CHAPTER VI ORGANISATION OF HEALTH SERVICES IN DELHI

Transcription

1 CHAPTER V ORGANSATON OF HEALTH SERVCES N DELH

2 Organisation of Health Services in Delhi ntroduction The following section looks at the health sector in Delhi in the present times. t looks at the macro picture of medical services available in the public and private sector and the organisation and distribution of health services at the state level. Delhi attained its statehood recently when the sixty-ninth amendment to the Constitution of ndia in 1991, granted Delhi the status but with limited powers and officially changed its name to the National Capital Territory (NCT) of Delhi. The population ofnct of Delhi at present is 138 lakhs within an area of 1483 sq km (Census, 2001 ). Delhi's metropolitan area, informally known as the National Capital Region (NCR), comprises of the NCT and the neighbouring satellite towns of Faridabad and Gurgaon in Haryana, and Noida and Ghaziabad in Uttar Pradesh. The name Delhi for the study is used to refer to the National Capital Territory, jointly administered by the Central government, NCT's elected government and three municipal corporations (Municipal Corporation of Delhi, New Delhi Municipal Corporation and the Delhi Cantonment Board). Delhi has gone through major transitions that have led to coming of migrants in large numbers. Although migration to the city is a constant phenomenon, there are two phases that have seen rapid growth in population: post partition with the influx of refugees and post 1991 with the onset of economic liberalisation. The former saw a dramatic growth of population overnight and latter though not an overnight phenomenon of growth has been equally dramatic. Post independence Delhi has seen an influx of the trader community as well as large number of central government employees who came from all over ndia. With the onset of liberalisation, employment opportunities in the private sector have increased in the last two and a half decade. The last decade ha~ seen a large influx of migrants from all segments of society and this population growth corresponds to the onset of liberalisation and a growing market economy. The resultant of all these forces has been a process of rapid industrialisation and demand for labour. The literature on urban economies explains the existence, structures of urban areas, size as market responses to opportunities for production and income. n more recent times the impact of infonnation and communication technology on human settlement 136

3 has manifested itself in what is called 'divided city' where, new landscapes of innovation, economic development, cultural exchanges, political dynamics and social inequalities within cities and urban regions are emerging (Dasgupta, R. 2003). Delhi has witnessed a burgeoning new middle class working in the private sector. Being one of the largest urban cities and the capital, the impact of the State's accommodation of a market oriented economy was visible in Delhi. This visibility was linked to in inflow of foreign capital and new industries like large manufacturing units, those based on technical expertise, information and communication industries that have led to new job opportunities and consequently the expanding of the city towards neighbouring States ofharyana and Uttar Pradesh. The bordering towns are now part of the larger region of the capital. As a consequence, Delhi's population growth rate is double the national average and continues to increase. The wo.rk force in Delhi increased from percent in 1991 to 52:52 percent in 2001 whereas at the National level it marginally decreased from percent in 1991 to percent in 2001 (Table 6.2). Between the two cerisus years of 1991 and 2001 one can see a major jump in the total number of workers. The per capita income of Delhi has increased from Rs 30,865 in 1999 tors 61,676 in 2006 which is the highest in thecountry and the highest jump in the past few years (Govt. NCT of Delhi, 2007). Table 6.1 -Distribution of population in Delhi Estimated Percentage of persons Households Male Female Total Rural Urban Delhi Source: NSSO, S1xt1eth Round, Table 6.2- Growth of population and workforce, Census Total population (in Total number of workers (Main Percentage increase in Year lakhs) +Marginal) (in lakhs) workforce ndia Delhi ndia Delhi ndia Delhi NA Source: Econom1c Survey of Delhi,

