73353 KOLKATA FOR MOTHER AND CHILD a case study M. Badrud Duza In collaboration with G.N.v. Ramana and Sanchita Chowdhury Copyrighr © 2003 The Internarional Bank for Reconstrucrion and Deveiopmem/The World Bank 1818 H Street, N.W Washington D.C. 20433 U.S.A. All rights reserved Manufactured in the Unired Stares of America First Priming March 2003 ISBN 0-8213-4473-0 Photographs: Courtesy of IPP VIII, Kolkata Kolkata for Mother and Child A Case Study M. Badrud Duza In collaboration with G. N. V. Ramana and Sanchita Chowdhury THE WORLD BANK IContents Abbreviations and Acronyms 5 Acknowledgments 7 Why is the Kolkata Experience Salient? 9 A Success Story from India Family 10 Welfare Urban Slums Project: Key Findings Kolkata: Mega City of Great Challenges and 13 Unique Opportunities Responding to Local Needs: 14 Urban Slums Project Advent of IPP 8 Kolkoto Kolkoto Innovotions Measuring Success: 18 Outputs and Outcomes Methodology Improving Access to Bosic RCH services Generating Demond for RCH Services RCH Outcomes What made Kolkata a Success? 23 The Immeasurables that made a Difference 29 Cascading Partnership among the 34 Key Stakeholders Contents Lessons Learnt and the Replicability Riddle 36 Pillars and Heroes Accent on Start from the Outset Participatory Process Provider Supervision Replicability Issues Looking Forward 39 The Unfinished Agenda Sustainability Annex I 42 Structure of Service Delivery IPP VIII Kolkata Annex 2 43 Project Director: Holistic View of Project Evolution and Outlook Annex 3 46 Senior Manager, MOHFW: Achievements and Outlook IAbbreviations and Acronyms AHO Assistant Health Officer AIDS Acquired Immuno Deficiency Syndrome ANM Auxiliary Nurse Midwife BIP Bustee (Slum) Improvement Program BPL Below Poverty Line CMA Calcutta Metropolitan Authority CMDNKMDA Calcutta Metropolitan Development Authority/ KolkataMetropolitan Development Authority CPR Couple Protection Rate CUDP Calcutta Urban Development Project DFID Department for International Development (United Kingdom) ESOPD Extended Special Out Patient Department FP Family Planning FW Family Welfare GIS Geographical Information System GOI Government of India GOWB Government of West Bengal HAU Health Administrative Unit HHW Honorary Health Worker HIV Human Immuno Deficiency Virus HO Health Officer ICDS Integrated Child Development Services Scheme IDA International Development Association IEC Information, Education and Communication IMR Infant Mortality Rate IPP-8 India Population Project-8 MCH Maternal and Child Health Abbreviations and Acronyms MIS Management Information System MMR Maternal Mortality Rate MOHFW Ministry of Health and Family Welfare (GOI) MTR Mid-Term Review NGO Non-Government Organization ODA Overseas Development Association (United Kingdom) PMP Private Medical Practitioner PTMO Part Time Medical officer PVO Private Voluntary Organization RCH Reproductive and Child Health RDC Regional Diagnostic Center STD Sexually Transmitted Disease STI Sexually Transmitted Infection TFR Total Fertility Rate TMC Trina Mul Congress (Political Party) UNFPA United Nations Population Fund WB World Bank WHO World Health Organization IAcknowledgments The present research has been a great learning experience for us. We have been fortunate to be scribes for an inspiring tale told by many actors. This is a case study in exemplary delivery of family welfare and public health care against the backdrop of desperate poverty in the vast slums of Kolkata city. Our greatest debt is owed to the numerous slum residents who were the recipients of services and their grass-roots service providers - both groups mainly comprising of poor women in the urban slums -- who presented the materials that enrich our work. The municipal chairmen and other local leaders and dedicated professionals shared with us the process of community mobilization and ownership of the low-cost innovations, and equally deserve our deep appreciation. Our warmest congratulations are accorded to the Kolkata Metropolitan Development Authority (KMDA) that implemented the Kolkata city part of the India Population Project VIII (IPP VIII) and facilitated the present documentation. Senior KMDA officials including Mr. Prabh Das, lAS, Chief Executive Officer and Ms. Roshni Sen, Special Secretary, KMDA and Project Director, and Mrs. Nandita Chatterjee, lAS, former Project Director, provided valuable insights for our understanding. We are particularly thankful to Dr. B. Bhattacharjee, Chief of Health and a key driving force of IPP VIII Kolkata, and his colleagues for the infinite help at the field phase of the study and for hours of invaluable deliberations on various important topics. We are also grateful to the Ministry of Health and Family Welfare (MOHFW), New Delhi, for the extensive support extended at every stage of the study. Particular mention must be made of Mr. Gautam Basu, former Joint Secretary and Mr. A. K. Mehra, Director, Area Projects. The Kolkata Experience Sharing Workshop organized by KMDA and MOHFW was attended by IPP VIII officials from the project cities, representatives of development parrners, and several members of the cabinet from the Government of West Bengal. This provided an opportune forum for reflections over the genesis and vision underlying the project, the achievements and the outlook, and for gleaning the Acknowledg ments lessons learnt in the process. Finally, we do appreciate the long support from the World Bank -- the New Delhi Office for various operational matters; and the Human Development Unit for the South Asia Region, Washington, D.C., for financial support and substantive guidance. The participatory research and delibera~ions within the study team proved highly productive. Dr. G. N. V. Ramana, Task Leader for IPP VIII, brought in great analytical rigor to the design and write-up. He also provided an extremely useful comparative perspective vis-a-vis other IPP VIII cities. Ms. Sanchita Chowdhuty, Anthropologist-Consultant, took meticulous care and ensuted exceptional quality control duting weeks of arduous field investigations, including a series of focus group and in-depth interviews at various levels. Their genuine contributions and excellent collaboration are warmly acknowledged. Together we were able to orchestrate a very complex story line from many angles, and feel fully rewarded in the prospect for wider sharing of our findings and conclusions. We all in the study team would remain nostalgic about this satisfying ventute. Why is the Kolkata Ex erience Salient? This is a story of partnership between reViewers, in-depth studies undertaken beneficiaries and providers of by the Kolkata Metropolitan Reproductive and Child Health (RCH) Development Authority (KMDA), and services successfully orchestrated by reports of the Government of India dedicated local leaders. Indeed, this is a (GOI), the World Bank, and story of proactive community several development partners. The ownership of low cost interventions for achievements evidenced in the present the utban poor and under-served, the document speak for themselves in voiceless women, children and men. absolute terms of outputs and outcomes And this is the essence of why India as well as several non-measurable Population Project 8 (IPP 8) Kolkata changes the program could successfully has been acclaimed as an innovative bring about, against the backdrop of the approach to addressing needs of the desperate milieu. They are corroborated poorest of the poor from the by key stakeholders at all levels, starting disadvantaged urban slums, with from the beneficiaries at the family level possibilities for emulation elsewhere. to the community leaders, local service The experience has been resonated as a providers, and KMDA managers, and laudable success by independent GOI policy makers. A SUCCESS STORY FROM INDIA FAMILY WELFARE URBAN SLUMS PROJECT: Key Findings The poor people 5 turn always comes at the end. They are made to flel that they are placed at the receiving end only. This must change. The services must literally reach their doorsteps. The cost of service should be such that these poor people can afford without constraints. The services must also take into account the convenience of the poor people to access them. The timing of the services will be such that the poor beneficiaries need not waste their productive time to avail them. - Dr. B. Bhattacharjee, Chief ofHealth, IPP VIII Kolkata The Setting The Model This is a documentation of effective The project provided basic community partnership that helped to improve outreach as well as facility based RCH Reproductive and Child Health (RCH) services including counseling to the outcomes for the urban poor in Kolkata, urban poor. Subsequently, non- India. This partnership was supported beneficiaries" (above poverty line) also by the IDA financed (US$ 71.4 million) received services on payment of costs at Family Welfare Urban Slums Project. lower-than-market rate. This model has The project was implemented subsequently been extended to 20 more concurrently in four metro cities of cities in the state of West Bengal with India under the stewardship of Union support from the Department for Ministry of Health and Family Welfare International Development (DFID) over an eight year period (1994 to and IDA. 2002). The Kolkata Metropolitan A large fleet of trained neighborhood Development Authority (KMDA) workers, designated as Honorary Health implemented the project using a Credit Workers (HHWs), mobilized the poor of about US$17 million. communities for immunization, family A total of 3.8 million urban poor planning and other basic and referral (family income less than US$ 32 per services. They were also actively month) from three municipal involved in women's empowerment corporations (Howrah and Chandan initiatives supported under the project, Nagar, and part of Kolkata), and 37 including reproductive health education smaller municipalities benefited from for young women and training women 10 . this partnership. in vocational skills and entrepreneurship • A Success Story ftom India Family Welfore Urban Slums Project: Key Findings development. The HWWs, were drawn specialized care were provided at the out for the same community they served and patient