DETAILED PROJECT REPORT

DETAILED PROJECT REPORT For UPGRADATION OF URBAN HEALTH INFRASTRUCTURE OF THE AHMEDABAD MUNICIPAL CORPORATION UNDER THE NATIONAL URBAN HEALTH MISSION Submitted to Ahmedabad Municipal Corporation Submitted By Urban Management Centre Feb 2009 Contact Details: Ms. Manvita Baradi Director, UMC III Floor, AUDA Building, Usmanpura Ashram Road, Ahmedabad, Gujarat Tel: 079 27546403 Email: info@umcasia.org www.umcasia.org

DETAILED PROJECT REPORT For UPGRADATION OF URBAN HEALTH INFRASTRUCTURE OF THE AHMEDABAD MUNICIPAL CORPORATION UNDER THE NATIONAL URBAN HEALTH MISSION Submitted to Ahmedabad Municipal Corporation Submitted By Urban Management Centre February 2009 Contact Details: Ms. Manvita Baradi Director, UMC III Floor, AUDA Building, Usmanpura Ashram Road, Ahmedabad, Gujarat Tel: 079 27546403 Email: info@umcasia.org www.umcasia.org UMC/ICMA 2

Table of Contents Acknowledgements List of Acronyms CHAPTER 1... Introduction... 9 1.1 Introduction...9 1.1.i About the Study...9 1.1.ii Scope of Work for the DPR... 10 1.1.iii Methodology... 11 CHAPTER 2... About the National Urban Health Mission... 13 2.1 Overall Health Scenario in India... 13 2.2 Issues in Health Service Delivery... 14 2.3 NUHM Focusing on Health Issues in Urban Areas... 16 2.4 Vision of NUHM... 17 2.5 Salient Features of the NUHM... 18 2.6 NUHM... 18 CHAPTER 3... Existing Health Services and Health Indicators of Ahmedabad... 19 3.1 City Profile... 19 3.2 Institutional Structure of Health Department of AMC... 21 3.3 Second Tier Health Service centres in Ahmedabad... 43 3.4 Current Reporting Structures... 45 3.5 Current training provisions... 46 CHAPTER 4... Accessibility to Health Infrastructure Facilities- Analysis and Outcomes... 47 4.1 Methods... 47 CHAPTER 4... Proposal for Improved Health services in Ahmedabad... 52 5.1 Key issues for up-gradation of health services and infrastructure in Ahmedabad.. 52 5.2 Proposed Model for Urban Health Service Delivery... 54 5.3 Formation of Urban Health Society... 56 5.4 Number of Health Centres... 59 5.5 Staffing... 61 5.6 Proposed Health Insurance Model... 65 5.7 Training and Capacity Building of AMC Health Department Staff... 65 5.8 Monitoring and Evaluation Mechanism... 68 5.9 Model Layouts for various health centres... 68 UMC/ICMA 3

Proposed Budget... 69 6.1 Estimated phasing of the Establishment of various health facilities... 69 6.2 Proposed Budget... 69 6.3 Funding patterns from NUHM... 74 Annexure 1... List of Participants in SWOT Analysis... 76 Annexure 2 Supporting Tabl 79 Annexure 3 Resolution 83 UMC/ICMA 4

LIST OF TABLES Table 1: Health Scenario in India... 13 Table 2: Disease Incidence in India and Gujarat, 2007... 14 Table 3: Health Infrastructure of Gujarat in Rural Areas (till March 2007)... 15 Table 4: Statistical Information for Ahmedabad... 20 Table 5: Mortality Rate in Ahmedabad... 21 Table 6: Trend of Gastroenteritis (G.E.) Cases and Deaths Recorded till October 2008... 23 Table 7: Trend of Viral Hepatitis Cases and Deaths Recorded till September 2008... 23 Table 8: Trend of Typhoid Cases and Deaths recorded till September 2008... 24 Table 9: Trend of Cholera Cases and Deaths Recorded till September 2008... 25 Table 10: Revenue expense of Ahmedabad Municipal Corporation Budget 2008-09... 25 Table 11: Zone-wise Slum Population... 28 Table 12: Zone-wise Slum Population Covered by RCH... 29 Table 13: Performance of the RCH Program... 30 Table 14: Immunization in Ahmedabad Achieved Against Targets Given by State Govt... 33 Table 15: Trend of Serum Tested and Positivity Rates in last 3 years... 35 Table 16: Registered Cases and Deaths Due to Dengue till Aug 2008... 35 Table 17: Trend, Blood Samples Collected, Examined & Confirmed Malaria Cases... 35 Table 18: Staff Details in Tuberculosis Treatment Units... 36 Table 19: Available Microscopic CentreCentres and DOT CentreCetres... 37 Table 20: Trend of TB cases... 38 Table 21: Trend of Budget for RNTCP... 40 Table 22: ICTC Information... 41 Table 23: PPTCT Information... 42 Table 24: STI Services Available in Ahmedabad... 42 Table 25: Information of 1051 HIV/AIDS Helpline... 43 Table 26: Trend of Budget Allocated to AMACS... 43 Table 27: Second Tier health Service Centres in Ahmedabad... 43 Table 28: Zone-wise Distribution of AMC-run Hospitals... 45 Table 29: Percentage of Slum Area and Slum Population Not Accessible to UHCs... 47 Table 30: A detailed list of zone wise location of various health centres is as follows... 48 Table 31: Proposed Health Centres in Ahmedabad... 59 Table 32: Detailed List of Location of Urban Health Centres in Ahmedabad... 59 Table 33: Need for Community Health Centres... 61 Table 34: Requirement of Urban Health Centres... 61 Table 35: Proposed Staff at Community Health Centres in Ahmedabad... 62 Table 36: Proposed Staff in UHCs in Ahmedabad... 62 Table 37: Staff Gap Analysis... 63 Table 38: Existing MPWs and LWs in Ahmedabad... 65 Table 39: Proposed Training Module... 66 Table 40: Proposed training schedule... 67 Table 41: Phasing of Establishment of Various Health Facilities in Ahmedabad... 69 Table 42: Budget Summary... 70 Table 43: Funding Pattern... 74 Table 44: Year wise Budget Summary... 74 Table 45: Participants of SWOT Analysis (AMC, Nagari Eye Hospital)... 76 Table 46: List of Participants of SWOT with medical officers of AMC at Nagari eye hospital. 77 UMC/ICMA 5

