CONVERGENCE FOR

IMPROVED PLAN OF ACTION HEALTHGwalior City, JuneAND 2019 WELLBEING

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INDEX

Page No. List of abbreviations

Executive Summary

1. Background 1

2. Current health system scenario in city 5

3. Conceptual framework for Plan of Action 16

4. Key components of Plan of Action for Convergence 19

5. Logical Framework for operationalizing plan of action 22

6. Outputs and Outcomes 28

7. Non-negotiables and negotiables 29

8. Monitoring 30

Annexures:

1. Ward wise area and population in Gwalior city (2018) 31

2. Comparative Demographic Indicators for district Gwalior 32

3. Comparative Demographic Indicators for rural and urban areas of Gwalior 33

List of Tables

1. Comparison of key health indicators (NFHS-4, 2015-16) 4

2. Detailed findings from landscape assessment – Governance 7

3. Detailed findings from landscape assessment – Management 9

4. Detailed findings from landscape assessment – Implementation 13

Diagrams 34

LIST OF ABBREVIATIONS

ANC Ante Natal Care ANM Auxiliary Nurse and Midwife APM Assistant Programme Manager ASHA Accredited Social Health Activist AWC Aangan Wadi Center AWW Aangan Wadi Worker CEO Chief Executive Officer CMHO Chief Medical and Health Officer CS Civil Surgeon DHFW Department of Health and Family Welfare DPM District Programme Manager DPMU District Programme Management Unit DUDA District Urban Development Authority FMIS Financial Management Information System FOGSI Federation of Obstetric and Gynaecological Societies of FP Family Planning GIS Geographical Information System GMC Gwalior Municipal Corporation GUA Gwalior Urban Agglomeration Hb Haemoglobin HMIS Health Management Information System HR Human Resource IAP Indian Academy of Paediatrics ICDS Integrated Child Development Services IMA Indian Medical Association IUCD Intra Uterine Contraceptive Device JSY Janani Suraksha Yojana M&E Monitoring and Evaluation MAS Mahila Arogya Samiti MC Municipal Corporation MNCH Maternal, Newborn, and Child Health MO Medical Officer MP NCR National Capital Region NFHS National Family Health Survey NGO Non-Government Organization NHM National Health Mission NUHM National Urban Health Mission OPD Out Patient Department ORS Oral Rehydration Salts

PIP Programme Implementation Plan PMU Programme Management Unit PNC Post Natal Care POA Plan of Action QA Quality Assurance RKS Rogi Kalyan Samiti RMNCAH Reproductive, Maternal, Newborn, Adolescent, and Child Health RMNCH Reproductive, Maternal, Newborn, and Child Health SNCU Special Newborn Care Unit sq km Square Kilometre SWOT Strengths, Weaknesses, Opportunities, Threats TCIHC The Challenge Initiative for Healthy Cities TOR Terms Of Reference UCHC Urban Community Health Center UHND Urban Health and Nutrition Days ULB Urban Local Bodies UN United Nations UPHC Urban Primary Health Center USAID United States Agency for International Development WCD Woman and Child Development

EXECUTIVE SUMMARY

India’s fast urbanization trends are leading to ‘urban chaos’ and deterioration of quality of human life. The urban population in the country is expected to reach 40.7%, i.e. nearly 590 million, by 2030. Cities, in particular, are confronted by the triple threat of communicable and non-communicable diseases and poor environmental conditions. The health of the urban poor is considerably worse than that of the urban middle- and high- income groups, and possibly even worse than the rural population. The public s urban healthcare delivery system has so far been sporadic, far from adequate, and limited in its reach, especially for the por. Other, non-health factors, are also contributing to the inadequate reach of services. These include ineffective outreach, weak referral system, barriers to access, social exclusion, lack of information, and lack of economic resources. Limited resources with the health department often limits the interventions and reach of services.

In order to address these issues and improve the health of the urban population, particularly of the poor and other disadvantaged sections, the National Urban Health Mission (NUHM) is attempting to facilitate equitable access to quality healthcare through a revamped public health system. The implementation framework entailed the development of city specific health plans by the health departments with equal participation and support from other related departments, such as Social Welfare, Education, Woman and Child Development (WCD), and Urban Development, to name a few. This goal was to prevent duplication of resource utilization through an impactful convergence and coordination between all related stakeholders.

Gwalior, one of the prominent cities from central India facing the brunt of increased urbanization and unplanned settlements, has been designated a Smart City under Government of India’s flagship ‘Smart Cities Mission’. A landscape assessment conducted in Gwalior, along with three other cities of Madhya Pradesh in 2017 by a donor funded project, revealed many gaps in the governance, management, and implementation of public healthcare delivery system.

Improper water supply, inadequate health facilities, polluted drinking water, dust and heat are some of the major arising from the fast growth of urban Centers in Gwalior that negatively impact the health and wellbeing of its citizens.

The policies and programs implemented by non-health sectors and departments, can have a significant impact on public health. A desk review of various schemes and programs implemented by different Ministries and Departments revealed that there are many flagship schemes which have health related

components and have resources to operationalize these components. Therefore, a convergence between these departments will not only lead to more effective implementation and optimum resource utilization, but will also have a significant impact on the health of the citizens. To this end, a plan of action has been developed that describes the steps necessary for the development of a comprehensive health plan for the city of Gwalior based on this principle of convergence. The specific objectives of the plan include identifying departments and stakeholders that can collaborate, explore areas for collaboration and develop guidelines, assess available resources, and develop measurable indicators to monitor the progress.

The plan of action envisages a convergence plan at three levels. city level, ward level, and at the level of urban slums and mohallas and includes specific sections on step wise activities that need to be undertaken. Broadly, the activities include assessment of different schemes and programs, stakeholder analysis, development of convergence plan, situation analysis, gap identification, stakeholder consultation for development of city health plan, finalizing timelines and budget source, and institutionalizing a monitoring framework. Each of these steps have been included in a logic framework describing the steps under each activity, process to be followed to achieve it, responsible party, and the outcome of every step. The document also describes the outputs and outcomes that shall be achieved when the plan is stringently followed and proposes a monitoring framework to be finalized following a consultative process.