departments at a modest cost. For paid a token monthly honorarium of this, the project strategically used services about Five Hundred Rupees (about Ten of specialists with community orientation US Dollars) and yearnings available in the locality through convenient scheduling of services These workers were supported by a during their lean hours. The KMDA fully limited contingent of paramedics and Part decentralized the program and limited its Time Medical Officers (PTMOs) role for technical oversight and trouble providing services. They were supported shooting. This made the elected by two levels of supervisors. The first level representatives of local bodies fully included HHWs who excelled in their accountable for program implementation. performance and the second level, trained paraprofessionals (either Auxiliary Nurse Midwives or male health workers). The The Impact PTMOs, drawn from the private sector on Independent evaluations during project contract, provided medical care during implementation and at the end indicate specified hours at the clinics. Maternity significant improvements in RCH and obstetric care, diagnostic facilities, and outcomes and processes. Changes in Key Impact Indicators Infant Mortality Rate Total Fertility Rate 60 2 1.8 50 1.6 40 1.4 1.2 30 0.8 20 0.6 0.4 10 0.2 0 0 1993 2002 1993 2002 Changes in Key Process Indicators 100 90 80 70 60 50 40 30 20 10 0 Prenatal Care Institutional Fully Immunized Use of Terminal Contaceptive Delivery Children· methods of Prevalence Contraception Rate· 1_ 1993 . 2002 1 . Baseline Data from mid term review 1998 .1 Kolkata fo r Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.J-_ In addition to the changes which could agency which is development be measured, there were several gains oriented (such as KMDA in this which are difficult to measure. These case) is better suited to engage the include strong community ownership communities in a dialogue than and development of broad political the agencies that provide CIVIC consensus on positioning reproductive amenities routinely. and child health as an important social • To firmly institutionalize the priority cutting across party lines. reform, there IS need to decentralize the program and fully Key lessons engage local self governments in Some of the critical features and the process. Ownership by local underlying processes from Kolkata municipalities is one of the critical initiative are worth noting for possible factors contributing to the emulation elsewhere: observed changes. • No single agency can effectively • Although providing basic health address the growing health needs serVIces continues to be the of the urban poor. There is need primary responsibility of the for strategic partnerships between government, identifying and public and private sectors targeting these services to the working closely with the poor is important to improve communities. Such partnerships health outcomes. Provided the among honorary workers, part- poor have been well identified, time doctors and specialists from differential user fee could be an the private sector, local bodies effective instrument to protect and KMDA not only improves and cross subsidize the poor. access to the poor but also can help keeping the program • It IS important to ensure recurring costs low. appropriate essential referral back-up (small neighborhood • Demonstrating change requires maternity homes) beyond home long-term societal commitment based RCH care, with optimal and support to health and equity cost-sharing. in the context of the urban poor, with synergic linkages among • Empowering women about their ongoing health and development reproductive rights and inputs for programs. The Kolkata initiative making them more economically was built on successive Bank and self-reliant should go hand in DFID supported community hand with supply driven development programs during initiatives to improve physical two preceding decades . An access to RCH services. 12 . KOLKATA: Mega City of Great Challenges and Unique Opportunities Kolkata, capital of the State of West At the same time, Kolkata also has Bengal, has been a mega city since been a city of perennial hope and . decades. It has long been a pre-eminent rejuvenation. It is the city of Mother seat of culture as well as a commercial Theresa. It is a city of exquisite and industrial center attracting huge traditions, with a long history multi-ethnic populations from all parts of pro-people social movements . As of India. Independence from British underscored by many respondents in and partition of Bengal in 1947 the present investigation, these resulted in the influx of millions of movements had been led by refugees from East Bengal to Kolkata. outstanding saints, reformers, and The resulting overcrowding and leaders in politics and culture. Ram strained public utilities became highly Krishna Paramhansa, Swami pronounced in the form of vast Vivekananda, Acharya Prafulla stretches of slums in greater Kolkata. In Chandra, Raja Ram Mohan Rai, recent times, the situation got Iswar Chandra Vidyasagar, Rabindra aggravated by fresh population Nath Tagore, Sarat Chandra movements during and following the Chatterjee, and Netajee Subhash war of liberation for the creation of Chandra Bose are part of the galaxy Bangladesh (1971). The oceans of slum that has kindled beacons of population Below Poverty Line (BPL) inspiration and reforms for the posed high volatility, and social and disadvantaged and the downtrodden political pressures. The challenge for over the generations. All these create provision of minimal and decent RCH an enabling environment and care in such a milieu - and the optimism for the millions of women, implications for failure to do so - drew children and men below the poverty the attention of policy makers, line, more than 40 per cent out of planners and societal leaders in greater Kolkata's population of nearly early 1970s. ten million. RESPONDING TO LOCAL NEEDS: Urban Slums Proiect Advent of IPP 8 Kolkata counseling to women, men and children belonging to poor families Kolkata is one of the four sister cities ("the beneficiaries") at no or minimal covered under Family Welfare Urban cost. At a later stage, non- Slums Project, known as India beneficiaries" (above poverty line) also Population Project 8 (IPP 8). The other received services on payment of costs three cities were Bangalore, Hyderabad at lower-than-market rate. This added and Delhi. Carried out under the credibility to the free or minimal cost auspices of the Union Ministry of care extended to the poor and also Health and Family Welfare helped to generate revenues for (MOHFW), Government of India maintenance and further support to (GOI), and supported by the World the beneficiaries. During the final Bank, IPP 8 Kolkata was a major Urban phase of the Project, this model was Slums Project to address the RCH extended to 20 more cities outside issues mentioned above. It was the KMDA areas (half supported by implemented by the Kolkata the UK Department of International Metropolitan Development Authority Development/ DIFID), which IS not (KMDA) between 1994 and 2002. part of the present analysis. A total of 3.8 million urban poor - The advent of IPP 8 was preceded by about 40 percent population in two years of learning and evolution on Municipal Corporations (Howrah and urban issues, side by side with a Chandan Nagar) and part of Kolkata number of projects that were Corporation, and 37 smaller implemented in related fields. The municipalities - were covered under the GOI policy context, which flagged project. For the first time, quality basic comprehensive urban needs, included: health care at low or no cost was provided to Below Poverty Line (BPL) • Krishnan Committee Report beneficiaries at their doorstep (1982) complemented by referral back up for • Urban Revamping Scheme essential services. These would have (under the Seventh and Eighth been inconceivable without the strides Five Year Plans) made under IPP 8. • Urban Basic Services for the Poor The focus was on providing basic community outreach as well as facility • Environmental Improvement ill based RCH services including Urban Slums Program t- 14 • • Responding to Local Needs: Urban Slums Project • Nehru Employment Scheme programs laid by three successive Bank- supported CUDPs from the 1970s to • Seven World Bank (IDA)-assisted the early 1990s would appear to be Population Projects since 1973, specially relevant: including one urban slums project (IPP V -1988), covering • CUDP I (IDA funding of US $35 Bombay and Madras cities million), 1970-71 to 1978-79: • Calcutta Urban Development This included the Bustee (Slum) Projects (CUDP I, II and III) Improvement Program (BIP), since the late 1980s with focus on upgrading existing infrastructure rather than on • Calcutta Slum Improvement creation of new ones, with a view Project supported by British to arresting the rapid deterioration Overseas Development Agency m the urban environment, (ODA) especially in the metropolitan The significant achievements made by core. Calcutta Metropolitan IPP VIII Kolkata deserve recognition by Development Authority (CMDA their own right. Nonetheless, the project which has been lately designated was enormously benefited by the strong as KMDA) was in charge of foundation laid by the above milestones budgeting, supervlsmg and during two preceding decades. Enhanced coordinating the interventions, insight into the dynamics of community while the actual execution was mobilization and growing involvement done by a number of line agencies of the local community in urban health in the field. and development programs for the poor • CUDP II (IDA funding of US were most pivotal in the process. These $87 million) , 1978-79 to 1983- paved the way for innovative RCH 84: It followed a poly-nodal programs responsive and adaptive to strategy of urban growth and local needs, with flexibility to link them pruning of service delivery norms to broader community contexts and for design of infrastructure to demands. In view of the above cover a wider population for a developments and historical backdrop, given investment. Programs for Kolkata did enjoy a comparative mcome and employment advantage over the