-—‘--7

141.1—13171

~penenceSin Healthand

ommuflitv pevelopmeflt

II -1 ~1~i~‘i : i i :

The Anubhav series is published to disseminate information on innovative projectsproviding health, nutrition, family planning and community development services in India Theseries was developed out of a widely shared concern about what could be done in order tostrengthen the performance of health and community development programmes in India TheIndian government has assumed the primary responsibility for the provision of basic services toIndia’s 844 million people, particularly to the disadvantaged living in rural areas. As a pluralisticsociety, however, India has also witnessed the growth of a rich variety of private efforts,complementing the work of the government. Though limited in resources and scale of impact,many voluntary agencies have beenexperimenting with innovations learned through many yearsof extraordinary dedication.

Information about these small, private, and widely dispersed projects has been limitedLack of descriptive information, project analysis, and presentation in a readable format haveprevented the many lessons learned from these innovative efforts from reaching the broaderaudience of policy-makers, programme managers, academics, social activists, and the interestedpublic The Anubhav series attempts to disseminate the e periences of these voluntary organi-zations, with the goal of contributing to greater understanding of their work and thereby improvingthe delivery of health and community development services in India. In the documentationendeavour, effort has been made to stress on the procesE of development of these voluntaryorganisations rather than development alone.

Financial support for the production of the Anubhav series is provided by the FordFoundation. Selection and review of the case studies is undertaken by Mr Alok Mukhopadhyayof the Voluntary Health Association of India, working with an informal committee drawn from thosein the field of health and community development

Individual acknowledgement could not be given clue to paucity of space However,Anubhav series would like to express its deepest gratitude to all those but for whom thedocumentation of these projects would not have been possible

Index

Preface

UrbanHealth:Whither Lie Solution? FutureChallenges 34

Introduction 3CaseSludiesHealthandthe UrbanPoor 7

UrbanEconomy 8 Action for SecuringUrbanizationandHealth Health for All 37The UrbanEnvironment 13 Yout~ifor Unity andPnrnaryHealth Careand Voluntary Action 45UrbanPoor 21 TheJajmauChallenge 53ThePresentScenario:GovernmentSchemes& Intervention 27 Refer 63

f ‘ ~ExperiencesinHealthand.

Community Development ~ I

~cuaURBAN HEALTH Ic) . I

L~dh~A&

INTERNATIONAl REFERENCE C~NT!?FOR COMMUNITY WATER ~SANITATION (lRC~ ANI

PREFACEPopularsaying, alndia lives in villages” perhapsdoesnot hold true any more.Atpresent26 percentof our population live in unplanned,chaotic and ever-growingurban centresofIndia. Thepaceofurbanizationis expectedto increaseevenfurtherin thecomingdecadesin consonancewith theenvisagedeconomicgrowthin India.

In Post-IndependenceIndianplanning,therehasbeenconsiderableeffort towardstheprocessofrural development,thoughmuchofwhichmaynothaveproduceddesiredresults,but in urbanplanninganddevelopmenttheprocesshasbeendelayed,halfheartedandmainlyconcentratedfor megacities. Urbancentresarereferredto as ‘enginesofgrowth’fornationaleconomyas theycontributeoverhalfofthegrossdomesticproduct.Despitetheapparentaffluenceofthesecentresurbanpovertyhas increased,while therural povertyincidenceshave declinedsharply (LakdawalaCommitteeReport).Evidently,thehighurban incomeis distributedunequallyamongtheurbanresidents.Like in everysphereofoursocietaldevelopment,rich andthefamous’havecorneredmostoftheavailablefacilities, leavingnotso well offcitizensto ekeoutahumiliatingexistence.In all ofurban India, it is a Taleof Two Cities.’

Thesituationis directlyaffectingthehealthandwell beingofthepeopleliving inurban India. Unhygienicliving conditions,squalor, lack ofpublic conveniences,pollution, inadequateandunsafewatersupplyareall partoffamiliarcommentaryontheseareas. This is further highlightedby recentoutbreakofprimitive diseaseslikeplague,choleraandmalaria.

This suggeststhat there needsto be a radical departureon theaffairs of urbanmanagement.To begin with, couldthere be a semblanceofequitabledistributionofavailableinfrastructureandresourcesamongthe entirepopulationliving in urbanareas?Canwe reorganizeurban managementinto a decentralized,people-orientedsystemrather than currentcentralizedstate managedsystem?In this area Chineseexperienceofurban managementis ofconsiderablerelevance.Lastly, can weensure

more rapid andbalancedgrowth of the villagesso that theprocessof migration issloweddown. Perhaps,balancedrural andurbangrowth in Punjabandits overallimplicationon thelivesofpeopleis worth lookingat.

This issueofAnubhavis trying to understandsomeoftheseproblemsandpresentsomeoftheinterestingmicro levelalternativeurban developmentinitiatives. Wehopeit will generatemorediscussionandcoordinatedactionon thisimportantissueofournationaldevelopment.

URBAN HEALTH:WHITHER LIE SOLUTIONS~

0~

Infroducion

is estimatedto growto 290-350 millionby 2000. As popula-tions cometogetherfor security and abetter city life, theurbanisationprocessin India and otherparts of the worldconstituteamajorde-mographic issue ofthe 21st century.

The complexity of theurban environment andthe social strata thereinpresenta tough challengeto the sustainability andrelevanceof health anddevelopmentprogrammes.

According to

Seventhplan esti-

mates,50.5millionpersonsin urban

~ areaswere livingbelow the povertyline in 1984-85comprising 27.7%of the urbanpopu-

• lation. Thepaceof:..:1~’”• urbangrowthin In-

dia (SeeTable 1)

D ndia’surbanpopulationofaround217million, oneofthelargestin theworld

million by the year 2000 comprising45 % of India’spopulation,about1/3 -1/5th of theurban populationis expectedto be living in slums.

Of thestaggeringexpectedfigureof460 hasbeenhigh during 1951-91 and the

TABLE 1. Urban Growth in India (1901-1991) E~’No.ofUrban

Census Agglonieratlons/ Population in (thousand) DecennialGrowth Rate

Year Town Total Rural Urban Total Rural Urban

1901 1,827 238,395 212,544 25,851 - - -

1911 1,815 252,092 226,151 25,941 575 640 035

1921 1,949 23i,321 223,235 8,086 -031 .129 827

1931 2,072 278.976 245,521 33,455 11,00 998 1912

1941 2,250 318,660 274,507 44,153 1422 1181 3197

1951 2,843 361,087 298,644 62,443 1331 879 41 42

1961 2,365 439,234 360,298 ‘78,936 21 64 2064 2641

1971 2,590 548,158 439,045 109,113 2480 2186 3823

1981 3,378 683,328 523,866 159,462 2466 1932 46 i4

1991 3,768 844,323 627,146 217,177 2356 1971 3619

Ref MathurO P 1993

(PersonsinLakhs)

TABLE 2. India : Estimatedurban population and slumpopulation, 1990

Statesl Urban Identified Estimated EstimatedUnionTerritories Population Slum Urban Slum

Population Population Population1981 1981 1990 1990

INDIA 1,59727 27914 2,41544 51228

SEates

AndhraPradesh 124 88 28 58 19037 3807Assam 2047 124 3314 663

Bihar 8719 3270 13772 3270

Gujarat 10602 1532 15505 3101

Haryana 2827 274 45 86 9 17

HimachaiPradesh 3 26 076 4 58 0 92

Jammu&Kashmir 1260 627 1944 627

Kamataka 10730 574 16562 3315

Keraia 4771 410 6816 1363

MadhyaPradesh 10586 1075 16881 3376

Maharashtra 21994 4315 312.55 625i

Manipur 375 0 17 961 1 92

Meghalaya 241 066 399 080

Nagaiand 120 — 275 055

Orissa 3110 282 5302 1060

Punjab 46 48 11 67 68 93 13 79

Rajasthan 72,11 1025 11569 2314

Sikkim 051 002 129 026

TamjiNadu 15952 2676 21378 4276

Tnpura 226 018 324 065

UttarPradesh 19899 2580 32654 6531

WestBengal 14447 3028 19857 4964

UnionTerritories

Andaman& Nicobar

Islands 0 49 N A 0 93 0 19

ArunachaiPradesh 041 N A 093 0 19

Chandigarh 423 N A 765 1 53

Dadra&NagarHaveli 007 N A - —

Delhi 5768 1800 9284 3825

Goa, Daman& thu 3 52 024 5 45 1 09

Lakshadeep 019 NA — —

Mizoram 1 22 N A 3 80 0 76Pondicheny 3 16 094 5 13 1 03

Source. A Compendium on Indian Slums, Town and Couritiy Planning Organisation, 1985

number of towns has increasedfromaround3,000in 1951 to 4,689 in 1993(Sivaramakrishnan1993). With thepresentdifficulties in estimating theurban and slum populationsthe actualfacts aboutthe urban poor especiallyrelating to their healthand nutritionalstatus remain hidden. A somewhatconservativestatewiseestimatemay bereferredto in Table 2. At the nationallevel trendsindicatethat while theruralpoverty is declining, the urbanpovertyis increasing.‘The numberofurbanpoorandthe percentageof peoplebelow thepovertyline in the 1 970sand 1980splacethe urbanpoverty estimatebetween35and 40 percentas canbe referredto inTable3. In 1991, 28%of the estimated20 million peopleliving in 23 majormetropolitanareasresidein slums. Thenumberof citiesover 1 million hasnearlydoubledsince 1980 from 12 to 23 withtheurbanpopulationrising from 26.8%

0*

to over 35%. In just the majormetropolitancities more than9 millionpeoplelive in urbanslums: 12,50,000in Bombay, 11,00,000 in Calcutta,9,00,000in Madras and 7,00,000 inDelhi. By the year2000 India facestheincreasinglygrim challengeofprovidingPrimaryHealthCare to around80-120million slumpopulation.