LIST OF FIGURES Figure 1: Health Service Delivery Model... 10 Figure 3: Visit to CHC at Chandkheda... 11 Maternity Home... 11 Figure 4: Model of Community Risk Pooling Proposed in NUHM... 16 Figure 5: Health Insurance Model Proposed in NUHM... 17 Figure 6: Map of Ahmedabad Municipal Corporation... 20 Figure 7: Structure of Ahmedabad Municipal Corporation Health Department... 22 Figure 8: Occurrence of G.E. Cases From 2003-2007... 23 Figure 9: Occurrence of Jaundice Cases from 2003-2007... 24 Figure 10: Occurrence of Typhoid Cases from 2003-2007... 24 Figure 11: Organisational Structure of RCH... 28 Figure 12: Performance of Family Planning Methods under RCH program... 31 Figure 13: Organisational Structure of Registration of Birth and Death... 32 Figure 14: Organisational Structure of Malaria and Epidemic Department... 34 Figure 15: Structure of Ahmedabad TB Society... 37 Figure 16: Organisational Structure of RNTCP... 38 Figure 17: Trend of NSP Cure Rate, Ahmedabad Municipal Corporation... 39 Figure 18: Organisational Structure of Ahmedabad AIDS Control Society... 41 Figure 19: Reporting System of Health Division... 45 Figure 21: Proposed Model of Health Service Delivery at Different Levels... 55 Figure 22: Organisational Structure of Proposed Urban Health Society... 58 UMC/ICMA 6

ACKNOWLEDGEMENTS The Urban Management Centre likes to acknowledge the Ahmedabad Municipal Corporation for facilitating all information and meetings to prepare this detailed project report for the National Urban Health Mission. We extend our sincere thanks to Mr. Dilip Mahajan, Deputy Municipal Commissioner, AMC, who initiated discussions regarding this report. We also thank Mr. Devendra Makwana, Deputy Municipal Commissioner (Health) and Mr. H K Patel Deputy Municipal Commissioner, AMC, for their valuable suggestions on the report. Municipal Commissioners Mr. Dilip Mahajan, Mr. Devendra Makwana and Mr. H K Patel for their valuable suggestions on this report. Our heartfelt thanks to Dr. S. Kulkarni, Dr. Jyotiben Desai, Dr. Kinnariben Mehta, Dr. P M Parmar, Dr. Jaivin Patel and Dr. Chirag Shah who were very patient in explaining to us the complex functioning of health system and in providing data, information and maps for the assignment. Many thanks to the health staff of AMC, who whole heartedly participated in the many focused group meeting and interviews. Last but not the least, our thanks to Environmental Planning Collaborative for providing us with old AMC area base map. UMC/ICMA 7

LIST OF ACRONYMS AMC BPL CHC GIS JnNURM IPHS NHP NIUA NRHM NUHM MoUD O&M PHC PPP RHC RNTCP RTI SC SWOT TNA UCD UHC UMC Ahmedabad Municipal Corporation Below Poverty Line Community Health Centres Geographical Information System Jawaharlal Nehru National Urban Renewal Mission Indian Public Health Standards National Health Profile National Institute of Urban Affairs National Rural Health Mission National Urban Health Mission Ministry of Urban Development Operation and Maintenance Primary Health Centres Public Private Partnership Reproductive and Child Health Program Revised National Tuberculosis Program Right to Information Sub-Centres Strength Weakness Opportunities Threats Training Needs Assessment Urban Community Development Urban Health Centres Urban Management Centre UMC/ICMA 8

CHAPTER 1 Introduction 1.1 Introduction India, like rest of the developing world, is witnessing rapid urbanisation. Almost 27.8 per cent of its population of 285.4 million lives in urban areas. In the decade 1991- which is significantly higher than the rural population growth rate of 17.9 per cent. This means that urban population increased by 68 million people during this period. Population projections by the United Nations (2005) indicate that urban population will grow to 538 million with more than half of the total population living in urban areas. Accompanying this rapid pace of urbanisation has been a faster growth in slum population. Estimates show that slums represent the fastest growing segments of urban population at nearly 6 per cent per annum which is double the growth rate of the overall urban population. Crowded living conditions, unhygienic surroundings and lack of basic amenities such as garbage disposal facilities, water and sanitation characterise slums. The near total absence of civic amenities coupled with lack of primary health care services in most urban poor settlements has an adverse impact on the health status of its residents. The health of the urban poor is significantly worse than the rest of the urban population and is often comparable to the health conditions in rural areas. Utilization and reach of primary health services is poor among urban slum communities in India even though there may be physical proximity to advanced health care facilities. Primary health care facilities have not grown in proportion to the explosive growth of population, especially the poor. Also, the facilities may not be in physical proximity to urban slum clusters. 1 1.1.i About the Study To meet the health service demands of the population in quality and quantity and to effectively address health concerns of the urban poor, the Ministry of Health and Family Welfare, Government. of India proposes to launch the National Urban Health Mission (NUHM). The duration would be the remaining period of the 11 th Five Year Plan (2008-2012). The NUHM document mentions an analysis of the NFHS III data stating that under 5 Mortality Rate (U5MR) among urban poor is at 72.7. This is significantly higher than the urban average of 51.9. About 47.1 per cent urban poor children aged below three years are underweight compared to the urban average of 32.8 per cent and rural average of 45 per cent. Among the urban poor, 71.4 per cent children are anaemic compared to the urban average of 62.9 per cent. Sixty per cent of the urban poor children miss complete immunisation compared to the urban average of 42 per cent. Only 18.5 per cent of urban poor households have access to piped water supply at home. The urban average is 50 per cent. Among the urban poor, 46.8 per cent women have received no education compared to 19.3 per cent in urban average 1 Paper on Urbanization, Urban Poverty and Health of the Urban Poor by Siddharth Agarwal, Aravinda Satyavada, S. Kaushik and Rajeev Kumar UMC/ICMA 9