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BACKGROUND

Along with economic development, India is undergoing intense urbanization that started at the beginning of this century. According to 1901 census, the population residing in India’s urban areas was 11.4%, 28.5% according to 2001 census, and reached 31.2% in the 2011 census. This proportion increased to 34% in 20181 and is expected to reach 40.7%, i.e. nearly 590 million, by 20302..

This rapid urbanization leads to ‘urban chaos’ associated with deteriorating quality of life Experts say that the health of the urban poor is considerably worse than those in the urban middle- and high- income groups, and even worse than the rural population where health services are inaccessible. The situation in cities is exacerbated by poor living conditions which enable the triple threat of infectious diseases, non-communicable diseases, and unhealthy behaviors such as tobacco use, unhealthy diets, stressful routine, sedentary lifestyle. and finally injuries, road accidents, violence and crime.

The public urban healthcare delivery system has been failing the urban poor, due to inconsistent service delivery, poor quality, and limited reach. Additionally, non-health factors, of social and structural nature, contribute to the inadequate reach of services. These include unrecognized/illegal settlements, social exclusion of slums, hidden slum pockets, weak social fabric, lack of coordination among various stakeholders, sectors and departments, and neglected political consciousness. This has led to the rapid proliferation of an ‘informal private health sector’ in urban areas, led by non- medical practitioners that is contributing to this public health crisis.

GAPS IN URBAN PUBLIC HEALTH DELIVERY SYSTEM

 Ineffective outreach and weak referral system  Limited access and social exclusion for the urban poor  Lack of information and assistance at the secondary and tertiary health facilities  Lack of economic resources inhibiting/restricting the service utilization

 Lack of standards and norms for urban health delivery

 More strain on available infrastructure and human resource due to large population

1United Nations Population Division. World Urbanization Prospects: 2018 Revision, https://data.worldbank.org/indicator/SP.URB.TOTL.in.zs

2 State of World Population 2007. Unleashing the Potential of Urban Growth, UNFPA (2007), https://www.unfpa.org/publications/state-world-population-2007

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The National Urban Health Mission (NUHM) aims to address these gaps and improve the health status of the urban population, particularly for the poor and disadvantaged population, by facilitating equitable access to quality healthcare through a revamped public health system by using community based mechanisms with the active involvement of the urban local bodies and private sector players.

NUHM’s vision is to develop and implement a comprehensive ‘City Health Plans” led by the Department of Health and Family Welfare (DHFW) to address city-specific issues, with equal participation and support from other departments, like Social Welfare, Education, Woman and Child Development (WCD), and Urban Development. This collaboration across departments will help reprioritize and allocate resources under the NUHM to facilitate a seamless flow between the NHM Program Implementation Plan (PIP) and operational plans. Additionally, it will prevent duplication of resources through an impactful convergence and coordination between all related stakeholders.

A glimpse of Gwalior city

Gwalior, is a major city in central India, with a total population of 20.32 lakhs, 62.6 percent of which is urban3. Gwalior has been selected as one of the hundred Indian cities to be developed as a smart city under Government of India’s flagship ‘Smart Cities Mission’. However, the absence of comprehensive ‘Gwalior City Health Plan’ has caused a delay in reaching the desired urban population segment as envisioned under NUHM. This lack of plan resulted in low demand for services and underutilization of resources for an underserved population, and failed to engage the active

3 India Census 2011

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participation of the private sector, which despite a significant presence doesn’t supplement the efforts of the public health care delivery system.

Table 1 offers a snapshot on the status of health indicators as per the fourth round of National Family Health Survey (NFHS) 2015-2016. The results reveal the grim status of maternal and child health related indicators, specifically in the urban areas of Gwalior, when compared with the overall status of the city, compared to the State and National level indicators.

This document describes the process for developing a convergence plan for urban public health and other related departments, and other important stakeholders. The intended audience for this document include departmental heads, program managers, nodal officers, and coordinators who are involved in planning and implementing department specific activities and oversee the resource allocation and utilization. The specific objective of this ‘Plan of Action’ is to guide different departments on ways of working together with the goal of generating better health outcomes of Gwalior city.

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Table 1: Comparison of key health indicators (Source: NFHS-4, 2015-16)

Madhya Gwalior Indicator India Pradesh Urban Rural Total Mothers having antenatal checkup in first trimester (%) 58.6 53 56.5 48.9 53.8 Mothers who had full antenatal care (%) 21.0 11.4 17.1 10.3 14.6 Mothers whose last birth was protected against neonatal tetanus 89.0 89.8 94.7 93.0 94.1 Average out of pocket expenditure per delivery in public health facility Rs. 3,197 Rs. 1,481 Rs. 1,931 Rs. 1,372 Rs. 1,725 Institutional births in public facility (%) 52.1 69.4 66.6 71.0 68.4 Children 12-23 months fully immunized (%) 62.0 53.6 51.4 54.4 52.5 Children 12-23 months who received most vaccination in public facility 90.7 95.7 87.9 100.0 92.3 Children 9-59 months who received Vitamin A in last 6 months 60.2 60.4 62.2 63.0 62.5 Prevalence of diarrhea (2 weeks preceding the survey) 9.2 9.5 9.6 8.2 9.1 Children with diarrhea who received ORS (2 weeks preceding survey) 50.6 55.2 51.2 49.8 50.7 Children with respiratory infection taken to health facility (2 Wk prior) 73.2 70.9 79.7 82.0 80.4 Children under 3 years breastfed within one hour of birth (%) 41.6 34.4 25.8 28.9 26.9 Children under 5 years who are stunted (height for age) 38.4 42.0 42.1 44.1 42.8 Children under 5 years who are underweight (weight for age) 35.8 42.8 47.6 50.0 48.5 Children 6-59 months who are anemic (Hb < 11 gm/dl) 58.6 68.9 69.5 67.1 68.6 All women age 15-49 years who are anemic (%) 53.1 52.5 56.1 60.1 57.4 Total unmet need for family planning (%) 12.9 12.1 12.0 12.0 12.0

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CURRENT HEALTH SYSTEM IN GWALIOR

A landscape assessment was performed in four cities of Madhya Pradesh (Gwalior, Dewas, Ujjain, and Indore) in 2017 by ‘The Challenge Initiative for Healthy Cities (TCIHC)’, a project jointly supported by the Bill and Melinda Gates Foundation (through the Bill and Melinda Gates Institute for Population and Reproductive Health) and USAID/India (through the Maternal and Child Survival Program), with the following objectives:

 Understand functioning of the private and public healthcare sectors in delivering public health services to the urban poor population  Assess the supporting functions and roles performed by the health systems stakeholders with respect to policy and utilization of services by the urban poor communities  Assess the preparedness of the urban healthcare service delivery system, including the Municipal Corporation and government frontline workers for providing Reproductive, Maternal, Newborn, and Child Health (RMNCH) services.