Urban Growth

Urbangrowthis influencedboth by the‘pull’ forcesofeconomicopportunityincities and the ‘push’ factors of ruralpoverty andunemployment.The rural-urbangrowth ratesover 1971 to 1991can be referred to in Table 1. Thedecennialrates of urban growth havebeenmuch higher than the rural ratesfor thepastseveraldecades.In absolutenumberstheurbanpopulationhasnearlyquintupledin the last50 years from 44million to 217 million. A direct result

TABLE 3.NumberofPoorand PercentageofPeoplebelowthePovertyLinein the1970sand 1980s

Planning DirectAll India AggregationofCommission E.stlniate StateEstimates

Estimate _______________________________ ____________________________(Percent) (No. in (Percent) (No.in (Percent)

million) million)

1970-71

Urban — 5007 4589 4993 4617

Total — 30176 5505 30590 5625

1983Urban 2810 6596 3833 6839 3974

Total 37.40 333 27 4646 34326 48 ii

1987-88

Urban 1940 7496 3652 7657 3776Totai 2920 33642 4270 35783 4585

Reference M:nhas, Join &Teridulkar (1991)

4iu~r UI

0*0

of this urban populationexplosionhasbeena tremendousincreasein theurbanslumpopulationwith inadequateaccessto basichealthandsocialinfrastructureand services.With the existing urbangrowth rate, the National Institute ofUrban Affairs task forcetherewill be62-78million people inthe slums out of anestimatedtotal of 310million urban pop-ulation by the endof the century.Giventhe difficulties inestimating slumpopulations thisprojectedfigure appearsrealistic estimatefrom the estimatedfigure of 512.28 lakhs in 1990 asdeterminedin 1985by theCompendiumon Indian Slums, Town and CountryPlanningOrganisation(Table2).

In 1990, 42.3% of the worldpopulationhadbeenreportedto be livingin urbanareas.By theyear2000this isexpectedto accountfor 46% andby 2020for 56.4% (United Nations 1987).

Reasonsfor urban growth are mainlynatural populationgrowth, responsiblefor more than60% andmigration fromruralareas(Harpham1988).Thepresentpatternsof economicgrowthhavebeengeneratingrapidrural-urbanandurban-urbanmigrations.Underemploymentin

rural areas, frag-mentationof land-holding patternsdue to thepopula-

• tion growth andbreakdownofjointor extendedfami-lies, non imple-mentationof land

• reforms due topolitical influences of rich peasants,increasedawarenessamong landlesspopulations of possible economicindependencein urban areas allcontribut’~to increasein migration.

The complexity of the urbanenvironment and the social stratatherein present a tough challenge tothe sustainability and relevance ofhealth and developmentprogrammes.

The inability of the urban

Sustainable Human Settlements Development-Implefl’Jefltiflg Agenda 21.” preparedfor the U NCommission on sustainable Development by UNCI-JS (Habitat). March 1994

projectedthat

The inability of theurban administratio:ij tocope with the pressuresof urbanisation has ledto serious deprivationamongthe urban poor.

to be a more

Ur}.7crn ManagimentChallenge

From 1990to 2030,global populationwil grow by3.7 billion people.Ninety percent ofthis increase will takeplace in thedevelo;ing countries.NinentypercentwiH be urban.virtually alt of it will accrue to humafl s ttlementsin the developingworld. By 2030.urban populations will be twicethesize of uralpopulations.Primarily due toa decayingurban environment, at least 600 million p :ople in human settlements already live in lifethreatening situations. up to one-third n ore live in substandard housing. At least 250million urban residents have no easy acces~:o safe piped water,400mitlion lack sanitation.

UI

administration to cope with thepressuresof urbanisation has led toserious deprivation among the urbanpoor.

Health and theUrbanPoor

The health statusof the urbanpoor isinfluencedby severalfactors. In thisissuethesehavebeenexplainedunderthreesectionsA. UrbanEconomyB. UrbanisationandHealthC. The UrbanEnvironment

Thesectionon PrimaryHealthCareoftheUrbanPo-or, their healthproblems andthe Urban He-alth CareDeliv-ery System(Sec-tion D) is fol-lowed by thePresentScenario

of GovernmentschemesandIn-terventions(Sec-tion E) and Fu-ture Urban He-aithChallenges(SectionF).

The NGO Sector

Currently in India, a largemajority ofhealth care projects tend to emphasisapproachesto provide curative carewhile others have evolved moremultisectoralprogrammeswith greateremphasison involvement of slumcommunities and partnershipwithgovernment and other NGO

0*prograninies.The outreachservicestoslumpocketswho donot haveaccesstoservicesand their integration withgovernmenthealthprogrammesremainan importantchallenge.

Thereis anincreasinginterestamongbilateral agenciesto support severalprogrammesand projects on urbanPrimary Health Care. In some casesefforts are made in the sameareas,concentratingresourcesandduplicatingactivities under different approacheswithout strengthening referralmechanismsor planning community

interventions in-____ ____- -, a coordinated

manner. Thegapin coordina-tion and plan-

~ ning among or-~ gamzationsand~ theabsenceof ak~ thoroughcorn-

mumty needas-sessmentpro.-grammetarget-

— —~-I~~ed at thosesec-tions who are

most disadvantagedhave reducedthesuccessof theseproject interventions.

To whatextenthavetheUrbanhealthcare projects within the NGO sectoracted as agenciesof changeto bringaboutabetterqualityof life within urbancommunities?Slum dwellers oftenlabelledas ‘socialparasites’by theurbanelite perform substantialvaluableserviceswithin theurbaneconomy.Cantheybecomepartnersin thedevelopment

The search to provideequitable accessto healthservicesand to respondto themany needsofthe urban poorin the light of severehealthandenvironmentalconditionshaveconstitutedthe activitiesof several urban projectswithin the NGO sector.

0*of theurbaneconomyandreceivetheirshareof the benefitsof this economy?

The searchto provide equitableaccessto healthservicesandto respondto the many needsof the urbanpoorin the light of severehealth andenvironmental conditions haveconstitutedtheactivitiesof severalurbanprojects within the NGO sector. Aneffort has beenmade hereto describesome of theseinitiatives as will beexplainedbelow.

Although various aspectsof someNGO initiativeshavebeendocumented,the guiding forces behind projects,their extent of collaborationwithgovernments, partnership withcommunitiesandallocationofresourcesstill hold out importantlessonsas hasbeenillustratedbelow throughselectedinterventionsmade by threeNGOs(SectionG) Action for SecuringHealthFor All (ASHA) in New Delhi, Youthfor Voluntary Action (YUVA) inBombay,Maharashtraandthe UrbanHealthCareProject (UHCP) andotherprogrammesin Kanpur, Uttar Pradesh.There remain crucial factors thatinfluencewhy someprojectinterventionsareor arenot successfuland theseneedto be more widely understoodandreplicated.

Theseand other NGOs havebeenstriving to find their own solutionsthroughdifferent forms of pannershipwith slum women and communitiesin parts of the country withheterogeneouscommunities.Can theyinfluence the way in which urban

plannersand administratorsview theurbanpoor in order to formulatemorecomprehensiveand needbasedfuturestrategies?

A. Ui1uui Economy

Insteadof being a sign of economicprogress,urban growth as in theindustrialized country model maybecome an obstacle to economicprogress:the resourcesneededto meettheincreasingdemandfor facilities andpublic servicesare lost to potentialproductheinvestmentelsewherein theeconomy.(Lob Levyt 1990).

