ang
AT
, B
ang
RA
, B
aitu
le
SB
, R
eddy
MH
, D
esh
mukh
MD
Stu
dy
report
H
om
e-bas
ed
neo
nat
al c
are
Neo
nat
al c
are
is n
ot
avai
lable
to m
ost
neo
nat
es i
n
dev
elopi
ng
coun
trie
s bec
ause
hosp
ital
s ar
e in
acce
ssib
le
and c
ost
ly.
We
dev
eloped
a p
acka
ge o
f h
om
e
bas
ed
neo
nat
al c
are,
in
cludin
g m
anag
emen
t of
sep
sis
(sep
tica
emia
, m
enin
giti
s, p
neu
mon
ia),
an
d t
este
d it
in
th
e fi
eld,
wit
h t
he
hyp
oth
esis
th
at i
t w
ould
red
uce
th
e n
eon
atal
mort
alit
y ra
te b
y at
lea
st 2
5%
in
3 y
ears
.
45
S
poil
t fo
r ch
oic
e? C
ross
-sec
tion
al s
tudy
of c
are-
seek
ing
for
hea
lth
pro
ble
ms
duri
ng
pre
gnan
cy i
n
Mum
bai
slu
ms;
More
NS
1,
A
lcock
G, D
as S
, B
apat
U,
Josh
i W
, O
srin
D.
Stu
dy
report
C
are
seek
ing
beh
avio
r of
wom
en
Th
is s
tudy
con
sider
s ca
re-s
eekin
g pat
tern
s fo
r m
ater
nal
m
orb
idit
y in
Mum
bai
’s s
lum
s. T
he
obje
ctiv
es w
ere
to
docu
men
t w
om
en’s
sel
f-re
port
ed s
ympto
ms
and c
are-
seek
ing,
an
d t
o q
uan
tify
th
eir
choi
ce o
f h
ealt
h
pro
vid
er, ca
re-s
eekin
g del
ays
and r
efer
rals
bet
wee
n
pro
vid
ers.
46
P
rosp
ecti
ve
study
of
dete
rmin
ants
an
d c
ost
s of
h
om
e bir
ths
in M
um
bai
slu
ms;
S
ush
mit
a D
as,
Ujw
ala
Bap
at, N
een
a S
hah
More
, L
atik
a C
hord
hek
ar, W
asun
dh
ara
Jo
shi
an
d D
avid
Osr
in
Stu
dy
report
H
om
e bir
ths
and
fact
ors
in
fluen
cin
g th
e sa
me
Aro
un
d 86%
of
birt
hs
in M
umba
i, I
ndi
a, o
ccur
in
hea
lth
care
in
stit
uti
on
s, b
ut
this
agg
rega
te f
igure
hid
es
subst
anti
al v
aria
tion
an
d l
ittl
e is
kn
ow
n a
bout
urb
an
hom
e bir
ths.
Th
e st
udy
ai
med
to e
xplo
re f
acto
rs
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
93Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
in
fluen
cin
g th
e ch
oic
e of
hom
e de
liver
y, c
are
pra
ctic
es
and c
ost
s, a
nd t
o i
den
tify
ch
arac
teri
stic
s of
wom
en,
house
hold
s an
d t
he
envir
on
men
t, w
hic
h m
igh
t in
crea
se t
he
like
lih
ood o
f h
om
e bir
th.
47
S
till
bir
ths
and n
ewbo
rn d
eath
s in
slu
m s
ettl
emen
ts
in M
um
bai
, In
dia
: a
pro
spec
tive
ver
bal
auto
psy
st
udy;
Ujw
ala
Bap
at, G
lyn
Alc
ock
, N
een
a S
hah
M
ore
, S
ush
mit
a D
as, W
asun
dh
ara
Josh
i an
d D
avid
O
srin
Stu
dy
report
C
ause
s of
del
ay
in s
eekin
g an
d re
ceiv
ing
hea
lth
care
for
mat
ern
al a
nd
new
born
hea
lth
pro
ble
ms
Th
ree
mil
lion
bab
ies
are
stil
lborn
eac
h y
ear
and
3.6
m
illi
on
die
in
th
e fi
rst
mon
th o
f li
fe. In
In
dia
, ea
rly
neo
nat
al d
eath
s m
ake
up f
our-
fift
hs
of
neo
nat
al d
eath
s an
d i
nfa
nt
mort
alit
y th
ree-
quar
ters
of
un
der
-fiv
e m
ort
alit
y. I
nfo
rmat
ion
is
scar
ce o
n c
ause
-spec
ific
per
inat
al a
nd n
eon
atal
mort
alit
y in
urb
an s
etti
ngs
in
lo
w-i
nco
me
coun
trie
s. T
he
study
co
nduc
ted v
erba
l au
topsi
es f
or
stil
lbir
ths
and n
eon
atal
dea
ths
in M
um
bai
sl
um
sett
lem
ents
. T
he
obje
ctiv
es w
ere
to c
lass
ify
dea
ths
acco
rdin
g to
in
tern
atio
nal
cau
se-s
pec
ific
cri
teri
a an
d t
o
iden
tify
maj
or
cause
s of
del
ay i
n s
eekin
g an
d r
ecei
vin
g h
ealt
h c
are
for
mat
ern
al a
nd n
ewbo
rn h
ealt
h p
roble
ms.
48
M
ater
nal
an
d n
eon
atal
hea
lth
ex
pen
ditu
re i
n
Mum
bai
slu
ms
(In
dia
): A
cro
ss s
ecti
on
al s
tudy;
Jo
len
e S
kord
is-W
orr
all, N
oem
i P
ace,
Ujw
ala
Bap
at, S
ush
mit
a D
as, N
een
a S
More
, W
asun
dh
ara
Josh
i, A
nn
i-M
aria
Pulk
ki-
Bra
nn
stro
m an
d D
avid
O
srin
Dat
a an
alys
is
docu
men
t M
ater
nal
hea
lth
ex
pen
ditu
re T
he
cost
of
mat
ern
ity
care
can
be
a ba
rrie
r to
acc
ess
that
may
in
crea
se m
ater
nal
an
d n
eon
atal
mort
alit
y ri
sk.
Th
e ar
ticl
e an
alyz
ed s
pen
din
g on
mat
ern
ity
care
in
urb
an s
lum
com
mun
itie
s in
Mum
bai
to b
ette
r un
der
stan
d t
he
equit
y of
spen
din
g an
d t
he
impac
t of
spen
din
g on
house
hold
pove
rty
49
In
tim
ate
par
tner
vio
len
ce a
gain
st w
omen
duri
ng
and a
fter
pre
gnan
cy: a
cross
-sec
tion
al s
tudy
in
Mum
bai
slu
ms;
Sush
mit
a D
as, U
jwal
a B
apat
, N
een
a S
hah
More
, Gly
n A
lcock
, W
asun
dh
ara
Josh
i, S
han
ti P
antv
aidya
an
d D
avid
Osr
in
Stu
dy
report
P
artn
er v
iole
nce
At
leas
t on
e-th
ird o
f w
omen
in
In
dia
exper
ien
ce
inti
mat
e pa
rtn
er v
iole
nce
(IP
V)
at s
om
e poin
t in
ad
ult
hood. T
he
study
obje
ctiv
es w
ere
to d
escr
ibe
the
pre
val
ence
of
IPV
duri
ng
pre
gnan
cy a
nd a
fter
del
iver
y in
an
urb
an s
lum
set
tin
g, t
o r
evie
w i
ts s
oci
al
det
erm
inan
ts, a
nd t
o e
xplo
re i
ts e
ffec
ts o
n m
ater
nal
an
d n
ewborn
hea
lth
.
50
C
om
mun
ity-
bas
ed h
ealt
h p
rogr
amm
es: ro
le
per
cepti
on
s an
d e
xper
ien
ces
of
fem
ale
peer
fa
cili
tato
rs i
n M
umbai
’s u
rban
slu
ms;
Alc
ock
G,
More
NS
, P
atil
S, P
ore
l M
, V
aidya
L, O
srin
D.
Stu
dy
fin
din
gs
Pee
r fa
cili
tato
rs T
his
art
icle
pre
sen
ts f
indin
gs f
rom
a s
tudy
of
fem
ale
pee
r fa
cili
tato
rs i
nvolv
ed i
n a
com
mun
ity-
bas
ed
mat
ern
al a
nd n
ewborn
hea
lth
in
terv
enti
on
in
urb
an
slum
are
as o
f M
um
bai
. U
sin
g qual
itat
ive
met
hods
we
explo
re t
hei
r ro
le p
erce
pti
on
s an
d e
xpe
rien
ces.
Our
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
94 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
fin
din
gs f
ocu
s on
how
th
e fa
cili
tato
rs u
nder
stan
d a
nd
enac
t th
eir
role
in
th
e co
mm
un
ity
sett
ing,
how
th
ey
neg
oti
ate
rela
tion
ship
s an
d h
ealt
h i
ssues
wit
h p
eer
groups,
an
d t
he
infl
uen
ce o
f cr
edib
ilit
y.
51
In
equal
itie
s in
mat
ern
ity
care
an
d n
ewborn
outc
om
es: on
e-ye
ar s
urv
eill
ance
of
bir
ths
in
vuln
erab
le s
lum
com
mun
itie
s in
Mum
bai
; M
ore
N
S, B
apat
U, D
as S
, B
arn
ett
S,
Cost
ello
A,
Fer
nan
dez
A, O
srin
D.
An
alys
is
docu
men
t C
are
dif
fere
nti
al
acco
rdin
g to
ec
on
om
ic s
tatu
s
Agg
rega
te u
rban
hea
lth
sta
tist
ics
mas
k i
neq
ual
itie
s.
Th
e an
alys
is des
crib
ed m
ater
nit
y ca
re i
n v
uln
erab
le
slum
in M
um
bai
, an
d e
xam
ined
dif
fere
nce
s in
car
e an
d
outc
om
es b
etw
een
more
an
d l
ess
dep
rived
gro
ups.
52
T
raci
ng
pat
hw
ays
from
an
ten
atal
to d
eliv
ery
care
fo
r w
om
en i
n M
um
bai
, In
dia
: cr
oss
-sec
tion
al s
tudy
of
mat
ern
ity
in l
ow
-in
com
e ar
eas;
More
NS
, A
lcock
G, B
apat
U, D
as S
, Jo
shi
W, O
srin
D.
Stu
dy
fin
din
gs
Sec
tors
an
d
resp
on
sibil
itie
s in
mat
ern
al a
nd
new
born
hea
lth
In m
any
citi
es, h
ealt
hca
re i
s av
aila
ble
th
rough
a
com
ple
x m
ix o
f pri
vat
e an
d p
ubli
c pro
vid
ers.
Th
e li
ne
bet
wee
n t
he
form
al a
nd i
nfo
rmal
sec
tors
may
be
blu
rred
an
d m
ovem
ent
bet
wee
n t
hem
un
char
ted. W
e quan
tifi
ed t
he
use
of
pri
vat
e an
d p
ubli
c pro
vid
ers
of
mat
ern
ity
care
in
low
-in
com
e ar
eas
of
Mum
bai
, In
dia
.
53
A
Rap
id A
sses
smen
t S
core
card
to I
den
tify
In
form
al S
ettl
emen
ts a
t H
igh
er M
ater
nal
an
d
Ch
ild H
ealt
h R
isk i
n M
um
bai
; O
srin
D., D
as S
, B
apat
U, A
lcock
G, Jo
shi
W, M
ore
NS
Rap
id
asse
ssm
ent
report
Info
rmal
se
ttle
men
ts,
hig
h
risk
popula
tion
s
Th
e co
mm
un
itie
s w
ho l
ive
in u
rban
in
form
al
sett
lem
ents
are
div
erse
, as
are
th
eir
envir
on
men
tal
con
dit
ion
s. C
har
acte
rist
ics
incl
ude
inad
equat
e ac
cess
to
saf
e w
ater
an
d s
anit
atio
n, poor
qual
ity
of
housi
ng,
over
crow
din
g, a
nd i
nse
cure
res
iden
tial
sta
tus.
In
terv
enti
on
s to
im
pro
ve
hea
lth
sh
ould
be
equit
y-dri
ven
an
d t
arge
t th
ose
at
hig
her
ris
k, but
it i
s n
ot
clea
r h
ow
to p
riori
tise
in
form
al s
ettl
emen
ts f
or
hea
lth
ac
tion
. In
im
ple
men
tin
g a
mat
ern
al a
nd c
hil
d h
ealt
h
pro
gram
me
in M
um
bai
, In
dia
, w
e h
ad c
on
duct
ed a
det
aile
d vuln
erab
ilit
y as
sess
men
t w
hic
h, th
ough
im
port
ant,
was
tim
e co
nsu
min
g an
d m
ay h
ave
incl
uded
co
llec
tion
of
redun
dan
t in
form
atio
n. S
ubse
quen
t dat
a co
llec
tion
all
ow
ed u
s to
exam
ine
thre
e is
sues
: w
het
her
co
mm
un
ity
envir
on
men
tal
char
acte
rist
ics
wer
e as
soci
ated
wit
h m
ater
nal
an
d n
ewborn
hea
lth
care
an
d
outc
om
es; w
het
her
it
was
poss
ible
to d
evel
op a
tri
age
score
card
to r
ank t
he
hea
lth
vuln
erab
ilit
y of
info
rmal
se
ttle
men
ts b
ased
on
a f
ew r
apid
ly o
bse
rvab
le
char
acte
rist
ics;
an
d w
het
her
th
e sc
ore
card
mig
ht
be
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
95Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
use
ful
for
futu
re p
riori
tisa
tion
.
54
N
utr
itio
nal
sta
tus
of
youn
g ch
ildre
n i
n M
um
bai
slum
s: a
foll
ow
-up a
nth
ropo
met
ric
study;
Das
S1,
Bap
at U
, M
ore
NS
, A
lcock
G, Fe
rnan
dez
A, O
srin
D
.
Stu
dy
fin
din
gs
Ch
ild
mal
nutr
itio
n C
hro
nic
ch
ildh
ood
mal
nutr
itio
n r
emai
ns
com
mon
in
In
dia
. A
s par
t of
an
in
itia
tive
to i
mpro
ve m
ater
nal
an
d
chil
d h
ealt
h i
n u
rban
slu
ms,
we
coll
ecte
d an
thro
pom
etri
c dat
a fr
om
a s
ampl
e of
chil
dre
n
foll
ow
ed u
p f
rom
bir
th. W
e des
crib
ed t
he
pro
port
ion
s of
un
derw
eigh
t, s
tun
tin
g, a
nd w
asti
ng
in y
oun
g ch
ildre
n, a
nd e
xam
ined
th
eir
rela
tion
ship
s w
ith
age
.
55
C
on
flic
t, C
risi
s, a
nd A
buse
in
Dh
arav
i, M
um
bai
: E
xper
ien
ces
from
Six
Yea
rs a
t a
Cen
tre
for
Vuln
erab
le W
om
en a
nd C
hil
dre
n; N
ayre
en
Dar
uw
alla
, A
rmid
a Fer
nan
dez
,
Jen
ny
Sal
am,
N
ikh
at S
hai
kh
,
Dav
id O
srin
Art
icle
A
buse
T
he
Cen
tre
for
Vuln
erab
le W
om
en a
nd C
hil
dre
n
serv
es c
lien
ts c
opin
g w
ith
cri
sis
and v
iole
nce
in
th
e ch
alle
ngi
ng
urb
an s
etti
ng
of
Dh
arav
i, M
um
bai
. W
e dis
cuss
fac
tors
th
at s
hap
ed t
he
dev
elopm
ent
of
the
Cen
tre
over
six
yea
rs I
nte
rven
tion
was
oft
en g
uid
ed b
y cl
ien
ts’ d
esir
e to
kee
p th
eir
fam
ilie
s to
geth
er.