other three IPP 8 generation for the urban poor project cities, and had a better edge for received more attention, as these results on the ground. would help improve sustainability of the assets created, particularly Kolkata Innovations in the slum areas. Accordingly, To understand the genesis of IPP 8, the the project included interventions building blocks of urban health for health, employment Kolkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _..JI-. generation and primary IDA support of about US$17 million education, with the urban poor as out of the total project outlay of the target group. US$71.4million, it was implemented between 1994 and 2002. The • CUDP III (IDA funding of overarching rationale for the RCH US$147 million), 1983-84 to interventions during this period was the 1991-92: This proved to be a continued development and further further sharpening of important reinforcement of human capital as a processes and developments. strategy to alleviate urban poverty Financial and institutional targeting the most vulnerable: poor strengthening of the municipalities women and children who ran the was more systematic during this perpetual risk of falling through the phase, along with improved already tenuous safety net. Some management of outreach and counseling and educational programs extension services; cost recoveries were developed also for adolescent girls. for certain servICes were It was a holistic, innovative and flexible introduced; and there was approach to RCH aimed at: emphasis on community based health care facilities and on • Crystallizing and strengthening schemes for generation of demand employment through small scale • Augmenting supply enterprises. Evaluated by WHO in September 1991, it was rated as one • Enhancing access, equity, and of the most successful health affordability service schemes in the world, • Promoting women 5 empowerment which concentrated on urban slum populations. Implementation The intervention package included family experience with variants of this welfare with basic health services, model, especially with ODA- enhancing community awareness on assisted health projects in Kolkata public health and hygiene, and women's and Hyderabad as well as the welfare and income earning opportunities. evaluated experiences of UNICEF, Sustainable partnerships were built among Private Voluntary Organizations local communities, PVOs and the private (PVOs), and Private Medical health providers. Practitioners (PMPs) In the The design of the program provided for provision of health services to targeted interventions that delivered urban slum populations was also quality RCH services at doorstep to the taken into account. urban poor (with monthly family income IPP 8 Kolkata was a culmination of the of less than Rs. l,sOO.OO/US $ 32.00, above antecedents and processes. With defined as the poverty line). Toward this 16 . • Responding to Local Needs: Urban Slums Project end, it was a volunteer-based approach to (PTMOs) provided medical care during RCH delivery, with a large fleet of trained specified hours at the clinics. Maternity neighborhood workers, designated as and obstetric care, diagnostic facilities, and Honorary Health Workers (HHWs) and specialized care at the Extended Special supported by a limited contingent of Out Patent Departments (ESOPDs) were paramedic and Part Time Medical also made available locally at a modest Officers (PTMOs). The HWWs, paid a cost, mostly utilizing local private token monthly honorarium of about Five practitioners with community orientation Hundred Rupees (about Ten US Dollars), and yearnings, on a part time basis were drawn from the same community through convenient scheduling of services they served as social mobilizers for during their lean hours. These were later immunization, family planning and other expanded to non-beneficiaries above th~ basic and referral services. They were poverty line on cost sharing basis. Such an supported by two levels of supervisors. extensive network of well-functioning The first level included those HHWs who services in the urban slum environment excelled in their performance and the would have been inconceivable without second level paramedics (either Auxiliary the developments made under IPP 8. Nurse Midwives: ANMs or male health Annex 1 provides the structure of service workers). The Part Time Medical Officers delivery under the Project. 7 .1 MEASURING SUCCESS: Outputs and Outcomes Methodology Improving Access to Basic The study gleans relevant documents RCH services from various secondary sources and In a near stagnant setting and despite refers to key output and outcome a slow start-off, IPP 8 Kolkata was indicators from primary data for the able to bring in truly substantial Project collected by independent changes in the RCH indicators and agencies. Numerous studies and reports performance in the course of a few ranging from the Project design phase years. As noted earlier, nearly fout to regular World Bank-GOI-KMDA million beneficiaries below the monitoring visits have been analyzed poverty line (BPL) received doorstep and utilized. These have been service, for the first time in their life complemented by additional primary an d m the life of the slum data from 29 Focus Group discussions communities. It is a tribute to the and 23 in-depth interviews covering a Project that well-equipped and well- total of about 300 key actors. They staffed facilities also attracted clients included program managers, above the poverty line, ready to pay community leaders, service providers for the services. and their supervisors, and beneficiaries Access to quality RCH services at the grass-roots levels. Extensive field improved significantly through the visits by the authors have gone into critical implementation issues and modalities, crosschecking and Box 2. Project Inputs to corroborating the findings through improve Access dialogue with key stakeholders. Finally, • Health Administrative Units the preliminary findings of the study (HAUs): 116 were shared with a cross section of participants in a major national • Health Sub-Centers: 273 workshop held in Kolkata in February • Maternity Centers: 23 2002, which was organized by KMDA In collaboration with MOHFW. • ESOPDs: 25 Besides representation of IPP 8 • Regional Diagnostic Centers: 8 Kolkata, this was attended by four members of the West Bengal Cabinet, • School improvement (toilet managers of the other three IPP 8 cities, facilities for female students): 297 "'18 . and donor representatives. • Measuring Success: Outputs and Outcomes establishment of a network of about Generating Demand for 445 conveniently located service RCH Services outlets with well-equipped physical Profound improvement also took place infrastructure. This enhanced in client behaviors with cumulative institutional capacity for serVice effect on the RCH outcomes. There was delivery significantly, besides a pronounced change in the health providing suitable venues for quality seeking behavior; demand for services; care. In addition, nearly 300 schools and more important, in the public received toilet facilities for female awareness of individual rights to the students. The targets for physical community health facilities. The project infrastructure were achieved 100 per used innovative and indigenous cent or more (See: Box 2). Behavior Change Communication Vastly expanded client access to RCH (BCC) approaches, including direct services and personnel is also spelled provider-client trust and reinforcements, out by the beneficiaries themselves in for generating and sustaining demand Box 3. for RCH services. Empowering women Box 3. Beneficiaries: On Doorstep Services • We are receiving the services at our doorstep. The DidislElder Sisters (HHWs) always inquire about our health. We discuss our health related troubles with the HHWs. They provide us medicines for the common ailments and give ORS packets for diarrhoea. We don't need to go to the clinic for such diseases most ofthe time. - Beneficiaries, Bali Municipality • The HHWs give us MALA-N and always remind us to take it regularly. Earlier, we were not so much aware ofhow to prevent pregnancy. Even if we knew some of the methods, we did not know how to use them. Moreover, we flit shy to buy them from the medicine shop. We knew that we could get them from the Government hospital but it is too far from our place and takes a lot of time. Now we are getting these at our home. Definitely these services have helped us a lot. - Beneficiary, Naihati Municipality • When she (HHW) visits our houses, we can ask her privately about our (reproductive and sexual) health without any hesitation. We could not think of receiving this kind of service earlier. Moreover, she stays in (our) locality, and we can approach her at any point oftime in case ofemergency. - Beneficiaries, Sreerampur Municipality Kolkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _...... Box 4. Emerging RCH Norms and Behavior Change + Pronounced improvement in RCHI Health seeking behavior since the baseline + Better appreciation of Quality of Services + Resultant changes in fomily size norms (about two; among many, one: even with a single girl child); preference for higher age at marriage; later age at first birth; wider child spacing; and increased value ofgirl child and adolescent girls through income Mid-Term Review, the End Line Surveys generating enterprises, female education, revealed considerable progress in both and counseling further complemented mortality and fertility decline, and the the BCC initiatives. Boxes 4 and 5 accompanying levels of immunization, provide a glimpse of the emerging institutional delivery, contraceptive transformation. prevalence, and delayed age at marriage. The figures that follow may, thus, be deemed as nontrivial achievements, even There was a significant improvement in in absolute terms. Judged against the RCH indicators. Compared to the formidable levels of poverty and the baseline figures at Project inception or slum setting, the accomplishments - - 20 .