The contribution of India’s urbansectorto the netdomesticproductrosefrom 29% in 1950-51 to 41% by 1980-81 andislikelytogoover60%by200l.Almost two thirds of theemploymentinmanufacturing,trade,transportationandcommercesectoris concentratedin urbanareas.Howeverthebenefitsof thisurbangrowth arenot sharedby all. In largecities one third to one half of thepopulation lives in slums and around15% of themalework forceand25 % ofthe femalework force haveno regularemployment (Mathur 1993). Thesignificant addition to the urbanpopulationis notabsorbedinto theurbaneconomy but remains marginallyemployed in unproductivefields orunemployed.

However,therehavebeeninnovativeand successfulinitiatives with selfemployedwomen workers within theNGO sector that are directedat botheconomicaland social integration

I

EJ~\nub~

into the mainstreamof society. SEWAoperatingin ninedistrictsofGujaratwitha total member-shipof 53,000 selfemployedwomenis onesuchexample.SEWA establishedin 1972 as a tradeunion for self employedwomen grewout of the Textile Labour Association,India’s oldestunion of textile workersfoundedby MahatmaGandhi in 1920.

The SEWAUnionorganiseswomenbelongingto differ-enttrades,Cooper-atives help thewomento build a!-ternativeeconomicstructuresto in-creasecontroloverthe meansof pro-duction. These in-clude Land based,Livestock, Craftand Artisans, Ser-vices and TradingCooperatives.The SupportiveServicesinclude Health Care, Child Care,Savingsand Credit, Housing, LegalServicesand Insurance.

It appearsas if SEWA has beeneffective in emphasisingthe role ofwomenasvital workersin thehouseholdand local economyratherthan asmereclients for welfareservices.

A recentstudyby JhabwalaandBalirevealedthat92% of SEWA’s memberswere interestedin the healthserviceforthe curativeservicesoffered includingthe servicesof the community healthworkers,doctorsand theavailability ofessentiallow costdrugs.SEWAhasalso

0*helpedactasa link to improveoutreachof four governmentservicesnamelyfamily welfare,immunization,maternitybenefitsandhospitalcare.It was foundthatamongthemembers43.7% availedthe irmnunizationprogrammeand22%the maternitybenefitsprovided.

Accordingto the 1981 census,15.6%ofurbanhouseholdsdidnothaveasingle

The non participation

~ of men in the1~ curativeandpre-

ventlive healthcare of familiesremainsan im-portant chal-lenge.Socio-ed-ucationalinter-ventions target-ed at both menand women in

I particularwithin~ ~. ~

the family con-text are clearly important. The familyhealth status is closely linked toeconomicand social factors includingunemployment,wastefulexpendituresondrugs,alcoholandtobacco,lackofbasicamenitiesincluding water supply,sanitation,housingand food security.

B. Urbaiiisaflon andHealth

Urbanisationcan be perceivedas apositive phenomenonwhen it leadstoresettlementof workers in ruralpopulations in are as where nonagriculturalopportunitiesareavailableand lead to productiveand gainfulemployment.In realityhowever,it tends

literate member.

Therehavebeeninnovativeand successfulinitiativeswith selfemployedwomenworkers within the NGOsectorthat are directedatboth economicalandsocialintegration into themainstreamofsociety.

t

~)_4’

I

0*to be more of transferof rural povertyto the urban environment.The link

betweenurbanisation,environment,inaccessibility to healthcareand the

Proper water and sanitation facilities still remain beyond the reach of the mijonty of the urban poor

~Th~v

threatto the quality of life in particularemergeas importantissues.

Slums have beendescribedassubcultureswith a set of norms andvalues which is reflected in poorsanitationandhealthpractices,deviantbehaviourandcharacteristicattributesofapathyandsocial isolation.

Slumification orslum expansionandits negative impacton the larger city envi-ronment constituteim-portantprocessesof ur-ban decline (VHAI1992). An increasein female responsibilityandtheirengagementinstressfuloccupations •.

outside the~home,placesa doublebur-denon them. S..

Despitethis reality urbanareasinIndiacanstill be describedasNehrusaid:‘A cultural Unity amidstdiversity — Abundle of contradictionsheld togetherby strongbut invisible threads.’

The urbanisationprocesshas alsobeen found to create individualisticlifestyles in contradictionwith ruralculture, impersonal interactions,increasedsocial stressand ill health,specialisationof occupationsand casheconomyand breakdownof familynorms,customsand traditions. Studieson internalmigrantshavealso shownhigher rates of mental morbidity(Chakraborthy1990, Sethi et al 1972).

Amongsttheurbanpoor, the rapid

0*populationgrowthmakespovertymorevisible. It is well known that in thedevelopingworld theproblemsof citieshaveexacerbatedasaresultnotsomuchof the population growth itself, but ofgrowthwithin the contextof a legal andinstitutionalstructureunableto copewiththeneedsof thepopulationandthetasks

of providing andrunningcity services(HardoyandSather-

waite 1989).Thus, urbanpoli-

cy issuesposeseriouschallengesto plan-

- ners in developingcountries.Thecomplex-

ity andrapidgrowthofurbanpovertyaccom-paniedby the dete-riorating environ-

mentalconditionsneedseriousattentionandlong termplanningmust replace adhoc decisionsforimplementingimmediatesolutions.

C. TheUrbanEnviromiieut

The urbanenvironmentenablesone togainabetterunderstandingofthenatureandmagnitudeof theproblemsaffectingIndian cities andhow theseresult inthe deterioration of the urbanenvironment.The city - a stagefor awide rangeof problemsis alsothesilentaudience of the consequences.Unfortunately,most of theseproblemsrest beyond the perceivedor realmandateof municipalitiesjeopardisingany interventionswith any real impact

Urban areasin Indiacan still be describedas: ‘A cultural Unityamidst diversity—A..bundle of contradic-tions held togetherby..strong but invisiblethreads.’

— JawaharLalNehns

0*on thehealthandquality of life’ or thoseaverting further damageto urbanenvironmental degradation.(Sivaramakrishnan1993)

Around 39 to 43 % of India’s slumpopulation is distributed in themetropolitancitiesof Calcutta,Bombay,Delhi andMadras.Slumdensitiesarearounda na-tionalaverageof 243 per-sons/hectare.According tothe 1983 taskforce Kanpurhas the high-estdensity ofl2l0persons/hectarewhileDethiandlly-derabadhave638 and 525respectivelyviz a rangeof 8-19squaremetersofareaperpersonin aslum.TheNTUA 1988studybroughtoutdatafromtwenty sampletowns of various sizesrevealedthat about 50 percentof theslumpopulationlives belowthepovertyline. The study also shows that 80percentof theper capitaexpenditureofslumhouseholdsbelowthepovertylineis on food alone, excluding panandtobacco,fuel and electricity.

Somemajorproblemsarisingin sucha contextrelate to inadequatewatersupply and sanitation, solid wastedisposal, rights over land tenure,IiIiI~J?\nubjlalr

inadequatefood suppliesandincreasingdemandfor employmentand socialservices.

In 1985 nearly27.1 percentof theurbanpopulationhadno accessto safewaterand ‘71 .6 percentwasreportedtobe without basicsanitation.As can be

seenin Ta-ble4, inab-solute num-bersit is es-timated thatnearly 47million peo-ple in urbanareasarenotcoveredbysafe watersupply, 124million arewithout ba-sic sanita-tion and 49million (ov-

er 5 Yeais) are without schooling(Mathur 0. P 1993).

With the rising densitiesof slumpopulationsmore than90% of theslumhouseholdsdo not have accesstoindividual ] atrines.A study doneby theCentrefor ScienceandEnvironmentin1985showedthatmore than40% oftheslums in cities are waterloggedgivingrise to intestinal, respiratoryand skindiseases.The All India figure (NSSO1987) displaysthat36.82%householdsare without a latrine facility.Undoubtedly,a large majority of thehouseholdswhich do not havelatrines

1

~ The city - a stagefor a wide range~I of problems is also the silent

audienceof the consequences~ Unfortunately, most of these~# proble,nsrestbeyondthe perceived

or real mandateof municipalities~ jeopardisinganyinterventionswith

any real impacton the health andquality of life or those averting

0 further damage to urban~ environmental degradatto~i

Reference (MathurO P 1993)

0*

belongto thelower socio-economicandslumpopulations.Among thehouseholdswhichhavesometypeof toilet! sanitationfacility 57.6% shareit with others,alargeproportionof theseareobviouslyslum dwellers.