4 Table 6.3- Category of workers in Delhi, 2001 Total Total Cultivator Agricultural Working in Other population Workers workers workers Household workers ndustrial workers Total (100) (32.82) (0.82) ' (0.35) (3.08) (95.75) Male l (100) (52.06) (0.68) (0.28) (2.84) (96.20) Female (100) (9.37) (1.81) (0.78) (4.70) (92.71).. Source: Delht Stattsttcal Handbook, 2007 As per the 2001 census the population of Delhi by districts is given in the following table. There is a higher concentration of population in North-West, South and West districts of Delhi. Table 6.4-District.,wise population of Delhi, 2001 District Population % total~_j)ulation North-west South West North-east South-west East North Central New Delhi Total Source: Delht Statistical Handbook, 2007 The Organisation of Health Services at the State Level and the Actors Delhi government implements its health activities through the Department of Health and Family Welfare. This department has three directorates under it: Directorate of Health Services, Directorate of Family Welfare and the Directorate of ndian System of Medicines (Figure 6.1 and Figure 6.2). The Department of Health & Family Welfare of Government of NCT of Delhi is headed by the Principal Secretary. Slhe coordinates on behalf of the Government ofnct of Delhi with the Ministry of Health & Family Welfare, Government of ndia at the Centre. Slhe is the controlling authority for all agencies providing health services. There are multiple state agencies providing health services in Delhi at the primary level of care and also at secondary and tertiary levels. The agencies include: Directorate of Health Services, Directorate of Family Welfare; all large Hospitals under Government of 138

5 NCT of Delhi; autonomous Bodies under Government of NCT of Delhi providing medical care, Delhi ADS Society, Centralised Accident and Trauma Services (CATS); Directorate of Food Adulteration; Drug Controller and other National Health Programmes. The Health & Family Welfare department has to liaison with all other local bodies - MCD, NDMC, Cantonment Board and other Government and Non Government health care facilities functioning in the State of Delhi. This however has also resulted in overlapping of services and since these agencies are controlling authority for the dispensaries and hospitals under them. There is vertical and horizontal segregation and lack of coordination with other agencies {Table 6.5). The various state agencies with health facilities in the NCT of Delhi are: The Directorate of Health Services and Family Welfare, Directorate General of Health Services (DGHS), Municipal Corporation of Delhi (MCD), New Delhi Municipal Council, Central Government Health Scheme (CGHS), Employees State nsurance Corporation (ESC for factor employees), Autonomous Bodies (6 autonomous public hospitals) have health facilities (Table 6.6). The Directorate of Health Services is supposed to coordinate the work of all state agencies that provide health services. 139

6 Figure 6.1- Organisational Structure of Health Services at the State Level Govt. of National Capital Territory of Delhi Directorate of Health Services + ADS l D epa rt men t o fh ea lth an d F amty ' W e lfi are Delhi State Drugs Directorate of Food Society Controller & Adulteration Directorate o ffamily Welfare (shown in Fig ure 2 (i) J Dispensaries Nursing Home Cell Mobile Health Scheme School Health Scheme NHPs State Program Emergency Medical Care State Agencies involved in providing the above services: Department of Health and Family Welfare Directorate of Health Services Directorate of Family Welfare Directorate General of Health Services Municipal Corporation of Delhi New Delhi Municipal Corporation Employee State nsurance Ministry of Railways Cantonment Board CDMO (looks after all health and FW services of the district). NHPs -National Health Programs UJP- Universal mmunisation Programme RCH- Reproductive and Child Health Services 140

7 Figure 6.2 ~Organisational Structure of Directorate of Family Welfare Director (post-partum/gas forngos) State FW Officer State MCHO l PNDT/MTP (CMO) (Safe Motherhood and Stores) ~, ' Policy (Addl Director), Statistical Dept. (Addl. Director.) Mass media/education Officer Training (Principal HFW) MCHO - Maternal and Child Health Officer PNDT- Pre-natal and Diagnostic Techniques MTP- Medical Termination of Pregnancy CMO- Chief Medical Officer CDMO- Chief District Medical Officers 141

8 Table 6.5: Agency-wise distribution of beds Agencies No. of units Beds 1 >euhi<jovernrnent >irectornte of Health Services MC> (Maternal and Child Welfare) MC> (Health) MC> (PP-V Maternity Homes) N>MC (Health) CGHS >GHS A YUSH Department ESC Autonomous/Statutory Body Northern Railway >euhi Cantonment Board Total public Private (Profit/Non-profit) Total public and private % beds in_pl!hlic sector % beds in private sector Source: >irectory of Health Services, 2006 Other government agencies like the Delhi Cantonment Board has three hospitals and one Polyclinic for the defence personnel, Northern Railways; Delhi Jal Board; Delhi Transport Corporation; the Reserve Bank of ndia; the State Bank of ndia and the Social Welfare Board also have few hospitals and dispensaries under their jurisdiction. Local bodies who deliver primary level care include the Municipal Council of Delhi (MCD) (Figure 6.3) and the New Delhi Municipal Council (NDMC). The MCD is divided into 12 zones (City, Central, South, Karol Bagh, Sadar Paharganj~ West, Civil Lines, Shaha~ra South, Shahadra North, Rohini, Narela, Najafgarh) and covers 90 percent of Delhi's population. t takes care of primary level care through its dispensaries and maternity centres and hospitals. The local bodies are also responsible for preventive measures like controlling. communicable diseases by providing safe environment and clean water supply. The health, services function under two separate heads - i) Public Health Department is headed by the Municipal Health Officer (Figure 6.4) who looks after vector borne disease prevention, other public health measures and also has a citizen service bureau that registers birth and deaths. Every zone has its Deputy Health Officer; ii) Curative and medical services are under the control of Director, Hospital Administration (Figure 6.5) who monitors MCD run hospitals, 142