Succ
essf
ul i
nte
rven
tion
req
uir
es s
tron
g li
nks
wit
h
hea
lth
car
e pro
vid
ers,
th
e po
lice
, le
gal
serv
ices
, an
d
com
mun
ity-
bas
ed o
rgan
isat
ion
s
56
C
om
mun
ity
Mobil
izat
ion
in
Mum
bai
Slu
ms
to
Impro
ve P
erin
atal
Car
e an
d O
utc
om
es: A
Clu
ster
R
andom
ized
Con
troll
ed T
rial
; N
een
a S
hah
More
, U
jwal
a B
apat
, S
ush
mit
a D
as, G
lyn
Alc
ock
, S
arit
a P
atil
, M
aya
Pore
l, L
een
a V
aidya
, A
rmid
a Fer
nan
dez,
Was
un
dh
ara
Josh
i, D
avid
Osr
in
Res
earc
h
Art
icle
C
om
mun
ity
mobil
izat
ion
, m
ater
nal
hea
lth
, urb
an s
lum
s
Impro
vin
g m
ater
nal
an
d n
ewborn
hea
lth
in
low
-in
com
e se
ttin
gs r
equir
es b
oth
hea
lth
ser
vic
e an
d
com
mun
ity
acti
on
. P
revio
us
com
mun
ity
init
iati
ves
h
ave
bee
n p
redom
inan
tly
rura
l, b
ut
India
is
urb
aniz
ing.
W
hil
e w
orkin
g to
im
pro
ve
hea
lth
ser
vic
e qual
ity,
we
test
ed a
n i
nte
rven
tion
in
wh
ich
urb
an s
lum
-dw
elle
r w
om
en’s
gro
ups
work
ed t
o i
mpro
ve
loca
l per
inat
al
hea
lth
. 57
P
oli
ce i
nves
tiga
tion
s: d
iscr
etio
n d
enie
d y
et
un
den
iably
exer
cise
d; J
. B
elura
, N
. T
ille
ya, D
. O
srin
b, N
. D
aruw
alla
c, M
. K
um
ard &
V.
Tiw
arie
Journ
al a
rtic
le
Poli
ce, w
om
en’s
dea
ths
Dra
win
g on
fie
ldw
ork
in
Del
hi
and
Mum
bai
, th
is p
aper
ex
plo
res
how
poli
ce i
nves
tiga
tion
s un
fold
ed i
n t
he
spec
ific
con
text
of
wom
en’s
dea
ths
by
burn
ing
in I
ndia
. In
par
ticu
lar,
it
focu
ses
on
th
e us
e of
dis
cret
ion
des
pit
e it
s de
nia
l by
those
exer
cisi
ng
it.
58
T
he
soci
al c
on
stru
ctio
n o
f ‘d
ow
ry d
eath
s’; Jy
oti
B
elur,
*, N
ick
Til
ley,
Nay
reen
Dar
uw
alla
, M
een
a K
um
ar, V
inay
Tiw
ari
d,
Dav
id O
srin
Art
icle
D
ow
ry d
eath
s T
he
clas
sifi
cati
on
of
cause
of
deat
h i
s re
al i
n i
ts
con
seque
nce
s: f
or
the
reput
atio
n o
f th
e dec
ease
d, fo
r h
er f
amil
y, f
or
those
wh
o m
ay b
e im
plic
ated
, an
d f
or
epid
emio
logi
cal
and
soci
al r
esea
rch
an
d p
oli
cies
an
d
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
96 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
pra
ctic
es t
hat
may
foll
ow
fro
m i
t. T
he
study
report
ed
her
e re
fers
spe
cifi
call
y to
th
e pro
cess
es i
nv
olv
ed i
n
clas
sify
ing
dea
ths
of w
om
en f
rom
burn
s in
In
dia
. In
par
ticu
lar,
it
exam
ines
th
e det
erm
inat
ion
of
‘dow
ry
dea
th’,
a cl
ass
use
d i
n I
ndia
, but
not
in o
ther
ju
risd
icti
on
s. 59
S
hap
ing
citi
es f
or
hea
lth
: co
mple
xit
y an
d t
he
pla
nn
ing
of u
rban
en
vir
on
men
ts
in t
he
21st
ce
ntu
ry; Y
von
ne
Ryd
in, A
na
Ble
ahu, M
ich
ael
Dav
ies,
Jul
io D
Dáv
ila,
Sh
aron
Fri
el, G
iovan
ni
De
Gra
ndis
, Nora
Gro
ce, P
edro
C H
alla
l, I
an
Ham
ilto
n,
P
hil
ippa
How
den
-Ch
apm
an, K
a-M
an L
ai,
C J
L
im, Ju
lian
a M
arti
ns,
Dav
id O
srin
, Ia
n R
idle
y, I
an
Sco
tt, M
yfan
wy
Tay
lor,
Pau
l W
ilkin
son
, Ja
mes
W
ilso
n
Rep
ort
E
con
om
ic
grow
th,
dem
ogr
aph
ic
chan
ge, urb
an
pla
nn
ing
Th
is r
eport
arg
ues
aga
inst
th
e as
sum
pti
on
th
at u
rban
h
ealt
h o
utc
om
es w
ill
impro
ve
wit
h e
con
om
ic g
row
th
and d
emogr
aph
ic c
han
ge, an
d i
nst
ead h
igh
ligh
ts t
he
nee
d f
or
urb
an p
lan
nin
g fo
r h
ealt
h n
eeds.
60
C
lust
er-r
andom
ised
con
troll
ed t
rial
of
com
mun
ity
mobil
isat
ion
in
Mum
bai
slu
ms
to i
mpro
ve
care
duri
ng
pre
gnan
cy, del
iver
y, p
ost
par
tum
an
d f
or
the
new
born
; N
een
a S
hah
More
, U
jwal
a B
apat
, S
ush
mit
a D
as, S
arit
a P
atil
, M
aya
Pore
l,
Lee
na
Vai
dya
, B
hav
esh
ree
Kori
ya,
Sar
ah B
arn
ett,
A
nth
on
y C
ost
ello
,
Arm
ida
Fer
nan
dez
and
Dav
id
Osr
in
Pro
toco
l
Com
mun
ity
inte
rven
tion
Th
e pro
toco
l des
crib
es a
tri
al o
f co
mm
un
ity
inte
rven
tion
aim
ed a
t im
pro
vin
g pre
ven
tion
, ca
re
seek
ing
and o
utc
om
es.
61
C
om
mun
ity
reso
urc
e ce
ntr
es t
o i
mpro
ve
the
hea
lth
of
wom
en a
nd c
hil
dre
n i
n M
umbai
slu
ms:
st
udy
pro
toco
l fo
r a
clust
er r
andom
ized
con
trol
led
tria
l; N
een
a S
hah
More
, S
ush
mit
a D
as, U
jwal
a B
apat
, M
ahes
h R
ajgu
ru, G
lyn
Alc
ock
, W
asun
dh
ara
Jo
shi, S
han
ti P
antv
aidya
and
Dav
id
Osr
in
Tri
al r
eport
C
om
mun
ity
reso
urc
e ce
ntr
es T
he
tria
l ad
dre
sses
th
e ge
ner
al q
ues
tion
of
wh
eth
er
com
mun
ity
reso
urc
e ce
nte
rs r
un
by
a n
on
-gov
ern
men
t org
aniz
atio
n i
mpro
ve t
he
hea
lth
of
wom
en a
nd
chil
dre
n i
n s
lum
s.
62
E
xam
inin
g th
e E
ffec
t of
House
hold
Wea
lth
an
d
Mig
rati
on
Sta
tus
on
Saf
e D
eliv
ery
Car
e in
Urb
an
India
, 1992–2006; P
rash
ant
Kum
ar S
ingh
, R
ajes
h
Stu
dy
report
M
ater
nal
hea
lth
ex
pen
ditu
re
Alt
hough
th
e urb
an h
ealt
h i
ssue
has
bee
n o
f lo
ng-
stan
din
g in
tere
st t
o p
ubli
c h
ealt
h r
esea
rch
ers,
maj
ori
ty
of
the
studie
s h
ave
looked
upon
th
e urb
an p
oor
and
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
97Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
K
um
ar R
ai, L
uck
y S
ingh
m
igra
nts
as
dist
inct
subgr
oups.
An
oth
er c
on
cern
is,
w
het
her
bei
ng
poor
and a
t th
e sa
me
tim
e m
igra
nt
lead
s to
a d
oub
le d
isad
van
tage
in
th
e ut
iliz
atio
n o
f m
ater
nal
h
ealt
h s
ervic
es?
Th
is s
tudy
aim
s to
exam
ine
the
tren
ds
and f
acto
rs t
hat
aff
ect
safe
del
iver
y ca
re u
tili
zati
on
am
on
g th
e m
igra
nts
an
d t
he
poor
in u
rban
In
dia
.
63
W
ork
shop o
n t
he
Hea
lth
of
the
Urb
an P
oor
in t
he
Con
text
of
NU
HM
; D
r. A
. D
yalc
han
d
Work
shop
report
U
rban
poor
hea
lth
, N
UH
M In
stit
ute
of
Hea
lth
Man
agem
ent,
Pac
hod (
IHM
P)
Pun
e ce
ntr
e, o
rgan
ized
a w
ork
shop o
n “
Hea
lth
of
the
Urb
an P
oor
in M
ahar
ash
tra”
fro
m N
ov. 4th
to
6th
, 2008, in
coll
abora
tion
wit
h Y
ash
wan
trao
Ch
avan
A
cadem
y of
Dev
elopm
ent
Adm
inis
trat
ion
(Y
AS
HA
DA
), P
un
e an
d t
he
Inte
rnat
ion
al I
nst
itute
of
Popula
tion
Sci
ence
s (I
IPS
), M
um
bai
. T
he
pri
nci
pal
obje
ctiv
e of
the
work
shop w
as t
o i
den
tify
str
ateg
ies
for
effe
ctiv
e im
ple
men
tati
on
of
hea
lth
car
e fo
r th
e urb
an
poor
in t
he
con
text
of
the
Nat
ion
al U
rban
Hea
lth
M
issi
on
(N
UH
M)
in M
ahar
ash
tra.
64
P
oor
Per
inat
al C
are
Pra
ctic
es i
n U
rban
Slu
ms:
P
oss
ible
Role
of
Soci
al M
obil
izat
ion
Net
work
s;
Zulf
ia K
han
, S
aira
Meh
naz
, N
ajam
Kh
aliq
ue,
M
oh
d A
thar
An
sari
, an
d A
bdul
Raz
zaque
Sid
diq
ui
Stu
dy
arti
cle
U
rban
per
inat
al
pra
ctic
es
To d
eter
min
e th
e ex
isti
ng
peri
nat
al p
ract
ices
in
an
urb
an s
lum
an
d t
o i
den
tify
bar
rier
s to
uti
liza
tion
of
hea
lth
ser
vic
es b
y m
oth
ers.
65
S
AA
RC
Soci
al C
har
ter:
In
dia
Coun
try
Rep
ort
2014; M
inis
try
of S
tati
stic
s an
d P
rogr
amm
e Im
ple
men
tati
on
Coun
try
report
In
terv
enti
on
s T
he
curr
ent
report
, fi
fth
in
th
e se
ries
, pr
esen
ts t
he
stat
us
of
ach
ievem
ent
on
dif
fere
nt
soci
al d
evel
opm
ent
outc
omes
un
der
dif
fere
nt
chap
ters
as
enum
erat
ed i
n t
he
var
ious
Art
icle
s of
the
Ch
arte
r. T
he
publi
cati
on
sk
etch
es a
luc
id d
escr
ipti
on
of
the
progr
amm
atic
in
terv
enti
on
s of
the
Gover
nm
ent
of I
ndia
aim
ed a
t ra
isin
g th
e li
vin
g st
andar
ds
of
its
citi
zen
s an
d p
rovid
ing
equal
opport
un
itie
s to
hit
her
to m
argi
nal
ized
sec
tion
s of
the
soci
ety.
66
M
ater
nal
, n
ewborn
an
d c
hil
d h
ealt
h f
ram
ework
; In
tern
atio
nal
Fed
erat
ion
of
Red
Cro
ss
and R
ed C
resc
ent
Soci
etie
s,
Fra
mew
ork
docu
men
t R
MN
CH
T
his
fra
mew
ork
pro
vid
es g
uid
ance
an
d d
irec
tion
to
Nat
ion
al S
oci
etie
s, t
hei
r pro
gram
me
man
ager
s an
d al
l oth
er p
arti
es i
nvo
lved
in
th
e pl
ann
ing,
des
ign
an
d
imple
men
tati
on
of
pro
gram
mes
an
d i
nte
rven
tion
s in
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
98 Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
m
ater
nal
/rep
rodu
ctiv
e, n
ewborn
an
d c
hil
d h
ealt
h
(MN
CH
, als
o re
ferr
ed t
o a
s R
MN
CH
).
67
A
Com
pen
diu
m o
n H
ealt
h o
f U
rban
Poor
in
South
Eas
t A
sia:
Abs
trac
t of
sele
ct P
aper
s an
d
Rep
ort
s; K
amla
Gupt
a, F
red A
rnold
, H
. L
hun
gdim
Rep
ort
U
rban
hea
lth
&
livin
g co
ndit
ion
s T
his
rep
ort
an
alyz
es h
ealt
h a
nd l
ivin
g co
ndi
tion
s in
ei
ght
larg
e In
dia
n c
itie
s (C
hen
nai
, D
elh
i, H
yder
abad
, In
dore
, K
olka
ta,
Mee
rut,
Mum
bai
, an
d N
agpur)
. T
he
report
is
base
d on
dat
a fr
om I
ndia
's 2
005-0
6 N
atio
nal
Fam
ily
Hea
lth
Surv
ey (
NFH
S-3
).
68
M
ater
nal
Hea
lth
Pol
icy
In I
ndia
– Fro
m
Inst
ituti
on
al D
eliv
erie
s to
Saf
e D
eliv
erie
s; B
S
ubh
a S
ri a
nd R
enu K
han
na
Poli
cy p
aper
S
afe
del
iver
y,
mat
ern
al h
ealt
h
poli
cy
Gro
ups
like
the
Jan
Sw
asth
ya A
bh
iyan
an
d
Com
mon
Hea
lth
hav
e bee
n e
xpre
ssin
g th
at t
he
mat
ern
al h
ealt
h p
olic
y in
In
dia
nee
ds
to m
ove
away
fr
om
th
e pa
radi
gm o
f in
stit
uti
on
al d
eliv
erie
s to
a
par
adig
m o
f sa
fe d
eliv
erie
s. W
hat
is
a sa
fe d
eliv
ery?
H
ow
do t
he
Jan
Sw
asth
ya A
bh
iyan
an
d
Com
mon
Hea
lth
en
vis
ion
saf
e del
iver
y? T
his
pap
er
explo
res
thes
e ques
tion
s an
d o
ffer
s an
un
ders
tan
din
g th
at h
as e
vol
ved
th
roug
h c
oll
ecti
ve
dis
cuss
ion
s am
on
gst
thes
e n
etw
ork
s
69
H
ealt
h S
tatu
s of
Mar
gin
aliz
ed G
roups
in I
ndi
a;
Zulu
fkar
Ah
mad
Kh
anda
y , M
oh
amm
ad A
kra
m
Stu
dy
pap
er
Hea
lth
sta
tus
Th
e obje
ctiv
es o
f th
e pre
sen
t pap
er a
re t
o st
udy
the
hea
lth
sta
tus
of
mar
gin
alis
ed g
roups-
w
om
en’s
, ch
ildre
n’s
, sc
hed
uled
cas
tes,
sch
edule
d t
ribes
, per
son
s w
ith
dis
abil
itie
s, m
igra
nts
an
d a
lso
the
hea
lth
sta
tus
of
aged
in
In
dia;
th
e vio
lati
on
of
thei
r ri
ghts
;
the
double
ex
plo
itat
ion
wh
ich
wom
en’s
fac
e in
th
eir
hom
e an
d a
t th
e w
ork p
lace
an
d a
lso t
o st
udy
how
th
e dif
fere
nt
fact
ors
aff
ecti
ng
the
hea
lth
of
the
mar
gin
alis
ed g
roups.