Key Recommendations from the Landscape Assessment

 Initiate convergence of the city health department/District Programme Management Unit (DPMU) with urban local bodies (MC), and other departments and ministries.

 Engage private sector (both individual service providers and organizations) in ensuring better access and quality service provision in urban areas.

 Strengthen the overall health system: infrastructure, human resource, capacity building, record keeping, HMIS management and monitoring mechanism at all levels of care.

 Operationalize the Urban Primary Health Center (UPHC) as primary level service delivery hub with a defined network of Urban Health and Nutrition Days (UHND) and outreach service delivery platforms.

 Integrate RMNCAH thematic divisions within urban health.

 Establish linkages between Mahila Arogya Samiti (MAS)- Accredited Social Health Activist (ASHA)- Auxiliary Nurse and Midwife (ANM)-UHND-UPHC through a community referral mechanism.

 Ensure convergence between ASHAs, Aangan Wadi Workers (AWW), and ANMs for better logistic management, periodic monitoring and supervision, and linkages with UPHCs.

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 Establish appropriate referral to provide a continuum of care from the community to the facility (forward referral) and back to the community (back referral); and from the facility to the community (counter-referral).

 Strengthen community-based platforms to increase the utilization of community level services through the UHND and primary level care at UPHC.

 Enhance the capacity of MAS to deliver their basic functions, development of citizen charter for MAS members’ roles and responsibilities, and linkages with public health network.

 Introduce community level supportive supervision mechanism for ASHA along with specific capacity building modules on soft skills.

Partnerships between community development, healthcare, social services, and public health hold the potential to realize measurable and critically needed improvements for people in low-income communities.

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Table 2: Detailed findings from landscape assessment of healthcare services in Gwalior - GOVERNANCE

Strengths Weaknesses Recommendations

 All health facilities of urban areas are  City and Divisional PMU have been  There should be a dedicated position of APM structured under the civil surgeon role discontinued after a state level decision. This and Accountant for urban health to support which in turn reports to the Chief Medical was done to address issues like HR DPM. and Health Officer (CMHO). The distribution continuation and poor utilization of NUHM  DPMU staff and other concerned health of financial powers and approval limits are funds. However, it has created a gap in officials must undergo special training on distributed between position. These implementation of urban health activities and financial planning and management. mechanisms have led to accountability, has district PMU staff is overburdened. empowered decision-makers, and led to  Mechanisms must be developed to assess  DPMs can allocate only up to 30% of time for reduction in delays and administrative financial accountability including monthly urban health activities, including the approval challenges. monitoring, internal and external audit, and disbursement of funds. This results in a correlation with planned activities, and  District PMU implement urban health delay for all the activities. performance. activities and provide services through  Financial management of urban health UPHCs and UCHCs, and during UHND with  Like NRHM dashboard indicators, NUHM facilities is done by the accountant at DPMU. support from ASHA and MAS members at should also have specific indicators to There is neither a dedicated accountant for the community level. measure progress and prioritize activities. urban areas nor any provision to hire a person  Primarily, DPM (and APM, where they are from contingency funds. This results in  Cities must have an independent team within posted) are responsible for PIP planning for administrative delays and challenges. the DPMU for planning and monitoring urban city areas and include urban health related health activities.  The functioning of RKS is not optimum and issues identified through monitoring in the uniform, which adversely affects fund  Cities should have five-year City Health Plans PIP. utilisation. In many cities, DPMU does direct to guide concerned departments by  Processes related to flow of funds are purchases and spending of funds for the identifying needs, setting priorities, and plan structured. Funds are distributed from the UPHC, resulting in delays. resources and activities in annual PIPs. State to districts and from there to the implementing units (UCHC, UPHC and MAS)

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facilities. Activities are implemented as per  Apart from the financial audit, there are  Grassroots level healthcare functionaries the PIP and to ensure timelyfund release is limited formal accountability mechanisms in must be consulted on gaps and unmet needs not contingent on submission of utilization place in order to strengthen bottom-up planning. certificate. Fund utilization is tracked by  Cities have no annual or long-term City Health  Mechanisms are needed to monitor DPMU using a Financial Management Plans to guide the PIP on resource allocation accountability and performance through Information System (FMIS). and other urban health related activities. monthly reviews and performance appraisals.  All transactions (receipts/payments) are State government can also explore  The cities follow a format-driven, top-down done through bank transfers, allowing for mechanisms of linking increments and approach, with minimal customization of greater speed, transparency, and efficiency. incentives with performance. plans informed by the city health needs. Most  Financial audits are regularly conducted to of the activities included are based on ten  At the primary health care level, a systematic monitor and document utilization of funds percent variation from previous PIPs. assessment process must be established to and the activities that are being rate UPHCs based on clear performance  Community involvement is insignificant implemented. DPMU audits utilization of indicators and a scorecard, and a process of during PIP development and there is no funds on a monthly basis. The release of periodic reviews to check and document mechanism to incorporate inputs from the next installment is done only after 80% of changes or improvements. community and grassroots-level service the previous installment gets utilized. providers.  A dialogue process for policy amendment must be initiated at the state level to initially  The Role of MC with respect to public health is strengthen shared responsibilities, followed limited to provision of sanitation and waste by gradually supporting the ULB/MC to take management services. Other activities include the responsibility of supporting health service outreach assistance for spraying and other delivery. disease control measures.