In the early 1980s the concernforwatersupplyandsanitationled to theadoptionoftheMasterPlanfor theWaterSupply and SanitationDecade.Manyambitioustargetswerefixed to providetheseservicesto the urbanareaswithspecialprovisionsto extendtheseto thefringe areas,however thesewere notaccompaniedby allocationof resourcesor efforts to strengthenthe existingdelivery systemand ensureit’s bettermanagement.The per capita cost ofimplementationof the EnvironmentalImprovement of Urban Slumsprogrammeis estimatedatRs500crores.In the mid 1980s when the slumpopulationwas estimatedat around40million the SeventhPlanallocationforfunds shouldhave been2,000 crores.The actual outlay however is onlyRs 27 crores. As a result the accessparticularlyof thepoorto watersupply,

propersewerageandsanitationattheendof thedecaderemainslargelyunchanged.

It is well known that the better offurbanpopulationin a few metropolitanandClassI citiesof our countrymanageto haveaccessto theseweragefacifities.Although the undergroundseweragesystemis the bestand most hygienicmethodof disposingsewageandsullagewater, only 12.18 percentof the townsin selectedstateshavethisfacility (1981census)while only a small section ofthis populationis being covered(referTable 5A & Table 5B). Most townsdependon opensurfacedrains (OSDs)for disposalof wastewaterwhichin theabsenceof propermaintenanceposeamajor threat to environmentalhealth(Kundu 1993).

Accordingto a surveyconductedin1988 by the Central Pollution ControlBoard, only 71 of the 212 Class I cities(populationof over I lakh) had sewersystems.Citieswith sewerpopulationonlyprovidedcoverageto about60% of theirpopulation;StatecapitalsofLucknow andJaipurhadno sewersystems.Of the 6.5billion litres of sewagegenerateddaily in

TABLE4. LevelsofUrban Deprivationf

Not covered Without Without ~Vithout Withoutbywater basic sanitatioii schooling anyeniploynient any regularsupply (+5years) employment

1985 1985 1981 1987-88 1987-88

male female male female

Percentage ofurbanPopulation 27 I 716 352 6 1 85 146 250

Number ofpersons(million) 473 1249 49 I 46 — — —

Total 220 11 60 87.22 41.36 307 10 15 88 57 19 04

Source: Based on date from Census ofIndia (1981)Note:BSD = Box SurfaceDrains OSD = Open Surface[)rains S = Sewerage

0*.~j TABLE 5A. PercentageDistributionofTowns by Classesand

S

ClassofTownWStates

ClassI ClassII

No.of

Towns

% of Townswith

BSD OSD S

No.of

Towns

% of Townswith

BSD OSD S

1 2 3 4 5 6 7 8 9

AnclhraPradesh 21 - 95 24 21 42 33 - 95 62 24.24

Bthar 14 2143 9286 21.42 25 800 10000 -

Gujarat . 11 - 36.36 63 64 27 - 51 85 51 85

Haryana 9 - 88.89 8889 7 - 71.43 8571

Karnataka 14 714 9286 8571 16 3750 7500 31.25

Kerala 6 - 50 00 50 00 8 - 25 00 62.50

Jammu&Kashtnir 2 5009 10000 - 0 000 000 000

Maharashtra 29 689 9655 1379 25 1600 9600 800

MadhyaPradesh 14 57 14 100.00 - 27 2592 10000 -

Mampur I - - 0 0.00 000 000

Onssa 6 1662 100.00 3333 0 1250 10000 -

Punjab 7 - 10000 10000 10 - 10000 8000

Rajasthan 11 - 10000 1818 10 - 10000 -

TairnlNadu 21 952 71.43 2381 41 244 9268 488

UttarPradesh 30 1333 90.00 4667 38 1053 10000 1579

WestBengal 24 3333 91.67 3750 40 1750 8500 1000

L~17A~T

TypesofSewerage/DrainageFacifities in SelectedStates,1981

0*

ClassIll Class1V & Below All Towns

No. % of TownswithNo. % ofTownswith No. % of Townswithof of of

Towns BSD OSD S Towns BSD OSD S Towns BSD OSD S

10 Ii 12 13 14 15 16 17 18 19 20 21

91 - 9560 25.22 107 - 8691 30.84 252 - 92.86 31.35

75 400 100.00 433 106 3.77 100.00 377 220 15.45 99.55 3.64

56 - 46.43 3036 160 250 58.62 21.25 254 1.57 77.65 28.33

15 - 80.00 66.67 50 - 88 00 20.00 81 - 85 10 41.97

71 28.17 88.73 8.45 180 21.67 91.11 778 281 23.49 89.68 13.17

64 1.56 15.62 26.56 28 - 10.71 10.71 106 - 16.98 26.41

5 40 00 100.00 - 51 13.72 98 84 - 58 15.52 98.27 -

89 2 25 95 00 3.37 164 3.66 92.68 4.87 307 4.56 94 14 5.54

48 - 97.92 - 2.38 - 94.54 - 327 4 59 95.72

2 - - - 29 - - - 32 - - -

26 - 9230 1538 68 4.41 76.47 882 108 4.63 8426 11.11

27 - 96.24 7772 90 - 98.89 4.11 134 - 98.51 54.48

55 - 96 36 1 82 125 - 95 20 4.80 201 - 96 10 4.48

89 - 7977 337 283 106 7809 4.24 434 138 7949 5.07

98 2 01 94.90 9 78 538 0.74 99 07 3 90 704 1.99 98.15 7.09

52 5.77 8461 2.69 175 - 6628 228 291 6.87 74.25 7.22

863 5.82 8354 15.78 2392 290 8561 8.02 3790 435 8344 1218

~nub~puU~J

0*

Source: Midterm review of wotersupply and sanitation decade MinisttyofUrbni Development Govt ofIndIa 1985

TABLE 5B. StatewiseUrban PopulationCoverageby Sanitation Services(SeweragelDrainage)1985

States Urban Populationcoverage Below(-)fabove(+)(Percemtageto total) average

AndhraPradesh 109 —

Assam 157 —

Bihar 229 -

Gujarat 380 +

Cioa 133 —

HimachaiPradesh 137 —

Haryana 284 Average

JammuandKashmir 77 —

Karnataka 384 4-

Kerala 282 —

MaclhyaPraclesh 7 8 —

Maharashtra 398 +

Manipur 08 —

Onssa 95 —

Punjab 485 —

R~asthan 96 -

Sikkim 329 +

TamilNadu 475 +

Tnpura 132 —

UttarPradesh 14 1 —

WestBengal 195 —

While employment may not be a major problem in urban cities like Delhi, h~usingis.

1i~7\nub~mr

0*

0*

the 12 major metropolitancities only 1.5billion litres were collected (CentralPollutionBoard 1991).

Underdifferenturbanschemes,lowcostsanitationfacilitieshavebeenextendedto theurbanpopulationwith 50% of thecostasagrantandtheremainingasaloanatalow rateofinterest.This still remainsbeyondthe reachof themajority of theurbanpoorand the recoveryof theimplementationchargeortheloanhasbeenvery poor. The recoveryratehasrisenwhenprivateorganisationsorNGOssuchasSulabhInternationalhavetakenup theconstructionandmaintenancejobs. (SeeBox 1)

The city is thus a stagefor a verydiverserangeof problemsand thesilentaudienceoftheconsequences.Therecent‘Plague’ epidemicprovidesa glaringexample of the repercussionsofenvironmentalsanitationandbreakdownofessentialpublichealthfacilities in smalltowns and growing cities. The urbanenvironmentenablesoneto gainabetterunderstandingof the nature andmagnitudeof theproblemsaffecting

Indian cities and how theseresult indetrimentallyaffecting its deterioration.The urban slum environment,characterisedby overcrowding,poorenvironmentalsanitation,occupationalhazardscausedby small industries,violence and stressful occupationstogetherwith alackofspacefor children’srecreation,canbeparticularlydetrimentalto thosein the younger age groups.Exploitation,abuse,maltreatmentarepartof the lives of worker children. Theadverseeffects of hazardousexposuresrelatedto occupationson children inselectedurbanslum areasin thecountrywhich areparticularly vulnerablecallsfor further study.

For new migrants, the traditionalextendedfamily is replacedby thenuclearfamily andthechangesof socialstructuresincreasetheir vulnerability.Single-parenthouseholdsheadedbywomenproduce limited child care,childrenare often pressedto work toimprove householdincome, at veryyoung ages or to take care of smallersiblingswhile themotheris absent.