9 dispensaries and other health centres. Each zone has a Chief Administrative Medical Officer (CAMO) who sees to the working of the MCD medical providers of the zone under their jurisdiction. The disease control prognimmes (Malaria, Tuberculosis, leprosy eradication programme) are implemented by the local bodies. For e.g. the TB programme is implemented through the MCD health centres or DOTS (Directly Observed Treatment, Short Course) centre. A separate body called the Delhi State ADS Control Society looks after and implements HV/ADS control programme. 143

10 Figure Organisational Structure of the MCD Political Structure Central level Zonal level Mayor Chairman (Zone) Sanitary Comtnittee Chairman Health Committee Health Committee Councillor Commissioner Additional Commissioner (Health) District Health Officer (DHO) Chief Admin. Medical Officer (CAMO) Deputy Commissioner (DC) (Health) The ones in bold are politically elected. Assistant Commissioner (Health) Municipal Health Officer Director (Hospital Administration) Director (Veterinary Services) 144

11 Municipal Health Officer (MHO) J Figu re 6.4- Function of Municipal Health Officer, MCD Deputy MHO (Malaria & other vector borne diseases) Deputy MHO (Epidemiology- water borne diseases outbreak investigations & management EC PH laboratory vaccinations Additional MHO (PH) Deputy MHO (PH) OVS Health Trade Licensing Health nformatics - Cremation Burial grounds vital statistics Health Rabies Control nformation System Deputy Health Officers (Zone) integrated functions at this level / Entomologist (contract) Malaria J Anti-Malaria Officer Senior Malaria nspector Malaria nspector Assistant Malaria nspector Lab Technicians Beldar (Worker) Seasonal Domestic Breeding Checkers Chief PH nspector Citizen Service Bureau (CSB) PH nspector. Assistant PH nspector Registration of births and deaths (contract) 145

12 Figure 6.5- Function of Director (Hospital Administration), MCD Director (Hospital Administration) MO (HQ) Medical Reimb. Mobile Health Scheme Additional MHO (General Duty) Chief Admin. Medical Officer (CAMO) for every zone Providers in Allopathy dispensaries Polyclinics Leprosy clinic ST clinics Family Welfare Centres/ Colony hospitals/ nfectious Disease MS(MCD Hospitals) 2 Deputy MHO (MCW) 1 DFWO (Dist. Field Work Officer) MCWhomes centres Additional MHO (MCW) ProjeCt Division (ndia Population Project 8) Health centres /Family Welfare Centres (Doctors Public Health Nurses /ANMs) Additional MHO (TB) r Chest Clinic (10) Sr.M.O. fm.o. Additional MHO 3DHO (School Health Scheme) (Ayurveda Homeopathy Unani) l DHO (SHS) Providers in Dispensaries 2 Ayurvedic hospital M.O. & P.H. Nurses 2 Homeopathy Hosoitan DOTS treatment supervisor (contract RNTCP) DOTS providers lab technician (contract- RNTCP) 146