statistics. Among the urban poor, only 44 per cent deliveries are institutional, compared to the urban average of 67.5 per cent. 2 The proposed national urban health service delivery model intends to make a concerted effort to rationalise and strengthen the existing public health care system in urban areas, promote effective engagement with the non-governmental sector (for profit/not for profit) for better reach of the services to urban poor and strengthen the community participation in planning and management of health care service delivery. All services delivered under the urban health delivery system will be based on identification of target groups (slum dwellers and other vulnerable groups); preferably through distribution of family/ individual Health Suraksha cards. In view of this proposed mission, the Ahmedabad Municipal Corporation (AMC) has felt a need to upgrade its facilities available at its urban health centres and to provide second tier facilities like community health centres. The newly merged areas and some of earlier wards require additional sub-centres to help the Corporation effectively provide health out-reach services to its population. Figure 1: Health Service Delivery Model Public or empanelled Secondary/ Tertiary private Providers Urban Health Centre (One for about 50,000 population-25-30 thousand slum population)* Strengthened existing Public Health Care Facility Empanelled Private Service providers Community Outreach Service (Outreach points in government/ public domain Empanelled private services provider) Urban Social Health Activist (200-500 HH) Mahila Arogya Samitee (20-100HH) Referral -------------------- Primary Level Health Care Facility -------------------- Community Level 1.1.ii Scope of Work for the DPR Review existing urban health infrastructure and identify gaps between existing and proposed health infrastructure Prepare detailed report including o Required physical resources for upgrading urban health facilities in the entire AMC jurisdiction, o Required manpower, o Sample design of urban health centres, community health centres and sub centres; 2 Reanalyzed NFHS III data by Wealth Index; NUHM Document UMC/ICMA 10

o Measures to improve quality of health infrastructure like health information systems, training provision to health officials. Financial resources for all above. 1.1.iii Methodology UMC worked hands on with AMC health staff to identify required data on the existing urban health infrastructure and to collect data regarding spatial distribution of health facilities and slums across Ahmedabad. xisting UHCs and CHCs to understand their functioning and to understand the requirements for upgrading facilities. UMC developed a methodology which involved meetings and interviews with health staff including medical officers, pharmacists, lab technicians, multi-purpose workers (MPW) etc. Separate SWOT analysis was conducted with medical health workers and with pharmacists, lab technicians and MPWs. Figure 3: ternity Home (The list of officials who participated in the Figure 2: Visit to CHC at Chandkheda SWOT analysis is presented in Annexure 1). SWOT analysis is a useful tool for auditing an organisation and its environment to help organisations appreciate the strengths of a situation, define the weaknesses, make the most of the opportunities that present themselves and recognize the possible threats and treat them in a planned and organised manner. UMC with assistance of AMC staff identified slum pockets and communities on the base map of Ahmedabad and also marked existing health facilities provided by the AMC. These maps were later transferred to a GIS environment to analyse the accessibility of health facilities by slum dwellers. This assisted in locating newer health facilities as proposed under the NUHM. UMC/ICMA 11

SWOT Consultations with AMC Staff UMC/ICMA 12

CHAPTER 2 About the National Urban Health Mission 2.1 Overall Health Scenario in India In India, healthcare services are divided under State list and Concurrent list. While some items such as public health and hospitals fall in the State list, population control and family welfare, medical education and quality control of drugs are included in the Concurrent list. The Union Ministry of Health and Family Welfare (UMHFW) is the central authority responsible for implementation of various programs and schemes in areas of family welfare, prevention and control of major diseases. The following table presents a complete health sector profile for India 3. Table 1: Health Scenario in India Indicator Latest available Year data Remarks POPULATION AND VITAL STATISTICS Total population (in thousands) 1,097 million 2005 Population density (persons per sq km) 334 2005 Sex ratio (females per 1000 males) 933 2001 Computed value Population under 15 years (%) 35 2001 0-14 years Population 60 years and above (%) 7.8 2001 Crude birth rate (per 1000 population) 23.8 2005 Crude death rate (per 1000 population) 7.6 2005 Natural (population) growth rate (%) 1.95 2001 Computed value Average Exponential Rate Total fertility rate (per woman) 2.7 2005-06 Urban population (%) 27.78 2001 Prevalence of low birth weight (weight 23 1998- <2500 grams at birth) (%) 1999 Prevalence of underweight (weight-for-age) 46 2005- in children <5 years of age (%) 06 Facilities Number of hospital beds 6,83545 2002 Hospital beds per 10,000 population 9 2006 Number of health centres: Sub-Centre 137371 2001 Primary Health Centres 22842 2001 Community Health Centres 3043 2001 Human resources Physicians per 10,000 population 7 2005 Computed value Nurses per 10,000 population: 7.85 2004 Computed value Professional nurses Pregnant women attended by trained personnel during pregnancy (%) Deliveries attended by trained personnel (%) 51 2005-06 48 2005-06 annual Growth Received at least three antenatal check up 3 WHO South East Asia regional office: http://www.searo.who.int/en/section313/section1519_10856.htm UMC/ICMA 13