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Table 3: Detailed findings from landscape assessment of healthcare services in Gwalior - MANAGEMENT

Strengths Weaknesses Recommendations  Formal structures for recruitment, training,  The recruitment of MO, staff nurses, and  Recruitment should be decentralised to delegation, reporting, procurement and ANMs is centralized and done by the state ensure selection of appropriate staff for any planning are in place. government. This leads to bureaucratic delays location and consistent program and in many instances, recruitment of non- implementation  Process of ASHA recruitment is under way local professionals who leave their jobs to and MAS have been newly inducted in the  In larger cities with migrant populations, return to their own areas. state. mobile health clinics should be considered for  ANMs attached to urban areas have been improved service delivery for hard to reach  A well-defined online software-based transferred to rural areas and their positions in populations mechanism of performance-based annual urban areas remain vacant. This has resulted HR appraisal is in place for all employees of  Different cadres of health professionals must in poor service delivery in the urban areas. the NHM at all levels (block, district and be recruited in numbers as established under state).  ASHA supervisor cadre has been discontinued the NUHM framework. leading to a disconnect between the ASHA workers, the UPHC and the DPMU. This often leads to delays in releasing ASHA incentives  80% of the procurement from the total  Though the procurement policies exist, lack of  All efforts must be made to make RKS allocated budget is performed at the state RKS and poor involvement of UPHC result in functional. Meantime, stringent guidelines level, while the remaining 20% is done procurement delay. As a result, there is must be implemented to streamline local locally (MP State Procurement Rules). frequent stock out of essential drugs and procurement to address shortage of drugs shortage of family planning supplies and and supplies.  At the district level, all procurement is done equipment. by the Civil Surgeon for Civil Dispensaries  There is need to review and revise inventory and by the CMHO for UPHC.  In many instances, procurement is done by management system at every level to prevent the DPMU on ad-hoc basis doing cash stockouts and ensure availability of required  At the UPHC level, procurement payments. stock at outreach and the health facilities as committees are constituted with well- well as in the stores. defined responsibilities, standard operating procedures and accountability.  The Procurement of drugs is done based on “Revised Fast-Moving Essential Drug List”,

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which is reviewed every 2 years at the state level by a technical committee. The medications not included in the list can be procured by open tender, consistent with the requirements of district level health facilities.  E-Aushadhi, an innovative approach, has streamlined the supply chain management, thus addressing major concerns such as order placement, payment, and quality control.  UPHCs are the only urban health facilities  There is lack of any mechanism for capturing  Challenge related to data literacy and its use that upload data in HMIS. The Data flow health information from the urban health must be addressed through trainings for process is streamlined and follows the facilities. different cadres of health staff. following sequence –ASHA registers are  There is a disconnect between the data on  To improve service delivery in the urban submitted from each ward to the respective OPD attendance and available staff indicating areas, segregated data on services provided in UPHC, ward level data is collected at the a lack of adequate monitoring mechanisms. urban areas must be available. A robust UPHC by the headquarter ANM, data is quality assurance (QA) assessment checklist then validated by the Urban Data Manager,  There is also a discrepancy in data pertaining also must be introduced. and is uploaded into HMIS. to service delivery, like under JSY, and the incentives disbursed.  DPMU collect data from the public health facilities and to some extent, private providers.  Data on deliveries from secondary level facilities is made available directly to the DPMU on a monthly basis  M&E team at the district level monitor  A formal mechanism of supportive  There is a need for a robust system of data performance by comparing achievements as supervision, monitoring, and quality triangulation and validation at every level. received from the health facilities with assurance for rural health facilities from all Additionally, an effective monitoring and levels, but similar system does not exist for supportive supervision system using

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expected target, identify reasons for gaps, urban facilities. There is no standard standardized tools and hands on support to if any, and take relevant actions. supervisory checklist for use in urban areas. the staff must be institutionalized at the urban level.  Monitoring of frontline functionaries is only done as surprise visits by the Medical Officers during UHND. There is no institutionalised system of monitoring input and outcome indicators.  The DPMU coordinates with ICDS,  Except for the field level coordination with  A review committee focusing on inter-sectoral Education and Social Justice and Disability ICDS, there is no formal coordination with any and inter-departmental coordination must be Welfare Departments for health service other department and the inter-departmental set up, preferably under the co-chairmanship delivery meetings are generally not result oriented. of the district collector and municipal commissioner.  DPMU works with the Education  The Health department faces issues with the Department for deworming, health check- Education department in their  A roadmap for inter-sectoral coordination ups, anaemia prevention and eye testing in implementation of the deworming program should be developed jointly by all the relevant schools. It coordinates with the Social resulting in poor coverage every year. stakeholders and then rolled out. Justice and Disability Welfare Department for the Divyang programme, under which differently abled children are provided aids. Coordination with the ICDS Department facilitates conducting UHNDs at the Anganwadis  Most healthcare staff look forward to new  There is no mechanism for in-service or  A District training center or a training institute and refresher trainings refresher trainings for frontline functionaries must be established for urban areas to (ANM, AWW, ASHA). They only attend implement capacity building activities for  Many trainings are conducted by the state orientation sessions when any new scheme is urban health staff. NUHM office for the DPMU staff, which help launched. Medical Officers also do not receive improve their understanding of financial  A training needs assessment, followed by any formal training after their pre-service systems and administrative responsibilities properly planned refresher trainings for trainings. different cadres of health, including the  Most of the trainings are organized on ad-hoc private providers, can lead to standardized basis and not based on the needs of the care and improved service delivery.

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program managers, financial and administration staff

 There is no infrastructure and trained personnel to organize trainings for urban staff.  Several private practitioners and clinics are  There is no mechanism for direct engagement  The municipal corporations should take the engaged and regulated by professional of private providers for service delivery. lead in establishing a regulatory mechanism bodies like the Federation of Obstetric and Moreover, health care providers from both for private providers given that they generate Gynaecological Societies of India (FOGSI), the public /government and private sectors significant revenue and are practicing within the Indian Medical Association (IMA), the are largely unaware of the guidelines or the jurisdiction of the municipal corporation. National Neonatology Forum (NNF) and the agencies responsible to monitor the service  Provisions for the accreditation of private Indian Association of Paediatrics (IAP) quality standards. providers and a memorandum of  The Nursing Homes Association is a  The private facilities do not have any understanding with the professional potential vehicle for collaboration and accreditation from the government or an associations would provide subsidized and engagement across a large number of external agency, and there is no regulatory quality care for the urban poor. private nursing homes. mechanism to monitor the quality of private

healthcare services.  Private sector is involved in some public sector programmes, such as Pradhan Mantri  There is no government database listing the Surakshit Matritva Abhiyan (PMSMA), private providers. This is problematic as a few Rashtriya Bal Swasthya Karyakram (RBSK) types of private informal service providers and Rajya Bimari Sahayata Yojana (RSBY), practice without a recognised medical degree. Mukyamantri Bal Hriday Yojna, and State This group of providers generally cater to Illness Assistance Fund (SAIF) vulnerable populations groups and they dispense drugs without correct documentation.