-"--_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Measuring Success: Outputs and Outcomes Box 5. Beneficiaries: On RCH Norms and Changing Health Seeking Behavior • We live in the tiny shanties jostling on each other. We have very little space to live in. But we know that if we keep it clean, we can prevent some of the diseases. So, we try to keep our houses clean and the surrounding areas too. - Beneficiaries, Bali Municipality • Nowadays almost all of the mothers in our area know the positive aspects of keeping their family small. We have realized that it is difficult to manage the expenses of a large family with our limited earning. Now most of us have either one or two children. As we have small number ofchildren, we are able to take care of them better. We can pay more attention to their health and education. We are sending our children to school. - Beneficiaries, Baranagar Municipality • We went to our native place, Bihar, for some time. During that time I filt that I was pregnant. Traditionally in our village all the deliveries take place at home. There are no doctors and the Dai conducts these deliveries. People never fiel that they should go to a hospital for deliveries. But I filt hospital is much safir than home. IfI would have any problem during delivery, I will not get doctors or nurses at my home in my native place. The facilities available at the hospital cannot be arranged at home. My first child was born at hospital in this area. I faced no problem at that time. This time also I wanted to go to the hospital for my delivery. Hence, I have returned foom my native place in a hurry. I have got examined at the Sub-Center, and I have received a card. The HHW and doctor told me that they would arrange for the same hospital for me where my first child was born. - Beneficiary, Titagarh Municipality • The HHW had told me repeatedly to get my delivery at the hospital. But I was scared to go to the hospital because I had heard foom my relatives that the doctors slit the birth passage at the hospital. My mother-in-law and other elderly relatives told me that they gave birth to a number of babies at home without any problem. So they decided that my delivery would be at home. My baby was born at our home. A trained Dai conducted the delivery. I do not want my next baby within three years. Our HHW has brought me here and I have been inserted Copper T today I was so scared that it would be painfol But it is not like that. Our HHW was always with me. The Doctor has also discussed with me as to why it is not safi to give birth at home. - Beneficiary, Titagarh Municipality . 21 -. Kolkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _..... • Previously we heard from our elderly relatives that the Copper- T pierces through the internal organs after its insertion and so it causes severe bleeding. We were scared. But we have seen that lots of women have inserted copper T, and they have no problem. We felt convinced. Our HHW has taken us to the clinic for insertion of Copper- T. Now a few months later, we are facing no problem. - Beneficiaries, Bali Municipality • Some of the elderly women said that if we give immunization to our babies they would become impotent when they grow up. We did not believe these, because the HHWs told us that each and every child is getting immunized, and immunization helps the children grow necessary strength to fight against some serious illnesses. The HHWs said that children in their families have also received immunization. Now every child in our neighborhood area receives immunization. - Beneficiaries, Bali Municipality appear to be genuinely worthwhile. vision of the Project architects proved to Relative to the earlier stage of poor be a reality, exceeding expectations on demand for and highly inadequate access many fronts. There was a synergic to the rudimentary RCH service outlets blending and matching of the demand and the services themselves, they were and the supply sides of the RCH now within reach of the urban poor -- at equations in Kolkata slums. Some an affordable cost and within the local highlights of the ourcome are summed community itself. For the first time, the up in Box 6. Box 6. Key Outcome Indicators • Increased Contraceptive Prevalence Rate among eligible couples (45 to 72%) • Increased immunization (About 70 to nearly 100% of eligible children folly immunized) • Increased Antenatal and Postnatal care (nearly 100%) • Nearly complete institutional delivery (approaching 100%) • Early identification and referral ofhigh risk pregnancies by the HHWs • Improved sanitation and community health through collective help • Significant declines in fertility (TFR 1.9 to 1.7), and infant mortality (IMR 56 to 26100), and maternal mortality increasingly rare in Project sites t- 22 • IWhat made Kolkata a Success? A vast and intricate mosaic of unique counseling, services (including early processes provided the route map in identification and referral of high risk Kolkata to realize the vision of the pregnancies), and follow-up at policy makers and planners. These household, community and clinic helped translate the thrust on levels. Deployment of the Part Time community ownership and Medical Officers (PTMOs) and commitment to the cause of the urban strategic use of specialists at selected poor, especially their needs for basic hours helped provide quality care at health care, hygiene and sanitation. low cost. The basic diagnostic, Large-scale acceptance of the new RCH maternity and some specialized norms and the corresponding health services were made available to the seeking behavior were reinforced and beneficiaries on a modest cost sharing sustained by systematic operational basis. The support was made possible modalities. by additional revenues generated through opening up some of the Focus on Outcomes: There was a services at lower-than-market costs to vital point of departure from the non-beneficiaries above the poverty previous preoccupation with Project level. All in all, the key underpinning inputs to outputs and outcomes. The was for a demand-driven mode, prime focus now was on outcomes, reinforced by streamlined and salient results on the ground -- ensuring the supplies. delivery of the stipulated quality and quantity of the services to the Public-Private Partnership and beneficiaries. This was also evident Curative Back-up: In view of their In the deliberations of the special importance in the present Honorable Ministers referred to context, some additional elaborations before and was widely shared by all are called for. The earlier experience actors and agencies involved in with CUDPs evidenced that the implementation. public sector in the outlying areas was highly constrained with respect to Client responSIve serVIces: The availability of doctors, particularly overarching emphasis was on specialists. This resulted in inadequate expanding access to doorstep and care for the urban poor and gross client-friendly service delivery at under-utilization of the existing affordable cost. This was done by the health infrastructures. IPP 8 use of an essentially volunteer-based effectively exploited the huge outfit (HHWs and their supervisors) potential to make use of both for the outreach, covering selective generalist and specialist doctors living KoLkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Jl-. in the vicinity during their free time. It of the health systems, with very weak resulted in a Win-Win situation for all linkages and support. concerned: the private practitioners (in terms of added credibility in the Well-defined Program, with Supportive community and personal business); Supervision and Monitoring: the common people (better access to A distinct feature was that it was a doctors and reputed specialists); and simple but well-defined field the municipalities (increased program, meticulously implemented utilization of services and facilities and carefully monitored. A good deal created). Positive outcomes accrued to of accountability was built in, starting beneficiaries as well as to non- from providers and supervisors at the beneficiaries above the poverty line. ground level to the medical Another important issue related to personnel, community leaders, and curative back up for RCH and basic ma nagers at KMDA and GOL health care. The project was aware of Systematic micro planning was the national and international characteristic of the Project. Advance experience that a strong/minimal time-bound action plans included curative back up is essential for primary protocols of daily, weekly and health care to fully succeed. This has monthly work plans, and schedules been widely documented - for example, for service delivery, and review and in Jhamkhed in Maharashtra; Child in supervision of household, community Needs Institute (eINI) in Kolkata and and clinic based work. These proved useful for all concerned, including the Janani in Bihar; and International Center for Diarrheal Disease Research, beneficiaries themselves. Bangladesh, (ICDDR, B) in Dhaka. In Supportive supervision in the field and the absence of such back-up, RCH or weekly review meetings helped resolve primary health care would appear to be implementation Issues and interventions in isolation from clients' strengthened staff development, with broader health needs and security. By practical feedback to program ensuring such back up for essential improvement. It is also unique that referral services, the project brought in program monitoring was not limited to high credibility for the outreach external managers making field visits volunteers (HHWs) and, at the same occasionally. Rather, the inherent time, immense benefit and satisfaction strength was continual vigilance by the to the clients. This was a vastly superior leadership and other stakeholders ever arrangement, compared to the primary present 10 the community and, care systems elsewhere in the state or importantly, by the empowered and the country where the referral services vocal clientele themselves who were are provided by other divisions or units made conscious that the expected • What made Kolkata a Success? services should indeed be in place and delivery. Service round the clock was were delivered on time and to their not a matter of official requirement satisfaction. but a natural extension of community and good-neighborly bonding, an The mode of community ownership element