Draft Summary Situational Analysis Report of Agra City for Guiding Urban Health Program February 2005 Better Health in Underserved Urban Settlements Draft Summary Situational Analysis Report of Agra City for Guiding Urban Health Program December 2004 Key USAID Contact: Dr Massee Bateman, Senior Child Health Advisor USAID-EHP URBAN HEALTH PROGRAM Supported by United States Agency for International Development through a contract with Camp Dresser & McKee International Inc. ii Acknowledgements We gratefully acknowledge contribution of many urban health stakeholders of Agra, for their active help, support and insights without which it would not have been possible to compile this short situation analysis report. We wish to express our gratefulness to Shri Nitishwar Kumar, I.A.S, District Magistrate; Dr. Roshan Lal, Chief Medical Officer for providing information on various subjects and supporting the process of obtaining and analyzing information. Many thanks are due to Dr Deoki Nandan, Principal S.N. Medical College for helping start the situation analysis process through the first stakeholders meeting in Agra. Dr. Shamsher Singh, Deputy Chief Medical Officer, Dr. Anita Gupta, Senior Medical Officer and all Lady Medical Officers (Urban), Health Visitors and ANMs were very helpful in understanding the Urban Health Delivery system and analyzing the difficulties and possible options. Shri A.K. Singh, Municipal Commissioner, Shri S.K. Singh, Former Municipal Commissioner, Dr. R.S. Jaiman and Dr. P.K. Agarwal, Senior Municipal Health Officers, Ward Councilors and Sanitary Inspectors are gratefully acknowledged for sharing their perspectives and providing information on different aspects particularly important insights on Agra slums. We would also like to thank District Project Officer, C.D.P.O., Supervisors and Anganwadi Workers of the Department of Women & Child Development; Project Officer - SIFPSA; Project Officer - DUDA; Project Officer - CARE; SMO - NPSP, WHO, Shri Ravi Kashyap, SNBI, General Manager, Jal Sansthan, Director, ESI, Agra, Director, JALMA, Agra Iron and Foundry Association, Dr. P.S Mehra, Relief Hospital, Dr. Irshad, Meena Charitable Hospital, Presidents, Jatav Panchayat, Mahila Utthan Samiti for their active participation during the stakeholders’ consultations and individual interactions. Learnings gained from these meetings helped in building the situational analysis and are reflected in this document. Our special thanks go to Dr. Massee Bateman, USAID India for his active interest and constant guidance during the entire course of the study. Untiring efforts of EHP colleagues Ms. Kirti Ghei, Mr. Anuj Srivastava, Ms. Madhvi Mathur, Mr. Pravin Jha, Shivani Taneja and Dr. Sainath Banerjee are greatly valued. Support, encouragement and comradeship of Mr. S.K. Kukreja, Arti Bhanot, Sandeep Kumar, Prabhat Jha and Rajeev Nambiar have been of immense value. This report has been prepared by Karishma, Dr. Rajesh Dubey, Anju Dadhwal, Srinivas Varadan, Mani Gupta and Dr Siddharth of the USAID-EHP Urban Health Program team. We hope that this report will be able to extend its reach as it is used by various stakeholders and program implementers. We look forward to comments and suggestions from its readers. iii Table of Contents 1.1. City Profile 1.2. Urban Poverty in Agra 1.3. Existing Public Sector Health Facilities 1.3.1. Public Sector Health Facilities 1.3.2. Other Central Government Facilities 1.3.3. Private Health Facilities 1.4. Health Scenario Among the Urban Poor in Agra 1.5. Other Development Programs in Agra 1.5.1. Swarna Jayanti Shahari Rozgar Yojana 1.5.2. Integrated Child Development Services 1.5.3. Early childhood Care for Growth, Survival and Development Project (ECCD) 1.5.4. SIFPSA Supported Projects 1.5.5. CARE 1.6. NGOs and CBOs Working in Agra 1.6.1. Current activities of NGOs and CBOs 1.6.2. Implementations and Existing Options for EHP 1.7. Private Industry 1.7.1. Footwear Industry 1.7.2. Foundries 1.7.3. ESIS Registered Units 1.8. Need Analysis and Pointers for Improving the Health Delivery System 1.8.1. Location of the Health Facilities 1.8.2. Targeting of the Vulnerable slum population 1.8.3. Public private partnership 1.8.4. Strengthen and optimize Use of Infrastructure 1.8.5. Regularity in Services 1.8.6. Integration of development programs in the city iv List of Abbreviations AMC Agra Municipal Corporation ANM Auxiliary nurses midwife ANC Ante-natal care ARI Acute Respiratory Infection AWW Anganwadi Worker BCG Bacillus Calmette Guerin BPL Below Poverty Line CBD Community Based Organizations CBO Community Development Society CDS Community Development Society CMO Chief Medical Officer CPR Couple Protection Rate DDK Disposal Delivery Kit DoMHFW Department of Medical Health and Family Welfare DPT Diphtheria Pertussis Tetanus DTHC D Type health centre DUDA District Urban development Agency DWCUA Development of Women and Children in Urban Areas ECCD Early Childhood Care for Survival, Growth and development Project EHP Environmental Health Project ENT Ear, Nose & Throat ESIS Employee State Insurance Services FGD Focus Group Discussion FICCI Federation of Indian Chambers of Commerce and Industries GoI Government of India GoUP Government of Uttar Pradesh HIV Human Immunodeficiency Virus ICDS Integrated Child Development services IPPI Intensive Pulse Polio Immunization IFA Iron Folic Acid IFPS Integrated Family Planning Services LHV Lady Health Visitor LMO Lady Medical Officer MCH Maternal and Child Health MTP Medical Termination of Pregnancy NABARD National Bank for Agriculture and Rural development NFHS National Family Health Survey NGO Non Government Organization NHC Neighborhood Committee NHG Neighborhood Group NSS National Sample Survey OPD Out Patient Department ORS Oral Re-hydration Salts PPC Post-Partum Centre RCH Reproductive and Child Health RCV Resident Community Volunteer v RTI Reproductive Tract Infection SIFPSA State Innovations in Family Planning Services Project Agency SJSRY Swarna Jayanti Shahari Rozgar Yojana SLI Standard of Living Index STD/STI Sexually Transmitted Disease/Infection TT Tetanus Toxoid UFWC Urban Family Welfare Centre UHC Urban Health Centre UNICEF The United Nations Children’s Fund UP Uttar Pradesh UPAP Urban Poverty Alleviation Programme USAID United States Agency for International Development vi Draft Situation Analysis, Agra 1.1 CITY PROFILE India is experiencing rapid and unplanned urban growth. Of India’s total population of 1027 million1, 285 million (27.8%) live in urban areas. The percentage decadal growth of population in rural and urban areas from 1991 to 2001 is 17.9 and 31.2 percent respectively. The slum population in 2001 is estimated to be tune of 60 million 2 , comprising 21 percent of the total urban population. However, these estimates do not reflect the true magnitude of urban poverty because of the “un-accounted” for and unorganized squatter-settlements and other populations residing in inner-city areas, pavements, constructions sites, urban fringes, etc. Undoubtedly, significant proportions of the urban population live in slums or slum like conditions, which seriously compromise health and sanitary conditions, putting them at a much higher morbidity and mortality risk than non-slum populations. Therefore, Urban Health Program for slum is one of the thrust areas in the 10th five year plan, RCH II, National Population Policy and National Health Policy. In continuation to this, GoI identified four cities, Delhi, Agra, Bally and Haldwani to develop sample urban health proposal. In effect, Agra was taken up for the development of urban health plan. Urban population in Uttar Pradesh constitutes 20.78% of the total population. While the urbanization rate of the state is still well below the national average of 27.78%. In absolute terms, this amounts to nearly 35 million people residing in 684 towns and cities3. With nearly one in three city dwellers estimated to be poor, it amounts to approximately 10 million people4 living below the poverty line in the urban areas of UP. There is increasing evidence that the urban poor, particularly those residing in slums and squatter settlements, have health indicators comparable to or even worse than their rural counterparts. Addressing health inequities within cities and providing quality health care to slum dwellers has emerged as an issue of critical importance for Uttar Pradesh. Agra city, which is spread over an area of 140 sq. km. along the banks of the river Yamuna, is one of the major cities of Uttar Pradesh. The history of the city dates back to 1475 AD when Raja Singh Badal laid the foundation for the city. The post-independence growth of the city was linked to the large scale influx of refugees as well as migration from rural areas. This led to the congestion of the central part of the city, which to date remains highly congested with very poor civic facilities. With planned industrial development in the 70s and 80s, three important industrial areas of Agra, namely Nunhai, Sikandra and Foundry Nagar were established. This led to the further growth of the city in the north-western and north-eastern directions. 1 Census 2001 2 National Commission on Population, 2000, Ministry of Health and Family Welfare, GoI 3 Population Estimate, Census 2001 4 NSS Consumer surveys, Official Poverty Lines and Corrected Estimates from Deaton, 2001 1 Table 1.1: Population Growth (Census data) 1991 2001 Growth rate (in lakhs) (in lakhs) (1991-2001) AGRA District 27.51 36.11 31.27% AGRA Urban 9.43 13.31 41.14% The total population of Agra urban agglomeration (which includes Cantonment areas, Swamibagh and Dayalbagh) is 1,331,339; whereas the population under Agra Municipal Corporation as per the 2001 census is about 12.75 lakhs. The city is now growing in the western direction following the Delhi-Agra corridor in a linear pattern. The decennial growth rate of Agra city (1991-2001) is 41.14% which is twice the national decennial growth rate of 21.34%. Population density of Agra is 897 persons per square kilometer as compared to the Indian average of 324.