13 Table 6.6- Distribution of clinics and dispensaries in tbe public sector State Allopat Homeopat Ayurve Unani MCW Healt PHC Polyc Schoo Mobil TB Grand Agencies hie Dis. hie Dis. die Dis. Dis. Centres h linics 1 e clinic Total & Centr Healt Healt s Matemi es h h ty Clinic Clinic centres s s Delhi Govt DHS MCD (MCW) MCD loq (Health) MCD(PP VT) NDMC 13 2 O 4 50 DGHS 2 2 CGHS ESC Northern Railways Delhi 1 Cantonme ntboard Delhi Jal Board DTC RB 8 8 SB 9 9 Total DHS -Directorate of Health Services; MCD- Municipal Corporation of Delhi (PP- nternational Population Project initiated by World Bank); NDMC- New Delhi Municipal Corporation; MCW- Maternal and Child Welfare; CGHS- Central Government Health Scheme; DGHS- Directorate General of Health Services; ESC- Employee State nsurance Corporation; DTC- Delhi Transport Corporation; SB- State Bank oflndia; RB- Reserve Bank of ndia (The institutions for state agencies in bold are accessed only by their employees) The Private Health Sector There has been an increase in the number of public dispensaries and hospitals (public and private) since Table 6.7 gives the growth of medical institutions in Delhi. The Directorate of Health Services registers allopathic private bedded facilities (nursing homes and hospitals) under the Delhi Nursing Home Registration Act, The number of private nursing homes also shows a drastic increase. Table 6.7 only gives the,data for registered private nursing homes i.e. those registered with the nursing home cell of the Directorate of Health Services. n 1993 there were only 130 registered nursing homes compared to the 070 unregistered ones (Nanda and Baru, 1993). The directorate has registered 562 nursing 147

14 homes/hospitals in the year 2005 and they claim that around 1,560 are not registered. n terms of numbers another 1000 nursing homes/hospitals (registered and unregistered) have established themselves in the last decade which has been the direct result of the subsidies given by the government as part of the reform process and the increased commercialisation of the health services sector. The public sector has always provided more number of beds as the larger institutions is public and there are many small private institutions (Fable 6.5). The total bed capacity of the 1560 unregistered private facilities is 5000, thus on an average the institutions have 3-4 beds. Table 6.8 gives the distribution of health facilities by bed and shows that there is a larger concentration of small-bedded facilities in the private sector. Out of the 562 registered private hospitals the Directorate claims that 60 are run through societies and trusts which is an underestimate. Table 6.7- Growth of medical institutions in Delhi, Year No. of PHCs No. of No.ofMCW Polyclinic No. of No. of Public Dispensaries homes, nursing special Hospitals centres and homes clinics Sub-centres (Pvt.) ll Nursing homes includes trust hospitals, otherprivate hospitals and nursing homes Source: Economtc Survey oflndta, Table Distribution of health facilities by number of beds ll >250 Total Public Private Source: compiled from Drrectory of Health Serv1ces, 2006; DHS private clinic~ The Directorate of Health Services in Delhi does not provide data on the innumerable providing out-patient services through general practitioners, specialists and quacks. The 57'h round gives an estimate of it (Table 6.9). The NSSO conducted a nation- 148

15 wide sample survey ofunorganized services (57'h Round of Sample Survey) during This survey does not include enterprises under the government {central, state and local) and public sector enterprises. Enterprises on this survey typically involve- i) own-accountenterprises {OAE); and ii) establishments. OAEs are the one that are run by household labour, usually without a hired labour on a 'fairly regular basis'. On the other hand, establishments are the ones that hire at least one labour on a 'fairly regular basis'. The survey covered 'Health and Social Work' which included all dispensaries, clinics and consultation chambers run by doctors. Further, an employed doctor and paramedical person doing private practice have been considered an enterprise under this survey. The survey covered allopathic and SM practice as well. t also considered diagnostic laboratories and blood banks. For Delhi an estimate of 16,071 OAEs and establishments has been calculated. There S a total of 340 not-for-profit health enterprises {61 OAEs and 279 establishments) calculated; and 15,731 for-profit health enterprises {7,335 OAEs and 8,396 establishments) estimated for Delhi (GO, 2005). Table 6.9 shows the distribution of health services in the unorganised sector as profit and non-profit. Being an estimate from a sample there might be errors in estimation. Table 6.9: For-profit and non-profit institutions in nnorganised health services in Delhi- 57th round, NSSO Hospitals Physicians Ayurveda Unani Homeopaths Nurse& Others Total and Practitioners Practitioners paramedic (ambulance) specialists For profit Not-for profit rill Source. NSSO, 57 Round, GO, 200 l-02 Spatial Distributions of Public Hospitals, Dispensaries and Private Nursing Homes/Hospitals in Delhi A GS mapping exercise on health services in Delhi shows that on an average there are 45 public dispensaries for a million population but it is not evenly spread. The New Delhi area (Central Delhi) has good coverage, almost 5 times the average of whole of NCT of Delhi. Map 6.1 shows the spread of public dispensaries. "From central government to municipal bodies, the number of key agencies involved in the public health care makes an integrated health care system quite impossible. Each agency limits its concern to its own 149