commonly in abeyance in played a decisive role in the process, most public sector interventions. with the Municipal Chairmen and Leaders, providers and clients - and in leaders at the Ward level Committees many cases, the managers - were all taking a special responsibility and from the same soil, with common pride on the positive outcomes. interest and a shared vision with Strong implementation guidance and respect to defining a holistic agenda of technical support was readily community needs, RCH and health. available from the KMDA Project These also included broader aspects of Team. The MIS reporting format was also kept user-friendly and minimal, neighborhood hygiene and sanitation, , keeping in view its practical use and women s empowerment, income utilization. Finally, regular World generation and self-reliance; and Bank review missions helped make adolescent counseling. The the superViSIOn and monitoring decentralized implementation and process highly transparent, educative engagement of the local bodies noted and productive for all concerned - the above were found most fruitful. community leaders, the managers, the Satisfied Stakeholders: At all levels - technical supervisors, and the service leaders, providers and clients - there providers. Such a system was a was a good deal of contentment and prerequisite for the efficient gratification on their respective functioning of a volunteer-based perspective. The leaders obviously outreach setting and medical care had altruistic as well as political provided essentially by Part Time interests satisfied. Many providers Medical Officers and private had a new meaning of life as well, practitioners under constant derived from their rather rare community oversight. opportunity to serve and receive Participatory Mode and Leaders- community commendation. Clients - Client-Provider Bonding: The beneficiaries and non-beneficiaries community based volunteers were (above poverty line) -- previously selected with due attention to their unhappy because of the inadequate track record of community work and care available, were now satisfied with came from the clients' own socio- the service they received within easy cultural setting. This allowed for a reach and affordability. These factors spontaneous sense of mutual brought III broad societal identification and affection in service commitment in favor the Project. Kolkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Box 7. Providers: On Satisfaction and New Meaning of Life + Previously we used to waste time during the noon, either gossiping or sleeping. Now we are utilizing the time more fruitfully. We have satisfaction that we are a small part of this vast social service. We never thought that we could get this much of respect and love from the general people. They respect us as doctors. We have an opportunity to share our fielings amongst ourselves as colleagues. The program has given a new meaning to our life. -- HHWs, Sreerampur Municipality Box 8. Beneficiaries: On Participatory Decisions and as Satisfied Clients + We have seen that the HHWs and other staff members of the program try to realize our needs. They don't impose their opinions on us but give adequate importance to our views. We also fiel encouraged to give our opinions and at the same time we try to follow their advice. + The programs like nutrition program, mothers' meeting, magic show, and drama are very informative and at the same time very enjoyable. Although we didn't want to participate in these programs previously, now with increasing participation we have learnt a lot from these programs. Now we encourage others to take part in these programs. Inspired by the role of HHWs, a fiw mothers are . voluntarily motivating others to receive the services and spreading health awareness messages. We have realized that the program has benefited the poor people. We want these programs to continue. Beneficiaries, Naihati Municipality • What made Kolkata a Success? Box 9. Successful Entrepreneur: The New Opportunities .. This training has helped me a lot to become self-sufficient. I had to leave my education when I studied at Class VIII due 0 financial comtraints. I am now earning Rs. 3000.00 to 4000.00 per month and looking after my family. I have started a trainer agency and presently I am providing training in different municipalities under the program ofSwarna Jayanti Rojgar Yojona and IPP8. I never thought ofleading such a prosperous life. I am sure that I will continue with the same after my marriage too. - Successfol Entrepreneur, South Dumdum Municipality Box 10. Satisfied Adolescent Beneficiaries: On Adolescent Sexual and RH Program .. On the first day of the training program, we felt shy, but Madam (RH Educator) was so friendly with us that we did not hesitate later. .. I never thought that I could talk openly about sex. I had lot of questions in my mind But I did not find any body to ask. I was scared to ask a few questions that I always wanted answer to, but could not ask anyone fearing to be marked as a "bad girl. " we got an opportunity to know so many things that we never knew earlier. .. I thought menstruation is dirty. There are so many myths related to this. we are not allowed to work in kitchen and touch the idols. Now we know that as we are growing, this is quite natural. .. I had heard about AIDS. But I didn't know what it was. I thought AIDS and STDs are were the same. Now I understand clearly. I know how it is transmitted; how it could be prevented; what should be our attitude towards an HIV positive person. .. I was told that if any boy misbehaves with me I would get pregnant. I felt so nervous. Now it has become clear to me what actually happens. I have come to know about our body and reproductive systems. Madam has taught us why early pregnancy is harmful to health. I do not want to get married before I am 20. .. I got married early. If I had the knowledge before, I would not have the baby at an early age. However, I will try to have the second baby at least five years later. Then I will take some permanent family planning method. I shall pass this knowledge on to my daughter when she grows up. .. we already have discussed with our friends regarding what we have learnt from this training. The training is really helpful to us. we can protect ourselves in future. This type of training should be arranged for all girls of our age. The boys should also get this training. Otherwise, we cannot utilize the knowledge fully. - Adolescent Girls in South Dumdum, Madhayamgram and Naihati Municipalities Kolkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _,. Box 11. The Satisfied Non-Beneficiaries + We won't get such specialized treatment facilities at this cost charged at the Municipality Health Clinics (ESOPDs). The cost o/services is even less than half than in other private medical institutions in the locality. The doctors and other staff take care 0/ patients adequately and they are well behaved. The specialist treatment facility with a moderate charge was a demand in our area for a long time. We are happy that these facilities are being provided by the municipality under IPP 8. - Non-Beneficiary Service Recipient The Immeasurables that made a Difference A number of rather intangible factors delivery for the mass and, created an enabling environment, concurrently, the enormous political helped build strong commitment, and capital that could be made by serving sustained the RCH initiatives across the the people. It was a mutually urban slums. They were: reinforcing platform for both the leaders and the led in the local o Community ownership of the communiry. A satisfied client was also interventions, institutionalized by a guaranteed voter in the local and the Municipal Chairpersons and State elections. It was no wonder that shared by the communiry leaders the presence of the Municipal o Broad consensus on the RCH and Chairperson in the service outlets basic health programs at the local became an increasingly common sight. level across political divides, ensuring In many instances, a Chairperson was uninterrupted implementation found to have an office in the health regardless of political contours and facilities, spending hours monitoring changes in the local government the service providers and maintaining direct client contact. o Women's and child health placed on a high profile community As repeatedly echoed in the in-depth and State political agenda, interviews and focus group sessions, increasingly seen as an intrinsic the above thrusts were reinforced in and irreversible right, and view of the critical power base of the blended with a mix of: cabinet and the politicians in the Kolkata municipalities. Indeed, • Altruistic motives of communiry apart from representing their servICe political constituencies, the Project • Keenly perceived political stake at areas include residences and long local, ciry and State levels drawn connections of several ministers and members of the State • Empowered and vocal clientele Assembly as well as opposition demanding qualiry service and politicians. These provide a very accountabiliry in health care distinct fabric of opportunities and delivery personal as well official policy and The leaders were keenly aware of the programmatic commitment on the high political stake and volatiliry of part of key leaders and decision failings in health care access and makers in community and family , Kolkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . health. The recent expanSlOn of the the slum dwellers and an program to 20 more municipalities unim peachable sense , of (10 supported from the project and commitment to make that happen 10 by D FID) and keenness of were most phenomenal in the GOWB to follow a similar model project. This was especially true at even in rural areas, reflect the the level of senior professional positive internalization process by management of KMDA. The the decision makers. dynamic role played by the Chief of o Leadership driven with a vision: A Health, IPP 8 Kolkata, Dr. B. lofty vision for providing basic Bhattacharjee, deserves special health care at the doorstep of mention in this regard (The opening Box 12. Community Leadership and Pillars: Ownership and Commitment + Strong but friendly administration and supervision is being internalized in our program monitoring and it has been made possible by our Chairman. He is always beside us. He personally takes care of each and every aspect of program implementation. His involvement stimulates us to feel more encouraged. The Chairman visits Health Administrative Unit (HAU) at least once in a month and visits ESOPD, Maternity Center and Regional Diagnostic Center very frequently. He also visits the Sub-Centers and the field. Besides the visits, he regularly keeps track of program activities through the councilors. He knows most of the health workers personally and they also can approach him directly. - Health Officer and Assistant Health Officer, Bhadreswar Municipalitycipality + People are getting services, which they never received earlier. Their expectation has increased. At this juncture, we cannot move away. We have to continue the program any way. - Chairman, Naihati Municipilatycipality + Fortunately, we are able to cater to the people 5 satisfaction. The demand for service is growing. We have to maintain the services that we are rendering now. Not only that, we have to surge ahead. We believe, If we do something good for the people, we will definitely get the support from them as we have been receiving and will be able to generate resources necessary to continue the program. - Chairman, Bhadreswar Municipality - --------------------------- The Immeasurables that made a Difference remarks in Box 1 of the present write- recelvmg his serVICes without any up - The Challenge and the Vision - interruption. Similar projects are excerpts from him}. Backed with a elsewhere should also explore and strong public health background identify leaders with such vision and and long experience with the earlier drive. CUDP III interventions, his unflinching mission proved to be The above comments (Box 12) were equally inspiring to the senIOr reverberated at the highest levels of project management, the the State polity. As many as four community leaders, the service members of the cabinet of the West providers at all levels, and the Bengal State Government attended technical team that he led. Starting the Experience Sharing and from the design stage and Dissemination Workshop for IPP VIII throughout the implementation Kolkata, held in the city, on February phase, his singular dedication and 14 and 15, 2002. Here are a few determination were always found to quotes (Boxes 13 to 16 tracing the be far beyond the calls of duty. The Project's community focus and project was very fortunate in strategies. Box J3. Honorable Dr. Asim Das Gupta, Minister of Finance, West Bengal: Milestone in Community Management + IPP 8 Kolkata is a milestone in participatory community management. .. . We posed the health problems through the eyes of the common man. Shall we allow them to fall sick and then treat them? Or ensure that they do not fall sick and lose income? We realized that at least 50 percent of the morbidity is preventable through provision of safe drinking water. and immunization; and nearly 85 percent of the people can be treated locally. As a sequel to CUDP Ill, we have involved and empowered the local community, decentralizing program management and implementation at that level. ... The basic contours of the program have been the use offemale community volunteer workers providing health care, surveillance and referral Jor 200 households, on token honorariums; seven such workers are supervised by a supervisor, also a female volunteer from the community itself. . . . On the basis of certification by the local municipality, health cards were issued to the BPL beneficiaries - initially for totally free service, later on adding a small charge Jor diagnostic and relatively specialized care. The venture has been enormously cost-effective; financially feasible; with enormous pay-off· .. Kolkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Box l4. Honorable Dr. Surya Kanti Misra, Minister of Health and Family Welfare, West Bengal: Safety of Community Health + IPP 8 is a landmark in community based interventions. As a physician I must say, health ofthe community is not safe with the Ministry ofHealth; it is not safe with health professionals alone. Health professionals around the world have a curative emphasis (rather than a holistic and preventive thrust). Community health is safe only in the hand of the community. . . Health workers from the community, available at any hour, odd hour, has been the key to the success (of IPP 8). Decentralization (of health interventions) does not simply mean decentralization from the Center to the State to Local Bodies. Decentralization must not stop until involvement of the people. They can help their health more than anyone else. Planners and specialists are not substitutes for the people. In participatory programs, people formulate, implement and monitor (health interventions) activities while the Government participates. • The ImmeasurabLes that made a Difference Box 15. Honorable Shri Ashok Bhattacharya, Minister of Municipal Affairs and Urban Development, West Bengal: Community based Door Step Institutions + The urban poor contribute significantly to the economy; and women make a very substantial contribution. Yet the fruits ofdevelopment remained beyond the reach of the urban poor. In particular, the health facilities did not cater to the demand profile ofthe poor. The community based efforts in IPP8 made a breakthrough for the first time, opening up the facilities to the slum dwellers. There was also a healthy blending of bottom-up and top-down planning. The interventions were made demand-driven, with effective community protected safety nets. This was a big departure from the previous supply-driven efforts, which did not attract and serve the poor. Box J6. Honorable Ms. Manju Kar, State Minister of Municipal Affairs and Urban Development, West Bengal: By the Community, for the Community + The success of the Project was rooted in the community based design, a design by the community, for the community. ... Women members ofthe community proved to be the pivot -- both as beneficiaries and providers, both from the same community. They were the pillars. Cascading Partnership among the Ke Stakeholders A very distinguishing mark and o GOWB: achievement of IPP 8 Kolkata has been • Demonstrating strong political a great orchestration of a grand commitment supported by symphony with a cascading partnership state policies of many key actors: • Ensuring uninterrupted funds o Institutional Level GOI- flow to the project GOWB--KMDA- World Bank: • Committing financial The continuing policy dialogue sustainability after the project and critique among these key partners proved murually • Supporting expansion of the reinforcing and inspiring, and Kolkata model to other towns most central in the design and and rural areas execution of the operations. The o KMDA Management: process helped identify and resolve major implementation • Catalytic guidance and issues and take corrective steps technical assistance to the municipalities and its during the life of the Project, leadership and concerned especially following the Mid- health functionaries Term Review (MTR). The crucial roles played by these four • Institutional arrangements and agencles included the following training of the service agenda. providers, supervisors, and professional staff o GOI: • Supportive monitoring and • Enabling RCH policy quality control environment • Inter-municipality • Interface between KMDA, coordination, exchange and Government of West Bengal experience sharing (GOWB) and World Bank • Accelerated implementation, especially following the MTR • Assured and steady fund flow • Commitment to urban RCH o World Bank: at national, State and city • Policy dialogue at GOI, State levels and KMDA levels .,----------------------- Cascading Partnership among the Key Stakeholders • Funding support Strong commitment, effective mobilization and coordination of • Coordination, monitoring and myriad input, outputs and outcomes reVlew mlsslOns at this level proved to be the decisive • Technical support and quality factors in the Kolkata success story, as control harped upon throughout this report. • Gleaning and sharing best KMDA provided overall guidance practices among the four IPP 8 and support. The Municipal sister cities Chairmen spearheaded the process of community ownership and vigilance • Flexible operations and that became the heart and soul of the program adaptation interventions, which the Municipal • Following up on demanding Councilors and Members of the benchmarks Ward Committees were expected to • Mitigating bottlenecks and emulate. expediting implementation Enduring and strategic partnerships o Community Level-KMDA-Munici- among the local bodies, the private palities- Wards: This was the sector and the community have proved operational arena of the Project. to be the crux of a viable operation. Lessons Learnt and the Replicability Riddle Throughout the preceding analysis, we laced with inspiring commitment at all have captured many insights emerging levels and a proud sense of ownership out of the Kolkata innovations in RCH at the community level. interventions for the urban poor in the city slums. Let us recapitulate the Accent on Start from the highlights: Outset A number of activities should be Pillars and Heroes flagged for an early start-off: The Honorary Health Workers • Start service delivery early on. Do (HHWs) and their supervisors, and not wait for the infrastructures to the municipal chairpersons clearly be completed. come to the fore. The empowered clients - previously voiceless and • Blend volunteer-based community unnoticed follow interactively; mobilization and follow-up without their active and collaborative programs with a back up of good participation, the success story would quality clinical care, which IS have remained a mirage. And so do the affordable and easily accessible. KMDA management; their • IdentifY and acquire suitable conscientious and catalytic interface land/venue for construction, with with GOI and the State Government, good client catchments, failing on the one hand, and with the cross- which expensive