Indicator Latest available Year data Remarks Contraceptive prevalence (%) 56.3 2005-06 Infants reaching their first birthday that 44 2005- have been fully immunised against 06 diphtheria, tetanus and whooping cough (%) Infants reaching their first birthday that 70 2005 have been fully immunised against poliomyelitis (%) Infants reaching their first birthday that 56 2005 have been fully immunised against measles (%) Infants reaching their first birthday that 73 2005 have been fully immunised against tuberculosis (%) Women that have been immunised 71 2005 with tetanus toxoid (TT) during pregnancy (%) OUTCOMES Life expectancy at birth (years): Male 63.87 2001- Female 66.97 2006 Infant mortality rate 57 2005-06 (per 1000 live births) Under-five mortality rate 85 2000 (per 1000 live births) Maternal mortality ratio 301 2001-03 (per 100,000 live births) Out-of-Pocket Spending on health (OOPS) as 97 2003 % of Private Expenditure on Health (PvtHE) Life expectancy at birth ratio (females as a % of males) 2.2 Issues in Health Service Delivery All across the country, it has been observed that either primary health Centres are unavailable or are inaccessible due to their location, resulting in over-crowding in secondary and tertiary centres. According to National Health Profile 2007 4, as on March 2006, there were 1,44,988 Sub Centres (SC), 22,669 Primary Health Centres (PHC/UHC) and 3,910 Community Health Centres (CHC) in India, out of which Gujarat had 7,274 SCs, 1,072 PHCs and 273 CHCs. Table 2: Disease Incidence in India and Gujarat, 2007 Cases India Gujarat Chikungunia 2,001 225 Dengue 12,317 545 TB 8,34,037 41,730 Malaria 17,80,777 89,835 ARI 261,52,957 8,33,339 103 Computed Value 4 National Health Profile is published by Central Bureau Of Health Intelligence, Government of India, started from 2005. web link: http://www.cbhidghs.nic.in/index2.asp?slid=987&sublinkid=697 UMC/ICMA 14

Deaths India Gujarat Chikungunia 0 Dengue 184 5 Malaria 1,704 45 ARI 3,736 17 TB 7,244 238 Source: National Health Profile, 2007 In 2006, more than 17 lakh patients were registered as malaria cases and more than 261 lakh patients were reported with Acute Respiratory Infection (ARI). Although the number of TB cases registered in 2006 was less, but maximum deaths due to TB were registered. Many health programs have been launched in India to check the incidence of communicable diseases, especially vector-borne diseases (malaria, dengue, chikungunia), TB and for family welfare and child health. In 2007, all districts of India were covered under the Revised National Tuberculosis Program (RNTCP). In 11th Five Year Plan for 2007-2008, the budget allocated for health and family welfare under Bharat Nirman 5, increased by 21.9 per cent to Rs.15,291 crore, the National Rural Health Mission (NRHM) 6 funds increased from Rs.8,207 crore to 9,947 crore, Integrated Child Development Services funds rose from Rs.4,087 crore to Rs.4,761 crore. The budget allocated for National AIDS Control program (NACP)-III, introduced in 2007-2008, for AIDS control program is Rs. 969 crore and for polio is Rs. 1,290 crore. 7 Table 3: Health Infrastructure of Gujarat in Rural Areas (till March 2007) Particulars Required In position Short fall Sub-Centres 7,263 7,274 - Primary Health Centres 1,172 1,073 99 Community Health Centres 293 273 20 Multipurpose workers (Female)/ANM at Sub 8,347 7,071 1,276 Centres & PHCs Health workers (male) MPW (M) at Sub Centres 7,274 3,347 3,927 Health Assistants (female)/lhv at PHCs 1,073 267 806 Health Assistants (male) at PHCs 1,073 2,421 - Doctors at PHCs 1,073 1,034 39 Obstetricians & gynecologists at CHCs 273 6 267 Physicians at CHCs 273 0 273 Pediatricians at CHCs 273 6 267 Total specialists at CHCs 1,092 82 1,010 Radiographers 273 124 149 Pharmacists 1,346 814 532 Laboratory technicians 1,346 899 447 Nurses/Midwives 2,984 1,585 1,399 Source: http://mohfw.nic.in/nrhm/state%20files/gujarat.htm#hp The above table highlights the gap between the existing and the required government health infrastructure after implementation of NRHM. Considering the improvements in rural areas 5 Bharat Nirman is a four- year (2005-2009) business plan for upgrading rural infrastructure covering roads, telephone, irrigation, water supply, housing and electricity. 6 NRHM was launched by the Central Government in April 2005 to provide accessibility and affordability for quality health services to rural population. This mission focuses on all the health determinants such as water, sanitation, nutrition, education and social and gender equality. 7 Source: http//indiabudget.nic.in UMC/ICMA 15

after the implementation of NRHM, it is expected that the implementation of NUHM will improve the health infrastructure in urban areas. The Government of Gujarat has allocated Rs 565.20 crore for health and welfare in the year 2007-08. It allocated Rs 197.20 crore for women and child development and Rs 8,272.42 crore for social services including health care. The government has earmarked Rs 67.44 crore for upgrading 144 PHCs, 94 CHCs and 30 Sub-Centres, and for contruction of 200 additional PHCs and CHCs across the state 8. Though the NRHM covers rural areas along with towns with a population of less than 100,000, problems of the urban poor remain predominantly untouched. A National Health Policy (NHP-2002) was introduced in 1983, which was revised in 2002. This policy envisages a key role for the Central Government in designing national programs with the active participation of the State Governments. Also, the policy ensures the provisioning of financial resources in addition to technical support and monitoring & evaluation at the national level by the Centre. NHP-2002 refers to the organised structure for urban healthcare and a joint funding by the local self-government institutions, state and central governments. 2.3 The National Urban Health Mission (NUHM)- Focusing on Health Issues in Urban Areas To cover the limitation of outreach of health services to the urban poor, the Government of India has introduced the National Urban Health Mission, focusing on slum dwellers. The four-year mission (2008 to 2012) aims to cover 430 cities, with population more than 1 lakh and the state capitals. A hundred cities will be covered in the first phase. The duration of the mission is 4 years, from 2008 to 2012. NUHM aims to address the health concerns of the urban poor through facilitating equitable access to available health facilities by rationalizing and strengthening the existing capacity of health delivery. The existing gaps are planned to be filled up through partnership with nongovernment providers. The mission, based on the key characteristics of the existing urban health delivery system, proposes a broad framework for strengthening the extant primary public health systems, rationalising the available manpower and resources, filling the gaps in service delivery through private partnerships through a regulatory framework and also through a community risk pooling/ insurance mechanism with IT enablement, capacity building of key stakeholders, and by making special provision for inclusion of the most vulnerable amongst the poor. To improve the access and quality of health care service, especially for the urban poor or slum and vulnerable population, NUHM has introduced two mechanisms - Community Risk Pooling and Community Health Insurance Model. i. Community Risk Pooling This mechanism aims to ensure better health care facility and choice of providers for the poor. A common health fund (or micro-credit fund) would be created by slum women, organised into Mahila Arogya Samiti Figure 4: Model of Community Risk Pooling Proposed in NUHM 8 Source: http://financedepartment.gujarat.gov.in/budget/budget8-9.php UMC/ICMA 16