70
In
dia
’s c
oun
try
exper
ien
ce a
ddre
ssin
g so
cial
ex
clusi
on
in
mat
ern
al a
nd c
hil
d h
ealt
h; K
. R
N
ayar
Pap
er
Mat
ern
al h
ealt
h,
soci
al e
xcl
usi
on
Th
is p
aper
pre
sen
t so
me
of
the
key
in
itia
tives
th
at h
ave
bee
n u
nder
taken
an
d t
he
pote
nti
al i
mpl
icat
ion
s of
thes
e m
easu
res
for
wom
en a
nd c
hil
d h
ealt
h b
ased
on
in
terv
iew
s w
ith
pro
gram
man
ager
s an
d h
ealt
h w
ork
ers
as w
ell
as r
evie
w o
f off
icia
l do
cum
ents
, publ
ish
ed
pap
ers,
rel
evan
t co
nte
nt
on
off
icia
l w
ebsi
tes,
an
d d
ata
sourc
es m
ain
ly f
ocu
sin
g on
th
e S
tate
s.
71
V
uln
erab
le G
roups
In
In
dia
; C
han
dri
ma
Ch
atte
rjee
an
d G
un
jan
Sh
eora
n
Res
earc
h
docu
men
t H
ealt
h r
igh
ts o
f vuln
erab
le
Th
e h
ealt
h r
igh
ts o
f vuln
erab
le g
roups
rem
ain
det
ach
ed
from
th
e st
ate
syst
ems
i.e.
poli
cy, pro
gram
me
and
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
99
gr
oups
pra
ctic
e. T
he
docu
men
t id
enti
fies
th
e vuln
erab
le
groups
in I
ndia
, th
eir
hea
lth
an
d h
uman
rig
hts
co
nce
rns
wh
ile
explo
rin
g th
e
deg
ree
and k
inds
of
thei
r vuln
erab
ilit
y vis
-à-v
is t
hei
r lo
cati
on
an
d i
den
tity
.
72
W
hy
wom
en c
hoose
to
give
birt
h a
t h
om
e: a
si
tuat
ion
al a
nal
ysis
fro
m u
rban
slu
ms
of
Del
hi;
N
ived
ith
a D
evas
enap
ath
y, M
ath
ew S
un
il G
eorg
e,
Supar
na
Gh
osh
Jer
ath
, A
rch
na
Sin
gh, H
iman
shu
Neg
andh
i, G
urs
imra
n A
lagh
, A
nura
j H
Sh
anka
r,
San
jay
Zodpey
An
alys
is p
aper
S
ervic
e del
iver
y In
crea
sin
g in
stit
uti
on
al b
irth
s is
an
im
port
ant
stra
tegy
fo
r at
tain
ing
Mil
len
niu
m D
evel
opm
ent
Goal
-5.
How
ever
, ra
pid g
row
th o
f lo
w i
nco
me
and m
igra
nt
popula
tion
s in
urb
an s
etti
ngs
in
low
-in
com
e an
d
mid
dle
-in
com
e co
un
trie
s, i
ncl
udin
g In
dia,
pre
sen
ts
un
ique
chal
len
ges
for
pro
gram
mes
to i
mpro
ve
uti
lisa
tion
of
inst
ituti
on
al c
are.
Bet
ter
un
der
stan
din
g of
the
fact
ors
in
fluen
cin
g h
om
e or
inst
ituti
on
al b
irth
am
on
g th
e urb
an p
oor
is u
rgen
tly
nee
ded
to e
nh
ance
pro
gram
me
impac
t. T
o m
easu
re t
he
pre
val
ence
of
hom
e an
d i
nst
ituti
on
al b
irth
s in
an
urb
an s
lum
popula
tion
an
d i
den
tify
fac
tors
in
fluen
cin
g th
ese
even
ts.
73
L
earn
ing,
Sh
arin
g, A
dap
tin
g: I
nn
ovat
ion
s in
M
ater
nal
Hea
lth
Pro
gram
min
g; C
AR
E
Ref
eren
ce g
uid
e M
ater
nal
hea
lth
CA
RE
’s d
ecad
es o
f ex
peri
ence
in
an
d le
arn
ing
from
m
ater
nal
hea
lth
pro
gram
min
g h
as r
esult
ed i
n t
he
accr
ual
of
a ri
ch b
ody
of
kn
ow
ledg
e. T
his
ref
eren
ce
guid
e on
in
nova
tion
s in
mat
ern
al h
ealt
h p
rogr
amm
ing
pro
vid
es p
ract
ical
exa
mpl
es, ev
iden
ce,
in
novat
ion
s,
less
on
s le
arn
ed a
nd
solu
tion
s to
new
an
d o
ld c
hal
len
ges
to i
mpro
ve
pro
gram
qual
ity
and t
o i
ncr
ease
im
pac
t.
74
N
atio
nal
Con
sult
atio
n o
n "
Pote
nti
al R
ole
of
Pri
vat
e S
ecto
r P
rovi
der
s in
Del
iver
ing
Ess
enti
al
New
born
Car
e in
un
der
-ser
vie
d u
rban
an
d p
eri-
urb
an s
etti
ngs
"; S
ave
the
Ch
ildre
n, L
uck
now
Con
sult
atio
n
report
U
rban
new
born
h
ealt
h c
are,
urb
an p
oor
Th
e co
nsu
ltat
ion
com
pri
sed
of
nat
ion
al c
ham
pio
ns
of
evid
ence
, pro
gram
mes
an
d poli
cy w
ith
reg
ards
to
new
born
car
e fo
r th
e urb
an p
oor.
It
is s
ign
ific
ant
to
note
th
at t
he
reco
mm
endat
ion
s h
ave
per
tin
entl
y fo
cuse
d on
dev
elopi
ng
a st
ate
and c
ity
level
G
over
nan
ce S
truct
ure
s fo
r U
rban
Hea
lth
. T
he
city
in
itia
tives
an
d i
nn
ova
tion
s in
Utt
ar P
rades
h,
Mah
aras
htr
a an
d G
uja
rat
hav
e def
init
ely
bro
ugh
t fo
rth
th
e ev
iden
ces
of
effe
ctiv
enes
s of
BC
C,
KM
C a
nd
oth
er
inn
ovat
ive
stra
tegi
es.
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
100
75
S
tatu
s of
bir
th p
repar
edn
ess
and c
ompli
cati
on
re
adin
ess
in U
ttar
Din
ajpur
Dis
tric
t, W
est
Ben
gal;
D
ipta
Kan
ti M
ukh
opad
hya
y, S
ujis
hn
u
Mukh
opad
hya
y, S
har
mis
tha
Bh
atta
char
jee,
S
usm
ita
Nay
ak, A
sit
K B
isw
as, A
kh
il B
Bis
was
Stu
dy
report
B
PC
R, m
ater
nal
m
ort
alit
y B
irth
Pre
pare
dn
ess
and C
ompli
cati
on
Rea
din
ess
(BP
CR
) is
cru
cial
in
aver
tin
g m
ater
nal
morb
idit
y an
d
mort
alit
y. O
bje
ctiv
e of
th
e st
udy
was
to f
ind
out
awar
enes
s an
d p
ract
ices
reg
ardin
g B
PC
R a
mon
g pre
gnan
t an
d r
ecen
tly
del
iver
ed w
om
en i
n U
ttar
D
inaj
pur,
Wes
t B
enga
l. 76
P
rogr
ess
in H
ealt
h-R
elat
ed M
ille
nn
ium
D
evel
opm
ent
Goal
s in
th
e W
HO
South
-Eas
t A
sia
Reg
ion
; P
oon
am K
het
rapa
l S
ingh
Opin
ion
art
icle
M
DG
in
south
-ea
st A
sia
Th
is a
rtic
le p
rovid
es a
sn
ap s
hot
of
pro
gres
s th
us
far,
key
ch
alle
nge
s an
d opport
un
itie
s in
WH
O S
outh
-Eas
t A
sia
Reg
ion
an
d la
ys d
ow
n t
he
way
forw
ard f
or
the
global
hea
lth
age
nda
post
2015.
77
3.6
Mil
lion
Neo
nat
al D
eath
s—W
hat
Is
Pro
gres
sin
g an
d W
hat
Is
Not?
; Jo
y E
. L
awn
, M
BB
S, M
RC
P (
Pae
ds)
, M
PH
, P
hD
, K
ate
Ker
ber
, M
PH
, C
hri
stab
el E
nw
eron
u-L
arye
a, M
BB
S,‡
an
d
Sim
on
Couse
ns,
Dip
Mat
h S
tat
Opin
ion
art
icle
N
eon
atal
dea
ths
global
ly
Th
is a
rtic
le r
evie
ws
pro
gres
s fo
r n
ewborn
hea
lth
gl
obal
ly, w
ith
a fo
cus
on
th
e co
un
trie
s in
wh
ich
most
dea
ths
occ
ur—
w
hat
dat
a do w
e h
ave
to g
uid
e ac
cele
rate
d ef
fort
s? A
ll r
egio
ns
are
advan
cin
g, b
ut
the
level
of
dec
reas
e in
neo
nat
al m
ort
alit
y dif
fers
by
regi
on
, co
un
try,
an
d w
ith
in c
oun
trie
s.
78
S
tren
gth
enin
g M
ater
nal
&
Ch
ildca
re N
utr
itio
n
and H
ealt
h i
n U
rban
Set
tin
gs; N
IPC
CD
W
ork
shop
report
IC
DS
A t
wo d
ay w
ork
shop
was
org
anis
ed b
y th
e M
inis
try
of
Wom
en a
nd C
hil
d D
evel
opm
ent
(MW
CD
) on
18th
an
d 1
9th
Jul
y 2012 a
t N
IPC
CD
. T
he
obj
ecti
ve
of
the
work
shop w
as t
o u
nde
rsta
nd t
he
chal
len
ges
in
imple
men
tati
on
of
ICD
S i
n u
rban
set
tin
gs a
nd t
o ev
olv
e st
rate
gies
fro
m c
ross
lea
rnin
g.
79
Fam
ily
Pla
nn
ing:
Eff
ect
of C
ity
Siz
e; U
HI
W
hit
e pap
er
Fam
ily
plan
nin
g T
he
expan
sion
of
fam
ily
pla
nn
ing
serv
ices
in
Utt
ar
Pra
des
h r
equir
es a
th
oro
ugh
kn
ow
ledge
of
the
poli
cy,
soci
al, an
d e
con
om
ic f
acto
rs t
hat
aff
ect
con
trac
epti
ve
use
. T
his
docu
men
t is
on
e in
a s
erie
s of
wh
ite
pap
ers
that
an
alys
e re
cen
t dat
a w
ith
th
e ai
m o
f un
der
stan
din
g th
e im
pact
of
thes
e fa
ctors
on
fam
ily
pla
nn
ing.
In
crea
sin
g co
ntr
acep
tive
use
pre
ven
ts u
npla
nn
ed
pre
gnan
cy, an
d re
duce
s m
ater
nal
an
d n
ewborn
dea
ths.
In
th
is b
rief
, w
e co
nsi
der
how
cit
y si
ze a
ffec
ts
con
trac
epti
ve u
se. G
iven
th
at c
ity
size
is
asso
ciat
ed
wit
h t
wo c
ruci
al i
ndic
ators
of
repro
duc
tive
an
d ch
ild
hea
lth
, it
would
see
m i
mport
ant
to a
lso
con
side
r ci
ty
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
101
si
ze a
s a
fact
or
that
mig
ht
be
asso
ciat
ed w
ith
co
ntr
acep
tive
use
. T
hus
th
e pu
rpose
of
this
bri
ef i
s to
det
erm
ine
wh
eth
er t
her
e ar
e in
dee
d v
aria
tion
s in
co
ntr
acep
tive
use
ass
oci
ated
wit
h c
ity
size
, an
d i
f th
ere
are,
to p
ropose
str
ateg
ies
that
mig
ht
be e
mplo
yed t
o
incr
ease
volu
nta
ry c
on
trac
epti
ve
use
in
all
are
as.
80
In
equit
y in
In
dia:
th
e ca
se o
f m
ater
nal
an
d
repro
duc
tive
hea
lth
; L
inda
San
nev
ing,
Nad
ja
Try
gg, D
eepa
k S
axen
a, D
ilee
p M
aval
ankar
an
d
Sar
ah T
hom
sen
Rev
iew
docu
men
t S
oci
al
det
erm
inan
ts,
poli
cies
In I
ndia
, ec
on
om
ic s
tatu
s, g
ender
, an
d s
oci
al s
tatu
s ar
e al
l cl
ose
ly i
nte
rrel
ated
wh
en i
nfl
uen
cin
g use
of
and
acce
ss t
o m
ater
nal
an
d r
epro
duct
ive
hea
lth
car
e. I
n t
his
re
vie
w, a
fram
ework
dev
eloped
by
the
Com
mis
sion
on
S
oci
al D
eter
min
ants
of
Hea
lth
(C
SD
H)
is u
sed t
o
cate
gori
ze a
nd e
xpla
in d
eter
min
ants
of
ineq
uit
y in
m
ater
nal
an
d r
epro
duct
ive
hea
lth
in
In
dia
.
81
T
he
Eff
ect
of
Hea
lth
-Fac
ilit
y A
dmis
sion
an
d
Skil
led
Bir
th A
tten
dan
t C
over
age
on
Mat
ern
al
Surv
ival
in
In
dia:
A C
ase-
Con
trol
An
alys
is; A
nn
L
. M
on
tgom
ery,
Sh
aza
Fad
el, R
ajes
h K
um
ar, S
ue
Bon
dy,
Rah
im M
oin
eddin
, P
rabh
at J
ha
Eval
uati
on
re
port
H
um
an r
esourc
e,
acce
ss t
o a
nd
qual
ity
of
serv
ices
Th
e ef
fect
of
hea
lth
-fac
ilit
y ad
mis
sion
did
var
y by
sk
ille
d a
tten
dan
t co
ver
age,
an
d t
his
eff
ect
appe
ars
to b
e dri
ven
par
tial
ly b
y re
ver
se c
ausa
lity
; h
ow
ever
, in
equit
able
acc
ess
to a
nd
poss
ibly
poor
qual
ity
of
hea
lth
care
for
pri
mar
y an
d e
mer
gen
cy s
ervic
es a
ppea
rs
to p
lay
a ro
le i
n m
ater
nal
surv
ival
as
wel
l.
82
U
tili
zati
on
of
Mat
ern
al a
nd
Ch
ild
Hea
lth
Car
e S
ervic
es b
y P
rim
igra
vid
a Fem
ales
in
Urb
an a
nd
Rura
l A
reas
of
India
; H
eman
t M
ahaj
an a
nd
Bh
uw
an S
har
ma
Stu
dy
arti
cle
S
ervic
e del
iver
y an
d a
cces
s M
ater
nal
com
pli
cati
on
s an
d p
oor
per
inat
al o
utc
om
e ar
e h
igh
ly a
ssoci
ated
wit
h n
on
uti
lisa
tion
of
ante
nat
al
and d
eliv
ery
care
ser
vic
es a
nd p
oor
soci
oec
on
om
ic
con
dit
ion
s of
the
pat
ien
t. I
t is
ess
enti
al t
hat
all
pre
gnan
t w
om
en h
ave
acce
ss t
o h
igh
qual
ity
obst
etri
c ca
re t
hro
ugh
out
thei
r pre
gnan
cies
. P
rese
nt
lon
gitu
din
al
study
was
car
ried
out
to c
om
par
e uti
liza
tion
of
mat
ern
al
and c
hil
d h
ealt
h c
are
serv
ices
by
urb
an a
nd r
ura
l pri
mig
ravid
a fe
mal
es.
