Details for Reform Option "Kolkata Family Welfare Urban Slums Project, West Bengal"
Kolkata, capital of the state of West Bengal, suffers from huge overcrowding and strained public utilities because of mass migration into the city post Partition (1947) and the creation of Bangladesh (1971).
The migrations have resulted in a vast Below Poverty Level (BPL) slum population posing high volatility and social and political pressures. The challenges for provision of minimal and decent RCH care in such a mix are huge.
The India Population Project (8) Kolkata programme aimed to address the formidable challenge of delivering cost-effective, affordable and quality RCH interventions in the slums.
The project was a critical part of the World Bank’s strategy of supporting human development and poverty alleviation in India, providing the opportunity to extend rapid and targeted assistance to the most vulnerable slum populations who were not adequately covered by the existing primary health care infrastructure.
The objectives were to:
(i) reduce fertility by improving access to demand for family planning services.
(ii) improve maternal and child health by decreasing mortality rates.
The programme addressed this by:
(i) Recruiting volunteers: local women were trained and designated as Honorary Health Workers (HHWs). They were paid a monthly honorarium (INR 500) and told to work closely with the community and the health workers operating in the facilities created under the project.
(ii) Enhancing access to RCH services: through the construction of new service outlets and upgrading of existing facilities.
Emphasis was placed on
(a) pre-service and in-service training for medical and paramedical staff;
(b) training of female volunteers to help outreach service delivery;
(c) increased involvement of Community-based Organisations (CBOs) and private medical practitioners in training as well as service delivery.
(iii) Training cells were established to plan and implement systematic training to the above personnel. Essential supplies such as health worker kits, medicines, etc. were provided.
A two-pronged strategy was adopted to generate the demand for Family Welfare (FW) and Maternal Child Health (MCH) services – first, establishment of client-friendly services; second, development of an Information, Education, Communication (IEC) strategy, which had a focus on priority health seeking behaviours giving attention to inter-personal communication. Messages disseminated through entertainment media such as folk songs, drama, magic show, etc., However, the most important media of behavioural change was interpersonal communication, especially through HHWs.
To facilitate women’s empowerment and income generation, the project involved innovative schemes focusing on young females and adolescent girls and included vocational training, entrepreneurship development training, reproductive health education, etc. The implementation was done in close collaboration with CBOs and local municipalities.
Evaluation report by the World Bank found:
Infant mortality rate down from 55.6 to 25.6.
Institutional delivery up from 53.9 to 89.
Fully immunised children up from 57.1 (mid-term) to 89.1.
INR 94.76 crore ).
Funding included support from the International Development Association (IDA) of INR 3,28 crore and the Kolkata Metropolitan Development Authority (KMDA) which used a Credit of about INR 78 crore .
Kolkata 1994 – 2002.
Now ongoing under the supervision of Local Urban Bodies with technical oversight from Kolkata Metropolitan Development Authority and funding from the state budget of the Municipal Affairs Department.
Five to seven years.
Quality: Provides a network of quality infrastructures.
Better service: Provision and utilisation of service delivery.
Empowerment: Community mobilisation and involvement and ownership of low cost interventions.
Sustainable: Enhanced institutional and financial sustainability.
Needs comprehensive approach: No single agency can effectively address the growing health needs of the urban poor. There is a need for strategic partnerships between public and private sectors working closely with the communities.
Needs lengthy commitment: There needs to be a long-term social and political commitment to the programme for it to succeed.
Increased provision of RCH services needed: To keep pace with the demand from newly empowered women. There is no point in educating them about contraception or institutional deliveries and then not being able to provide the facilities.
Needs flexibility: There is no single solution to Urban RCH issues and strategies need to be flexible and based on local needs and capacities.
Formation of steering or executive committees to oversee implementation of project.
Training cell established.
Recruit female volunteers from community targeted.
Management training for project managers.
Minimising delays by obtaining all clearances in advance is critical for project implementation.
-- Bringing health on to the local political agenda through decentralisation is critical for sustained delivery of health care to the slum populations.
Who needs to be consulted
Ministry of Health and Family Welfare. State Government (State Urban Development Department; State Health Department; Municipal Affairs; State Finance Dept) The Municipal Corporation. Donor organisation (in this case World Bank). Community based organisations. Local private medical officers and facilities.
The project has been proven to be sustainable and is still ongoing (September 2004).
On the institutional side, the management has been decentralised to Local Urban Bodies and the chair persons/ mayors of the 40 local bodies are now managing the programme with technical oversight from KMDA.
Very high level political commitment by the State of West Bengal contributed substantially to institutional sustainability of the project.
On the financial sustainability side, a provision has been made for the recurring charges through provision in the state budget of the Municipal Affairs Department.
Chances of Replication
The project has already been extended to 20 more cities (outside the KMDA areas) in the State of West Bengal with support from the Department for International Development (DFID) and International Development Association.
The IPP (8) project was also being implemented concurrently in 4 cities (Kolkata, Bangalore, Hyderabad and Delhi). All the 4 cities followed different operational models to implement the IPP (8) project according to the city specific situation.
Replication may not be straightforward and would depend on the specific context. For example:
(i) Kolkata slums were stationary (vis-à-vis Delhi where slums shifted after the construction of health posts, adversely affecting utilisation);
(ii) using part-time doctors on modest compensation and volunteers on payment of nominal honoraria is unlikely to work automatically in other cities;
(iii) in the absence of social and political mobilisation and pressure, the community-based low-cost and cost sharing arrangements may not work easily; and
(iv) ethnic composition of the Kolkata slums was also more varied, allowing for a wide mix of interventions.
However, replication with suitable modifications is possible.
The positive lessons learnt from the Kolkata model would be useful in other settings: community drafted project; voluntary characteristic of grass root level workers; bottom-up approach; active involvement of CBOs acting as a solid platform; developing community partnership;
active involvement of elected representatives; effective management and supervision cell and involvement with private medical practitioners for service delivery.
The project was innovative, accepted by the community and provided ‘value for money’.
Clare Kitchen, Research Consultant, ECTA, New Delhi. September 2004.