infrastructures section of community stakeholders, on remain unavailable most of the the other, accounted for a good deal of Project period and under-utilized the accomplishments on the ground. later on. In this wider perspective, the dynamic confluence of contributions made • Focus initial project efforts in individually and collectively by these communities that are ready latter agencies made the difference. In institutionally and politically; and that sense, it has also been pointed out expand to more challenging and during our in-depth deliberations that less ready areas following due there perhaps are no specific heroes - preparation 10 them and and heroines, if one would wish to add demonstrated success elsewhere -- - in this venture. It was an artifact of consolidate achievements before teams and teamwork, and an exquisite unwieldy and non-responSIve orchestration of a grand partnership, expanslOn. .1___________________________ Lessons Learnt and the RepLicabiLity RiddLe • Ensure decentralization, devolution really be replicated? Is Kolkata too and community empowerment. unique in terms of its historical backdrop of pro-people social Participatory Process awareness and movements? Is it too special with respect to the political Building in a broad constituency of the attention and volatility of the huge partners is most critical. Toward this end: urban slums, which are also critical • Reinforce the alliance of the seats of power? Are opportunity costs principal stakeholders at the of alternative time use different in community, city, State, GOI and other metropolitan areas (such as donor levels. Delhi) whereby token honoraria and small payments may not be able to • Beneficiary participation is a key attract volunteers or part timers for to results on the ground and several hours of service a day in health ultimate success. care delivery? Answers to these . • Development agency (like KMDA) complex questions are also complex, is in a bener position to implement and issues relating to replicability and such innovations than a municipal transfer of the Kolkata innovations to administrative authority (like other cities in India and beyond Kolkata Metropolitan Authority: would need to be carefully thought KMA), as used in some other IPP 8 through. Project cities. At the same time, the foregoing discussions on the lessons learnt do Provider Supervision provide considerable optimism. Some Since the great bulk of the workforce of the vital processes underlying the (HHWs) is comprised of non-paramedic interventions deserve special volunteers, it is most crucial that their consideration. Foremost among them supervisors - at least the second/more are those relating to: institutional senior of the two tiers of supervisors - be arrangements; community ownership; paramedics. This would ensure better empowerment of the traditionally support to the HHWs and help provide voiceless poor slum dwellers; low cost bener quality of client care. service protocols, backed by meticulous micro-planning; the inherent value of Replicability Issues locally recruited service providers; The strides made by IPP 8 in strategic alliances of the key effectively addressing the RCH stakeholders and development challenge for the urban poor in partners; public-private mix in client- desperate slum settings have raised friendly service delivery at affordable expectations elsewhere. How can the costs; and above all, an innovations be replicated? Or can they uncompromising framework of strict .37 -, Kolkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _...1-. monitoring and accountability, In this context, one could also conceive coupled with a strong emphasis on replication of selective elements of the results on the ground. These are above innovations to rural RCH and profoundly inspiring elements of best health interventions, taking them to practices that Kolkata has evidenced; local bodies like "vibrant panchayet and are certainly worth emulating in samity" (Remarks of the Honorable different combinations or collectively, Minister of Finance, Government of depending on the particular West Bengal, at the Kolkata circumstances and community Workshop). contexts of the urban slums, poverty and RCH indicators. In other words, Some holistic perspectIve on the leaders and planners may plan Project's evolution, achievements, programs based on these valuable outlook and challenges are seen through insights from Kolkata, with the eyes of rwo senior program appropnate flexibility for local managers associated with IPP 8 Kolkata adaptations. in Annex 2 and 3. I Looking Forward The Unfinished Agenda This could be supplemented by special surveys and in-depth studies in order to During its relatively short life span, the identify the target populations. Ko-Ikata Project has received many commendations for making a Such selectivity would also help reduce difference in the life of the poor slum the cost of the present program, which dwellers. The RCH indicators have may have to give relatively less attention registered remarkable improvements, to population groups where the new especially since the Mid-Term Review RCH norms and health seeking five years ago (1998). During the behavior are firmly in place. With a coming phase, the city managers and view to reducing operational costs, it community leaders would have to would be worthwhile to review and devote attention to special targeted rationalize the worker-population interventions. These should include: density. This density may perhaps be • Focusing on inaccessible areas or substantially reduced in future, since disadvantaged population groups the basic demand for RCH is largely in where the fruits of RCH care still place; the work load of the providers remain largely tangential; has also significantly reduced in some areas as a result of lower service • Addressing the needs of sub- coverage needed - following from populations, such as adolescent reduced number of deliveries and boys (and girls already being smaller number of children being born. covered) and the floating Thus, one would envisage that in the populations that remain changed normative and behavioral particularly vulnerable to the setting, less frequent home visits would new generation of challenges like suffice; and only selective home based STIs and HIV/AIDS; services would be called for. Such • Involvement of the male modalities would also allow for savings population In contraceptive that could be targeted at new partnership with the females and intervention groups referred to above. sensitized on violence against women. Sustainability The GIS (Geographical Information The Kolkata innovations have already Services) pilots under IPP 8 Kolkata has built in several important foundations already produced very useful socio- for sustainability In terms of economic and ethnic mapping to institutional, human resource, and facilitate some of the above activities. financial resources. It would be Kolkata for Mother and Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Important to sustam these features, • Low operational costs and covering the following: determination of the o A strong demand base for RCH municipalities to carryon the program with local resources • Positive RCH norms and (community, individual charity), continuing health seeking behavior with supplementary assistance • Women's empowerment through from the State sensitization on RCH rights and programs of economic self-reliance o Institutional and human resource mechanisms • Continuing emphasis on equity and affordable service • Strong community ownership, reinforced by State and city level o An equally strong political support commitment in support of the urban • Trained and committed local poor providers as permanent resource • Health as a continuing and for the community, beyond the life unquestionable priority on the cycle of the Project community, city (KMDA) , State • Provider-client bonding and GOI political/policy agenda • Enduring partnerships among the • Ensured RCH funding support for local bodies, the private sector and the urban poor the community • Determination of the Municipal • Network of newly built, Chairmen and the Ministers that refurbished and well-equipped "there is no going back" on the local service outlets to sustain the above political agenda demand base All in all, however, It needs to be o Innovative resource mobilization appreciated that major RCH and public • Women and child health mapped health programs for the urban poor firmly for investment at the would need continued support and community level nurturing beyond the relatively brief • Cost sharing, health funds and time frame of the Project. The Kolkata community donations already III success story could come to fruition place in many municipalities following the pathway of salient • Visibility and support of interventions for at least two preceding BPLIRCH needs at the State level: decades. Their continuation, likewise, outlay at the State budget would remalll a challenge and • Linkage of the future urban RCH opportunity for many years to come. programs with other ongoing and When one talks of health equity and prospective interventions in the access of the poorest of the poor, it field would be critical to find a viable balance • Looking Forward between fully market-driven and fully- stakeholders emerged as the central Government operated facilities on a message of the project, with pre- relatively long time horizon. Access of eminence and bonding of the local . the slum dwellers in Kolkata has been client with the local providers in the traditionally very limited under both entire process. As aptly remarked by a these scenarios. This is where IPP 8 has senior GOI official (Mr. Gautam Basu, made a difference. Joint Secretary, MOHFW) in the It is in this context that the Honorable above mentioned workshop: "IPP 8 Minister of Health and Family opened up new vistas in reaching out Welfare, Government of West Bengal, to the common people in urban slums underscored in the workshop referred with an affordable and accessible to earlier: "You cannot leave public model of health care. It made a health entirely to the market, where departure from the previous efforts. It people