83
E
xposu
re a
nd L
earn
ing
Vis
it t
o B
est
Pra
ctic
es
Model
s of
Ah
med
abad
Mun
icip
al C
orp
ora
tion
(A
MC
); P
lan
In
dia
-
Hea
lth
of
the
Urb
an P
oor
(HU
P)
Pro
gram
;
Tour
report
U
rban
liv
ing
Aro
un
d 1.3
8 c
rore
peo
ple
in B
ihar
liv
e in
slu
ms
or
info
rmal
set
tlem
ents
an
d on
ly 2
.8 %
urb
an d
wel
lers
h
ave
acce
ss t
o p
iped
wat
er s
uppl
y at
hom
e. I
t is
es
tim
ated
th
at n
earl
y 60%
of
the
popul
atio
n w
ill
be
urb
aniz
ed i
n n
ext
two d
ecad
es; th
ereb
y
crea
tin
g un
pre
cede
nte
d c
hal
len
ges.
Due
to r
apid
urb
aniz
atio
n,
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
102
25%
slu
ms
dwel
ler
live
wit
hout
acce
ss t
o i
mpro
ved
hyg
ien
e an
d s
anit
atio
n f
acil
itie
s. S
upple
men
tin
g th
e pro
ble
m a
re w
ater
qual
ity
issu
es i
n 5
0%
of
the
dis
tric
ts.
Evid
ence
s re
flec
t th
at l
ack o
f sa
fe d
rin
kin
g w
ater
an
d open
def
ecat
ion
lea
d t
o a
ran
ge o
f dis
ease
s, w
hil
e fa
ctors
such
as
over
crow
din
g an
d poll
uti
on
con
trib
ute
to
hea
lth
pro
blem
s. 84
C
over
age
gap
in m
ater
nal
an
d c
hil
d h
ealt
h
serv
ices
in
In
dia
: as
sess
ing
tren
ds
and r
egio
nal
dep
rivat
ion
duri
ng
1992–2006; C
han
dan
Kum
ar,
Pra
shan
t K
um
ar S
ingh
, R
ajes
h K
um
ar R
ai
Stu
dy
report
C
over
age
of
serv
ices
In
crea
sin
g th
e co
ver
age
of
key
mat
ern
al,
new
born
an
d
chil
d h
ealt
h i
nte
rven
tion
s is
ess
enti
al, if
In
dia
has
to
atta
in M
ille
nn
ium
Dev
elopm
ent
Goal
s 4 a
nd
5. T
his
st
udy
asse
sses
th
e co
vera
ge g
ap i
n m
ater
nal
an
d ch
ild
hea
lth
ser
vic
es a
cross
sta
tes
in I
ndia
duri
ng
1992–2006
emph
asiz
ing
the
rura
l–urb
an d
ispar
itie
s. A
ddit
ion
ally
, as
soci
atio
n b
etw
een
th
e co
ver
age
gap a
nd u
nder
-5
mort
alit
y ra
te a
cross
sta
tes
are
illu
stra
ted.
85
P
ubli
c P
rivat
e P
artn
ersh
ips
form
ed b
y S
NE
HA
: C
ity
Init
iati
ve
For
New
born
Hea
lth
, A
SK
par
tner
ship
, A
rogy
a S
arit
a; S
ush
ma
Sh
ende
and
oth
ers
Pap
er
PP
P f
or
urb
an
new
born
hea
lth
Th
is p
aper
sum
mar
ises
on
e N
GO
’s e
xper
ien
ce i
n
buil
din
g par
tner
ship
s w
ith
th
e publ
ic s
ecto
r h
ealt
h
syst
em,
the
outc
om
es a
chie
ved
so f
ar a
nd l
esso
ns
lear
nt.
It
also
des
crib
es t
he
role
of
each
par
tner
an
d
sust
ain
abil
ity
issu
es i
nvolv
ed.
86
B
uil
din
g th
e In
fras
truct
ure
to R
each
an
d c
are
for
the
poo
r: T
ren
ds,
Obst
acle
s an
d S
trat
egie
s to
over
com
e th
em; D
ilee
p V
. M
aval
anka
r, K
.V.
Ram
ani,
Am
it P
atel
, P
arvat
hy
San
kar
Rev
iew
pap
er
MN
H
infr
astr
uct
ure
Th
is p
aper
rev
iew
s av
aila
ble
lit
erat
ure
an
d a
sses
ses
the
cover
age
and g
aps
in i
nfr
astr
uct
ure
in
MN
H. It
als
o
iden
tifi
es c
riti
cal
issu
es i
n m
anag
emen
t of
infr
astr
uct
ure
an
d a
nal
yses
th
eir
cause
s an
d i
mpac
ts o
n
serv
ice
del
iver
y to
th
e poor.
Th
e pap
er a
lso r
evie
ws
impac
t of
refo
rms
on
in
fras
truct
ure
an
d p
rovid
es s
ome
reco
mm
enda
tion
s fo
r im
pro
vem
ent
of
infr
astr
uct
ure
m
anag
emen
t so
as
to e
nsu
re b
ette
r se
rvic
es t
o t
he
poor.
87
T
oolk
it o
n m
on
itori
ng
hea
lth
sys
tem
s st
ren
gth
enin
g; W
HO
S
tren
gth
enin
g se
rvic
e del
iver
y is
a k
ey s
trat
egy
to
ach
ieve
the
Mil
len
niu
m D
evel
opm
ent
Goal
s. T
his
in
cludes
th
e del
iver
y of
inte
rven
tion
s to
red
uce
ch
ild
mort
alit
y, m
ater
nal
mort
alit
y, a
nd t
he
burd
en t
o
HIV
/AID
S, tu
berc
ulosi
s an
d m
alar
ia1. S
ervic
e pro
vis
ion
or
deli
ver
y is
an
im
med
iate
outp
ut
of
the
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
103
in
puts
in
to t
he
hea
lth
sys
tem
, su
ch a
s h
ealt
h
work
forc
e, p
rocu
rem
ent
and s
uppli
es a
nd
fin
ance
s.
Incr
ease
d in
puts
sh
ould
lea
d t
o i
mpro
ved
ser
vic
e del
iver
y an
d e
nh
ance
d ac
cess
to s
ervi
ces.
En
suri
ng
avai
labil
ity
and a
cces
s to
hea
lth
ser
vic
es i
s on
e of
th
e m
ain
fun
ctio
ns
of a
hea
lth
sys
tem
. S
uch
ser
vic
es s
hould
m
eet
a m
inim
um
qual
ity
stan
dar
d.
88
C
hil
d H
ealt
h a
nd
Imm
un
izat
ion
Sta
tus
in a
n
Un
regi
ster
ed M
um
bai
Slu
m; Jo
ya B
aner
jee
T
hes
is
Imm
un
izat
ion
T
his
th
esis
use
s th
e ca
se o
f an
un
regi
ster
ed u
rban
slu
m,
Kau
la B
anda
r (K
B),
in
Mum
bai
, In
dia,
to e
xam
ine
the
det
erm
inan
ts o
f ch
ild m
ort
alit
y an
d i
mm
un
izat
ion
co
ver
age
usi
ng
prim
ary
quan
tita
tive
and q
ual
itat
ive
dat
a fr
om
a h
ouse
hold
surv
ey (
n=
226 h
ouse
hold
s) a
nd
focu
s gr
oups.
Res
ults
In
dic
ate
that
alt
hough
im
mun
izat
ion
ser
vic
es a
re w
idel
y av
aila
ble
in u
rban
ce
nte
rs, a
“kn
ow
ledg
e-ac
tion
gap
” kee
ps
imm
un
izat
ion
ra
tes
low
—an
d c
hil
d m
ort
alit
y h
igh
— in
slu
m
com
mun
itie
s. 89
B
rin
gin
g E
vid
ence
in
to P
ubli
c H
ealt
h P
olic
y (E
PH
P)
2012:
Str
engt
hen
ing
hea
lth
sys
tem
s to
ac
hie
ve
un
iver
sal
hea
lth
cov
erag
e; U
pen
dra
B
hoja
ni,
Ari
ma
Mis
hra
, N
S P
rash
anth
an
d
Wer
ner
Soors
Con
fere
nce
pap
ers
H
ealt
h s
yste
ms
90
A
Soc
ial
Det
erm
inan
ts A
ppro
ach
to M
ater
nal
H
ealt
h; U
ND
P
Dis
cuss
ion
P
aper
S
oci
al
det
erm
inan
ts T
he
fun
dam
enta
l ra
tion
ale
of t
he
soci
al d
eter
min
ants
of
hea
lth
appro
ach
is
not
on
ly t
hat
soci
al d
eter
min
ants
sh
ape
hea
lth
outc
om
es b
ut
that
it
is p
oss
ible
to
im
pro
ve
hea
lth
outc
om
es a
nd r
educe
hea
lth
in
equit
ies
by
anal
yzin
g an
d ac
tin
g on
th
e m
ost
in
fluen
tial
of
those
so
cial
det
erm
inan
ts. T
his
docu
men
t co
ntr
ibute
s to
th
ese
dis
cuss
ion
s th
rough
th
e le
ns
of
on
e par
ticu
lar
global
hea
lth
ch
alle
nge
: m
ater
nal
hea
lth
. M
ater
nal
h
ealt
h p
rovid
es a
sal
ien
t ex
ample
of
how
adopti
ng
a so
cial
det
erm
inan
ts a
ppro
ach
can
buil
d s
yner
gies
acr
oss
dev
elopm
ent
sect
ors
to a
ccel
erat
e pro
gres
s on
a s
pec
ific
h
ealt
h i
ssue.
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
104
91
G
over
nm
ent
of
Wes
t B
enga
l: T
he
Urb
an H
ealt
h
Str
ateg
y; G
ovt
of
Wes
t B
enga
l, D
epar
tnm
ent
of
Hea
lth
& F
amil
y W
elfa
re &
Dep
artm
ent
of
Mun
icip
al A
ffai
rs
Str
ateg
y docu
men
t U
rban
hea
lth
Th
e G
over
nm
ent
of
Wes
t B
enga
l is
com
mit
ted t
o
ensu
rin
g ac
cess
ible
, eq
uit
able
an
d q
ual
ity
hea
lth
car
e se
rvic
es t
o t
he
urb
an p
opula
tion
of
the
S
tate
. T
ow
ards
this
en
d t
he
Dep
artm
ent
of
Hea
lth
& F
amil
y W
elfa
re
(DH
FW
) an
d D
epar
tmen
t of
Mun
icip
al A
ffai
rs &
U
rban
Dev
elopm
ent
(DM
A &
UD
) pro
pose
to
con
textu
aliz
e th
e st
rate
gic
fram
ework
wit
hin
wh
ich
th
e S
tate
sh
all
seek
to a
ddre
ss t
he
hea
lth
con
cern
s o
f th
e urb
an p
oor.
92
S
tren
gth
enin
g H
ealt
h M
anag
emen
t In
form
atio
n
Sys
tem
s fo
r M
ater
nal
an
d C
hil
d H
ealt
h:
Docu
men
tin
g M
CH
IP’s
Con
trib
uti
on
s; M
oll
y S
trac
han
, M
ary
Dra
ke,
Bar
bar
a R
awli
ns,
Vik
as
Dw
ived
i, B
ecca
Lev
ine,
Mouss
a L
y, G
ben
ga I
shola
Pro
ject
docu
men
t H
MIS
A
s par
t of
it i
ts e
ffort
s to
im
pro
ve
the
qual
ity
of
mat
ern
al, n
ewborn
, an
d c
hil
d h
ealt
h (
MN
CH
) ca
re i
n
low
-in
com
e co
un
trie
s, M
CH
IP h
as t
aken
spec
ific
ste
ps
to i
mpro
ve
the
mon
itori
ng
of
MN
CH
ser
vic
es t
hro
ugh
st
ren
gth
enin
g ro
uti
ne
HM
IS. T
hes
e ef
fort
s h
ave
led t
o
bet
ter
mon
itori
ng
and e
val
uat
ion
, h
igh
er-q
ual
ity
dat
a,
and i
nfo
rmed
dec
isio
n-m
akin
g in
28 c
oun
trie
s ac
ross
M
NC
H i
nte
rven
tion
s. O
ngo
ing
effo
rts
to i
mpro
ve
HM
IS w
ill
incr
ease
coun
try
and g
lobal
acc
ess
to
info
rmat
ion
-ric
h s
yste
ms
to s
upport
MN
CH
pro
gram
st
ren
gth
enin
g. T
his
rep
ort
sum
mar
izes
succ
essf
ul
HM
IS-r
elat
ed i
nte
rven
tion
s an
d i
nn
ovat
ion
s in
co
un
trie
s w
her
e M
CH
IP i
s oper
atin
g an
d a
t th
e gl
obal
le
vel
. It
hig
hli
ghts
wh
at M
CH
IP h
as d
on
e to
st
ren
gth
en H
MIS
an
d w
hic
h M
CH
IP c
on
trib
uti
on
s h
ave
bee
n i
nte
grat
ed a
nd i
nst
ituti
on
aliz
ed i
n n
atio
nal
H
MIS
sys
tem
s, a
nd d
escr
ibes
les
son
s le
arn
ed.
93
N
eed f
or
Ded
icat
ed F
ocu
s on
Urb
an H
ealt
h
wit
hin
Nat
ion
al R
ura
l H
ealt
h M
issi
on
; S
. A
garw
al, K
. S
anga
r
Art
icle
U
rban
hea
lth
in
N
RH
M
Th
is p
aper
dis
cuss
es i
ssues
per
tain
ing
to h
ealt
h
con
dit
ion
s of
the
urb
an p
oor,
pre
sen
t st
atus
of
serv
ices
, ch
alle
nge
s an
d s
ugg
ests
opti
on
s fo
r
NR
HM
to b
ridge
th
e la
rge
gap.
94
N
atio
nal
Con
sult
atio
n o
n
"Pote
nti
al R
ole
of
Pri
vat
e S
ecto
r P
rovid
ers
in
Del
iver
ing
Ess
enti
al N
ewborn
Car
e in
un
der
-se
rvie
d u
rban
an
d p
eri-
urb
an s
etti
ngs
"; S
ave
the
Ch
ildre
n
Con
sult
atio
n
report
Pri
vat
e se
ctor
in
urb
an n
ewborn
ca
re
Th
e G
over
nm
ent
of
Utt
ar P
rades
h (
Min
istr
y of
Hea
lth
an
d F
amil
y W
elfa
re)
and U
NIC
EF i
n p
artn
ersh
ip w
ith
S
ave
the
Ch
ildre
n a
nd S
avin
g N
ewborn
Liv
es l
ed a
n
atio
nal
lev
el c
on
sult
atio
n t
itle
d ‘R
ole
of
Pri
vat
e S
ecto
r P
rovid
ers
in N
ewborn
Car
e in
Un
der
ser
vic
ed
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
105
Urb
an a
nd P
eri-
urb
an S
etti
ng’
th
at h
igh
ligh
ted t
hes
e ch
alle
nge
s an
d d
evel
oped
a r
oad
map
wh
ich
pro
vid
es a
sc
ope
for
par
tici
pat
ion
of
var
ious
stak
e h
old
ers
in t
he
stat
e so
as
to t
ake
forw
ard t
he
reco
mm
endat
ion
s at
th
e poli
cy a
nd p
rogr
amm
atic
lev
el.