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Table 4: Detailed findings from landscape assessment of healthcare services in Gwalior - IMPLEMENTATION

Strengths Weaknesses Recommendations  For outreach service delivery, available  Only 60 - 80% of MAS have been formed and  An assessment checklist must be members of MAS are motivated to bring operational However, they are not utilised for institutionalized to assess the work and change in the community health and health delivery of MNCH and FP services. activities of MAS. Based on the Assessment seeking behaviour. findings, orientation and capacity building  A significant number of frontline staff activities can be rolled out through the NGO  Recently, NGOs have been engaged for positions are vacant. Almost 20% of partnerships. service provision in Gwalior, and the model sanctioned ASHA posts are vacant. has proven to be successful and worth  Recruitment for vacant staff positions needs  Less supply of kits used during the community exploring to be prioritized. Additionally, refresher and outreach is affecting the service delivery. in-service trainings for current ANM and

 There is a lack of mobile health units creating ASHA workers should be organized in order to a gap in service delivery build their knowledge and skills.  A sustainable and systematic approach is needed to address the gaps in the supply of drugs and kits at the community level .

 UHND are an important platform in the  In many locations were UHNDs are helped,  The infrastructure of AWC where UHND are urban areas for delivery of ANC services, there is a lack of space to carry out the held needs to be upgraded to ensure a childhood immunization, management of antenatal examination. Most of the events comfortable and proper health service infectious diseases, monitoring the focus on immunization services only. delivery. nutritional status of children, and  Services related to postnatal care are lacking  There is need to ensure regular supply of counselling and providing commodities for and wherever available are not as effective as essential instruments and kits to the frontline family planning. antenatal services workers at UHND sites.  Referral linkages at the primary care level are  Need-based training of frontline workers on missing, leading families to seek care directly MNCH and FP services must be undertaken to from secondary or tertiary level facilities strengthen their counselling skills.

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 An observed gap in nutritional counselling of pregnant women leads to a prevalence of myths and misconceptions related to the growth of the baby due to nutrition. UHND sites also lack instruments for growth monitoring of children.  FP counselling is poor. As a result, myths around IUCD insertion and side effects of oral pills still prevail in the community.  There is lack of dialogue between the community and frontline workers adversely affecting the identification of newborns requiring medical intervention

 Primary health care service delivery is done  Despite the availability of these facilities, their  Awareness generation activities are needed to through a network of UPHCs. Services use is significantly lower than secondary and inform the urban poor populations about the offered at these health facilities include tertiary care facilities due to a lack of fulltime availability of services for them at primary ANC/PNC services, routine immunization, specialists and lab services. health care facilities. counselling of mothers for exclusive  Of the service package, ANC/PNC services  The recruitment of healthcare staff must be breastfeeding, nutrition, and reproductive and immunization are specifically most prioritized, with a special focus on the health, management of childhood illnesses, underutilized at UPHC. specialist cadre to address the healthcare and delivery of FP products. requirements of urban community.  The supply of FP products is inconsistent.  Outreach camps are held regularly at the  Referral linkages in the community need to be UPHC. strengthened to reduce direct care seeking from secondary and tertiary level facilities. A strong counter referral system will help track the mothers and children reaching the facilities directly without being a part of the referral pathway.

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 Regular supply of essential drugs and FP products should be prioritized  The civil dispensaries should be converted to UPHCs and should be relocated, if required, for improved access.

 Secondary and tertiary level health care  These facilities are overburdened with  An appropriate referral mechanism is needed facilities provide specialized services in delivery cases and have a disproportionate to ensure optimal utilisation of services at all addition to the services available at primary bed-population ratio leading to overcrowding levels and to decongest secondary facilities. healthcare facilities. The specialized and shorter postnatal stay for mothers. These The community level referral system should services offered include management of conditions adversely affect the quality of care. be strengthened as well to ensure that complicated deliveries and C-sections, mothers, newborns and children are  Existing specialized cadre is insufficient to availability of Special Newborn Care Units examined during UHNDs and they can access manage the current patient load leading to (SNCU), inpatient and sterilization services. primary level care at UPHCs. This will ease the people seeking services at the private patient load at secondary facilities. facilities.  The Special Newborn Care Units should be  A limited number of secondary level facilities equipped with more beds and added into have functional sonography machines which more tertiary care hospitals. forces the urban poor to a private providers and bear the expenses.  A technical committee should be convened in order to conduct death audits, especially within SNCUs, to understand the causes of death of neonates and overall health care practices.  Supply chain and materials management need to be strengthened to ensure consistent availability of essential drugs and consumables, and guarantee the functionality of all equipment.

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CONCEPTUAL FRAMEWORK FOR PLAN OF ACTION

The constantly increasing size and density of cities raises costs and affects living standards, including increased risks of disease, accidents and crime (Quigley, 2009; Ellis and Roberts, 2016). The working and living conditions, and the access to basic services cannot keep the pace with this growth in most of the cities in India, including Gwalior. Poverty coupled with the lack of access to services emerge as a major issue for poor which leads to a worsening health situation among the urban population, predominantly affecting the poorest and most marginalised populations living in the slums.

There is a considerable body of knowledge explaining the complex relationship between urbanization and health4. Urban poverty is not only associated with slums, but other groups of urban poor as well, such as the homeless, daily wage labourers, construction workers, rag pickers, people who are institutionalized, male, female and transgender sex workers and other groups who do not live in slums, but are socially, economically, and geographically marginalized in cities.

Demographic characteristics of Gwalior:

 Gwalior is one of the fastest growing cities in Madhya Pradesh. ranks fourth in terms of share of urban population in Madhya Pradesh, after Indore, Bhopal, and Jabalpur with 6.3% in 2011.

 Gwalior District comprises of Gwalior Urban Agglomeration (GUA), Gwalior Municipal Corporation (GMC) and five other urban centers. These urban centers are , Bilaua, Tekanpur, Dabra and and all of them are located along the north-south corridor.