--

-.5 ;SS~-

5-- ~

Soanng above the fetid streets, sun-splashed luxury apartments - worth lakhs of rupees

Housing

The TaskForcesonUrbanDevelopmentasalso’theSixth andSeventhFive YearPlans have quite explicitly pointed outtheinability ofthegovernmenttoprovideminimum housing to the poor.Accordingto thePlanningCommission

5 (1983): ‘One of the key challengesforurbanpolicy over the next couple ofdecadeswill be a searchfor means toprovide for the possibility of givingaccessto the poorto adequateshelter.’The urbanpoor have very low payingcapacitiesfor theprovision of housing,watersupplyandseweragefacilities andthusinvolveslargegovernmentsubsidieswhichare non existent. An importantreasonprovided was the shortageofresources.The PlanningCommissionin 1980 pointedout that: ‘In view ofthe severe constraints of publicresources,the resourcesof institutions

like HUDCO andstatehousingboardswill needto beaugmentedto enablethem

to provide infrastructuralfacilities as ameansof encouraginghousing in theprivate sector.’

Many urban developmentprogrammeswerethus launchedin the1980s with shelter,water supply andsanitationas major components.Anoverview of theseurbandevelopmentprogrammeswhich soughtto reach asubstantiallylarger segmentof theuncoveredpopulationthan the otherformalprogrammesonhousingandbasicservicescanbereferredto in Table 6.

Under the Basic Services

0*Programmesonly servicesareprovidedin deficient slum areasor settlementswithout altering the physicalstructureof thehouses.The Snelter-cum-ServicesProgrammemakes availableservicedland, security and basic services. Theprogrammesunder the Shelter-cumSevicesprogrammewereinitiatedby theCentralGovernmentwith fundsprovidedby theapexpublicsectorinstitutionslikeHUDCO asalsofrom theWorld Bank.Initiatives and responsibility for theimplementationof theseprogrammesstill lies with the State governments(housingboards,slumclearanceboardsandothers)andasa resultare takenupin only somestates.The Basic Sevicesprogrammehoweveris spearheadedbythe central governmentdirectly andhenceto havea wider coverage.

Illegal occupation(‘invasions’) ofpublic unproductivelands as well asLegal rights over land tenureimply thefurther development of squattersettlements.The lowestquality housingis generallyfound in slumcommunitiesin which the threatof eviction reducesthe incentive to invest in houseimprovements.

fl PrimaryHealth CareandtheUrbanPoor

It is possibleto understandurbanprimaryhealthprogrammesasa ‘set’ ofhealthandnonhealthactivitiesthatincludepromotiveand preventivehealth together withcurativeaspects,water sanitation andenvironmentalimprovementprogrammes,

i~ubh~L~i1

(i) Environmentalimprovement ofurban slurns(EIUS)

(ii) UrbanBasicServsces(UBS)

(iii) Urbancommunitydevelopment(UCD)

(iv) Specialschemes

(b) Integrateddevelopmentofsmall & mediumtowns(IDSMT)development(v)Commencal

development

II Outside Central Sector

(c) Low-cost

Sanitation

(d) Shelter-cum-basicservices

1 Sites & Services

2 Slum improvementandupgradation(1) SIP-I

(i) Water Supply(ii) Sanitation

(i) Water supply(ii) Sanitation

(iii) Health(iv) Education

(i) Water Supply(ii) Sanitation(iii) Health

(iv) Education(v) Shelter

(Vi) Employment

(i) Water Supply(n) Sanitation

(i) Water supply(ii) Sanitation(iii) Shelter(iv) Industnal

(i) Sanitation(ii) HUDCO

(in) World Bank(certainschemesbycentralgovt)

(i) Water supply(ii) Sanitation

(iii) Shelter(iv) World Bank

(i) Water supply(ii) Sanitation

(iii) Health(iv) Employment

(i) Water supply

(ii) Sanitation

(lii) Shelter

(i) Centralgovt(ii) Stategovt

(i) Centralgovt.(ii) State govt.

(iii) UNICEF

(i) Centralgovt(ii) Stategovt.

(iii) Local authonty(iv) Overseas

developmentadministration

Centralgovt(PM’s fund &

ninth financecommission)

(i) Central govt(ii) Stategovt

(i) Central govt(ii) Stategovt

(iii) HUDCO

(i) Stategovt

(ii) Localauthonty

(i) HUDCO

(ii) World Bank

Loan-cum-grant

Loan-cum-

grant

*

I Central Sector

(a) Basicservices

Grant

Grant-cum-loan

Grant-cum-loan

Grant

Loan

(1) Stategovt

(ii) SIP-Il

(iii) SUP-I

(lv) SliP-Il

Grant

Reference Kundu (1993)

communicationandincome generationactivities. It may or maynotbeaprocessthat is a part of wider urbancommunity

0*developmentprogrammesincludingcommunity organisation,planning andimplementation(UrbanExamples 1983).

Arriving in uthan cities with a little more than dreams, some hit it big While thousands of others - like this womanand child - suffer from poverty, starvation, medical and social diseases.

7\nubJjav U~J

*

Althoughthehealthservicesdeliverysystemis concentratedin the urbansetting this areapresentsa greatresistanceto anyfundamentalchangeinPrimaryHealthCare.Thereis a lack ofunderstandingof PrimaryHealth Careon thepartof medicalprofessionalsandhospitals.The actualimplementationofPrimaryHealth Carein urbanareasiswroughtwith specialproblems• The heterogeneity of urban

popu}Lations has proved a majorobstacleto urban development.Indi’~idualismand a senseofcollective responsibility is low ascomparedto rural areas.

• Voluntary efforts are less commonpartly due to this and the fact thathouseholdsare headedby singleparentscrucially dependenton cashincomes.

• A multiplicity of agenciesare

55~ -

Inadequate out reach of public health care delivery system. dnves a poor man to carry his ailing wife on hisshoulders - Nut Who Cares I?f

1~J4ufrh~ur

involved, both governmentandNGO, in health care provisionmaking any form of coordinationmoredifficult.

• It is thepoorersectionsof theurbanpopulation do not have accesstoprimary healthcare.Vestedinterestscome not only from medicalprofessionalbut also the publicandpoliticians.

Major HealthProblems

Thereis a needto redefmehealthin thecontext of the urbanpoor. Rossi-Espagnet(1984) summarizestheconditionof healthin urbanpoorareasof developingcountriesas follows:‘The urban poor are at the inteifacebetween underdevelopmentandindustrialization and their diseasepattern reflects the problemsof both.Fromthefirst theycarry a hea%yburdenof infectiousdiseasesand malnutrition,while from the secondthey suffer thetypical spectrumof chronic and socialdiseases’.

Healthproblemsin the urbanpoorare practically determinedby 3 maingroup of factors which actsynergistically:• direct problems of poverty:

unemployment,low incomes,limitededucation, leading to prostitution,inadequatediet,malnutrition, lackofbreastfeeding,etc.

• environmentalproblems: alreadydescribed,leading to infectiousdiseases(air and water-borne),accidents,etc.

• psycho-socialproblems: stress,alienation,instability and insecurity,leadingto depression,smoking,drugaddiction, alcoholism, abandonedchildren, etc. (Harpham1988)Major healthproblems identified

in poor urban areasof developingcountries could be summarizedasfollows: diarrhoealdiseases,respiratorydiseases,infectious diseasespreventedby immunization, malnutrition,tuberculosis,malaria, gynaecologicalinfections,sexuallytransmitteddiseases,socio-psychologicalproblems: drugaddiction, alcoholism,home violence,child abuse,etc. HIV/AIDS is emergingas an important problem that is fastspreading is a potential threat topublic health,not only by its biologicalbut also its economic and socialconsequences(Nabarro 1989).

UthanHealth CareDeliverySystem

Theexistingmodelofhealthinfrastructureis an expansionof thatin rural areasviz.controlof communicablediseases,MCHandfamily planning.By its very designitis biasedin favour of public sectoremployees,workersintheorganisedsectorandpersonsinthehighincomecategories.About48 percentoftheurbanpoorgo toprivatedoctorsandanother12 percenttoprivatehospitalsfor outpatienttreatment.Long distancesandwaiting hoursas wellastheattitudesof medicalprofessionalshavebeenfoundto discouragethemfromusingpublic hospitals(Kundu 1993).

E~J

0*The ground reality of multiplicity

of agenciesproviding healthcareto themore opportunepopulationsand thescoresof existing private medicalpractitionersmakesthe presenturbanhealthcare systema complex one. Inthe urbansettingsecondaryandtertiarycare is provided by a multiplicity of

hospitals,voluntaryandprivatehospitalsandalmost80% of theavailableprivatepractitioner;in the country.

Thehealthinfrastructurein thepublicsector includes the: State GovernmentPrimary Health Care centres: PHUsestablishedon the rural PHC pattern,industrialhospitals,ESIdispensariesandhospitalsaspartof theEmployeesStateagenciesviz, the medical college

InsuranceSchemeparticularlyin largercities andtowns with a large industrialsectorandthe urbanhealthand familywelfarecentres(UHFWCs)run by thecity Municipal Corporations.All theseexceptthe latter provide essentiallycurative servicesand do not haveoutreachservicesfor slumpopulations.The HI-IFWCs in mostlargecitieshasatheoreticalcoverageof 50, 000 focusesexclusivelyfor maternalandchild healthand family planning servicesand isstaffed by One Medical Officer andANMs (1ANM/5000population)(SahniandXirasagar1993).