95
N
ouri
shin
g O
ur
Futu
re: T
ackli
ng
Ch
ild
Mal
nutr
itio
n I
n U
rban
Slu
ms;
DA
SR
A
N
ewborn
n
utr
itio
n N
ouri
shin
g O
ur
Futu
re f
ocu
ses
on
th
e is
sue
of
mal
nutr
itio
n f
or
infa
nts
age
d 0
-36 m
on
ths
in u
rban
sl
um
s. T
his
age
gro
up i
s th
e ‘w
indow
-of
opport
un
ity’
wh
ere
the
foun
dat
ion
for
ph
ysic
al a
nd c
ogn
itiv
e gr
ow
th
pote
nti
al i
s es
tabli
shed
. D
espit
e it
bei
ng
wid
ely
kn
ow
n
that
aft
er 3
6 m
on
ths,
th
e lo
ng-
term
eff
ects
of
mal
nutr
itio
n a
re i
rrev
ersi
ble
, m
ain
stre
am e
ffort
s to
re
duce
mal
nutr
itio
n a
re m
ain
ly t
arge
ted a
t ch
ildre
n
bet
wee
n 3
-6 y
ears
96
U
rban
Slu
m-S
pec
ific
Iss
ues
in
Neo
nat
al S
urv
ival
; A
rmid
a Fer
nan
dez
, Ja
ysh
ree
Mon
dkar
, S
hei
la
Mat
hai
Art
icle
S
yste
ms
for
urb
an m
ater
nal
h
ealt
h
Urb
aniz
atio
n i
s ra
pid
ly s
pre
adin
g th
rough
out
the
dev
elopin
g w
orl
d. A
n u
rban
slu
m p
ose
s sp
ecia
l h
ealt
h
pro
ble
ms
due
to p
over
ty,
over
crow
din
g, u
nh
ygie
nic
su
rroun
din
gs a
nd l
ack o
f an
org
aniz
ed h
ealt
h
Infr
astr
uct
ure
. T
he
pri
mar
y ca
use
s of
neo
nat
al
mort
alit
y ar
e se
psi
s, p
erin
atal
asp
hyx
ia a
nd
pre
mat
uri
ty. H
om
e del
iver
ies,
lat
e re
cogn
itio
n o
f n
eon
atal
ill
nes
s, d
elay
in
see
kin
g m
edic
al h
elp a
nd
inap
pro
pri
ate
trea
tmen
t co
ntr
ibute
to n
eon
atal
m
ort
alit
y. M
easu
res
to r
educe
neo
nat
al m
ort
alit
y in
urb
an s
lum
s sh
ould
focu
s on
hea
lth
educa
tion
, im
pro
vem
ent
of
ante
nat
al p
ract
ices
, in
stit
uti
on
al
del
iver
ies,
an
d e
nsu
rin
g qual
ity
per
inat
al c
are.
Succ
ess
of
a co
mpre
hen
sive
hea
lth
str
ateg
y w
ould
req
uir
e pla
nn
ed h
ealt
h i
nfr
astr
uct
ure
, st
ren
gth
enin
g an
d
un
ific
atio
n o
f ex
isti
ng
hea
lth
car
e pro
gram
an
d
faci
liti
es; fo
rmin
g a
syst
em o
f re
ferr
al a
nd d
evel
opin
g a
pro
gram
wit
h a
ctiv
e par
tici
pat
ion
of
the
com
mun
ity.
97
A
ll S
lum
s ar
e N
ot
Equal
: M
ater
nal
Hea
lth
C
on
dit
ion
s A
mon
g T
wo U
rban
Slu
m D
wel
lers
; Z
ulf
ia K
han
, S
aira
Meh
naz
, A
bdul
Raz
zaq
Stu
dy
arti
cle
M
ater
nal
pra
ctic
es
Th
e st
udy
exam
ines
wh
eth
er h
azar
dous
mat
ern
al c
are
pra
ctic
es e
xis
t in
an
d w
het
her
th
ere
are
dif
fere
nce
s in
th
e uti
liza
tion
rat
es o
f h
ealt
h s
ervic
es i
n t
wo d
iffe
ren
t
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
106
S
iddiq
ui, A
thar
An
sari
, S
alm
an K
hal
il, an
d
San
dee
p S
ach
dev
a
slum
s.
98
Im
pro
vin
g urb
an n
ewborn
hea
lth
: C
hal
len
ges
and
the
way
forw
ard; S
iddh
arth
Aga
rwal
P
aper
C
hal
len
ges
for
neo
nat
al c
are
and s
urv
ival
Th
is p
aper
dis
cuss
es t
he
situ
atio
n o
f n
eon
atal
car
e an
d
surv
ival
am
on
g th
e urb
an p
oor
acro
ss s
tate
s
wh
ich
are
at
dif
fere
nt
level
s of
soci
al d
evel
opm
ent.
Ch
alle
nge
s in
ad
dre
ssin
g n
eeds
of
the
new
born
s in
urb
an p
oor
sett
ings
oper
ate
at c
om
mun
ity
as w
ell
as p
rogr
am l
evel
an
d n
eed t
o be
addre
ssed
sim
ult
aneo
usl
y. T
he
pap
er
des
crib
es t
hes
e ch
alle
nge
s an
d su
gges
ts a
way
forw
ard
in l
igh
t of
the
exis
tin
g opport
un
itie
s an
d le
sson
s fr
om
su
cces
sful
exper
ien
ces.
99
N
ewborn
Car
e P
ract
ices
an
d H
ealt
h S
eekin
g B
ehav
ior
in U
rban
Slu
ms
and V
illa
ges
of A
nan
d,
Guja
rat;
Arc
han
a S
Nim
balk
ar,
Viv
ek V
Sh
ukla
, A
jay
G P
hat
ak A
nd S
om
ash
ekh
ar M
Nim
bal
kar
Stu
dy
fin
din
gs
Soci
o e
con
om
ic
fact
ors
Hea
lth
sta
tus
of
neo
nat
es i
n u
rban
slu
ms
has
not
bee
n
studie
d i
n s
mal
ler
tow
ns.
A q
ues
tion
nai
re w
as
adm
inis
tere
d t
o 1
54 f
amil
ies
of
10 u
rban
slu
ms
of
An
and
(popula
tion
- 197351)
and 1
60 f
amil
ies
fr
om 6
vil
lage
s of
An
and d
istr
ict.
Th
e so
cioec
on
omic
an
d
educa
tion
sta
tus
of
the
slum
dw
elle
rs v
ersu
s ru
ral
par
tici
pan
ts w
ere
sign
ific
antl
y lo
wer
in
urb
an s
lum
s, a
s co
mpar
ed t
o v
illa
ges,
Car
e se
ekin
g w
as l
ow
in
urb
an
slum
s, H
indus
and i
llit
erat
e m
oth
ers.
Hea
lth
car
e an
d
soci
oec
on
om
ic s
tatu
s of
neo
nat
es i
n s
lum
s of
smal
ler
citi
es i
s poore
r th
an i
n s
urr
oun
din
g vil
lage
s.
100
N
eon
atal
Car
e P
ract
ices
in
Urb
an V
illa
ges;
P
eeyu
sh G
rover
, In
tern
,Pra
gti
Ch
hab
ra,
Pro
fess
or
S
tudy
report
N
eon
atal
car
e N
eon
atal
hea
lth
is t
he
key
to c
hil
d su
rviv
al.
Car
e pra
ctic
es d
uri
ng
del
iver
y an
d n
eon
atal
per
iod
con
trib
ute
to
risk
of
mort
alit
y an
d m
orb
idit
y. T
he
pre
sen
t st
udy
was
con
duct
ed i
n t
wo u
rban
vil
lage
s of
east
Del
hi
to s
tudy
pra
ctic
es d
uri
ng
del
iver
y an
d n
eon
atal
per
iod a
mon
gst
moth
ers.
101
C
om
par
ison
Of
Pre
val
ent
New
born
Rea
rin
g P
ract
ices
, In
Urb
an A
nd S
lum
Popula
tion
Of
Ch
andig
arh
, U
t, I
ndia
; S
Puri
, V
Bh
atia
, M
S
har
ma,
H S
wam
i, C
Mag
nat
Stu
dy
report
N
ewborn
pra
ctic
es
To s
tudy
the
hom
e bas
ed n
ewborn
car
e pra
ctic
es i
n
slum
an
d urb
an a
rea
of
Ch
andig
arh
an
d t
o c
om
pare
th
e pra
ctic
es i
n b
oth
set
ups
.
102
N
ewborn
Car
e P
ract
ices
in
Urb
an S
lum
s of
Luck
now
Cit
y, U
P;
Pra
tibh
a G
upta
, V
K
Stu
dy
report
N
ewborn
car
e pra
ctic
es
A c
ross
-sec
tion
al s
tudy
in u
rban
slu
ms
of
Luck
now
cit
y,
UP
, in
cluded
524 w
om
en w
ho h
ad a
liv
e bir
th d
uri
ng
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
107
S
rivas
tava
, V
ish
waj
eet
Kum
ar, S
avit
a Ja
in, Ja
mal
M
asood,
Nai
m A
hm
ad, an
d JP
Sri
vast
ava
la
st 1
yea
r pre
cedin
g dat
a co
llec
tion
. D
ata
wer
e an
alyz
ed u
sin
g st
atis
tica
l so
ftw
are
SP
SS
10.0
for
win
dow
s. 103
M
ater
nal
an
d
neo
nat
al h
ealt
h e
xpen
dit
ure
in
m
um
bai
slu
ms
(In
dia
): A
cro
ss s
ecti
on
al s
tudy;
Jo
len
e S
kord
is-W
orr
all, N
oem
i P
ace,
Ujw
ala
Bap
at, S
ush
mit
a D
as, N
een
a S
More
, W
asun
dh
ara
Josh
i, A
nn
i-M
aria
Pulk
ki-
Bra
nn
stro
m1
and D
avid
O
srin
An
alys
is r
eport
H
ealt
h
expen
ditu
re T
he
cost
of
mat
ern
ity
care
can
be
a bar
rier
to a
cces
s th
at m
ay i
ncr
ease
mat
ern
al a
nd n
eon
atal
mort
alit
y ri
sk.
We
anal
yzed
spen
din
g on
mat
ern
ity
care
in
urb
an s
lum
co
mm
un
itie
s in
Mum
bai
to b
ette
r un
der
stan
d t
he
equit
y of
spen
din
g an
d th
e im
pact
of
spen
din
g on
h
ouse
hold
pover
ty.
104
S
tate
of
India
’s N
ewborn
s 2014;
PH
FI
R
eport
N
ewborn
hea
lth
st
rate
gies
T
his
sec
on
d ed
itio
n o
f th
e S
OIN
rep
ort
rev
iew
s th
e ev
iden
ce g
ener
ated
pro
gres
s an
d l
earn
ing
in n
ewbo
rn
hea
lth
in
In
dia
over
th
e pas
t te
n y
ears
, an
d a
ctio
ns
nee
ded t
o a
ccel
erat
e pro
gres
s in
new
born
hea
lth
an
d su
rviv
al i
n t
he
dec
ade
ahea
d.
105
N
ewborn
car
e pra
ctic
es i
n a
n u
rban
slu
m o
f D
elh
i;
Man
ju R
ahi, D
K T
anej
a, A
mri
ta M
isra
, N
B
Mat
hur,
Sure
sh B
adh
an
Stu
dy
report
N
ewborn
car
e pra
ctic
es
Des
pit
e ef
fort
s by
gover
nm
ent
and o
ther
age
nci
es,
neo
nat
al m
orb
idit
y an
d m
ort
alit
y co
nti
nues
to
be
hig
h
in I
ndia
. A
mon
g oth
er r
easo
ns,
new
born
car
e pra
ctic
es
are
maj
or c
on
trib
uto
rs f
or
such
hig
h r
ates
. T
he
aim
of
the
stud
y w
as t
o fi
nd o
ut
the
new
born
car
e pra
ctic
es
incl
udin
g del
iver
y pr
acti
ces,
im
med
iate
car
e gi
ven
aft
er
bir
th a
nd b
reas
t-fe
edin
g pra
ctic
es i
n a
n u
rban
slu
m o
f D
elh
i. 106
A
Tal
e of
Tw
o A
ppro
ach
es: M
ater
nal
an
d
Neo
nat
al H
ealt
hca
re f
or
the
Urb
an P
oor;
Ush
a G
anes
h
Art
icle
M
DG
T
his
art
icle
exa
min
es t
wo
appro
ach
es i
n B
angl
ades
h
and I
ndia
th
at h
ave
mad
e si
gnif
ican
t in
road
s to
mee
t th
e M
DG
on
mat
ern
al m
ort
alit
y.
107
M
ater
nal
an
d c
hil
d h
ealt
h c
hal
len
ge i
n u
rban
In
dia
: T
he
lack
of
acce
ss t
o p
reve
nti
ve
care
in
form
atio
n; D
r A
par
na
Heg
de,
Foun
der
an
d
Ch
airm
an, A
RM
MA
N
As
MA
MA
pre
par
es t
o la
un
ch i
n I
ndia
nex
t m
on
th,
we
take
a cl
ose
r lo
ok a
t th
e m
ater
nal
, n
ewborn
an
d ch
ild h
ealt
h c
hal
len
ges
face
d i
n i
ts u
rban
are
as
108
D
eman
d-s
ide
Fin
anci
ng
and P
rom
oti
on
of
Mat
ern
al H
ealt
h: w
hat
has
In
dia
lear
nt?
; B
enja
min
M H
un
ter,
Ram
ila
Bis
ht,
In
dir
a C
hak
rava
rth
i, S
usan
F M
urr
ay
Th
is p
aper
un
dert
akes
a s
yste
mat
ic r
evie
w o
f th
e ev
iden
ce t
o c
on
side
r h
ow
dem
and-s
ide
fin
anci
ng
has
bee
n u
sed a
nd w
het
her
th
ere
has
bee
n a
ny
impac
t on
m
ater
nal
hea
lth
ser
vic
e uti
lisa
tion
, m
ater
nal
hea
lth
, or
oth
er o
utc
omes
. T
he
fin
din
gs s
ugg
est
that
a r
elat
ivel
y
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
108
n
arro
w f
ocu
s on
ach
ievi
ng
targ
ets
has
oft
en
over
burd
ened
hea
lth
fac
ilit
ies,
wh
ile
inad
equat
e re
ferr
al s
yste
ms
and u
net
hic
al p
ract
ices
pre
sen
t over
wh
elm
ing
bar
rier
s fo
r w
omen
wit
h o
bst
etri
c co
mpli
cati
on
s. T
he
lim
ited
evid
ence
ava
ilab
le a
lso
sugg
ests
th
at l
ittl
e h
as b
een
don
e to
ch
alle
nge
th
e lo
w
stat
us
of
poor
wom
en a
t h
ome
and i
n t
he
hea
lth
sys
tem
109
N
ewborn
Car
e P
ract
ices
Am
on
g S
lum
Dw
elle
rs I
n
Ali
garh
Cit
y, U
ttar
Pra
des
h;
MH
Kh
an, N
K
hal
ique,
AR
Sid
diq
ui,
A
Am
ir
A c
om
mun
ity-
bas
ed s
tudy
was
con
duc
ted i
n t
he
fiel
d pra
ctic
e ar
ea o
f th
e U
rban
Hea
lth
Tra
inin
g C
entr
e (U
HT
C),
Dep
artn
men
t of
Com
mun
ity
Med
icin
e,
Jaw
ahar
lal
Neh
ru M
edic
al C
oll
ege,
Ali
garh
Mus
lim
U
niv
ersi
ty, A
liga
rh, U
P.
200 p
regn
ant
wom
en w
ere
chose
n f
or
the
stud
y, c
arri
ed o
ut f
or
1 y
ear.
obj
ecti
ve
was
to s
tudy
the
kn
ow
ledge
an
d p
ract
ices
rel
ated
to
new
born
car
e am
on
g sl
um
dw
elle
rs i
n A
liga
rh. fi
nsi
ngs
w
ere
that
th
ere
wer
e poor
new
born
pra
ctic
es a
mon
g sl
um
dw
elle
rs i
n A
liga
rh.
110
P
oor
Per
inat
al C
are
Pra
ctic
es i
n U
rban
Slu
ms:
P
oss
ible
Role
of
Soci
al M
obil
izat
ion
Net
work
s;
Zulf
ia K
han
, S
aira
Meh
naz
, N
ajam
Kh
aliq
ue,
M
oh
d A
thar
An
sari
, an
d A
bdul
Raz
zaque
Sid
diq
ui
To d
eter
min
e th
e ex
isti
ng
peri
nat
al p
ract
ices
in
an
urb
an s
lum
an
d t
o i
den
tify
bar
rier
s to
uti
liza
tion
of
hea
lth
ser
vic
es b
y m
oth
ers.