 GUA accounts for 86.6% of the total urban population while GMC accounts for 82.8% of the total urban population in the district.

4 Our cities, our health, our future; Report to the WHO Commission on Social Determinants of Health from the Knowledge Network on Urban Settings; Page 8; retrieved on Nov. 19, 2019 from https://www.who.int/social_determinants/resources/knus_final_report_052008.pdf

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 There are total 60 wards with 1417 colonies in GMC. Slums are located in 48 wards with 149 colonies, representing 80% of wards and 10.5% of colonies. The total population of GMC is 10,53,505 (Census 2011), 4,62,045 of which is slum population, or 43.9%. This data indicates that the slum colonies are densely populated and are very large.

 Improper water supply, inadequate health facilities, polluted drinking water, dust and heat are the few major issues cause by the growth of urban centers in Gwalior that negatively impact the health and wellbeing of its citizens.

The National Commission on Urbanization has designated Gwalior as one of the (Generator of Economic Momentum)5 ‘GEM’ towns therefore. The future development needs to be developed with this aspect in mind, so that it can provide a momentum for economic growth. The future solution for health care delivery in this historic city will be possible with a coordinated inter-sectoral development strategy.

Social determinants of health are the conditions in which people live, learn, and work. These determinants have direct and indirect bearing on health risks and outcomes. These also affect health equity in a community. For example, differences in health are striking in the communities with poor social determinants, such as unstable housing, low income, unsafe neighborhoods, or sub-standard education.

Likewise, the policies and programs implemented by non-health sectors and departments, directly and indirectly affect human health

5 The city has vast potential for economic growth; Sati & Mansoori, 2007. Trends of Urbanization in Gwalior Metro-City (India) and its environs; Journal of Environment Research and Development, Vol. 2 No. 1

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Figure: Relationship between thematic, and policy and programmatic determinants of health

Considering the demographic characteristics of Gwalior, especially those related to rapid urbanization and multifactorial nature of health outcomes, a Plan of Action became necessary to support the development if a Convergence Plan for Health and other Departments of Gwalior to address the health needs and strengthening the health system through a comprehensive City Health Plan.

The Plan of Action (POA) provides guidance to the stakeholders from different related departments regarding the components and steps that are required to be followed in order to achieve convergence that would benefit the health of the citizens of Gwalior City.

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PLAN OF ACTION FOR CONVERGENCE

Goal: The ‘Convergence’ of health and other government departments in Gwalior city to ensure the health of the citizens.

Objectives:

 Identify departments/ institutions/local bodies implementing schemes and programs having direct or indirect impact on the health of citizens of Gwalior city.

 Explore areas of collaboration between these departments/institutions/local bodies towards achievement of overlapping health related targets.

 List activities to be undertaken by each of these departments/institutions/local bodies to ensure coordinated efforts to guide the development of a City Health Plan.

 Identify measurable indicators to monitor progress towards the intended objectives ensuring that they are in line with the parameters fixed by policy for individual departments and programs.

 Assess available resources with each department/program to achievethe intended objectives for optimal utilization and avoiding duplication of efforts.

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Partnering departments:

 Department of Health and Family Welfare  Department of Women and Child Development  Department of Education  Department of Urban Development  Department of Labour  Department of Public Health Engineering  Department of Agriculture  Gwalior Development Authority  Urban Local Body/Municipal Corporation  Smart City Mission  District Administration  Private health sector, IMA, FOGSI, Medical Colleges  Development partners and NGO working in the field of urban health and development

Levels of Convergence: Collaboration is required at various levels to ensure convergence of healthcare service delivery at the community level within the city area These levels and initial actions required include:  City-Level Convergence

o Convergence between the heads and nodal officers of all partnering departments. o Establishment of “City Convergence Committee” under the chairmanship of CMHO/CS from the health department and members from partnering departments. o Setting up periodic committee meetings to facilitate the collective work from all members to develop the Convergence Plan. o Organize meetings to facilitate the implementation of the POA.  Ward-Level Convergence

o Convergence between health facility staff, ICDS supervisor, GDA officer, elected representative of the municipal ward and ward level representative for Primary Education and other departments. o Organization of monthly ward convergence meeting under the chairmanship of Medical Officer in charge of ward level health facility to review the progress and plans for the coming month.

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 Slum-Level Collaboration

o Convergence between ASHA, AWW, ANM and other community level workers. o ANM of the respective slum to lead with slum level convergence between functionaries, community and community groups. o Frontline workers from each slum to develop robust slum maps and household lists by sharing data to ensure service delivery in a comprehensive manner. o Sharing of resources, such as AWC and DUDA premises as spaces for meetings or community events like UHND and Out-Reach Camps.

Requisites of action plan -

 WHAT is the activity?

 WHO will do it?

 WHEN it must be done (timeline)?

 WHAT resources are available/required?

 WHICH departments will coordinate?

 HOW it will be measured?

KEY CRITERIA OF AN ACTION PLAN– 4’C’

1. COMPLETE: enlisting all action steps and activities required 2. CLEAR: establish roles and responsibilities of each stakeholder 3. CURRENT: processes and outcomes are relevant to the current context 4. CORRECT: in line with state and departmental policies and regulations

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LOGICAL FRAMEWORK TO OPERATIONALIZE the PLAN OF ACTION

This section outlines an activity framework, including details on step wise activities required, process to be followed, responsible stakeholder, and the expected outcome of the activity. These activities will further be supported by the timelines, budget requirement, and the indicators to monitor progress, which are described later in the document.

Specific activities that led to the development of this POA:

1. Assessment of different schemes and programs

2. Stakeholder analysis

3. Development of a convergence plan

4. Mapping the city

5. Finalizing the Plan of Action

6. Finalizing timelines and budget sources

7. Institutionalizing monitoring framework

The details regarding each of these specific activities along with the sub-activities, process to be followed, responsible parties, and expected outcomes are described in form of a log-frame in the subsequent pages.