16 health care network (hospitals, dispensaries) without any regard for the others. Their lack of coordination has led to a concentration of public infrastructure in the core of the metropolis, which does not meet the spatial equity objectives as claimed by different agencies" (Chapelet, P. and B. Lefebvre, 2005). Map 6.2 gives the spatial distribution of private beds and registered private nursing homes. South Delhi shows agglomeration of private nursing homes. According to the authors this area has the upper middle class residents who can access the private sector. The bigger private hospitals are also present here. They also note that rural areas of Delhi have no registered nursing homes (ibid. 2005). 150

17 Map Spread of Public Dispensaries in NCT of Delhi, 2002 National Capital Territory of Delhi Dispensaries (2002) 0; " v~.. -~.,, ~~.-, --~....,.. ~,..., 1-.:.- \, f.s~:j ~ L,:l. Source: Chapelet, P. and B. Lefebvre (2005) 15 1

18 Map 6.2- Distribution of Registered Private Hospitals, 2002 National Capital Territory of Delhi: Registered nursing homes (2002) No of prrvate beds per 1 M pop Km No of reg1stered nuismg homes per 1 M pop Messmg value /V mam roads Messmg value 1-. Source: Chapelet, P. and B. Lefebvre (2005) 152

19 Utilisation of Health Services in Delhi. A study on utilisation patterns in Delhi in 1993 showed 60 percent of the population in a resettlement colony visited the private practitioner for the initial diagnosis and treatment. For major ailments an equal number were in favour of government hospital and private nursing home. For surgery and hospitalisation majority were in favour of the government hospital. There is some influence of income groups on the utilisation pattern where the. higher income groups have a stronger prefere.nce for private nursing homes for treating major ailments and hospitalisation (Nanda and Barn, 1993). With the increase in services being provided by the private sector and limited presence of the public sector, the utilisation patterns of these services have changed over time. However, it should be noted that large influx of the people seeking medical care in public hospitals are from neighbouring states (Gupta and Dasgupta, 2000). Household survey data by NSSO shows that for outpatient services (national level) 72% of users in were accessing private practitioners and by this had gone up to 81 % (NSSO, 1986; 1996). The share.of the private sector in providing inpatient services has also gone up from 40.3% to 54.7% in rural areas and from 39.7% to 56.9% in urban areas between the two rounds of the NSSO. Compared to all ndia data there are more people using public hospitals for inpatient services in Delhi. Utilisation of public hospitals for out-patient services is also greater in Delhi as compared to all ndia data (NSSO, 1996). This is probably because Delhi happens to have a large presence of multi-facility public hospitals compared to other states.. This could be also due to the presence of substantial number of central government employees in the city. Table 6.10 gives an estimate specifically for Delhi which shows share of hospitalisation in public hospitals in Delhi is at percent which is greater than the all ndia level of 40.6 percent. Table Distribution of estimated cases of hospitalisation by type of hospital and ward in Delhi Type of Hospital Rural Urban Combined %of total. Public hospitals " Free Ward Paying general ward Paying special ward All Private hospitals Free Ward Paying general ward Paying special ward All

20 Share of public hospitals Rural Urban Combined Ail ndia Delhi Source: NSSO, SXtieth Round, 2006 According to an estimate, household expenditure as percentage of total health expenditure in Delhi is 56.41% as compared to 73.5 % for the whole of ndia. Public expenditure as percentage of total health expenditure is 40.48% in Delhi as compared to 22 % for whole of ndia (GO, 2005). Costs ofcare are higher in Delhi compared to the whole of ndia. This can be seen in Table 6.11 where average total expenditure as an in-patient for Delhi is more than three times that of ndia. Table Average total expenditure of hospitalised treatment in Delhi, 2006 (in Rupees) Delhi All ndia Rural Govt Private All Urban Govt Private All Combined Govt Private All Source: NSSO, SXtieth Round, 2004 The following section looks at the non-profit health sector at the community level. n the next chapter we look at this sector at the secondary and tertiary levels. Community based organisations (CBOs) Non-governmental organisations (NGOs) providing health services at the primary level Whilst there are innumerable numbers of non-profit set ups of different systems of medicine (Ayurvedic, Unani and Homeopathy) since pre-independence, there S no comprehensive listing of these providers. This section will look at NGOs/CBOs at the primary level providing health services - preventive, promotive and primary level curative services in Delhi. t looks at the types ofngos in health services, their interactions with the state and their networking amongst themselves if any. As stated in the ndia chapter, the 154

