CONVERGENCE FOR IMPROVED PLAN OF ACTION HEALTHGwalior City, JuneAND 2019 WELLBEING This page is intentionally left blank. INDEX Page No. List of abbreviations Executive Summary 1. Background 1 2. Current health system scenario in Gwalior 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 India 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 Madhya Pradesh 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. ~~~~~ 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