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Logical Framework for Operationalizing Plan of Action

Activity Process Responsibility Outcome 1. Assessment of different schemes and programs 1.1 Review of ongoing schemes and Desk review of published and Supporting Report highlighting the Ministry wise programs, especially the flagship unpublished literature and internet partner programs and schemes having direct programs, implemented by different search or indirect bearing on health and Ministries to identify those addressing wellbeing, especially in urban area. health outcomes directly or indirectly through affecting the social determinants of health and wellbeing 1.2 Identification of Ministries and state In-depth review of flagship programs Implementing Identification of Ministries and line departments implementing programs and and schemes department and departments for convergence schemes impacting health and wellbeing supporting partner 2. Stakeholder analysis 2.1 Seeking insights from the heads and In depth interviews with heads of the Supporting Inputs on possibility of convergence program managers from identified identified departments and program partner and areas of collaboration and Ministries and Departments regarding managers resource sharing with the Health activities undertaken having impact on Department the health and possibility of convergence with Health Department 3. Development of convergence plan

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3.1 Development of a Plan of Action for a Development of Log-frame to prepare Supporting Plan of Action for the development convergence plan for health and other the convergence plan partner of the Convergence Plan identified departments of Gwalior city 3.2 Consultative workshop with heads and Consultative workshop with group works CEO, Smart City Finalization of plan of action for the representatives from identified on different components of convergence Mission and purposes of convergence. departments to finalize POA plan supporting partner 4. Establishing institutional framework 4.1 Setting up a Technical Committee to District Collector as chair, District Letter regarding the establishment coordinate all activities related to CEO-Smart City Mission as Convening Administration of Technical Committee with its planning, implementation and monitoring Secretary, Representatives from all agenda and structure released with of POA departments as members copy to State Government. 4.2 Setting roles and responsibilities for each Develop Terms of Reference (TOR), Smart City Terms of reference for each department, stakeholder, and partner expected support from each department Mission department and stakeholder in implementing POA. developed and shared along with an Each department to have a point of official letter. contact for the POA List of points of contact from each department finalized and displayed. 5. Mapping the city 5.1 Listing and GIS mapping of Gwalior city, Using maps available on web search Smart City Development of detailed maps of especially wards, colonies and urban engines Mission Gwalior city indicating vulnerable slums. Consultation with GDA and GMC pockets (densely populated areas, lack of green belt, traffic zones,

dense housing, epidemic outbreak zones etc.)

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5.2 Ratify and finalize the urban mohallas and Consultation workshop with staff from Smart City Updated list of urban mohallas and slums for focused action Health Department, ICDS, MC, and GDA Mission slums with their ward wise distribution and targeted population available. 6. Concurrent review 6.1 Monthly review meetings to have Monthly meeting under chairmanship of District Progress and challenges discussed discussion on inputs, progress, and head of the Technical Committee Administration along with the activities for the next outcomes month 6.2 Quarterly meetings on progress of Quarterly meeting of Technical District Discussion on activities undertaken, monitoring indicators Committee under chairmanship of Administration challenges faced, support required, District Collector to discuss the activities and way forward. undertaken during the last 3 months

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ACTIONABLE STEPS FOR EACH DEPARTMENT

Activity under POA Leading Department Collaborating Departments

Identifying and assuring open spaces Housing Board 1

Housing Board 2 Certification of Green Buildings Quality Housing, Quality Drinking Water and Quality Gwalior Development 3 Sanitation Authority Work for ensuring amenities within reach for self- TNCP 4 sufficient colonies Health check-up camps for organized and unorganized Labour 5 labour

WCD 6 Health & Nutrition Education WCD 7 Increasing age of marriage Mainstreaming Children with Special Needs through WCD 8 preventive and curative Protocol Improving Health & Nutrition services in urban tribal WCD 9 pockets WCD 10 Addressing Anemia in Women and Children Mapping and joint planning of buildings, resource Gwalior Municipal 11 allocation & appropriation identification Corporation (GMC) Joint mapping of notified slums for city GMC 12

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13 Early sharing of information of epidemic provoking GMC situations 14 Capacity Building of Fogging staff/ cleaning staff on GMC preventive aspects of health & self-protection 15 Cleaning standards/ Certification of Government Facility – GMC regulation by municipal corporation 16 Sharing of health plans of Health department & GMC Municipal Corporation on a monthly basis 17 Electronic solutions to Control Mosquito Smart City Mission (SCM) 18 Sever line –Vacuum Technology SCM

19 Faecal/ Waste treatment- Innovative method SCM

20 Safety equipment & New technology (Threat SCM Notification) 21 Waste to Gas Formation SCM

22 Electrical Vehicle PPP Model SCM

23 Health ATM Project SCM

24 Prevent Vegetable growth from Sewerage water Agriculture

25 Prevent alternate natural method to ripen fruits and Agriculture Vegetables 26 Precaution strategy for milk extraction ( Oxytocin) Agriculture

27 Roof gardening / Kitchen Gardening in School, coaching Agriculture and others to be done.

28 Early Identification, Expert advice and Certification of Social Security and Divyang welfare

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29 Rehabilitation of Divyang with food available

30 Work for rehabilitation of old age people (Health Check- Social Security and up, Referral, Follow-up and Maintenance ) welfare 31 Unique ID provision for the Divyang members Social Security and welfare 32 Proper sensitization and capacity building of Divyang Social Security and welfare 33 Early Identification, Expert advice and Certification of Social Security and Divyang welfare

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EXPECTED OUTPUTS AND OUTCOMES OF THE PLAN OF ACTION

OUTPUTS:

1. Identification of departments and stakeholders implementing flagship programs and schemes having bearing on health and wellbeing

2. Stakeholder analysis revealing resource availability and potential influence on health outcomes of urban population

3. Convergence plan developed describing modalities, resource sharing, and terms of reference for inter departmental collaboration

4. Institutional structures established to guide, coordinate, and monitor convergence

5. Situation analysis and gap assessment done to guide development of POA to reach unreached areas in urban Gwalior

OUTCOMES:

1. Enhanced inter departmental collaboration in terms of communication, joint planning and monitoring, and resource sharing towards a common goal.

2. Formalization of roles and responsibilities for different departments towards improvement of health and wellbeing of citizens of Gwalior city.

3. Improved utilization of available resources to maximize gains and achieve the objectives.

4. Involvement of different departments ensured in planning, implementation, and monitoring of POA of Gwalior City:

a. Achieving universal access of services for the urban poor

b. Reduction of out of pocket expenditure for quality health services

c. Improved health outcomes for citizens of Gwalior city.