Rapid urbanisationwith the presentdegradationin environmentalconditionsand changinglife styles has seriouslyerodedthepatientdoctorrelationwhichconstitutesthe core of the healthcaresystemin this country. Child WelfareCentresandtheJuvenileServiceBureausrun by the Dept. of Women andChildren’swelfareexistin certainlargecities. Howeverthe needsfor outreachfamily and community servicesforpreventionand rehabilitationof healthproblemsarising out of the complexpsycho social environmente.g. drugabuse,alcoholism,prostitutionalsoneedto be providedfor.

Substantial restructuring in theorganisationof the public healthcaredelivery systemand improvementin itsquality are necessaryto make it moresensitiveto the urbanpoor. A betterquality of servicescould be ensured ifboth the rich and poor are dependenton the samesystem(Kundu 1993).

0*Local and nationalgovernmentshave

beenunableto deal with theseproblemsbecausetheir political and technicalapproaches,lackof skilled manpowerandscarcity of financial and managerialresources.Centralto this is the weaknessofmunicipalandcity governmentsandthepooravailableinfrastructure.Theproblemshavebeenfurthercompoundedbydecliningpublic investmentsin basic servicesandinappropriatemodelsof interventions.

E. The PresentSccnai4o:GovernmentSchemes&Intervenflon

Giventhepresentinfluenceof structuraladjustmentwithin the frameworkof theliberal politico-economicorder urbaninterventionsfor the provision of basicamenitiesi.e. drinking water, housing,sanitationandseweragefacilities, healthcare and the distribution of essentialcommodities through the publicdistribution systembecomecrucial(Kundu 1993).

Our 74thamendmentrepresentstheculmination of this prolongeddebateand seeksto promotestrengtheningofmunicipalauthoritiessothattheyacquirethe institutional capability to deal withthe problemscreated by urbanisationandurbangrowth. However, despiteanincreasingdemandfor servicesdue tourbanisationandurban growth the localresourcebasehasbeenshrinking. Theshareof Municipal authorities in thetotal public sectorexpendituredeclinedfrom 8% in 1960-61 to about4.5% in

~nu~3

The new model of development evolved in Kerala i

programmes by the poor themselves. PlariningandiCommunity oevelopment society (cos) WMC}i is a ffamilies within thejurisdictionofthe NagarfraIikafr

In Alleppeyand in twelve other towns in Keralais in the process of expansion to all 37 towns and otand Urban population.

Poverty eradication is the goal and poverty is (4called the poverty index. High risk (poverty) isdefinrisk factors viz:

Afamilybelonging toscheduled caste or Tribe.with children under five yearsolcihaving even qne illiterate adultwith only one or no adult.employed.living in kutcha house.withputa household latrine.with no access to safe drinking water.consuming only two meals, sometimes one in adwith an alcoholic or drug addictThe poor families who are identified by

community members themselves are (bundto beaUriskofhunger, malnutrition and ill heallh This condohasbeen established by an in-depth sample studwhich the indexwas found to besigni~cantlyassoCkwithmalnutrition among children beloWsyears (Wetforage) and~meninthe age group tS-45’yearc(heand weight) and with family illness and deaths.

A poverty index is ii simple tool that can be ueducation. The index analysis of each family giveswhatspeciflc package ofinterventionsareneeded.by this.

Theorganizational structure of the CDS proviwomen from poor families to plan, implementcmstructure isa three tiersystem. The basic ur~tisth,40 ftrrnilies. This group is representedby an electSfrom high risk familiesfrom the membershlpoftheAlevel, the Community Developnlentsqcfety (CDSJ f~as its branches. The ADS and the CDS areeachr~NWG level, micro-plans are made based onanalysirisk factors or reducing their impact. NHG pfr#integrated to form the Action Plan orthe CDS, call

Theprogrammes for the poor are implem~ADS are empowered and authorisect by the cD5Govërrirnertt, NABARD, Banks orother dqnort 7responsible for implementing all planned activiØePJWG Committee is responsible for impleptentatloi

- The CD5 are established as perthe modell~-mobilised from donors such as UNICEF and frant~emsSes through beneficiary contribLitidn aØdrë~ourcesundervarious existing an~payektyp$Yojana (NRY), Environmental lmprowmentoft44

tables successfu) operatlnalisadon of anti-povertyipleinentatxrn ofnewly created structure called the~maIlyregistered society of women from the poorichaypt.is model has been successfully operationalised andentire district of Malappumm covering both rural

ned in an alternative way on the basis of Risk Indexasthepresenc~in a familyof fouror more of nine

y.

elb‘Ptin

lit

thy local community members with even very littletearpicture of whatór~the needsof the-family andanningof activities is made easierand more effective

5 a canvnunity administration system that enablesmciflitorprogrammes for their own benefit The CDSdei9hboinbood Group consisting of women from 25-ye mcmbercom mittee. At theward level, the women~aDevelçtpment Society (noS). At the rown/Panchayatflsthe apexbodyofwhich the ADS canbe consideredesentSby elected committees/governing bodies. At~rlocØlpr*lem5withth~objective of eliminating theire consolidated int~Ward plans which are finallyAtM tL’S Town or Panchayat Plan.~lby intended b!neflcia*es themselves. The CDS andre4a~to directly approach and receive funds formces and ADS maintain bank accounts are directly

atTown and Wc rcA leyel. At neighbourhood level, the

wsajiprovedby the Government ofKerala. Funds arethe bwt and IJABA(~D,and from the poor families~4tand credit societies in addition to the pooling ofarnn~esinthe urban sectorsuch as the Nehru RozgariSlUn~~lUS),UrbanBasic services forthe Poor (UBSP)

*Box)

The Kérala Zxperience

Kerala’s programme tobetterthe lot of the poorhas, to a large extent,been successful. This ismainly because the taskof implementing theanti-poverty program-mes was given to thepeoplethemselves.

IAn articie by P K Gopinathan and v L srilatha published in Hindu, April 2, 1995)

L~J4ubhav

*

~‘ ~ ~

- z

* *~ ~*~***~

4 ~2 ~t44SU~With usonotb~a*a4~L1 *.

Ø~riJJ~basI~ *

• i~ #th4v~ionQt4ke~~==~~— ~4

~ ~ ~*

*1977-78 with no evidence to suggestan increasethereafter obviouslyconstraining the provision of servicesand their operational upkeep.Elaborateprovisions have beenmadefor initiating theplanningprocessin thePanchayats,Municipalities and theurbansettlementsin settingup DistrictPlanning Committees but arewrought with practical difficulties.(Jha 1994)

Uilan CommunityDevelopmentSfrategies

To what extentdo the developmentoflocal leadership,selfhelp andpeople’sparticipationin economicimprovementinfluenceliving conditionsandchangesin health practices such asimmunisation, family planning,personal useof nutritiousandweaning

foods. Whatarekey factorsresponsiblethat lead to improvedaccessto healthand social servicesor even economicchange?

Under the UBSP scheme,(SeeBox 2) collaborationwith other urbandevelopmentprogrammeslike theNehruRozgarYcjana(NRY), EnvironmentalImprovementof Urban Slums (EIUS)and Liberation of ScavengersthroughLow CostSanitationis an importantprinciple, (Ministry of UrbanDevelopment1994).ExamplesfromtheNGO sectorconstitutemore innovativeandeffectivesolutionsfor this importantchallenge. Given below are twoexamplestitledTheKeralaExperiencesandUrbanNutritionProject(SeeBox 3& 4) which provide field insights intopractical strategiesand approachestocommunitydevelopment.

While the Urban Poor Strive for living space,hundred of acres are presentlybeing used for few Samadhis of NationalJeade,~.