21 NGO sector has seen an upsurge post 1980s. The emergence of NGOs was also skewed towards the urban centres. These have emerged as outreach services supported by faith-based organisations or development organisations that emerged post 80s. A comprehensive list ofngos working on health issues in Delhi is not available due to weak networking among NGOs. Nevertheless there are some large networks like the Voluntary Health Association of ndia, Christian Medical Association ndia, Catholic Health Association of ndia, People's Health Movement or Jan Swasthya Abhiyan, and a web-site on ndian NGOs ( that provide a state-wise list ofngos in health in their network. A comprehensive list for Delhi has been drawn from information from these networks (Table 6.12). Many of these NGOs listed provide health services to a specific target group (e.g. women or children) or relating to specific issue (e.g. HV/ADS). There are very few that actually provide health services in the holistic sense. There are many organisations that are part of the women's movement and therefore indirectly address the issue of health in the larger context. Many others provide simply health awareness and education and are not listed in the table. Almost all community based organisations have their outreach services in resettlement and slum areas. Delhi has a large concentration of these NGOs or CBOs. These CBOs are present in the communities and their outreach services are mostly visible in resettlement and slum areas. These organisations have received greater support from the government in the last two decades. Government partnership with NGOs is primarily in the form of delivery of national health programmes. These programmes get rooted through NGOs where government facilities do not exist. NGOs have been linked to the Family Welfare programme since 1950s. Collaborations and partnerships with the government at the primary level The interaction between the state and the non-government sector has transformed in character over time from mere support and collaborations to partnerships. Partnerships with the NGOs and the state since the 1950s have been more in the form of collaborations but by the late 1990s these partnerships became more defined and contractual. The latter is what is now popularly known as public-private partnerships (PPPs). These partnerships are seen in the National Health Programmes (NHPs) like HV/ADS prevention, care and support, Revised National Tuberculosis Control Programme (RNTCP), immunization and Reproductive Child Health (RCH) programme. n fact the role of NGOs has received much 155

22 attention in the last two decades and they have been urged to take active involvement in delivering the vertical programmes. A Mother NGO scheme was started by the government in early Several NGOs have been identified in Delhi and have been given the status of Mother NGOs. These organisations are expected to screen the credentials of other NGOs, support smaller NGOs, release money in deserving cases, guide and monitor its work. The scheme has not taken off beyond identification of the Mother NGOs. The Director, Family Welfare says, "/have the funds lying with me for such a long time but there has been no implementation so far... these NGOs who have been identified seem to have their own list of priorities and we do not seem to come to a consensus as a result with so much confusion the proposal is not getting passed." (Director, Family Welfare) Some larger NGOs feel that their involvement is sought by the state more in the recent years in planning than it was before. People working in these organisations generally feel that government's response towards them as a 'noteworthy' sector has increased over the last decade. For e.g., the coordinator of an NG0 7 based in South Delhi says that, "the government has opened up in the last few years. There is an openness to address sensitive issues and now we see the government approaching NGOs rather than the other way round." During the fortnulation of the Tenth plan this particular NGO was invited to review the area of adolescent health. But the experience below of a partnership between the state and NGO at the primary level raises issues of transparency and accountability as it is skewed in favour of the state. Another CB0 8 working in the area of health care for poor migrants with a focus on de-addiction feels that the government support has definitely increased in the last few years and that is primarily.because the government recognizes the contributions being made at the community level by various NGOs. They have a project with the Delhi government to provide shelter to the homeless especially during winters. The Director of the NGO feels that the government cannot shirk its responsibilities towards its citizens. n an interview he stated that "the larger issues can only be addressed by the government... we were asked to assess the TB programme by the state and we found that important issues like nutrition, water have not been addressed by the government. Health cannot mean just taking pills, there has to be a synergy of services"'. 7 Mamta works on issues relating to reprodudive health (nterview with a member in March 2006) 8 Shanln works in poor communities (nterview with the Director, March 2006) 156