(MAS), by pooling their money as savings on monthly basis. This micro-credit fund can be used for meeting expenses at the time of health emergencies. The lending norms and the rate of interest would be decided by members of the MAS. Incentives have also been proposed to groups that achieve savings targets. The NUHM would provide the initial amount of Rs. 2,500 as the seed money @ Rs. 25 per household represented by MAS. ii. Urban Community Figure 5: Health Insurance Model Proposed in NUHM Health Insurance Model This model is aimed at ensuring quality medical care for without the burden of high expenses. This insurance model will cover slum population and vulnerable population with a subsidised rate of premium. Smart card/individual or Family Health Suraksha card (photo-identity) would be provided to identified families for a maximum for five members. Card holders would be free to go to any empanelled service provider (private or government) for the desired health care facility as per the package. 9 2.4 Vision of NUHM The National Urban Health Mission aims at improving the health status of the urban poor, particularly slum-dwellers (listed or non-listed) and other disadvantaged sections, by facilitating them to access to quality health care services through implementation of various strategies like partnerships, community-based risk pooling, health insurance etc. The focus is on improving efficiency of public health care services in cities by reaching out at household level with involvement of NGOs, community-based organisations/groups and private service providers. This missions aims to increase awareness among the disadvantaged sections and plans to lessen the burden of expenditure on the specific section by introducing community risk pooling and health insurance mechanisms. This will also help integrate or increase the co-ordination among various public health programs and maximize the outreach and delivery of these programs. The envisaged outcomes through the implementation of the mission can be: Centralization and uniform distribution of health Centres Accessible and affordable health services for the poor Decrease in IMR, MMR, TFR Decrease in communicable diseases like malaria, dengue, tuberculosis 9 Source: the charts for the model : Draft NUHM http://www.uhrc.in/uhdigest.php UMC/ICMA 17

2.5 Salient Features of the NUHM To promote the role of urban local bodies in planning and management of urban health programs To provide a system for convergence of all communicable and non-communicable disease programs including HIV/AIDS through an integrated planning at the city level Provision of additional managerial and financial resources at all levels A 100 per cent centrally sponsored scheme in the first year of its implementation during the 11th Plan period. However, for sustainability of the mission from the second year, a sharing mechanism between the Central Government and State/Urban Local Bodies is being proposed. It proposes detailed health care infrastructure such as USHA (Urban Social Health Activist), MAS (Mahila Arogya Samitis), ANM, medical outreach camps, community health centres, urban health centres and sub-centres. 2.6 Approach for the National Urban Health Mission AMC Vision to provide integrated and sustainable health care delivery systems at the doorsteps for urban poor and marginalized s Ahmedabad currently has seven speciality hospitals and Specialty 55 urban health centres under the state and central government to cater to a population of 50,32, 062. Seventeen nagarpalikas and 27 gram panchayats were merged into AMC limits in 2006, increasing the municipal boundaries by 257.32 sq. kms. Moreover, the number of sub-centres are few compared to the almost 40 per cent slum population in the city. Although Ahmedabad is considered as one of the best performing cities in terms of provision of health services to the urban poor, AMC wishes to access funding in order to cater to the newly merged population and to improve the outreach of its services and overall health care management of the city. UMC/ICMA 18

CHAPTER 3 Existing Health Services and Health Indicators of Ahmedabad 3.1 City Profile Ahmedabad Municipal Corporation (AMC) is the seventh most populous city as per Census 2001 with more than 3.5 million people. Ahmedabad was formerly known as the Manchester of India for its textile industry. The in 2006 have expanded to almost 464 sq. kms in 2006 and the Municipal Corporation boundary houses a population of almost 50 lakh. There has also been a rise in immigrant population to Ahmedabad. Ahmedabad city has been consistently contributing more than 15 per cent to the total state income. The per capita income in the city was found to be almost double than that of the State average (NIUA, 2001). From this it is clear that to sustain high rates of economic growth, cities have to be more competitive. While cities generate more than proportionate share of s s, they also pose certain challenges like providing access to serviced land for housing the urban poor, provision of basic amenities and a system to plan and manage these. Hence, urban investments in economic, physical and social infrastructure at adequate levels are a prerequisite. Urban Governance AMC is divided in to six zones and 43 wards for better administration. Three corporators are elected from each ward, who in turn elect the Mayor. Executive powers are vested with the Municipal Commissioner, appointed by the Gujarat state government. AMC has forged partnerships with NGOs, private industry, educational institutions and international agencies for enhancing its urban development capacities and for improving municipal service delivery. Services They city is divided in to six zones and has 16 civic centers. The civic centers offer facilities like tax collection, approval of building plans, shops and establishment, estate hawkers etc. The Ahmedabad Municipal Corporation has set a unique example of e-governance. The corporation has a tie-up with a private bank, which accepts tax collections from citizens through internet. The completion and operation of the Sardar Sarovar Project of dams and canals has improved the supply of potable water and electricity for the city. In recent years, the Gujarat government has increased investment in the modernization of the city's infrastructure, providing for the construction of larger roads and improvements to water supply, electricity and communications. The water supply needs of the city are met mainly from surface water supply through Raska Project, French well in Sabarmati river and from intake wells constructed in Sabarmati river. UMC/ICMA 19

Figure 6: Map of Ahmedabad Municipal Table 4: Statistical Information for Ahmedabad Indicator Latest available data Year Remarks Population and Vital Statistics Total population 50,32,062 2008 Projected Population density Sex ratio 882 2007 Birth rate 10 19.88 2007 Projected Death rate 11 6.85 2007 Projected Infant Mortality Rate 22.53 2007 Projected Maternal Mortality Rate 0.64 2007 Projected Urban population (%) 41% Includes chawls, LIG Slums and slum-like 2001 colonies, and Gamtal population (%) areas Literacy rate 82.91% 2001 10 Birth rate - Number of births per 1000 per year 11 Death Rate- Number of deaths per 1000 per year UMC/ICMA 20