-. ~ ~ -

*

~.fl...,wy7 w~fl~n -~w~nw.-fl ~ ~3J~fl~ W~ 1tt~W~? ~“~-n

otcommunItywotkonandotherslumwoiientapa~u~Si~gotoôn~~voSs ~sa~ 4’g~1o~Ü~S~j~o -

hdormSorIenlattonandfra**r3 hngsapctprojectSEt*iwstefr’ ens’tm$flMa vanety of fin cIu*rgassessmen~of pro ifle~tprobMoidentification and ptlorftisatiQnh -resourcemothistior iqnrqand~ni ~ueMSupporthasbeen Mtrolnloqaflfluntdpátbodies,extst Ute iCQ$ancjthe India PgpulatlonProjMVaaøasNGOi .~ - *

wwch has becoMetn9taMeéjs igoiñeñ-beg~nIq~adófecent flisreatisidMthesre not I ‘

Tt&MahffaMandai’ - - -

sMbesódiN1V$haSY*W

1:

- ;~-: ‘~ ~--~-. -,---

p :~~t -~yi. r4 ~ g~~2*1*~t*~ —

• LackoravommQfnisb*a cooperation

Excerpt from an article contributed by Dr Shobha A Udipi. Programme coordinator, Dept of Postgraduate Studies andResearch in Home Sciences, SNOT Women’s Univenity,Bombay

i\nuhJjmvL~fl

*ResourceAflocaflon &Repercussions

Only 2 % of the total governmentexpenditureis allocatedto the healthsectorwhich is obviously rankedas avery low priority. This is alsoreflectedin theurbanhealthsector.Thepercapitaexpenditureonhealthin Indiais ~only Rs 21 ofwhich 75% isspenton medicalcolleges andlarge hospitals.Forexample,inDelhi’s ap-provedplanout-lay for 1992-93of Rs20 crores,healthis thelast -~

amongstthe sixpriorities.

According toDigestofEconomics& Statistics,Bureauof Economics& Statistics, DelhiAdministration, for the next five yearsEnergyretainstop priority (275 crores),with GeneralEducationbeingRs72 andHealthas only Rs 65 crore.

The appalling inequalitiesin thedistribution and accessof the basicamenitiesandservicesfor theurbanpoorareobviouslylinked up closelywith themaldistributionof resources.Over 55percentof thecountry’s grossdomesticproductaccruesfrom the urbanareas.Although the shareof urbanareasinexperts,financial andtradetransactions,E~J~nuk,hmtr

manufacturingoutput and providingservicesare equ-allingsignificant, thebenefits are certainly not sharedbythe urban poor who contributesignificantly to the economy.Theinadequacyof the urbanadministrationto copewith thepressuresofurbanisationis reflectedin seriousdeprivationof the

es (Mathur 1993).

urbanpoor.Formsofdep-

rivation rangefrom the absenceof adequateem-ploymentoppor-tunities to ade-quateshelterandabsenceof ade-quate accesstowater supply,sanitation andother healthandeducationservic-

In thecity of Delhi for instancethereis a tremendousshortfall betweentherequiremeats andthe reality of servicesprovided Table 7). While the urbanpoorarestriving for living space,thereis a total of 300acres that is presentlybeingusecL for theSaniadhiland with afuture estimateof 115 lakh acresreservedfor futuresaniadhis.The annualexpenditure on maintenanceandlandscapingof thesesamadhisincurredby the Public Works Departmenthasbeenestimatedat Rs 50 lakh!

The other important ‘left outs’ in acity like Delhi with an estimated9,370,475populationincludethe Child

The hardshipsand inhumanexistence that the urban poorencounter as part of theirdaily ‘existence’areimpo?tantforces that drive this sectionof the urban population toextrememeasuresandsocial-ly unacceptedformsofbehav-iour.

ii -

the Delhi Quarterly

Water

Existing capacity of Water Supply (in million gallons a day)Present requirement at the norms of 70 gallons per capita a dayPresent shortage of water supply

Sewage

Present generation (in million litre a day)Installed capacity of SewageTreatmentUntreated Sewage

Electricity

4443 MGD700 MGD

255 6MGD

1700 MLD

1270 MLD430 MLD

*

Presentpower demand(in megawatt)

Generation ofpower by DESUThermalPower StationShortfallLosses suffered by DESUapproxTotal number of consumers

Housingstock(1989)

1700 MW

Total 850 MW

850 MWRs 2000crores

lSlakh

Number ofhouseholdsin DelhiEstimatedcurrent housing stock(including thosein theslum,squatter, unauthorisedcolorued)ShortageofDwelling Units(DUs)Shortageof DUsby 1995

Villageswithout sewage

Total urbanvillagesVillagesconnectedwith functional sewageVillage without sewage

Milk supply

11 6 lakh

l6lakh4 40 lakhS2Slakh

1088325

Milk requirementMilk supplied by Mother Dairy (setup in 1974,autonomous)Milk supplied by Delhi Milk Scheme(setupin 1959,slateowned)

(Accumulated lossesofover Rs200 ct-ore till 1991)Organisedprivate sectorandotherstaecooperatives

Shortfall

(VHAI 1993)

25 lakh litres per day (llpd)6 5 llpd4 5 llpd

4llpdl0llpd

Workers (41 lakhs-UNICEFestimate)mentally retarded(2.6 lakhs), Visuallyhandicapped(1.5 lakh) (WHO estimate)andmentallyill (1 lakh) (Table8). Thiscity rankssecondin Indiain criminality.

murder, rape, kidnapping,abduction,theft, criminal breachof trust andcheating(VHAI 1993).

Thehardshipsandinhumanexistencethat theurbanpoorencounteraspartof

TABLE 7. Existing shortfalls under various servicesin Delhi - 1993

Among the metropolitancities Delhi their daily ‘existence’ are importantranksNumberOnein murder,attempted forcesthatdrivethis sectionof theurban

*

A = Number of case B = Volume of total cognizable cnmes incidence per likh of population

Natsonol Cnnw Records ~ureou- 1991C = Ranking

I?

populationto extrememeasuresandsociallyunacceptedforms of behaviour.The largegapbetweenthe urbanpoorand othersin cities cannotcontinue.

Essentialamenitiesthat should beprovidedto theurbanpoorcanno longerbe neglectedand constitutesa vitalchallengefor urban planners in theforthcomingyears.

l~.FutureChallenges

The futurechallengein developingviableurban healthprogrammeslies in theincreasedselfrelianceamongcommunitiesespeciallythe poorersectionsof slumpopulationsin selectingpriorities, theirinvolvementin multi-sectoralinterventionsand greateraccessibilityto betterqualityhealthservices.

• More innovative and systematicmethods are required for theidentificationandunderstandingof urbanpoorpopulationsto targetandgaugetheeffectiveness of theseinterventions.Approachesthat have been foundeffectiveneedto takeinto considerationthe hetercgenousandmigratory natureof urbanslum populations. The useof

- - TABLE 8. Incidenceof cognizahiecrimes (IP(’) und’r different crime headsin four major cities

(‘ilic~ Murder Attempt to Rape Kidnapping Thift Criminal breachof Cheatingconunitmurder and abduction trust

a b c a b c a b c a b c a h c a h c a b c

Delhi

Bombay

Calcutta

Madras

41749 1 43852 1

473 37 2 261 20 2

92 08 4 149 14 4

81 15 3 118223

195 23 1 767

114 09 2 332

17 024 110

26 053 24

90 1

26 2

10 3

04 4

12587 1484 1

16201 127 I 2

6899 i,28 4

6135 1136 3

51561 1

6W? 54. 2

322 29 3

126 23 4

1331 157

1255 98

584 53

394 73

2

4

3

BombayCalcutta 646 22 — 528 18 — 157 (35 — 466 16 — 29235 1013 — 113539 — 2233 78 —

Madras(Combined)

Halt ot Bombay’s population live in ramshackle huts orlike this - on thestreets

J7\nub~mir

*L

— / ,-a- -t,,,. .,•~ ~- -t’-t _n$ ,~, a—

~-~fl’ &‘ ~I ~ “l’ ~ cwtle~

— -a~~.--~ ~ ~ _—_~-,: - w•t - ~r~’-~ -

..~c~-.e;W.4 ~H-%J ~ —, ‘a.