23 The coordinator of another NG0 9 in East Delhi echoes similar sentiments. She says, "NGOs cannot address all issues. We know water, sanitation is a problem but we work under limitations. We are providing services for health, education and income generation and have tried to make our activities as comprehensive as possible. " n recent times the Government has also sought the assistance of many NGOs in monitoring the programmes related to use of Prenatal Diagnostic Techniques (PNDT), which is used. for determining the sex of an unborn child. NGO and government representatives are required to conduct inspections at private diagnostic centres to stop the use of this technique to prevent cases of female foeticide. There are some instances of contractual partnerships between the government and NGOs like management of PHCs in Delhi. For example, an NG0 10 and the MCD each has fixed responsibilities and provides a share of resources as agreed in the partnership contract for the ndia Population Project VU (PP V). This is part of the urban RCH project. The NGO is responsible for organising and implementing services in the project area, while the MCD is responsible for monitoring the project. The MCD provides with the infrastructural inputs i.e. building, furniture, medicines and equipment, while the NGO provides. maintenance of the building, water and electricity charges, management of staff and medicine. Such partnerships are seen as promoting greater efficiency and quality but the dynamics of these partnerships are very context specific and the interview with the members brought forth the complexities between the players (Barn and Nundy, 2007). The partnership was initiated by the NGO when they started work in a new resettlement colony in Delhi.that lacked basic services. The member says, "... we approached the MCD and after a lot of convincing that we are an organisation which means business. They saw all our records in Himachal and Haryana and they finally gave us this building as an PP 8 project for 5 years. This is our first agreement and in addition we said we will run a complete diagnostics centre here because the people from Japan had given a lot of equipment in terms of an ambulance, an ultra sound machine and a 500 ma X-ray machine installed in this dispensary. So on 2 P 1 July 2003 the health centre took off and over the years it has proliferated in to a full diagnostic centre with all sorts of facilities. We have 2 doctors who are full time, one a general physician and one gynaecologist Then we have 24 visiting surgeons from the best of hospitals in Delhi including head of the paediatrics department in Apollo... " 9 St. Stephen's Health Centre is the community outreach programme unit of the St. Stephen's hospital, one of the oldest non-profit hospitals in Delhi. 10 nterview with members of Arpana Swasthya Kendra, July

24 When asked whether the partnership was equal and how the parties were accountable the response was that it was totally one-sided. The Memorandum of Agreement (MOU) was designed completely by the MCD and the member explained by stating, "Which NGO is going to get into a tussle with the government. There is a power relationship here. MOU says, 'n the interest of the successful implementation of the services specified in the attached terms of reference, requiring a reasonable period of time, and taking into account of the heavy financial outlay in personnel, medical and diagnostic equipments etc., on the part of Arpana, the Agreement will be initially for 5 years, extendable for a further period of 5 year blocks by mutual consent. t shall be however, be open to the commissioner to terminate the Agreement after giving due notice of at least one month period to the Trust. n the event of such termination expiry of this Agreement, the commissioner shall be free to take possession of the entire portion with materials without giving any charges to the Trust. Further, Arpana will provide the Commissioner, such reports or pans thereof. of any information and documentation gathered under this Agreement, at the lime of the termination of the Agreement. ' Th,is is totally one-sided. They take the materials and reports. Agreement says, 'Arpana will be responsible for appropriate insurance coverage. n this regard it will maintain workers compensation, employment liability insurance for their staff on assignment. t shall also maintain comprehensive general liability insurance, including contractual liability coverage adequate to cover the indemnity of obligation against all damages, costs and charges and expenses of injury to any person or damage to any property, arising out of. or i11 connection with, the services which result from the fault of Arpana or its staff' We are ensuring all the equipment, doctors, anything and everything... electricity we are paying to the extent they saidthat you pay for the connection 60,000 Rs. said nothing doing, am not going to even entertain your request... at least give us the connection... we will pay for it~ Since we are working quietly and honestly and totally committed to the cause we said forget it. We have our own tube wells, water supply, own ambulances... everything of our own. That is one of the reasons why the director PP V gives us a lot of importance and says yes, whenever Arpana comes to me it comes with a very valid and genuine reason. Sometimes when we run short of medicines like i:alcium we buy from the local market... let people not suffer. " Voicing health concerns by non-government sources in Delhi Many studies try to explore. whether the collective voices of non-government agencies result in provision of better services. Collective voices of people demanding better health services are almost non-existent in. the capital. Resident Welfare Associations (R WAs) 11 and 11 RWAs are not representative of the entire Delhi population. There are no RWA's for the large slums/jj clusters, unauthorised and resettlement colonies and hence demands made are not representative of the poor population of Delhi. n fact number of RWAs along with the government have been responsible in shifting slums to the outskirts in order to keep their 'environment' clean. 15S