with no purchasing power has dealt with hearts and minds of the won't be able to purchase health. people." By leading this unique Community participation is not a venture, IPP 8 Kolkata has also made a substitute for Government lasting contribution to a successful and intervention." Thus, a judicious and innovative clue to serving the urban pragmatic blending of both public and poor and the under-served slum private sector efforts with community dwellers in a low-income country. Annex - 1 STRUCTURE OF SERVICE DELIVERY IPP VIII Kolkoto Block Caters to 1000 population Staffed by one HHW Sub Center Caters to 5000 population Staffed by 2 PTMOs who attend Sub Centers by rotation and One First Tier Supervisor Health Administrative Unit Caters to 20 - 35,000 population Staffed by Health Officer, 2 PTMOs & Two Second Tier Supervisors Maternity Home & Ess. Specialist Out Patient Dept. Caters to about 100,000 population Delivery, in-patient and Specialist services Local Coordination Committee Chaired by Mayor of Municipal Corporation Members: Municipal Commissioners, Health Officers, Ward Councilors Annex - 2 PROJECT DIRECTOR: Holistic View of Proiect Evolution and Outlook o Structural arrangements made a o Cost sharing collections through the difference with the functional outcome Local Bodies - rather than through for IPP8 Kolkata. The Project was State Government mechanisms -- implemented under CMDA, not proved a strategic modality, avoiding under CMA, unlike some other City the audit restrictions that would Corporations, as in the case of IPP 8 have been involved if the proceeds Delhi. had to be retained by the service providing institutions. o There were several critical foctors in the success of the Project. The o The Project was initially designed decentralized mode, including for the BPL beneficiaries. Later, community ownership proved very when the standard of care improved, important. So was the physical it was opened to non-beneficiaries. proximity and close linkage with the This added valuable credibility to political power-base at the State level. the services provided to the poorest A number of important Ministers of the poor and also generated good and Members of the State Assembly revenue to sustaining the quantity hailed from the nearby municipalities and quality of care for the covered by the Project. These brought community. in a lot of political visibility and o Vocational and skill development political pressure that helped the training provided a strategic entry Project's success. It drew even the point activity for the Project, with a personal attention and commitment lot of exposure and empowerment to from the Chief Minister himself the poor women. o Successful implementation of IPP 8 o The turning point for the Project has been an issue in both State and was about the time of the Mid- local elections. However, despite such Term Review. Shortly before that, politicization of the implementation the new Project Director had taken process, serVIce delivery and over at the CMDA level. There was beneficiary access remained above a close scrutiny of the extremely politics. The Project received strong slow implementation by that time. support across political parties - such Construction of physical as from TMC in Madhyamgram and infrastructure, rather than service the Communist Party in New delivery, received major attention. .43 '" Barrackpore. Yet construction itself was very Kolkata for Mother and Child -------------------------------------- slow. Identification and acquisition servIce delivery, and thereafter of sites took a long time. On the transfer the mature service delivery side of the World Bank, procedures to a newly constructed premise. for clearances for procurement took • Local girls working for the too long. There was a change in the municipalities are loyal to the Bank's Project Management municipalities. Their new role was following the Mid-Term Review. a big fillip for their social status. Implementation escalated because of proactive collaboration between • Provide timely and required skill CMDA and the Bank. 1996 training to HHWs and other grass onward, many civil works; since roots workers. The selection of the 1999, even more numerous. Lot of HHWs should be careful and, and innovations at this time, including if necessary, even strict. Unless the GIS, given to 10 municipalities III workers have some commitment to the post-MTR period. social/ community work, their priorities may be different. o Lessons learnt? • Start with demand generation . • Ground Rules: The Project Without this, service delivery management may need to prepare efforts will remain under-utilized. the urban local bodies to receive and Don't overload the servIce accept the Project. Readiness of the providers. Be selective and go for urban local bodies is an important targeted interventions. factor. Initiating activities in too many urban local bodies will involve • HHWs and the First Tier Supervisors might start getting long gestation and also the Project stereotyped and stagnated III management may feel that it is routine things, which may not be running into too many blank walls. as important as before. Ensure Let the role models be built from professionalism by appointing pioneering municipalities. Other ANMs as second tier supervisors. municipalities will gradually learn from the experience of the early • Teamwork is most important. This starters, and will be ultimately is true at all levels - CMDA, motivated. municipalities, others. • Start with servzce delivery: Over- • Health indicators are encouraging. concentration on hardware Couples are now satisfied with activities should not lead to less one (girl) child only. Couples are priority to service delivery. It is increasingly resorting to spacing better to start services early on in methods and contraceptive rented premIses, consolidate choice. • Annex - 2 • Flexibility and speedier Project • The challenge ahead? Don't be restructuring during Mid Term complacent. Avoid stagnation. Review would have led to improved When the Project Management consolidation of outputs by changes in June 2002, "Life in the additional cities, which started Project" can be ensured through receiving Project inputss after Mid orchestrated work and Term Review. commitment. Let there be a consortium, a club . . . CMDA • CMDA has been innovative with Team . . . Team of Municipal the modality of technical Chairmen. Integrate Project management of the Project. It has activities with other ongoing utilized highly experienced development programs - ICDS, superannuated professionals, many CUDP - not stand-alone .... It is with CUDP III background at a a continuum - there will be an modest cost and good track record of element of good and bad apples. It commitment to community work. will work where Municipal • Sustainability? Build in sustainability Chairmen are dynamic. from the beginning. Don't start thinking of it at the end of a Project. • Replicability?The package will have to be carefully defined. Urban • Kolkata without IPP 8? Addressing based model: Difficult unless local urban issues at this scale and speed bodies involved. Begin with pilots; would have been inconceivable.... see if there is readiness; if it works. It has created demand and raised Don't get bureaucrat-dependent. quality of services. It has been an Political actors need to be the exemplary Project - improved bosses, in the driving seat. Urban hygiene and sanitation, created new areas that are virgin in the field can role models for the slum women, expenment with alternative have empowered them. There was models. increasing limelight, with a spurt of inauguration of many new facilities - Mrs. Nandita Chatterjee, and messages by Ministers and Former Project Director, other political influentials. IPP 8 Kolkata Annex - 3 SENIOR MANAGER, MOHFW: Achievements and Outlook + Key Achievements: Success story easily; and (4) The ethnic III (1) network of quality composition of the Kolkata infrastructures; (2) provision and slums also is more varied, utilization of service delivery; all owing for a wide mix of and (3) community ownership. interventions. Thus, in many ways, the Kolkata experience is + Factors behind Success: (1) unique. However, the positive Community involvement; (2) lessons learnt would be Part-time doctors (Toms); (3) valuable in all circumstances - Continuation of the Project the value of community Team and commitment of the ownership; use of local key personnel; (4) Powers providers; close monitoring of delegated to the Ptoject Director. the work by the managers, + Replicability: This may not be supervisors and community straightforward and would leaders; steady flow of funds, depend on the specific context: which was a problem for Delhi (1) Kolkata slums are (having a City as well as State stationary - vis-a.-vis Delhi Governments as part of the where ten slums shifted after institutional framework) and the construction of Health Hyderabad. Posts, adversely affecting + Could Kolkata have done utilization; (2) Because of better? Overall, IPP 8 should vastly differen t al ternative have involved the Urban opportunities in cities like Affairs Department from the Delhi, the Kolkata Model of design stage itself. Besides using part-time doctors on substantive program support modest compensation and during the life of the Project, volunteers on payment of this would have enhanced nominal honoraria is unlikely subsequent sustainability. to work automatically; (3) In Kolkata could also utilize the the absence of social and NGOs more extensively as political mobilization and done in some other cities. The pressure, the community-based private sector should also have low-cost and cost sharing been involved from the arrangements may not work beginning. Some of the • Senior Manager, MOHFW· Achievements and Outlook physical facilities that came up also think of moveable under the Project remalll structures for certain kinds of unutilized at some hours. These service delivery. This would could be made available to save costs and enhance private medical practitIOners utilization. during such hours against fixed - Mr. A. K. Mehra, Director, charges. Similarly, one could Area Projects, MOHFW The World Bank