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Platforms for Sustainable Health Systems in Disadvantaged Communities

Vimala Ramakrishnam, New Concept Communications, Jaishankar Memorial Centre

Randall Kuhn, Global Health Affairs Program, University of Denver

After years of emphasizing cost-effective, disease-specific interventions, the global health

agenda has returned to the need for sustainable health systems in disadvantaged societies. A
recent editorial in Proceedings of the National Academy of Sciences called for health programs
that “engage the local and national populations and enable the programs to expand to a
nationwide scale” (Bloom 2007). The case for finding pathways from interventions to systems is
bolstered by key epidemiologic factors including the presence of multiple competing disease
risks and comorbidities, the inevitable epidemiologic transition to costlier and more complex
conditions, and the important but tenuous relationship between health and economic
development (Kunitz 1987; Caldwell 1993; Marmot et al. 2009; Menken, Kuhn, Barham 2009).
Social and political technologies can play a powerful role in the development of effective and
sustainable health systems (Singer and Castro 2007; Kajikawa 2008). At the national scale,
levels of information technology, governance, public engagement, and collective efficacy are
positive predictors of public health outcomes (Sen 1999; Subramaniam et al. 2002; Raghupathi
and Wu 2008). At the programmatic scale, studies have documented the potential implications
of community knowledge, public engagement/oversight, and principal-agent collaboration in
improving both the effectiveness and sustainability of disease-specific health interventions
(Janvry et al. 2007; Bjorkman 2009; Castro et al. 2009). At present, however, the programmatic
literature consists largely of ad hoc lessons from a series of independent socio-political
interventions, usually emerging as adjuncts to well understood disease-specific interventions
(e.g. supply chain management for vaccine delivery) or evaluations of costly and
comprehensive social justice approaches (e.g. the Partners in Health HIV/TB programs).
This project therefore aims to develop and optimize replicable platforms and systematic
guidelines for community-based health interventions incorporating behavior change
communications (BHC), community governance (CG), and social capacity mapping (SCM)
technologies. Our work will leverage existing disease-specific interventions and ongoing
community-based research initiatives on i) promotion of maternal and child health (MCH) in
multiple slums in New Delhi, India; ii) social enterprise approaches to water and sanitation
(WASH) in Kibera slum in Nairobi, Kenya; and iii) emergency and preventive medicine in rural
and urban areas of the Peruvian Amazon. We also request funding for Stage 2 pilot
interventions in additional study sites to facilitate further optimization and preliminary evaluation.
The principal goal of this three-year project would be the development of a well-defined set of
sustainable intervention procedures that would be subject to subsequent experimental
Our key aims are to assess the impact of each of the three interventions separately and as an
integrated package on the utilization, impact, and sustainability of health services. We draw a
clear boundary between our more pressing goal – the sustainable management of existing
health services – and the long-term goal of stimulating the endogenous emergence of new
health services. We specify individual and integrative impacts of each technology and
summarize in the table below:
Behavior Change Communications (BHC) – Standard health education modules will promote
demand for existing health services; enhance intervention impact (e.g. hygiene education to
improve household sanitation in parallel with community sanitation improvements). Advanced
modules will utilize SCM data to achieve the aforemention aims, to promote community
engagement with health governance, and to improve local capacity to utilize SCM data.

Community Governance (CG) – Includes development of basic systems for local management
and maintenance of existing facilities, community accountability of local principal agents; and
effective community-government relations and utilization of SCM data for evaluation,
enforcement, and identification of future needs.
Social Capacity Mapping (SCM) – Geographic Information System (GIS) databases will link
data on community needs and capabilities and programs to facilitate better targeting of new
interventions to existing needs; promoting referrals and partnerships, encouraging individual
utilization of needed health services, and facilitating advanced health systems offerings such as
micro health insurance.
Impact on Existing Services Impact on
Utilization Impact Sustainability
Behavior Change +++ + + +
Community Governance ++ +++ ++
Information technologies + + + +++
Combined intervention + + ++ ++