25 NGOs are seen as civil society bodies through whom interactions are made with citizens and demands are voiced. Resident Welfare Associations have also gained an official status in the last few years. They have made demands for better services but in terms of health it includes seeking improved environment or preventive measures like anti-malarial services. The rising costs of medical care have not been collectively articulated. RW A's comprise of the middle and upper middle class of people who access private providers. There are instances where RWA's organise health camps for residents and in most cases they have a patron. A large segment of the Delhi's population stays in slums and resettlement colonies. A large population of these poor people are not on the electoral roles and hence have no association with councillors and cannot organise themselves like the RWA's. Since the advent of health sector reforms there have been two distinct and divergent modes of thinking within government and non-government players. One school of thought supports the reform process and has ~ncouraged the privatisation of health services because they feel it addresses the larger objectives of efficiency and quality. This view has extensively found support from the middle and the upper-middle class, medical professionals and pharmaceutical companies. This group has focussed away from a comprehensive and universal health care. to a dual system where the public sector is left for the poor and the better-off have a choice between the private and the public providers. On the other hand the Jan Swasthya Abhiyan (JSA) that could be termed as a 'social medicine movement' and is a network of individuals, activists, academicians and NGOs have continuously questioned the reform process that has resulted in further inaccessibility of services for the poor without any priorities set and have been incremental than holistic. This group is of the view that health has to be viewed in a holistic sense i.e. it has to include access to food, education, basic services like water, sanitation, livelihood and health services. They feel that the state has to play the larger role in providing comprehensive and universal health services and regulate the private sector. The convenor of Jan Swasthya Abhiyan was interviewed regarding the interactions, coordination and networking between NGOs providing health services and how far are the NGOs impact on health voicing for primary level health services. A senior activist and convenor of JSA states, "n the last 15 years, there has been erosion of public health facilities. ndia always has had the most privatised health services and in the 90s with the withdrawal ofthe state there was further impetus given to the private sector. General physicians (GPs) are a disappearing breed especially in Delhi and further specialization of medical professional have given them space in large private hospitals and the GPs have been pushed into the peripheries and can be seen functioning in the resettlements and slums with other quacks... now the situation 159

26 in public health care is akin to something like 'giving a bad name to a dog and shooting it'... these days one uses public services without having any expectations! myself will not recommend anyone to go to the public hospital.'' The Delhi chapter of JSA started in A gioup of activists, academicians and NGOs are members of this movement. Additionally, activists from the community area are also part of the JSA. Since the inception of JSA in Delhi, a Community Health Watch Group has been initiated in various areas of the city, mostly in resettlements and slum clusters. JSA attempts to build the capacity of the community they work with to empower them to voice their opinion regarding health services. There is public hearing at the local level where local leaders and MLAs (Member of Legislative Assembly) are invited and recommendations are put forth. For instance, in a new resettlement called Bawana:, it was found that not only the health centre was situated far from the community. The medical officer of the centre was also not available for most of the time. Such issues are highlighted in such public meetings. The Delhi based activists feel that the movement is still in its early stages and will take some more time to gather momentum. n the meantime they have created a network of 47 health NGOs in Delhi and are in the process of conducting a survey on the state of health services, their availability and accessibility for the urban poor residents of the city. Delhi has never had a tradition of social movements. This is perhaps due to a variety of historical and political reasons. As the convenor of the JSA points out, "Delhi has always been associated with a huge population of migrants, and historically they came from Pakistan at the time of ndia's independence and subsequently/rom the neighbouring states." Also along with this migrant population there is a large number of government employees, ('babus' as they are called in Hindi) who have always been Jooked after' by the government during their tenure as civil servants and therefore never had to 'demand' for better services. t is also important to note, especially in the context ~f social movements (or their absence) that Delhi attained its Statehood (partial) only recently, therefore it is still adjusting to a new culture of a State, where people can approach a local political leader to voice their demands but there is a lack of citizen participation. 160

27 Table 6.12-List of NGOS working on health related issues at the community level in Delhi 161

28 Source: compiled from various sources, 162