Infant Mortality Rate and Maternal Mortality Rate Table 5: Mortality Rate in Ahmedabad AMC limits Old Limits Year Projected Population Birth Rate IMR MMR 2006 38,94,430 21.55 30.86 0.75 2007 39,73,946 20.61 26.85 0.78 New 2006 10,05,455 9.81 3.85 0.00 Limits 2007 10,25,984 17.05 2.29 0.06 Source: Ahmedabad Municipal Corporation, 2007 As mentioned earlier, during 2007-08, the AMC limits increased with merger of additional wards. 3.2 Institutional Structure of Health Department of AMC r, who is supported by a chief medical officer of health. There are three deputy health officers in charge of Malaria & Epidemic, Health, and Birth & Death Registration departments.. Additionally, each of six zones is headed by a Deputy Health Officer. The Assistant Health Officer (AHO) at the zonal level acts as a link between the Medical Officer (MO) from each ward and the Deputy Health Officer at the zonal level. The Medical OAssistant Health Officer to ensure proper sanitation management in wards and zones. Local link workers (LW) report and register cases of cholera and diarrhoea with the Sanitation Department for proper preventive measures. Each health centre has at least one Medical Officer supported by pharmacists, lab-technicians (LT), multipurpose workers (MPW) and link workers. UMC/ICMA 21

Figure 7: Structure of Ahmedabad Municipal Corporation Health Department Ahmedabad Municipal Corporation Health Department Municipal Commissioner Deputy Municipal Commissioner- Health (Dy. MC) Chief Medical Officer Of Health Dy.H.O. In all Zones A.H.O In all Zones MO In all Wards PHS SI SSI AACS OMS Central Medical Stores FWO (RCH Society) 55 UHCs RNTCP Asst. Prof. TB Hospital 10 Maternity Homes 3 Referral Homes 2 Dispensaries (Allopathic) 2 Dispensaries (Ayurvedic) 1 Dental RBD & Supdt. Vaccine PH Lab Analyst Flying Squad (PFA) AE Malaria AHO MS, MI, MSI, Havaldars, Majdoors in all zones ICDS Mukamdams CDPO I CDPO II CDPO III CDPO IV CDPO V Safai Kamdars No. Of Anganwadis No. Of NGOs 3.2.i Linkages between the Health and Sanitation Departments The health of a city depends upon its infrastructure such as water supply and sanitation. To maintain the health standards, the Health Department needs to work and coordinate with other departments, mainly engineering and sanitation. The Engineering Department takes t solid waste management. By improving the quality of water supply and by improving sanitation facilities, the Engineering and Sanitation departments, in coordination with the Health Department, can control outbreaks of water-borne diseases that are mainly caused by contamination of drinking water. The number of water-quality of drinking water. The Sanitation Department is informed about cases of water-borne diseases in the city while the Engineering Department is intimated in the eventuality of insufficient chlorination of drinking water or any contamination in it. This helps both the departments to work out their action plan. UMC/ICMA 22

3.2.ii Incidence of Disease in Ahmedabad The table below indicates cases of water-borne diseases in Ahmedabad in 2008. Gastroenteritis Incidence Table 6: Trend of Gastroenteritis (G.E.) Cases and Deaths Recorded till October 2008 Month Jan Feb Mar April May June July Aug Sept Oct Total Central Zone 21 20 32 47 31 40 57 26 61 38 373 West Zone 5 5 9 16 11 20 11 15 5 1 98 New West 7 6 14 11 8 11 13 7 13 9 99 Zone North Zone 31 38 73 81 107 113 134 125 79 34 815 East Zone 65 61 91 111 138 103 164 123 87 68 1011 South Zone 29 40 82 92 103 117 246 194 100 69 1072 Total 158 170 301 358 398 404 625 490 345 219 3468 Source: Ahmedabad Municipal Corporation, 2008 Figure 8: Occurrence of G.E. Cases From 2003-2007 Source: Ahmedabad Municipal Corporation, 2008 The number of gastroenteritis patients can be seen to be unchanged till 2007. The sudden increase in the number of patients could be attributed to the newly merged areas in AMC after 2006. These areas did not have adequate water supply and sanitation infrastructure. Viral Hepatitis Incidence Table 7: Trend of Viral Hepatitis Cases and Deaths Recorded till September 2008 Month Jan Feb Mar April May June July Aug Sept Oct Total Central Zone 17 29 24 36 38 70 96 86 70 36 502 West Zone 0 5 3 2 35 14 11 6 8 4 88 New West Zone 5 10 30 10 9 11 12 37 22 7 153 North Zone 20 13 14 22 33 50 41 20 36 18 267 East Zone 18 22 17 18 28 51 38 43 40 9 284 South Zone 30 41 36 47 81 88 84 84 77 36 604 Total 90 120 124 135 224 284 282 276 253 110 1898 Source: Ahmedabad Municipal Corporation, 2008 UMC/ICMA 23

Figure 9: Occurrence of Jaundice Cases from 2003-2007 Source: Ahmedabad Municipal Corporation, 2008 It can be seen that the number of viral hepatitis cases registered in 2005-06 is higher compared to other years. This has been attributed to the epidemic in 2005-06 especially in Khadia, Jamalpur and Raikhad areas of the city. The epidemic was caused by contamination of drinking water. AMC has resolved occurrence of further such contamination by laying new water supply pipelines in these wards. Typhoid Incidence Table 8: Trend of Typhoid Cases and Deaths recorded till September 2008 Month Jan Feb Mar April May June July Aug Sept Oct Total Central Zone 1 2 2 6 1 2 0 1 2 4 21 West Zone 0 0 1 0 2 1 1 1 0 0 6 New West Zone 1 0 1 1 0 0 0 0 2 0 5 North Zone 3 5 12 10 9 16 10 8 12 6 91 East Zone 10 18 20 19 28 38 18 30 18 21 220 South Zone 8 15 12 19 16 16 11 19 21 5 142 Total 23 40 48 55 56 73 40 59 55 36 485 Source: Ahmedabad Municipal Corporation, 2008 Figure 10: Occurrence of Typhoid Cases from 2003-2007 Source: Ahmedabad Municipal Corporation, 2008 UMC/ICMA 24

