Details for Reform Option "Urban Health Programme, Kolkata"
This programme, undertaken by the NGO CINI ASHA, began in 1999 as the CINI-Local Initiatives Programme (CINI-LIP) financed by the Bill and Melinda Gates Foundation, and is now being continued by CINI ASHA as the Urban Health Programme with funding from the Irish Embassy, USAID’s Environmental Health Project and CINI’s own fundraising efforts.
It aims to make medical Reproductive Child Health (RCH) services accessible to people living in 12 of Kolkata’s most backward slums.
The programme includes:
(i) Setting up 17 health posts in the project slums, usually in youth clubs, so that the community provides the infrastructure and felt a sense of ownership. This is also an important contribution as space is at a premium in a congested slum. (More information on the activities held at each health post can be found in the Documents and Illustrations box below.)
(ii) Recruiting slum women to become Community Health Volunteers (CHVs) giving health education and supplying contraceptives. Each woman is trained to give 24-hour cover to a population of 1000,, making sure that people use medical services when they need to and with an emphasis on encouraging institutional deliveries.
(iii) Training the CHVs to do Eligible Couple (ELCO) mapping – charting each house and detailing how many children live there, whether they are immunised, whether there is a pregnant woman living there, whether she is registered at a hospital and whether the couple is using contraception. CINI ASHA developed a colour-coded scheme on a pictorial map because most of the CHVs are illiterate.
(iv) Recruiting Swasthya Sevikas (SSs - Health Workers), residents of the slum educated to Higher Secondary level, to supervise the CHVs. They follow up care for all pregnant women and children under two, using the ELCO map. They supervise 10 CHVs each.
(v) Establishing a referral network of 29 qualified private physicians who practice near the slums, using a system of referral slips or vouchers. Each beneficiary needing medical care is given a voucher by the CHVs entitling them to free treatment by these physicians, paid for by CINI ASHA.
The physicians charge the NGO INR 15 for two visits – discounted from the normal fees of INR 50-70 per visit. Their incentives for taking part include an increase in patient volume, endorsement by CINI ASHA, the opportunity to meet doctors from top hospitals at seminars organised by CINI ASHA and also a feeling that they are doing some good for the poor.
The physicians are instructed to prescribe generic drugs from the World Health Organisation’s essential drug list and the programme supplies these drugs to the health posts, so that they are available free of charge to the patients.
(vi) CINI Asha has also linked up with private diagnostic centres to do tests at subsidised rates.
Between January 2000 and the end of 2002 contraceptive acceptance went up from 34% to 59%; immunization coverage increased from 47% to 89% and the proportion of institutional deliveries rose from 67% to 83%.
On average, more than 50 vouchers are reimbursed per physician each month.
Seven hundred women have been trained in the community as CHVs (training is on-the-job for three to 6 months).
The programme was funded by the Bill and Melinda Gates Foundation until October 2004. It cost INR 2,706,900 per year.
CHVs are paid an honorarium of INR 200 per month.
SSs are paid INR 1,000 per month.
Eastern and central parts of Kolkata, covering a population of 240,000 in 10 municipal wards, since 1999.
Community involvement: The whole programme was developed with the participation of the community and has resulted in a feeling of community ownership.
Empowerment of CHVs: The programme gives the women recruited as CHVs new status within the community. They are given certificates, written in English, to hang in their homes.
Education: The programme has taught the CHVs about their bodies and they have been able to pass on this knowledge to others.
Increased workforce: The CHVs are now being used by the local health authority for other programmes such as the Pulse Polio immunization programme.
Cost: The programme currently depends upon external funding to be sustainable.
Motivation: Because the financial incentive is nominal, the programme depends upon the motivation and good will of the CHVs to be sustainable.
Cooperation of the community. Network of private physicians practising near the slums. Trainers.
Who needs to be consulted
Doctors, community, community leaders.
Sustainability depends on funding, community ownership and the goodwill and motivation of the CHVs. The programme has just introduced (May 2005) a health fund system in which the community contribute nominally to the cost of services provided.
Chances of Replication
Possible in any slum area which has an active community and access to private physicians. CINI ASHA is currently (November 2004) investigating whether it is feasible to replicate the scheme in Siliguri, West Bengal.
CINI ASHA believes in tackling the health status of the urban poor through the life cycle approach. Behaviour change is seen as the biggest challenge and the only way of making the scheme truly sustainable.
Clare Kitchen, Research Consultant, ECTA, New Delhi. May 2005.