111
C
om
mun
ity
Bas
ed N
ewborn
Car
e: A
Sys
tem
atic
R
evie
w a
nd M
eta-
anal
ysis
of
Evid
ence
: U
NIC
EF-
PH
FI
Ser
ies
on
New
born
an
d C
hil
d H
ealt
h, In
dia
; S
iddh
arth
a G
ogi
a, S
idda
rth
Ram
ji, $P
iyush
G
upta
, #T
arun
Ger
a, $
Dh
eera
j S
hah
, Jo
seph
L
Mat
hew
, P
avit
ra M
oh
an a
nd R
ajm
oh
an P
anda
To a
sses
s th
e ef
fect
of
com
mun
ity
base
d n
eon
atal
car
e by
com
mun
ity
hea
lth
work
ers
(CH
Ws)
on
NM
R i
n
reso
urc
e-li
mit
ed s
etti
ngs
.
112
C
om
par
ison
Of
Pre
val
ent
New
born
Rea
rin
g P
ract
ices
, In
Urb
an A
nd S
lum
Popula
tion
Of
Ch
andig
arh
, U
t, I
ndia
; S
Puri
, V
Bh
atia
, M
S
har
ma,
H S
wam
i, C
Mag
nat
.
To s
tudy
the
hom
e bas
ed n
ewborn
car
e pra
ctic
es i
n
slum
an
d urb
an a
rea
of
Ch
andig
arh
an
d t
o c
om
pare
th
e pra
ctic
es i
n b
oth
set
ups
.
113
Fost
erin
g M
ater
nal
an
d N
ewborn
Car
e in
In
dia
th
e Y
ash
oda
Way
: D
oes
Th
is I
mpro
ve
Mat
ern
al
and N
ewborn
Car
e P
ract
ices
duri
ng
Inst
ituti
on
al
Th
e Y
ash
oda
pro
gram
, n
amed
aft
er a
leg
endar
y fo
ster
-m
oth
er i
n I
ndia
n m
yth
olo
gy,
un
der
th
e N
orw
ay-I
ndia
P
artn
ersh
ip I
nit
iati
ve
was
lau
nch
ed a
s a
pil
ot
pro
gram
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
109
D
eliv
ery?
; B
een
a V
argh
ese
mai
l, R
eeta
bra
ta R
oy,
S
om
en S
aha,
Sid
sel
Roal
kvam
in
2008
to
impro
ve
the
qual
ity
of
mat
ern
al a
nd
neo
nat
al c
are
at f
acil
itie
s in
sel
ect
dis
tric
ts o
f In
dia
. Y
ash
odas
wer
e pla
ced m
ain
ly a
t dis
tric
t h
osp
ital
s,
wh
ich
are
hig
h d
eliv
ery
load
fac
ilit
ies,
to p
rovi
de
support
an
d c
are
to m
oth
ers
and n
ewborn
s duri
ng
thei
r st
ay a
t th
ese
faci
liti
es. T
his
stu
dy
pre
sen
ts t
he
resu
lts
from
th
e ev
aluat
ion
of
this
in
terv
enti
on
in
tw
o s
tate
s in
In
dia
. 114
C
ash
In
cen
tives
for
Inst
ituti
on
al D
eliv
ery:
Lin
kin
g w
ith
An
ten
atal
an
d P
ost
Nat
al C
are
May
En
sure
‘C
on
tin
uum
of
Car
e’ i
n I
ndia
; C
han
dra
kan
t L
ahar
iya
Eval
uat
ing
the
JSY
sch
eme.
115
Ja
nan
i S
ura
ksh
a Y
ojan
a: t
he
con
dit
ion
al c
ash
tr
ansf
er s
chem
e to
red
uce
mat
ern
al m
ort
alit
y in
In
dia
–
a n
eed f
or
reas
sess
men
t; R
ajes
h K
umar
R
aia,
Pra
shan
t K
um
ar S
ingh
b
116
A
Tal
e of
Tw
o A
ppro
ach
es: M
ater
nal
an
d
Neo
nat
al H
ealt
hca
re f
or
the
Urb
an P
oor;
Ush
a G
anes
h
Opin
ion
art
icle
P
ubli
c h
ealt
h
infr
astr
uct
ure
Th
is a
rtic
le e
xam
ines
tw
o ap
pro
ach
es i
n B
angl
ades
h
and I
ndia
th
at h
ave
mad
e si
gnif
ican
t in
road
s to
mee
t th
e M
DG
on
mat
ern
al m
ort
alit
y.
117
C
on
trac
tin
g-out
of R
epro
duct
ive
and C
hil
d
Hea
lth
(R
CH
) S
ervi
ces
thro
ugh
Moth
er N
GO
S
chem
e in
In
dia
: E
xper
ien
ces
and I
mpli
cati
on
s;
Ram
esh
Bh
at, S
un
il M
ahes
hw
ari,
Som
en S
aha
Work
ing
pap
er
Par
tner
ship
wit
h
NG
Os,
m
anag
emen
t of
RC
H s
ervic
es
Par
tner
ship
wit
h N
GO
s in
del
iver
ing
and p
rovi
sion
of
Rep
rodu
ctiv
e an
d C
hil
d H
ealt
h (
RC
H)
serv
ices
th
rough
moth
er N
GO
(M
NG
O)
in t
he
un
ser
ved
an
d
un
der
-ser
ved
reg
ion
s is
on
e of
the
import
ant
init
iati
ves
in
In
dia
. T
he
sch
eme
involv
es l
arge
num
ber
of
con
trac
ts b
etw
een
gover
nm
ent
and t
he
NG
Os.
As
of
Apri
l 20
06,
215 M
NG
Os
wer
e w
ork
ing
in 3
24 d
istr
icts
of
the
coun
try.
In
addi
tion
to t
his
th
ere
are
about
3 to
4 F
ield
NG
Os
atta
ched
wit
h e
ach
MN
GO
in
a
dis
tric
t.
Th
is p
aper
dis
cuss
es t
his
sch
eme
wit
h a
n o
bje
ctiv
e to
un
der
stan
d t
he
mak
e up o
f th
e par
tn e
rsh
ip a
nd t
he
dev
elopm
ent
of
man
agem
ent
capac
ity
in t
he
syst
em.
118
C
apac
ity
Buil
din
g on
Man
agem
ent
and
Imple
men
tati
on
of
Urb
an R
CH
Ser
vic
es a
nd
Publi
c P
rivat
e P
artn
ersh
ips;
UH
RC
Stu
dy
tour
report
P
PP
, urb
an
mat
ern
al h
ealt
h U
HR
C h
as b
een
work
ing
close
ly w
ith
th
e M
oH
FW
an
d s
tate
gover
nm
ents
in
dev
elopi
ng
stra
tegi
es,
oper
atio
nal
guid
elin
es a
nd c
apac
ity
to i
mpro
ve
the
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
110
hea
lth
of
the
urb
an p
oor.
In
ord
er t
o i
mpro
ve
capac
ity
of
key
off
icer
s m
anag
ing
urb
an h
ealt
h p
rogr
ams,
an
ex
posu
re v
isit
was
con
duct
ed t
o M
un
icip
al h
ealt
h
cen
ters
in
Ban
galo
re m
anag
ed i
n p
artn
ersh
ip w
ith
th
e pri
vat
e se
ctors
. T
hes
e h
ealt
h c
ente
rs i
nit
iate
d u
nder
th
e W
orl
d B
ank f
un
ded
eig
ht
roun
d o
f th
e In
dia
P
opula
tion
Pro
ject
(IP
P-V
III)
hav
e bee
n o
per
ated
su
cces
sfull
y by
non
-gover
nm
enta
l ag
enci
es f
or
the
pas
t se
ver
al y
ears
an
d s
om
e of
thes
e N
GO
s h
ave
man
aged
to
run
th
ese
faci
liti
es e
ven
aft
er t
he
end o
f th
e pro
ject
cy
cle.
119
B
uil
din
g P
ubli
c S
ecto
r –
N
GO
Par
tner
ship
s fo
r U
rban
RC
H S
ervic
es; S
iddh
arth
E
dit
ori
al
NG
O
Par
tner
ship
s,
Urb
an
par
tner
ship
s
Th
e ques
t fo
r bet
ter
livel
ihood o
pport
un
itie
s h
as l
ed t
o
larg
e-sc
ale
mig
rati
on
an
d t
he
mush
room
ing
of
slum
s in
se
ver
al I
ndia
n c
itie
s. U
nfo
rtun
atel
y, a
sig
nif
ican
t se
ctio
n o
f th
e urb
an p
oor
do n
ot
hav
e ac
cess
to m
any
of
the
ben
efit
s of
urb
an d
evel
opm
ent.
Much
of
the
chal
len
ge o
f del
iver
ing
serv
ices
to t
he
mar
gin
aliz
ed
groups
lies
in
iden
tify
ing
them
an
d e
ffec
tivel
y ap
pro
ach
ing
them
, so
th
at l
imit
ed r
esourc
es a
re u
tili
zed
wel
l an
d p
rogr
ams
addre
ss r
eal
nee
ds1
. T
her
e is
a
pre
sen
ce o
f th
e publi
c se
ctor
as w
ell
as N
GO
s in
urb
an
area
s. T
he
grow
ing
requir
emen
t fo
r h
ealt
h s
ervic
es f
or
the
urb
an p
oor,
ow
ing
to r
apid
urb
an p
opula
tion
gr
ow
th,
nec
essi
tate
s th
inkin
g ab
out
the
coll
abora
tive
appro
ach
of
the
publi
c an
d N
on
pro
fit
sect
or
for
hea
lth
se
rvic
es i
n u
rban
are
as 120
D
esig
n R
esea
rch
in
Neo
nat
al H
ealt
hca
re i
n U
rban
In
dia
; P
rera
k M
ehta
Res
earc
h r
eport
N
eon
atal
hea
lth
in
Urb
an I
ndia
Th
is p
aper
att
empts
at
un
der
stan
din
g th
e co
re i
ssues
pla
guin
g n
eon
atal
hea
lth
care
am
on
gst
the
urb
an s
ecto
r in
In
dia
, th
e ap
pro
ach
tak
en t
o u
nder
stan
d t
hes
e is
sues
an
d t
he
impli
cati
on
s of
the
appro
ach
. It
poin
ts o
ut
the
opport
un
ity
for
des
ign
in
terv
enti
on
s at
var
ious
jun
cture
s. A
n a
ttem
pt
has
bee
n m
ade
to g
o d
eeper
in
to
the
pra
ctic
al p
roble
ms
bei
ng
face
d b
y th
e var
ious
stak
ehold
ers
- M
oth
er a
nd f
amil
y (f
ath
er, m
oth
er-i
n-
law
, an
d m
ater
nal
mem
ber
s),
Doct
or
and s
upport
sta
ff
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t K
ey
Ch
arac
teri
stic
s/a
spec
ts
cover
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
111
(nurs
es, at
ten
dan
ts),
Publi
c h
ealt
h o
ffic
er/N
GO
an
d
support
sta
ff (
aan
gan
vadi
an
d c
omm
un
ity
level
hea
lth
w
ork
ers)
, an
d B
aby
pro
duct
s sh
opke
eper
s.
121
L
ife
S
pri
ng
Hosp
ital
s: C
an S
pec
ialt
y C
are
Fac
ilit
ies
Red
uce
Mat
ern
al a
nd
Infa
nt
Mort
alit
y R
ates
in
In
dia
?; C
arli
n C
arr
Art
icle
M
ater
nal
an
d in
fan
t m
orta
lity
in
In
dia
Th
is a
rtic
le d
escr
ibes
PP
P i
n t
he
mat
ern
al a
nd
neo
nat
al c
are
aren
a, L
ifeS
pri
ng
Hosp
ital
s P
rivat
e L
td.,
foun
ded
in
2005
, h
as e
mer
ged a
s a
lead
er i
n p
rovid
ing
routi
ne
obst
etri
c ca
re a
nd d
eliv
ery
serv
ices
for
expec
tin
g m
oth
ers
in u
rban
poor
area
s of
Sou
ther
n
India
.
S.
No.
B
ibli
ogr
aphic
Det
ails
T
ype
of
docu
men
t
Key
C
har
acte
rist
ics
/asp
ects
co
ver
ed
Abst
ract
/Mai
n f
indi
ngs
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
112
S
n o
Cit
y F
acil
ity
that
p
rov
ides
car
e to
m
oth
er a
nd
chil
d
No
.
of
faci
liti
es
Sta
tus
of
equ
ipm
ent
avai
labl
e/
tran
spo
rt m
ech
anis
m
Nu
mb
er o
f to
tal
po
pu
lati
on
Nu
mb
er o
f sl
um
s
Rem
ark
s
1A
mba
la
RC
H c
entr
e
3
C
aesa
rean
sec
tio
n,
an X
-ray
m
ach
ine,
US
G,
auto
clav
e,
ven
tila
tor,
an
aest
hes
ia,
lapa
rosc
op
y, a
uto
clav
e, S
NC
U,
T
ran
spo
rt n
ot
avai
labl
e
4,0
00
00
4
2 s
lum
s
T
he
typ
e of
car
e p
rov
ided
at
the
pri
mar
y le
vel
RC
H c
entr
es a
re t
hat
of
AN
C,
imm
un
izat
ion
, T
he
maj
or
pro
ble
m r
emai
ns
that
all
th
e fa
cili
ties
are
ru
nn
ing
in r
ente
d
apar
tmen
ts (
pu
cca
bui
ldin
gs n
ot
avai
labl
e in
th
e sl
um
s ).
MC
H
1
M
CH
II
1
Sec
on
dary
car
e u
nit
( F
RU
s)
3
2B
ard
ham
an
Hea
lth
Po
st
5
Av
aila
bil
ity
of u
ltra
sou
nd
and
oth
er d
iagn
ost
ic w
hic
h a
re
char
geab
le,
the
mat
ern
ity
hom
e is
ta
kin
g ca
re o
f an
ten
atal
ch
eck
up,
im
mu
niz
atio
n
34
7,0
16,
To
tal
slu
m
po
pu
lati
on
8
8,0
00
Th
e fa
cili
ties
ava
ilab
le a
re a
lmo
st d
efu
nct
an
d t
her
e is
no
spec
ific
in
form
atio
n o
n t
he
sam
e. T
he
spec
iali
zed
serv
ices
,
tran
spor
t fa
cili
ty f
or
acce
ssin
g th
e se
rvic
es a
vai
lab
le
at m
ater
nit
y w
ard
, th
e d
iscu
ssio
n o
n
emer
gen
cy c
are
pro
vis
ion
ing
fo
r m
oth
er
and
ch
ild
is a
lso
mis
sin
g
Su
b H
ealt
h P
ost
27
Mat
ern
ity
Hom
e at
urb
an h
osp
ital
1
Sat
ish
Sad
hu
Sm
riti
Po
ura
S
was
tha
Ken
dra
(2n
d u
nit
of
IPP
-V
III(
Ex
tn.)
K
ho
sbag
an
1
3
Bh
op
al
Mat
ern
ity
war
d
wit
h b
aby
frie
nd
ly
env
iro
nm
ent
NA
Co
un
seli
ng
faci
liti
es
avai
labl
e fo
r re
pro
duc
tiv
e h
ealt
h,
RK
S i
s av
aila
ble
,
ther
e is
no
clar
ity
on
th
e n
umb
er o
f eq
uip
men
t an
d
stat
us
of
the
bui
ldin
g
19
,14,
83
9
48
6 s
lum
s
Th
e ci
ty r
epo
rt i
nd
icat
es e
xis
ten
ce o
f fa
cili
ties
fo
r re
pro
duc
tive
an
d n
ew b
orn
h
ealt
h h
ow
ever
th
ere
is n
o c
lear
in
dica
tio
n
of
th
e n
um
ber
of
un
its,
ava
ilab
le
dia
gno
stic
an
d n
ew b
orn
car
e fa
cili
ties
Co
un
sell
ing
Ser
vic
es f
or
Do
mes
tic
Vio
len
ce,
Gen
der
V
iole
nce
, A
do
lesc
ents
, et
c
NA
4B
hu
ban
esw
ar
Urb
an h
ealt
h
po
sts
th
at t
akes
ca
re o
f A
NC
, im
mu
niz
atio
n
21
Th
e U
rban
hea
lth
po
sts
are
sup
po
sed
to
pro
vid
e an
ten
atal
ca
re, im
mu
niz
atio
n.