Cases of typhoid are reported by the Health Department staff to Sanitation Department. The Sanitary Inspector carries out the residual chlorine test for the affected area. Low level of residual chlorine indicates contamination of water. This is further reported to the Engineering Department for inspection. Cholera Incidence Table 9: Trend of Cholera Cases and Deaths Recorded till September 2008 Year Cases Deaths 2002 2 0 2003 17 0 2004 6 0 2005 0 0 2006 4 1 2007 36 0 2008 6 0 Source: Ahmedabad Municipal Corporation, 2008 Better coordination between the Health, Sanitation and Reproductive and Child Health departments has helped in checking the number of cholera cases in Ahmedabad. Immediate reporting of cases by RCH link workers to the Sanitation Department helps the department get an action plans ready without losing time. This helps in taking quicker remedial measures thus resulting in controlling the spread of the diseases in time. 3.2.iii Health Budget Health Department over last three years. Table 10: Revenue expense of Ahmedabad Municipal Corporation Budget 2008-09, (amounts in Rs. Thousand) Totals Budget Allocated (% of the total budget) 2005-06 2006-07 2008-09 % increase 2006-07 2008-09 Health Public Health Laboratory Disinfection RNVBDCP TB Control Rog Pratikarak Rashi Mukwani Yojana Bal Kanya Yojana Four Point Program ICDP 41,236 (28.4%) 1,209 (0.8%) 376 (0.3%) 28,979 (19.9%) 274 (0.2%) 3,125 (2.1%) 200 (0.1%) 5,933 (4.1%) 1,351 (0.9%) 45,770 (28.1%) 1,320 (0.8%) 435 (0.3%) 35,056 (21.5%) 283 (0.2%) 2,412 (1.5%) 200 (0.1%) 7,936 (4.9%) 2,268 (1.4%) 72,445 (32.0%) 2,030 (0.9%) 650 (0.3%) 47,065 (20.8%) 475 (0.2%) 2,320 (1.0%) 300 (0.1%) 10,290 (4.5%) 2,995 (1.3%) 11.0% 58.3% 9.2% 53.8% 15.7% 49.4% 21.0% 34.3% 3.3% 67.8% -22.8% -3.8% 0.0% 50.0% 33.8% 29.7% 67.9% 32.1% UMC/ICMA 25

Totals Budget Allocated (% of the total budget) 2005-06 2006-07 2008-09 % increase 2006-07 2008-09 Urban Family Welfare 6,957 7,114 7,620 (4.8%) (4.4%) (3.4%) 2.3% 7.1% ICDS 1,931 2,431 4,315 (1.3%) (1.5%) (1.9%) 25.9% 77.5% Birth- Death 12,291 12,310 19,665 (8.5%) (7.5%) (8.7%) 0.2% 59.7% Dispensaries 17,574 18,497 25,160 (12.1%) (11.3%) (11.1%) 5.3% 36.0% Maternity Home 24,017 27,093 31,145 (16.5%) (16.6%) (13.8%) 12.8% 15.0% Total 1,45,453 1,63,125 2,26,475 12.1% 38.8% Source: AMC, 2008 It can be deduced from the above table that the total budget allocated for health has increased by almost 39 per cent from 2005 to 2008. This amount does not include the funds earmarked for hospitals for the new wards merged into AMC limits. Salaries under different heads constitute nearly 80 per cent of the budget amount. It can be seen that 28 per cent of the total health budget is allocated for Sanitation Department and various IEC campaigns related to public awareness on health and diseases like tuberculosis, cleanliness programs, polio campaigns, child healthcare etc. The AMC also runs public health laboratories for food quality control. It can be seen that the budget amount under this head has also increased in absolute numbers since 2005-06. The fund allocation for tuberculosis control is almost 0.2% of the total budget and also shows an increase of 68% in 2008, which could be attributed to additional TB health centres in newly merged areas. This mostly only covers the establishment expenditure of hospital staff. The TB control program is implemented under the centrally funded Revised National Tuberculosis Program (RNTCP). It has been observed that the maximum percentage of the total budget has been allocated for the RNVBDCP, (implemented by the AMC), and dispensaries and maternity homes (run by AMC). The total increase of budget under these heads is around 30 per cent from 2005 to 2008. operates and implements various health programs as detailed below. To implement these programs effectively, the municipal corporation has formed various societies, like the RCH Society, RNTCP Society and the Ahmedabad District AIDS Control Society, in partnership with NGOs. These societies together cover major health care facilities and help in the implementation. This increases the outreach of the national programs. The details of each program and the organisation with implements the program is given below: 3.2.iv Reproductive and Child Health Program The Reproductive and Child Health (RCH) Program of the Government of India (GoI) aims at reducing total fertility rate, infant mortality rate and maternal mortality rate by providing services for safe family planning, antenatal care for mothers, safe deliveries, immunization and increasing awareness about child care, vaccines and diseases like HIV/AIDS. AMC began implementation of the RCH Program in 2004 through the RCH Society. The RCH UMC/ICMA 26

