Objective="Access to facility-based RCH services."
Details for Reform Option "Urban Health Improvement Programme, West Bengal"
Areas in and around Kolkata have seen a tremendous increase in population, initially in the form of migrants from Bangladesh and later as increased industrial growth attracted people from neighbouring states looking for work.
This led to the establishment of a large number of slums in these areas, bringing with it social problems such as poverty and illiteracy and health issues due to unhygienic conditions. Those most affected were women and children.
(For more see “Documents & Illustrations” column.)
To address these issues, the Health Department of the Government of West Bengal requested the Kolkata Municipal Development Authority (KMDA) to take up urban health services along with its other developmental activities.
Community based health programmes were initiated: Calcutta Urban Development Programme – III or CUDP-III (between 1984 and 1992), Calcutta Slum Improvement Programme or CSIP (1992-98), India Population Project - VIII or IPP-VIII* (1994-2002) and most recently the Urban Health Improvement Programme (UHIP) since July 2002 which helped set up the infrastructure to provide Reproductive and Child Health (RCH) services in the KMDA area.
The main features of the system were:
(i) Honorary Health Workers (HHWs) who work as link workers and are the first point of contact between the public and the health system. For more information on HHWs, see Documents and Illustrations.
(ii) Sub centres form the next level and are established for every five blocks. Five HHWs report to the supervisor (usually an upgraded HHW) who is based at the sub centre. Two part-time medical officers and the first-tier supervisor based here provide basic primary health care services including antenatal and post natal care, immunisation of children and family planning services. They also organise periodic meetings for parents.
(iii) The Health Administrative Unit (HAU) has 6 or 7 Sub centres under it. One sub centre is located at the HAU building. A HAU is manned by a health officer, assistant health officer, part-time medical officer and second-tier supervisor. The HAUs ensure procurement of drugs, storage and distribution.
(iv) The next level is the Extended Specialised Outpatient Department (ESOPD) serving a population of 200,000 and offering specialist services and charging user fees. For more details see Documents and Illustrations below.
In addition, a Regional Diagnostic Centre (RDC) has also been set up for a population of 400,000 providing services such as x-rays, ultra-sonography and other pathological tests. Here again user fees are levied at differential rates for those above and below the poverty line, but charges are slightly lower than the prevalent market rates as the RDC competes with other private diagnostic centers.
Under the European Commission-assisted Urban Health Improvement Programme (UHIP), six municipalities were identified as pilot areas in order to integrate the existing health delivery system with other parallel departments and programmes.
The programme includes:
(i) Upgrading the existing structures.
(ii) Provision of the following services: specialised service delivery for detection and management of Reproductive Tract Infection (RTI) and Sexually Transmitted Infection (STI) cases including preliminary laboratory investigations for screening of these cases at the HAU; safe Medical Termination of Pregnancy (MTP) services up to 10 weeks at HAU level (beyond 10 weeks at Maternity Home); female sterilisation/ IUD insertion at the HAU.
(iii) A School Health Programme.
(iv) A Management Information and Evaluation System (MIES).
(v) Resource mobilisation has been started with the setting up of a Health Development Fund.
See Documents and Illustrations for more details.
The endline evaluation survey for the IPP-VII (2002) shows an infant mortality rate (IMR) of 25.6 while the 6 municipalities under the UHIP had an IMR of 15.6 in the year 2003-04. Similarly the Couple Protection Rate (CPR) which was 75% in 2002 went up to 78.8% in the UHIP municipalities in 2003-04.
INR 703,000 for the first year. Total expenditure incurred under the UHIP upto 31 December 2004 was INR 37,281,000.
Costs for earlier programmes:
CUDP-III (1984-92) INR 767,57,000.
IPP-VII (1994-2002) INR 9841,63,000.
CSIP (1992-98) INR 558,90,000 (Euro 980,852)
Six municipalities in West Bengal – Bhadreswar, New Barrackpore, North Barrackpore, Naihati, Madhyamgram and South Dum Dum since July 2002.
Construction and setting up of facilities completed within one year from commencement of project.
Inclusive approach: Inter-sectoral convergence & integration with other similar development programmes.
Self-sustaining: Resource generation by local bodies.
Practical: Optimal use of existing infrastructure.
Effective use of manpower: Capacity building for better management at all levels including training on clinical, administrative, financial and logistics.
Needs specific: Provision of services based on the disease burden of the area.
Authorities and service providers are accountable and accessible to the population, hence service quality is maintained.
The operation being on a small scale, cooperation with and communication from other related departments is easy and can be readily accomplished, thereby making implementation smooth and successful.
Technical assistance on establishing the conceptual and operational framework and capacity building of the municipalities to provide health services is necessary.
Who needs to be consulted
Officials at the State Health & Family Welfare Government,
KMDA and Municipalities.
Initial funding is needed for upgradation of services, capacity building and awareness generation. After that it would be self reliant through the use of the community-based health development fund.
Chances of Replication
On achievement of successful reforms at the six municipalities, it will be replicated in the remaining municipalities under the KMDA area.
The programme largely owes its success to a strong political backing in West Bengal.
Sara Joseph, Researcher, ECTA, New Delhi, December 2004.