No
lab
te
chn
olo
gies
ava
ilab
le a
sso
ciat
ed
wit
h m
oth
er a
nd
new
bo
rn h
ealt
h
care
.
8,
81
,98
85
0-6
0
slu
ms
Mo
st o
f th
e U
rban
slu
m h
ealt
h c
ente
rs i
n
the
city
are
eit
her
ru
nn
ing
in r
ente
d b
uil
din
gs o
r co
mm
un
ity
cen
ters
. T
her
e ar
e P
PP
un
der
NR
HM
an
d in
dee
d th
ere
is
oft
en d
upl
icat
ion
of
info
rmat
ion
as
the
sam
e po
pu
lati
on
is
bein
g ca
tere
d b
y th
e u
rban
hea
lth
po
sts
and
the
PP
P u
nit
s
An
nex
ure
2
: C
ity
wis
e M
NH
pro
gram
mes
, sc
hem
es &
inn
ovat
ion
s in
som
e se
lect
cit
ies
acro
ss I
ndia
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
113
Tab
le: A
n a
nal
ysis
of
HM
IS a
cross
dis
tric
ts o
f var
ious
stat
es
Nam
e of
the
dis
tric
t M
eth
od
Sta
tus
of
HM
IS
Nort
h D
inaj
pur
( W
est
Ben
gal)
HM
IS /
MC
TS
( m
oth
er
and c
hil
d tr
acki
ng)
Alt
houg
h H
MIS
/ M
CT
S i
nfo
rmat
ion
is
sen
t to
th
e bl
ock b
ut
feed
bac
k i
s n
ot
rece
ived
pro
perl
y fr
om t
he
blo
ck, at
both
tow
n a
nd
vil
lage
lev
els.
Cooch
beh
ar
(Wes
t B
enga
l) H
MIS
/ M
CT
S S
C l
evel
off
icia
ls a
re n
ot
pro
perl
y tr
ain
ed i
n t
his
form
at. A
lth
ough
HM
IS /
MC
TS
in
form
atio
n i
s s
ent
to t
he
blo
ck
but
feed
bac
k is
not
rece
ived
pro
per
ly f
rom
th
e blo
ck.
Sit
apur
(Utt
ar P
rade
sh)
HM
IS /
MC
TS
Dis
tric
t H
osp
ital
-Sit
apur:
At
the
DH
on
e st
aff
is e
nga
ged
for
HM
IS a
nd
no o
ne
for
MC
TS
. D
H r
eport
s fo
r H
MIS
ar
e n
eith
er t
imel
y n
or
com
ple
te. C
HC
Lah
arpur:
At
the
CH
C t
her
e is
on
e per
son
wh
o lo
oks
afte
r H
MIS
an
d sa
me
per
son
als
o l
ooks
afte
r th
e M
CT
S a
ctiv
itie
s. T
he
HM
IS a
nd
MC
TS
dat
a per
tain
ing
to t
he
CH
C a
re b
ein
g pro
vid
ed
as p
er t
he
pre
scri
bed
tim
elin
es a
nd
are
com
ple
te. D
ata
vali
dati
on
ch
ecks
to s
om
e ex
ten
t fo
r H
MIS
dat
a ar
e be
ing
un
der
taken
pri
or t
o upl
oad
of
the
dat
a on
th
e port
al. P
HC
Bar
ai J
alal
pur
: A
t th
e P
HC
th
ere
are
two
per
son
s w
ho
look
afte
r H
MIS
an
d M
CT
S. T
he
HM
IS a
nd M
CT
S d
ata
per
tain
ing
to t
he
PH
C a
re b
ein
g pro
vid
ed a
s per
th
e
pre
scri
bed t
imel
ines
an
d H
MIS
rep
ort
ing
is c
om
plet
e w
hil
e as
MC
TS
is
com
plet
e to
80 p
erce
nt
level
. D
ata
val
idat
ion
ch
ecks
to H
MIS
dat
a ar
e be
ing
un
dert
aken
pri
or
to u
pload
of
the
data
on
th
e port
al.
MC
H C
entr
e M
adh
avpur
: T
he
AN
M r
eport
ed t
hat
sh
e se
nds
com
plet
e da
ta r
elat
ing
to H
MIS
an
d M
CT
S i
n t
ime
and
it w
as
info
rmed
by
dist
rict
off
icia
ls t
hat
dat
a ar
e of
reas
on
able
qual
ity
as f
ar v
alid
atio
n o
f th
ese
data
are
con
cern
ed.
P
ilib
hit
(Utt
ar P
rade
sh)
HM
IS /
MC
TS
Dis
tric
t H
osp
ital
-Pil
ibh
it: A
t th
e D
H n
o se
par
ate
staf
f is
en
gage
d f
or
HM
IS a
nd
MC
TS
. D
H r
eport
s fo
r H
MIS
are
ti
mel
y an
d c
omple
te.
CH
C P
uran
pur:
At
the
CH
C t
her
e ar
e tw
o per
son
s w
ho l
ook
afte
r H
MIS
an
d t
hre
e per
son
s w
ho l
ook a
fter
th
e M
CT
S a
ctiv
itie
s. T
he
HM
IS a
nd
MC
TS
dat
a pe
rtai
nin
g to
th
e C
HC
are
bei
ng
pro
vided
as
per
th
e pre
scri
bed t
imel
ines
an
d a
re m
ore
or
less
com
ple
te. D
ata
val
idat
ion
ch
ecks
to
som
e ex
ten
t fo
r H
MIS
dat
a ar
e bei
ng
un
dert
aken
pri
or t
o upl
oad
of
the
dat
a on
th
e port
al. P
HC
Mad
hota
nda
: At
the
PH
C t
her
e ar
e tw
o pe
rson
s w
ho l
ook a
fter
HM
IS a
nd
MC
TS
. T
he
HM
IS a
nd M
CT
S d
ata
pert
ain
ing
to t
he
PH
C a
re b
ein
g pro
vid
ed a
s per
th
e pre
scri
bed t
imel
ines
an
d th
ey a
re a
lso c
om
ple
te.
Dat
a va
lidat
ion
ch
ecks
to H
MIS
dat
a ar
e be
ing
un
dert
aken
pri
or t
o uplo
ad o
f th
e dat
a on
th
e port
al. S
C R
am N
agra
: T
he
AN
M r
eport
ed t
hat
sh
e se
nds
com
ple
te d
ata
rela
tin
g to
HM
IS
and M
CT
S i
n t
ime
but
it w
as i
nfo
rmed
by
dis
tric
t of
fici
als
that
dat
a ar
e n
ot a
lway
s va
lidat
ed w
hen
we
rece
ive
them
fr
om
AN
M (
dis
crep
ancy
) L
akh
impur
Kh
eri
(Utt
ar P
rade
sh)
HM
IS /
MC
TS
Dis
tric
t H
osp
ital
- L
akh
impur
Kh
eri:
At
the
DH
, on
e st
aff
is
enga
ged f
or
HM
IS a
nd
MC
TS
. D
H r
eport
s fo
r H
MIS
ar
e ti
mel
y an
d co
mpl
ete
but
no M
CT
S e
ntr
ies
are
bei
ng
don
e. H
MIS
dat
a ar
e n
ot v
alid
ated
bef
ore
sen
din
g to
th
e C
MO
Off
ice.
SC
Kat
oli:
Th
e A
NM
rep
ort
ed t
hat
sh
e se
nds
com
plet
e dat
a re
lati
ng
to H
MIS
an
d M
CT
S i
n t
ime
but
it w
as i
nfo
rmed
by
dis
tric
t of
fici
als
that
dat
a ar
e n
ot
alw
ays
vali
dat
ed w
hen
we
rece
ive
them
fro
m A
NM
.
Kau
sham
bi (U
ttar
Pra
desh
)
HM
IS /
MC
TS
CH
C S
arai
Akee
l: A
t th
e C
HC
no i
nfo
rmat
ion
coul
d be
rece
ived
on
HM
IS a
nd M
CT
S.
Har
doi
(Utt
ar P
rade
sh)
HM
IS /
MC
TS
Dis
tric
t H
osp
ital
-(Fe
mal
e)-H
ardoi:
At
the
DH
on
e se
par
ate
staf
f is
en
gage
d f
or
HM
IS a
nd
MC
TS
. T
imel
ines
s is
ap
par
entl
y m
ain
tain
ed a
nd
data
val
idat
ion
ch
ecks
are
appl
ied.
How
ever
, co
mpl
ete
dat
a is
not
rep
ort
ed.
T
iruch
irap
pal
li
Dis
tric
t (T
amil
Nad
u)
HM
IS /
MC
TS
Dat
a en
try
in t
he
cen
tral
port
als
HM
IS a
nd M
CT
S a
re n
ot
don
e at
th
e per
iph
eral
/ f
acil
ity
level
. T
he
data
fro
m
HM
IS p
orta
l an
d t
he
PIC
ME
port
al a
re t
ran
sfer
red
to t
he
cen
tral
port
als
at t
he
dist
rict
an
d st
ate
level
s re
spec
tive
ly.
Th
e da
ta q
uali
ty i
s fa
r fr
om s
atis
fact
ory
an
d th
e ti
mel
ines
s an
d t
he
accu
racy
nee
d t
o be
im
pro
ved
. U
tili
zati
on
of
the
dat
a fr
om
th
e port
al a
t th
e pe
riph
eral
lev
el i
s n
ot n
oti
ced.
Kri
shn
agir
i H
MIS
/ M
CT
S D
ata
entr
y in
th
e ce
ntr
al p
ort
als
HM
IS a
nd M
CT
S a
re n
ot
don
e at
th
e per
iph
eral
/ f
acil
ity
level
. T
he
data
fro
m
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
114
Dis
tric
t
(Tam
il N
adu)
TN
HM
IS p
ort
al a
nd t
he
PIC
ME
port
al a
re t
ran
sfer
red t
o t
he
cen
tral
port
als
at t
he
dist
rict
an
d st
ate
leve
ls
resp
ecti
vel
y. T
he
dat
a qu
alit
y is
far
fro
m s
atis
fact
ory
an
d t
he
tim
elin
ess
and t
he
accu
racy
nee
d im
pro
vem
ent.
Bun
di
dis
tric
t
(raj
asth
an)
HM
IS /
MC
TS
It i
s be
cause
in
man
y pl
aces
AN
Ms
are
new
ly a
ppoi
nte
d a
nd
they
did
not
rec
eive
d an
y fo
rmal
tra
inin
g of
HM
IS
reco
rdin
g an
d re
port
ing
HM
IS d
ata
are
usi
ng
for
revie
w o
f pe
rform
ance
of
RC
H i
ndic
ators
. On
e of
the
pro
blem
s in
en
suri
ng
good
HM
IS d
ata
is m
ult
ipli
city
of
reco
rd k
eepin
g of
som
e of
the
indi
cato
rs l
ike
BC
G a
nd
som
e ca
ses
of
del
iver
y al
so.
Del
hi
HM
IS /
MC
TS
Adeq
uat
e n
umbe
r of
trai
ned
per
son
nel
en
gage
d i
n H
MIS
Sourc
e: h
ttps:
//n
rhm
-mis
.nic
.in
/
Som
e pro
mis
ing
com
mun
ity
inte
rven
tion
s an
d in
nova
tion
s
Tab
le o
f C
hap
ter
: C
om
mun
ity
Inte
rven
tion
S
no
Pro
gram
/ im
plem
enta
tion
ag
ency
Sta
te /
Cit
y S
tatu
s In
fere
nce
1.
Mam
ta
Del
hi
( N
CR
)
Pre
-2003
Th
e 10K
Clu
b -
a cl
ub f
or
the
hea
lth
& d
evel
opm
ent
of t
he
poore
st’ w
hic
h f
ocu
ses
on
im
pro
vin
g th
e qual
ity
of m
ater
nal
an
d n
ew b
orn
hea
lth
by
elim
inat
ing
pove
rty
thro
ugh
pro
per
mobil
izat
ion
of
loca
l co
mm
un
ity
and
oth
er p
artn
ers
(NG
Os)
.A
fun
ctio
nal
Reg
ion
al R
esourc
e C
ente
r th
at h
as t
rain
ed N
GO
s , N
GO
com
mit
tees
, P
anch
ayat
mem
ber
s ac
ross
Pun
jab,
Har
yan
a an
d C
han
dig
arh
. Th
is h
as g
iven
spec
ial
emph
asis
on
mobil
isin
g w
omen
fo
r re
gist
rati
on
, A
NC
, P
NC
2 S
aath
A
hm
adab
ad,
Guja
rat
2005
1.
Jeev
an D
aan
Mat
ern
al a
nd
Ch
ild
Surv
ival
pro
gram
aim
s at
a) P
neu
mon
ia C
ase
Man
agem
ent
b).
Con
trol
of
Dia
rrh
eal
Dis
ease
s
c). N
utr
itio
n/B
reas
t Fee
din
g
d).
Expa
nded
pro
gram
on
im
mun
izat
ion
e
)Mat
ern
al a
nd N
ewborn
Car
e
2. A
nga
nw
adi
cen
ters
fun
ctio
nal
in
23
war
ds
that
cat
ers
to n
eon
atal
hea
lth
an
d pre
gnan
t w
omen
.
3. A
n R
CH
pro
gram
wh
ich
is
alig
ned
wit
h t
he
con
cept
of
care
giv
ing
and
indu
lges
lin
k w
ork
ers
for
hom
e vis
its.
* T
he
lin
k w
ork
ers
had
un
der
take
n r
igoro
us
hom
e vi
sits
to
reduce
myt
hs
asso
ciat
ed w
ith
pre
gnan
cy a
n
new
bor
n c
are.
3 S
NE
HA
M
um
bai
Cre
atio
n o
f a
impro
ved r
efer
ral
syst
em t
hro
ugh
fol
low
ing
pro
cess
a)
Work
shops
wer
e co
ndu
cted
, bri
ngi
ng
toge
ther
hea
lth
pro
vide
rs f
rom
dif
fere
nt
leve
ls o
f se
rvic
e an
d
acti
on
gro
ups
wer
e fo
rmed
wh
ich
met
on
a m
on
thly
bas
is.
b)
Th
ese
acti
on
gro
ups
crea
ted
a da
taba
se o
f ex
isti
ng
faci
liti
es f
or
mat
ern
al a
nd n
eon
atal
ser
vic
es,
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
115
usi
ng
a se
lf-a
sses
smen
t to
ol
c)
Th
ey s
tan
dard
ized
tec
hn
ical
an
d a
dmin
istr
ativ
e pro
toco
ls a
nd a
nte
nat
al a
nd
neo
nat
al s
ervi
ces
wer
e re
nder
ed t
hro
ugh
pri
mar
y ca
re u
nit
s in
slu
m s
ettl
emen
ts.
4 A
nkur
Mah
aras
htr
a 2000, (
Pil
ot
pro
ject
) ,
1.
Buil
din
g c
apac
ity
of
com
mun
ity
level
mobi
lise
rs, tr
ain
ing
of t
rain
ers,
2.
Cre
atin
g a
pro
cess
to
regi
ster
pre
gnan
t w
omen
, gi
ve
care
an
d al
so r
ecord
cas
es o
f e
ach
new
born
. It
ga
ve h
igh
im
port
ance
to
mon
itori
ng
and
reco
rdin
g dea
ths
and s
till
bir
ths.
3.
Th
e pro
gram
als
o h
ad u
nder
take
n a
str
inge
nt
proce
ss o
f ev
aluat
ing
its
trai
nin
g co
mpon
ent
thro
ugh
re
vie
win
g de
live
rabl
es s
et f
or
the
com
mun
ity
mobi
lise
r
5 Y
ash
oda
S
elec
ted
dis
tric
ts o
f In
dia
2007
Yas
hoda
has
bee
n c
ruci
al i
n t
rain
ing
com
mun
ity
level
work
ers
for
fost
er c
are
of n
eon
tas.