Along with RCH II, the Government of India has further introduced two additional programs to cater to the urban poor. The Chiranjivi Yojana, aimed at bringing down the infant and maternal mortality rates, was introduced in Gujarat in 2006. Under this scheme, the urban poor or slum residents with BPL cards can access cash-free medical assistance at private hospitals. Free maternity services, check-ups, medicine delivery are provided to BPL card owners. Bills for treatment of the urban poor at private hospitals in Ahmedabad city are paid by AMC. Initially, the Chiranjivi Yojana was implemented at district level and later (from July 2008) implemented by AMC through RCH. The Janani Suraksha Yojana was launched in Gujarat in 2007. This scheme targets at improving the health of post natal mothers from economically weaker sections of the society. The scheme makes cash available to them for availing required nutrition. The money is made available through an Auxiliary Nurse Midwife (ANM) or any other health worker who has been authorised to make the payment from the money provided by the disbursement authority. The Government of Gujarat has declared 2008-09 as the Nirogi Balak Year to bring down infant mortality rate and to encourage the concept of healthy child in terms of physical, mental and social health. The scheme focuses right from conception of a child to her adolescence, giving special attention to pre-natal care of mothers, vaccination, monitoring child growth, adequate nutrition, health check-ups and protection for proper physical and mental development of a child. Under this focus, AMC has intensified its vaccination drives, which has resulted in wider outreach. It also provides services like free delivery of children and free treatment for children aged below five years. AMC has begun observing Mamta Divas as per State Government guidelines to reduce infant mortality rate and deliver health and nutrition services on this day at a single venue. Anganwadi workers have been trained to educate the community about new born caring practices, health and hygiene. On Mamta Divas, a mother and child-friendly environment is created at anganwadis, exhibition panels on maternal and child health are displayed and films on childcare, health and hygiene awareness are screened. 3.2.iv.a Organisational Structure of RCH Program Ahmedabad currently implements the RCH program through a network of 55 urban health centres. These can be divided into the following groups based on their management: Nine centres are operated by AMC. 22 by RCH Society. 19 centres are operated by NGOs, Three by the Family Planning association of India, Nine by the Indian Medical Association, One each by Akhand Jyoti Foundation, Gujarat Research Association, Gujarat Sahayog Trust, Citizen Council, Akhil Hind Mahila Parishad, Arvind- Ashok Mill and Red Cross. Five by P.P. Unit which includes V.S. Hospital, Civil Hospital, S.G. Hospital, S.C.L. Hospital and Bapunagar General Hospital The RCH program is implemented through AMC and is headed by a Family Welfare Officer supported by a Medical Officer, an Administrative Officer and a Management of Information and Education Co-ordination Officer (MIECO) for each RCH centre. Each centre is headed by a Medical Officer followed by a pharmacist, a lab-technician, multipurpose workers and LWs. The number of multi-purpose workers and LWs depends on the population to be served. UMC/ICMA 27

The detailed organisational structure of the RCH Society is shown below. 22 of the total 55 health centres have been formed through RCH Society funding. These centres were added in 2004 under the RCH-II program. These centres, providing all facilities of an Urban Health Centre (UHC) also offer OPD services and department. Figure 11: Organisational Structure of RCH Reproductive and Child Health Society, AMC Deputy Municipal Commissioner-Health (Dy. MC) Chief Medical Officer of Health (CMOH) Family Welfare Officer Administration Officer Medical Officer (MO) Management of Information and Education Coordination Officer Clerk Pharmacist Lab-Technician (LT) Multi-Purpose Workers (MPW) Link Workers (LW) Table 11: Zone-wise Slum Population Zone Slum Pop. Central Zone 3,28,410 West Zone 3,13,307 North Zone 5,97,245 East Zone 7,18,645 South Zone 5,22,003 New West Zone 3,92,762 Total 28,72,372 Source: AMC, 2008 3.2.iv.b Job Functions of Medical Officers (MO) The MO provides general OPD clinic, family welfare and RCH services to the population covered under a particular UHC. The MO is overall responsible for provision of effective services to its target population and is the critical link between the ward and its zonal dy. Health officer. UMC/ICMA 28

An MO oversees the work of the supervisor, MPW and Health Visitor (HV) attached to the UHC and guides them on their field duties. MOs also monitor and reviews the implementation of national programs like RNTCP and RCH and are associated with specific drives and campaigns on dengue, school health, ICDS, STD control, blindness control, immunisation etc. They also regularly review the progress of work of the UHC team to meet the national and state targets. Medical officers are also responsible for general administration for drugs, equipment and vaccines supply, maintenance, monitoring health activities monthly, conducting medical check-ups, and providing treatment, MCH and RCH services to children and expecting mothers of all anganwadis in a ward. 3.2.iv.c Job functions of Multipurpose and Link Workers (LW) Multipurpose workers (MPW) and link workers are the critical link between urban poor communities and health infrastructure and staff. This is evident from their job profiles below: Every MPW has three to four LWs under him and caters to a population of 12,000. MPWs provide services like antenatal care to pregnant women throughout their pregnanc, immunization of mothers and children. Their job also requires creating awareness among the community on issues like nutrition for expecting and nursing mothers, care of new born babies, motivating couples for family planning, distribution of contraceptives to couples and distribution of iron and folic acid tablets to pregnant women and nursing mothers, Vitamin A solution to children and provide treatment to TB patients (DOT). MPWs collect general information about immunisation, vital events, registration of births and deaths, pregnant women, eligible couples etc fortnightly. They register number of births, deaths and eligible couples, categorizing them according to number of children and age of mothers and report to the Medical Officer periodically. MPWs are also trained to test urine for albumen and sugar, to collect blood samples of patients suffering from fever, test haemoglobin count and provide presumptive and radical treatment. They also identify abnormal high risk pregnancy, cases with medical and gynecological problems and cases that require help for medical termination of pregnancy and refer them to nearest approved institution. Additionally, they identify women leaders from the community and participate in Mahila Mandal meetings to utilize such gathering for spreading awareness on family welfare, RCH programs, nutrition, immunisations, minor ailments etc. Table 12: Zone-wise Slum Population Covered by RCH and Number of Health Service Providers under RCH and MPHW Population Health Service providers Sr. Total Coverage No. Zonal Division Population Multi (RCH) ( slum & (2007) Link Workers Purpose slum like) Workers 1 Central Zone 6,21,245 3,28,410 113 73 2 West Zone 7,10,952 3,13,307 108 39 3 North Zone 8,82,165 5,97,245 205 55 4 East Zone 9,78,454 7,18,645 247 60 5 South Zone 9,38,578 5,22,003 180 40 6 New West Zone 9,00,668 3,92,762 132 43 Total 50,32,062 28,72,372 985 310 Source: Ahmedabad Municipal Corporation, 2007 UMC/ICMA 29