The proposed three-year project will focus on the development and optimization of each of
these approaches in each context, with evaluation of impacts concentrated in the final year of
the project and in follow-up studies.
Background for Delhi Project
With 17% of the world’s population and 20% of births, India’s success in averting infant and
maternal mortality will also determine the world’s success (US Census Bureau 2008). In 2006,
India’s Infant Mortality Rate (IMR) was 37.1 per 1,000 infant (31.5 for boys, 42.1 for girls).
Although this is below the global average, India nonetheless accounts for more infant deaths
than any other country. With a Maternal Mortality Ratio (MMR) of 540 per 100,000 births, India
accounts for 26% of the world’s maternal deaths, more than three times the next biggest
Progress in these areas has posed continued challenges. Even as the Government of India rolls
out a nationwide catastrophic health insurance plan, only 51% of newborns receive a full battery
of childhood immunizations, compared to 86% of infants in its poorer neighbor Bangladesh.
While states in South India such as Kerala are pointed to as exemplars of low-cost delivery of
health services, states in the rural areas of the northern plains and Himalayan foothills as well
as urban slums face continued difficulties in meeting targets for infant, child, and maternal
health. The advanced technical capacity and innovation of India’s health system have led many
to conclude that there is a problem of demand, yet the evidence suggests problems of supply as
well as demand. Key supply side challenges include high rates of worker absenteeism, low
levels of worker productivity, and services inappropriate to population needs. While studies
suggests that overall health utilization is high among most population segments, poorer and
more isolated communities are often less likely to trap into modern medical practices and
preventative health services. A new national health insurance scheme focusing on catastrophic
care offers the promise of improving access, yet success and cost control will require efforts at
improved health education and prevention.

Delhi Project Work in Progress
Jaishankar Memorial Centre (JMC) is a non-profit society set up in 1990 with the objective of
working with disadvantaged urban communities in the areas of health, education, environment
and livelihood with focus on children, women and youth. Towards this end, the Society has
undertaken several programs, including research and evaluation studies, community
interventions, and the running of the Gender Resource Centre (GRC). In 2008 JMC was
requested to shift the location of the GRC to the informal settlements and peri-urban villages of
Jasola village, Sheenbagh, Madanpur village, and Abu Fazal on the southeastern outskirts of
Delhi. The majority of the population are vulnerable families living in cramped housing colonies.
Their livelihood is not secure, and the nature of work they do ranges from casual workers as
rickshaw pullers, construction labour, etc. Their problems are compounded by poor hygienic
surroundings, unsafe water, poor sanitation and poor nutrition intake. Quality of education is
poor and their children have no proper environment for play or leisure. Most girls marry young
and bear 4-6 children before they are 30 years. A sizeable number are migrants in search of
livelihood and “better opportunities” in the capital city.
In 2009, the Delhi NCR government began to implement the Samajik Suvidha Sangam
(convergence of services for vulnerable population) program, offering GRCs as a single window
outlet for improved utilization of services and schemes. The SSS-GRC provides health services
through camps and mobile clinics. However, a lasting solution will have to be found to equip
them to understand their health situation, to demand new services, and to mobilize the
economic and political resources to gain access to those services.
To this end JMC and the Josef Korbel School of International Studies at the University of
Denver (DU) jointly initiated the Delhi Capacity Mapping and Health Education Project. The
long-term goals of this program are three-fold
1) Develop a map and database of existing health, social service, and gender sector
resources to assess quality, to identify gaps in service or physical access, and raise
awareness of untapped resources
2) Provide general health education and map-based referrals to community members
through a cadre of trained community health assistants drawn from the community
3) Work with health assistants and community leaders to raise broader community
engagement with existing health services and to stimulate the action and resource
procurement necessary to fill resource gaps.
The project also seeks to evaluate the GRC’s capacity and services in line with the Delhi
Government’s Mission Convergence Initiative (SSS), which aims to better coordinate social
service delivery for the poor.
In Summer 2009 three interns from DU conducted an initial assessment and mapping in Jasola
and Abu Fazal of health services and facilities available in these two areas, to assess general
health facility utilization (particularly in regard to Maternal and Child Health services), to
determine the barriers to accessing and receiving care, and to assess the overall health needs
of this population. The data collected are currently undergoing statistical analysis, in addition to
spatial analysis, to support recommendations and proposals for improving health services and
utilization. These data are also being used to demonstrate the need for capacity building and
increased government support to GRC, which is still unknown and barely accessible to many
residents of the community. An example of the mapping is shown on the next page, where the
residences of surveyed populations are mapped against plausible service areas of existing
facilities including GRC. We note the proximity to the Apollo Indraprastha Hospital, which did not
participate in the initial assessment and was not listed by any of the surveyed respondents.

Next Steps
In the coming year New Concept, JMC, and DU will work together to formalize internal mapping
capacity at JMC and New Concept, to carry out further data collection/analysis, to lay the
groundwork for health assistant training programs in Summer 2010, to develop proposals for
conducting further work support of SSS, and contribute to joint DU-New Concept-JMC funding
proposals. Further, we plan to apply the lessons learned from this and other health education
projects in India to a training partnership with DU’s Masters of Development Practice (MDP)
program and universities in Delhi NCR.