6 S
ure
Sta
rt
Mum
bai :
Qual
ity
of
Car
e m
odel
Pri
or
to 2
012
Th
e m
ain
obj
ecti
ve
of
this
model
was
to
pro
vide
care
to p
regn
ant
moth
ers
and
new
born
s w
ith
th
e h
elp o
f av
aila
bil
ity,
acc
essi
bil
ity,
app
ropri
aten
ess,
an
d ac
cepta
bil
ity
of
publi
c an
d pri
vat
e h
ealt
h s
ervi
ces.
It
also
ai
med
at
esta
blis
hin
g n
ew a
nte
nat
al,
post
-nat
al c
lin
ics
and
com
mun
ity
cen
ters
.
Nav
i M
umba
i
Publi
c-P
riva
te P
artn
ersh
ip (
PP
P)
model
NG
O’s
lik
e D
ISH
A c
ame
fort
h f
or
ensu
rin
g co
mm
un
ity
part
icip
atio
n a
nd s
uper
vis
ion
for
impro
vin
g th
e qual
ity
of m
ater
nal
hea
lth
car
e se
rvic
es.
Th
e obj
ecti
ve
of
this
model
was
to
pro
vide
ser
vic
es li
ke A
NC
/PN
C c
lin
ics,
spec
ial
clin
ics
and
yoga
fa
cili
ties
for
pre
gnan
t w
omen
.
#U
nder
th
is m
ode
l, a
tota
l of
26,8
23 p
regn
ant
wom
en w
ere
exam
ined
in
131
cli
nic
s an
d 2
728 c
ases
wer
e se
nt
to s
peci
al c
lin
ics
P
un
e T
he
Con
ver
gen
ce
model
T
he
mai
n a
im o
f th
is m
ode
l w
as t
o c
reat
e aw
aren
ess
amon
gst
pre
gnan
t w
omen
abo
ut
HIV
an
d cr
eati
ng
a li
nk b
etw
een
In
tegr
ated
Coun
seli
ng
and
Tes
tin
g C
ente
rs a
nd e
stab
lish
ing
com
mit
tees
lik
e M
OM
S
(mon
itori
ng
of
mat
ern
al a
nd
new
born
sta
tus)
. It
has
wel
l in
corp
orat
ed m
oth
ers,
moth
er i
n l
aws,
lin
k w
ork
ers,
AW
Ws
to a
ct a
s a
pre
ssure
gro
up
on
fa
mil
ies
for
safe
r m
oth
er a
nd
new
born
car
e
Nag
pur
, E
mer
gen
cy
Hea
lth
Fun
ds
(EH
F)
E
HF i
s a
fin
anci
al m
ech
anis
m w
hic
h h
elps
in p
rovid
ing
hea
lth
ser
vice
s to
moth
ers
and
new
born
s at
af
ford
able
rat
es. T
o at
tain
th
ese
obje
ctiv
es, pre
pai
d c
ards
wer
e de
velo
ped
afte
r a
thoro
ugh
res
earc
h o
n t
he
nee
d as
sess
men
ts o
f th
e co
mm
un
ity
thro
ugh
soc
ial
mar
keti
ng
cam
pai
gns.
Nea
rly
1160
fam
ilie
s h
ave
rece
ived
ben
efit
un
der
this
EH
F m
odel
so f
ar a
nd
the
mon
ey h
as a
ppa
ren
tly
hel
ped i
n m
eeti
ng
the
cost
of
del
iver
y an
d tr
eatm
ent
of
new
born
s.
Mal
egao
n ,
Qual
ity
of
Car
e m
odel
U
nder
th
is m
odel
, ca
paci
ty b
uild
ing
of
mun
icip
al c
orp
orat
ion
sta
ff a
nd
par
tici
pati
on
& m
obil
izat
ion
of
com
mun
itie
s fo
r h
igh
qual
ity
hea
lth
ser
vice
s w
as t
arge
ted.
Mee
tin
gs o
n t
he
qual
ity
of c
are
in t
wo h
ealt
h p
ost
s h
avin
g an
all
ian
ce w
ith
th
e M
aleg
aon
Mun
icip
al
Corp
ora
tion
was
bei
ng
hel
d o
n a
reg
ular
bas
is
*th
e m
ajor
lim
itat
ion
of
this
pro
gram
was
a l
ack
of t
rain
ed m
anpow
er f
or
hea
lth
pro
visi
on
ing
and
sust
ain
ing
this
pro
cess
.
Sola
pur
Th
e m
ain
obj
ecti
ve
of
this
model
was
to
mob
iliz
e th
e co
mm
un
ity
of
Sola
pur
by
usi
ng
volu
nte
ers
to
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
116
Th
e V
olu
nte
eris
m
model
enh
ance
mat
ern
al a
nd n
eon
atal
hea
lth
ser
vic
es.
Th
e m
ode
l w
as a
suc
cess
an
d ac
cepte
d b
y th
e S
ola
pur
Mun
icip
al C
orp
ora
tion
as
it s
how
ed t
he
dev
elopm
ent
of
its
net
work
of
170
sel
f-h
elp g
roup
s (S
HG
s) w
ho h
eld a
dequat
e kn
ow
ledg
e ab
out
MN
H
care
N
ande
d
Th
e C
om
mun
ity
Bas
ed H
ealt
h
Insu
ran
ce
(CB
HI)
mode
l
In
troduct
ion
of
a se
rvic
e pro
vider
s’ n
etw
ork
an
d em
plo
yin
g co
mm
un
ity
bas
ed h
ealt
h i
nsu
ran
ce k
now
n a
s “A
pn
i S
ehat
”, w
as i
ntr
odu
ced i
n t
arge
ted s
lum
are
as o
f N
anded
cit
y.
Its
aim
was
to
star
t a
hea
lth
in
sura
nce
sch
eme
amon
g th
e poo
r urb
an s
lum
dw
elle
rs, w
ho
coul
d n
ot
mee
t th
e co
st o
f in
stit
uti
on
al d
eliv
erie
s an
d a
nte
nat
al c
are
chec
k-ups.
4.
Muth
ula
ksh
mi
Red
dy M
ater
nal
A
ssis
tan
ce
Sch
eme
Tam
il N
adu
Intr
oduce
d i
n
1989
Sta
te-f
un
ded
sch
eme
of
con
dit
ion
al c
ash
tra
nsf
er (
CC
T)
for
inst
ituti
on
al d
eliv
ery.
It
star
ted b
y off
erin
g a
cash
in
cen
tive
of
Rs.
500 t
o e
ach
pre
gnan
t w
om
an. T
he
sch
eme
was
in
itia
lly
run
by
the
soci
al w
elfa
re
dep
artm
ent
and s
ubse
quen
tly
han
ded o
ver
to
the
hea
lth
dep
artm
ent.
Th
is p
arti
cula
r am
oun
t w
as mea
nt
to
com
pen
sate
pre
gnan
t w
omen
for
wag
e lo
sses
duri
ng
preg
nan
cy.
Subse
que
ntl
y, t
he
amoun
t w
as i
ncr
ease
d to
Rs.
2000
and
then
to
Rs.
6000.
Th
is a
moun
t w
as r
ecen
tly
rais
ed t
o R
s. 1
2,000
per
pre
gnan
cy a
nd i
s pai
d
by
the
gove
rnm
ent
for
the
firs
t tw
o li
ve
birt
hs.
Apa
rt f
rom
wag
e lo
ss c
ompe
nsa
tion
, an
oth
er p
urp
ose
of
givi
ng
the
mon
ey i
s to
pro
vide
addit
ion
al n
utri
tion
to t
he
moth
er t
o p
reve
nt
anem
ia a
nd l
ow
-bir
th w
eigh
t bab
ies.
Th
is s
chem
e is
on
ly m
ean
t fo
r be
low
pov
erty
lin
e (B
PL
) fa
mil
ies.
5.
Th
ree
Sta
ff N
urse
M
odel
: 24x7
fun
ctio
nal
PH
Cs
Tam
il N
adu
Bet
wee
n 2
001
-2006
Th
is i
nn
ovat
ion
en
sure
s sa
fe d
eliv
ery
serv
ices
in
a P
HC
to
the
pre
gnan
t w
om
en, at
th
e on
set
of l
abor
pai
ns,
at
any
tim
e of
th
e day
or
nig
ht.
6.
Tec
hn
olo
gica
l in
novat
ion
s -
Iron
Sucr
ose
In
ject
ion
s
Tam
il N
adu
2009
Iron
suc
rose
is
an i
ron
hyd
roxi
de
sucr
ose
com
ple
x i
n w
ater
. It
is a
dm
inis
tere
d by
in
trav
enous
(IV
) in
ject
ion
or
infu
sion
. T
he
reco
mm
ende
d sc
hed
ule
is
to a
dmin
iste
r 100
mg
intr
aven
ous
ly o
ver
five
min
ute
s, o
nce
or
thri
ce w
eekly
, un
til
1,0
00 m
g h
as b
een
adm
inis
tere
d. T
he
rate
of
adm
inis
trat
ion
sh
oul
d n
ot
exce
ed 2
0 m
g pe
r m
inute
. A
tes
t do
se i
s al
so n
ot
requi
red a
nd
is a
t th
e ph
ysic
ian
’s d
iscr
etio
n.
Iron
su
crose
com
ple
x a
chie
ves
a re
lati
vely
sat
isfa
ctory
lev
el w
hen
use
d i
n s
ever
ely
anae
mic
iro
n d
efic
ien
t pre
gnan
t w
om
en.
7.
Non
-Pn
eum
atic
A
nti
-Sh
ock
G
arm
ent
(NA
SG
)
Tam
il N
adu
T
he
Gove
rnm
ent
of T
amil
Nad
u h
as i
nco
rpora
ted
the
use
of
NA
SG
in
to i
ts p
roto
cols
for
acti
ve
man
agem
ent
of t
hir
d st
age
of l
abou
r an
d r
outi
nel
y tr
ain
s st
aff
at a
ll l
evel
s fo
r it
s use
. N
AS
G i
s n
ow
als
o
bei
ng
kept
in a
ll 1
08 E
mer
gen
cy M
anag
emen
t an
d R
esea
rch
In
stit
ute
(E
MR
I) a
mbula
nce
s in
Tam
il N
adu.
8.
Rak
sha
Pro
ject
Bih
ar,
Raj
asth
an,
Tam
il N
adu
T
o i
mpl
emen
t th
e ‘C
on
tin
uum
of
Car
e’ p
hil
oso
ph
y, a
nd
wit
hin
th
at i
ntr
oduce
d th
e N
AS
G.
9.
Dev
elopm
ent
of
Em
bra
ce B
aby
War
mer
Ben
galu
ru,
Kar
nat
aka
2011
Th
e cu
rren
t fo
rm o
f th
e ba
by w
arm
er w
as a
lso b
ein
g use
d as
a t
ran
sport
dev
ice.
Her
e, i
f th
e L
BW
bab
y i
s re
quir
ed t
o be
tran
sport
ed i
ntr
a-h
osp
ital
or
inte
r-h
osp
ital
for
any
labora
tory
ch
ecks
or
refe
rral
s, t
he
bab
y w
arm
er m
igh
t be
use
d to
kee
p t
he
bab
y w
arm
. It
is
seen
to b
e a
suit
able
alt
ern
ativ
e, w
hic
h i
s ea
sy t
o u
se
and c
ost
eff
ecti
ve.
10.
Sm
ile
on
Wh
eel
Pro
gram
Ch
hat
tisg
arh
, D
elh
i M
ahar
ash
tra,
2006
Focu
sin
g on
wom
en a
nd
chil
dren
, S
mil
e-on
-Wh
eels
is
a n
atio
nal
mul
ti-c
entr
ic m
obil
e h
osp
ital
pro
gram
th
at p
rovid
es m
edic
al c
are
to r
ura
l an
d se
mir
ural
are
as a
nd
urban
slu
ms
wh
ere
gover
nm
enta
l h
ealt
hca
re
faci
liti
es a
re s
carc
e, n
on
exis
ten
t, o
r n
on
fun
ctio
nal
. P
rovi
de
both
pre
ven
tive
and c
ura
tive
ser
vice
s to
th
ose
Maternal and Newborn Health in Urban IndiaA report on literature review
Save the Children, India
117
Ori
ssa,
Tam
il
Nad
u,
Utt
arak
han
d,
Ah
med
abad
, H
yder
abad
, L
uck
now
in n
eed,
incl
udin
g outp
atie
nt,
an
ten
atal
, an
d post
nat
al s
ervi
ces,
iden
tifi
cati
on
of
diff
icult
pre
gna
nci
es a
nd
refe
rral
for
inst
ituti
on
al c
are,
im
mun
izat
ion
s fo
r m
oth
ers
and
chil
dre
n, m
inor
surg
ery,
blo
od p
ress
ure
exam
inat
ion
s, e
lect
roca
rdio
gram
s, f
irst
aid
, ir
on
foli
c ac
id t
able
ts, vit
amin
A p
roph
ylax
is a
nd
trea
tmen
t of
mal
nutr
itio
n.
11.
Inn
ovat
ive
serv
ice
deli
ver
y an
d r
isk
pooli
ng
by
NIC
E
Foun
dat
ion
, In
dia
An
dh
ra
Pra
des
h a
nd
Raj
asth
an
2002
It r
un
s tw
o h
ealt
h p
rogr
ams
in A
ndh
ra P
rades
h -
the
Sch
ool
new
born
hea
lth
care
Pla
n, th
e T
ribal
R
epro
duct
ive
New
born
hea
lth
pro
gram
an
d a
lso o
pera
tes
the
spec
iali
zed
Inst
itute
for
the
New
born
, H
yder
abad
, w
hic
h p
rovi
des
neo
-nat
al c
are
and c
on
duc
ts t
rain
ing
and r
esea
rch
. Th
e S
chool
new
born
h
ealt
hca
re P
lan
has
bee
n r
epli
cate
d i
n t
hre
e dis
tric
ts o
f R
ajas
than
, an
d fu
rth
er r
oll
out
is p
lan
ned
in
th
e st
ate.
12.
Inn
ovat
ive
serv
ice
deli
ver
y by
Lif
e S
pri
ng
Hosp
ital
s P
rivat
e L
imit
ed (
LH
PL
)
An
dh
ra P
rades
h,
Kar
nat
aka,
an
d
Mah
aras
htr
a
2005
Spec
iali
zed p
rovis
ion
of
mat
ern
al a
nd
chil
d se
rvic
es, in
cludin
g an
ten
atal
car
e, p
ost
nat
al c
are,
del
iver
ies,
fa
mil
y pla
nn
ing
serv
ices
, m
edic
al t
erm
inat
ion
of
pre
gnan
cy, ped
iatr
ic c
are
(in
cludi
ng
imm
un
izat
ion
),
dia
gnost
ics,
an
d p
har
mac
y se
rvic
es.
13.
Aro
gya
Rak
sha
Yoja
na
(AR
Y)
Kar
nat
aka
2005
Hea
lth
mic
ro-i
nsu
ran
ce s
chem
e pro
vidin
g af
ford
able
, h
igh
-qual
ity
hea
lth
care
for
the
un
der
serv
ed i
n r
ura
l an
d u
rban
are
as o
f th
e In
dian
sta
te o
f K
arn
atak
a, t
hro
ugh
an
acc
essi
ble
pro
vid
er n
etw
ork
of
pri
vate
h
osp
ital
s an
d cl
inic
s su
pport
ed b
y le
adin
g doc
tors
an
d su
rgeo
ns.
14.
Ch
iran
jeev
i Y
oja
na
(CY
)
Guja
rat
2005
Th
is i
s a
gove
rnm
ent
org
aniz
ed, qua
lity
dri
ven
vouc
her
pro
gram
con
trac
tin
g pri
vat
e obst
etri
cian
s an
d
gyn
ecolo
gist
s to
pro
vide
del
iver
y se
rvic
es t
o w
om
en w
ho
live
bel
ow
th
e pove
rty
lin
e, t
o r
educ
e th
e m
ater
nal
an
d n
ewborn
mort
alit
y ra
tes.
Maternal and Newborn Health in Urban India A report on literature review
Save the Children, India
118