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NON-NEGOTIABLES AND NEGOTIABLES

NON-NEGOTIABLES:

1. Development of a convergence plan as a road map towards enhanced inter departmental collaboration.

2. Fixed roles and responsibilities of individual departments, stakeholders and partners (terms of reference).

3. Institutional structure to guide and monitor the convergence plan.

4. Resource sharing between different departments to avoid under-utilization and duplication.

5. Universal availability of comprehensive and quality public health services to all citizens of Gwalior city.

NEGOTIABLES:

1. Situation analysis and gap assessment to explore strengths, weaknesses, and opportunities of public health service delivery system in Gwalior city.

2. GIS mapping of available health facilities to identify uncovered pockets within the city area.

3. Limiting to the departments having health as part of their implementation framework.

4. Leading role of city administration in the implementation of the convergence plan.

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MONITORING

POA Coordination Committee shall be responsible for the development and implementation of the convergence plan.

The committee meeting shall be convened on a monthly basis under the chairmanship of the head of health department to review progress and involvement from different departments and stakeholders towards the achievement of the common objectives.

The documented proceedings of the meetings along with the suggestions and feedback shall be shared with all partnering departments for required compliance.

Suggested indicators to assess the progress are as follows:

 Periodicity of the monthly review meetings and participation of nominated members from the respective departments.  Compliance on the suggestions and feedback by the individual departments documented in the department meeting minutes.  Proportion of budget utilized for the earmarked activities aimed to achieve the objectives.  Number of joint visits by the partnering departments to the urban health facilities and visit reports submitted to the health department.

Monitoring tools:

 Standard template for review meeting agenda and documentation (minutes)  Budget tracking template with columns for total budget available, allocated for specific activity, utilization (quarter or month wise), remaining balance  Joint visit check list and visit calendar

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ANNEXURE 1

Ward wise area and population in Gwalior city (2018) Source: Ministry of Housing and Urban Affairs, Government of India (published on February 21, 2019)

Total Total Zone Ward Area (in Population Zone Ward Area (in Population Name No. sq km) (in Name No. sq km) (in thousands) thousands) 1 1 8.21 24.72 16 35 0.4 1.2 7 2 0.62 1.86 7 36 0.33 0.99 7 3 1.5 4.5 16 37 1.26 3.8 1 4 0.96 2.88 17 38 1.78 5.35 1 5 6.47 19.48 17 39 0.36 1.07 2 6 0.37 1.12 18 40 0.2 0.59 3 7 2.48 7.47 16 41 0.33 1 3 8 0.69 2.06 15 42 0.2 0.61 2 9 0.37 1.12 15 43 0.33 0.98 2 10 0.36 1.08 19 44 0.27 0.81 4 11 0.32 0.96 12 45 0.53 1.6 5 12 0.55 1.66 19 46 0.25 0.76 4 13 0.37 1.12 20 47 0.21 0.62 4 14 0.54 1.63 20 48 0.37 1.12 3 15 1.02 3.06 18 49 0.81 2.45 5 16 0.68 2.05 19 50 0.34 1.03 5 17 1.18 3.56 20 51 0.5 1.5 8 18 19.27 57.97 21 52 3.92 11.79 8 19 3.09 9.3 20 53 0.41 1.24 9 20 1.79 5.4 21 54 0.93 2.8 10 21 5.36 16.12 21 55 2.73 8.2 10 22 2.35 7.08 12 56 3.38 10.18 10 23 0.55 1.67 13 57 1.02 3.06 11 24 0.66 1.97 13 58 3.41 10.26 8 25 1.29 3.87 13 59 10.72 32.26 9 26 0.42 1.25 14 60 21.82 65.64 9 27 0.45 1.35 22 61 41.14 123.78 11 28 0.52 1.57 22 62 58.18 175.05 14 29 2.09 6.29 23 63 42.74 128.6 11 30 2.49 7.5 23 64 19.63 59.06 6 31 0.55 1.65 24 65 21.09 63.46 6 32 0.96 2.88 25 66 66.99 201.56 7 33 0.34 1.02 26 FORT 47.61 143.24 15 34 0.32 0.96

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ANNEXURE 2

Comparative Demographic Indicators for district Gwalior Source: Census of India (2001 and 2011)

Demographic variable 2001 2011 Population 16.32 Lakhs 20.32 Lakhs Actual Population 1,632,109 2,032,036 Male 883,317 1,090,327 Female 748,792 941,709 Population Growth 26.20% 24.50% Area Sq. Km 4,560 4,560 Density/km2 358 446 Proportion to Madhya Pradesh Population 2.70% 2.80% Sex Ratio (Per 1000) 848 864 Child Sex Ratio (0-6 Age) 853 840 Average Literacy 69.38 76.65 Male Literacy 80.36 84.7 Female Literacy 56.4 67.38 Total Child Population (0-6 Age) 255,076 261,418 Male Population (0-6 Age) 137,647 142,098 Female Population (0-6 Age) 117,429 119,320 Literates 955,356 1,357,210 Male Literates 599,253 803,114 Female Literates 356,103 554,096 Child Proportion (0-6 Age) 15.63% 12.86% Boys Proportion (0-6 Age) 15.58% 13.03% Girls Proportion (0-6 Age) 15.68% 12.67%

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ANNEXURE 3

Comparative Demographic Indicators for rural and urban areas of district Gwalior Source: Census of India (2011)

Rural Urban Demographic variable (2011) (2011)

Population (%) 37.31% 62.69% Total Population 758,244 1,273,792 Male Population 409,349 680,978 Female Population 348,895 592,814 Sex Ratio 852 871 Child Sex Ratio (0-6) 844 837 Child Population (0-6) 114,953 146,465 Male Child(0-6) 62,354 79,744 Female Child(0-6) 52,599 66,721 Child Percentage (0-6) 15.16% 11.50% Male Child Percentage 15.23% 11.71% Female Child Percentage 15.08% 11.25% Literates 419,361 937,849 Male Literates 267,017 536,097 Female Literates 152,344 401,752 Average Literacy (%) 65.19% 83.19% Male Literacy (%) 76.95% 89.17% Female Literacy (%) 51.42% 76.37%

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