~ tiir c~- ‘~tV ~ ~—

1~ tè~j : ‘St —‘

* - — —~ ~ ~:r ri S~ —‘~---j~

______________ I -, -

I _ra~s. t, ~P~•,) )~-~i& “_d ~S’ ~ -. a_ - ~ - ~a,,,., ‘~t- - —______ I ~ ‘‘~ - -

— - - — / /

Building roofs with Delhi’s only inexhaustible resource - TRASH

other participa-tory methodsfor needassess-ment aswell asthe involvementofneighbourhoodgroups and othercommunity struc-tures. Theseap-proachesneedto bedevelopedfurtherandincorpo-rated into ongoinggovernmentpro-grammes on alarger scale.• Glaring dif-ferencesbetweenthe urbanpoor

significantthanmereprovisionof services. Inthe urban con-text the multi-

sectoralapproachincludingwaterand

sanitation, educa-tion, nutrition,housing, legal

rightsand incomegeneration pro-grammesbecomes

especiallyimpor-tant. Efforts to-wardsthecoor-dination andconvergenceof

health services

qualitativeapproachesactivelyinvolvingslum communitieshave been foundusefulandhave includedmappingand

consequencesof the underlying causesof ill health in order to solve healthproblemsarein thelong runmuchmore

The inadequacyof thehardshipsand inhumanexistancethat the urbanpoor encounteras part oftheir daily ‘existance’areimportantforcesthatdrivethis sectionof the urbanpopulation to extrememeasures and sociallyunaccepted forms ofbehaviour.

and others in cities exist and needto be analysed more carefully.Interventionsthat focus upon the

andtheseprogrammesto reachthe urbanpoor at the community level havebeensuccessfullydemonstratedandhaveled4

0*

to somevisible changes.Their ongoingstrengtheningprocessandsustainabilityremainsa challenge.• Thestrengtheningof theCommunityWorker movementin the Indian urbancontext presentsanotherimportantchallenge. Training strategiesneed totakeinto considerationtheurbanrealitiesand the essentiallyintersectoralnatureof their involvement. The role ofcommunityworkersin theidentificationof the urban poor, formation andstrengtheningof community structuresaswell asparticipationin thecommunitybasedmonitoring and evaluationofprogrammeshasbeenprovedby severalinitiatives. Capacity building andtraining of community workers shouldbe closely integratedwith the morespecialisedprofessionalsin communityoriented interdisciplinaryhealth teamswith strong support and referralnetworks.• Any policy that aims at improvingthe standardsof the urbanpoor needsto addressfactorswhich areresponsiblefor the manifestof diseasesas well asthe psychosocialdimensions.Policyformulation and planning in the healthsector are weak at the city level.Compart-mentalisedpolicies and thefractured and segmentedservicesgeneratingfrom them do not removechronic urban deprivation. For anyimprovementwithin the urban healthsector, a more comprehensivepolicyneedsto includenotonly basicservicesbut also land and housing issues,industrial andair pollution, crime and~ 7\F1U

delinquencyand mental and physicalhealth.

• The stzengtheningof Convergenceprocesseswithin eachcity, district andstatecould lead to betterutilisation oflimited resources.However this alsorequiresthe strengtheningof municipalbodies, their involvement andformulation of area and city plans,capacitybuilding and strengtheningofmanagementandaccountabilitysystemswith a more realistic allocation ofresources.

A search for a viable PartnershipbetweenNGOs and local governmentnetworks to reach the vulnerablesectionsof the populations in urbanslumsis certainlypossibleashasbeendemonstrated by ASHA, YUVA,IJHCP and other examples in thisdocument. This searchto provideequitableaccessto healthandotherbasicserviceshasled to severalinnovationsand community involvement strategiesthat have proved to be successful.Crucial factors and lessonsfrom theNGO sector on why some projectinterventionsare or are not successfulneed to be more widely sharedandunderstoodwith theobjectiveofadoptingspecificstrategiesona largerscale.Thiswill need a greater commitmentandunderstandingabout the needs of theurbanpoorand thepotentialthatlies intheir invclvement in developingtheirown programmes.

Christina De SaU

ACTION FORSECURINGHEALTH FOR ALL (ASHA)

*

A SHA a community health anddevelopmentsociety is presently

operatingin 21 differentslumsof Delhiand covers an estimatedpopulationof1,15,412.Thehealthservicesprovidedto a single slum population in DrAmbedkarBasti during the July 1988Cholera epidemichavenow expandedto encompass environmentalimprovement,housing upgradation,preventiveand promotivehealthcare.

The pioneeringteam ledbyDrKiranMartin explainedthatdespitetheutter lack ofinfrastructure and funds -

during the first year, it wasthe sheerneedof the choleraaffected communitiesthat challengedthemthemost. ‘It was the slumpeoplewhoweremy biggestteachers’shesays.Later in 1988, 15 women from thecommunity were selectedby someleadersandtheASHA teamto betrainedasCommunityHealthWorkers(CHWs).A slum development committeecomposedof the informal leadersandotherinterestedmemberswasformedtodiscussand getinvolved in communitydevelopment issues. The DelhiDevelopment Authority’s SlumCommissionerwas instrumental in alargedrain constructionand provision

of 4 deepbore wells with handpumps.These and other subsequentachievementsincluding regulargarbagedisposal, road constructionand therunning of a Day Care Centreby thelocal Mahila Mandal brought about ameasurable change in the slumpopulationregardinghealthpractices(especiallypreventive)promotedbyASIIA anda greaterconfidencein their

own ability to bring about

As a result of theseandother similar interventions

in otherslumareas,Partnershipwith slum communitiesand collaborativeventureswith municipalandgovernment

authoritieswith policy implicationshavebeensomeimportantachievementsof theproject.

Partnership

Selectionof ShunArea

Selectionof slums areasfor intensiveactivities are undertakennot onlythrough close dialogue with thecommunitiesthemselvesbut also withthe local governmentauthority. It isupon the insistenceof either thecommunitymembersdirectly or via theSlum Departmentthat ASHA initiated

4ni~rL~J

“It was the change.slum peoplewho weremy..biggestteach-ers ~

4

and expandedit’s programmesin thearea. Thisensuresthattheselectedslumlandis notearmarkedfor someotheruseandthereforecanbe entitledto receivepublic serviceson demand.

PartnershipbetweenASHA andthevarious governmentauthoritieshasbeenquite extensive.Public authoritieshave provided health centres,communitylatrines,waterpoints,roads,drains, building for the polyclinic andother facilities beyond ASHA’sresources.

Partnershipwith Community

Mahila mandalsare instrumental inworking collectively, to approachthepublicauthoritiesandalsoensureregularin the conimunity. Other activitiesinitiated by ASHA through the mahilamandals include Day Care Centres,healthSevices,Children’s cl-ubs, Non for-mal Educa-tion, AdultLiteracy, Vo-cationalTrain-ing. Collabo-ration withNGOs operat-ing in theareaor those who have expertisein the latter 3 programmesis soughtthroughMaliila Mandalsandcomprisespartnershipin selectedslums.

Progressmadeannualiy by projectactivities is monitoredand reportedtotheMahilaMandalrepresentativeson a

*yearly basisand future priorities, tasksandchallengesarediscussed.

Eiavironinent Improvement

Watersupply

With the help of municipal authoritieswatertapshavebeenprovided,tubewellsdugandreservoirsconstructed.As aresultthenumberofhouseholdsperwaterpointin the project areashave decreasedconsiderably.in factit hasbeenobservedthat the medianhouseholdsper waterpointis67 with allbut2oftheareasirispresentlyless 102to 156afigure reportedfor Delhi slumsin general(NIUA 1992).Vocationaltraining programmesin mostproject slums include hand pumpmaintenance.

WasteDisposal

While only 46-88%of Delhislumshavea communitylatrine all se-lected projectareashave atleastonecom-munity la-trine. In thepastmunici-palauthoritieshavebeenre-sponsiblefor

cleaningandmaintenanceoflatrineswitha chargeof 25 paisefor theuseof thefacility by community members.Presentlythemahilamandalssupervisethe maintenanceof latrines by outsidecontractorssupportedfmanciallyby themunicipalcorporation.Opendefecation

~HU~T~J

*

by children and others is also strictlydiscouragedby mahilamandalandothercommunity members.

Poor performanceof cleanersarereportedto managementauthoritiesbymabilamandalsandensurescleanlinessand betterutilisation of communitylatrines. These activities have beenresponsiblefor a city ordinancebeingpassedthat recommendsthis serviceinotherareasin the city.

Surfacewater drainageand brickpavingshavealsobeenbuilt in all areas.Municipal authorities have beenapproachedto provide cleanersforcollection of householdwastes,keepingdrainagepassagesclean.Thesemunicipalcleanersare supplementedby cleanersfrom within thecommunitieswhosesalaryis paid by them. Garbagebinshavealsobeenconstructedby authoritiesandcollectionoccurson a regularbasis.

HousingUpgradaflon Project

The slum upgradationproject wasinitiated by the Delhi DevelopmentAuthority SlumWingCommissionerandjointly organisedby ASHA and the~1 ~\n*v

community in two projectareas.It providesanexampleof a possible

outcomethatcanbe facilitated throughpolitical will and innovation.

A housing cooperative comprising

community memberswas formed, theland was licensedto the cooperativeforanannualf~eandallocationofplots(12.5sqmeters/lämily)wascarriedoutjointlyby thecommunity,ASHA andthe DDAslum wing. Ownershipof landplots wasgrantedto womenbut not without someresistancefrom the male sectionsin thecommunity. Low interest loans of Rs5000/- were provided towards theconstructionof houseswhich was doneby skilled labour from within thecommunity with assistancefrom DDAengineers.On completionof the housetheDDA slum wing alsoprovidedbricklanes,drains,watersupply, communitylatrines and streetlighting.

The housingcooperativeformed inthetwo projectareasin 1989and 1991respectiveJy hasnowtakenresponsibilityfor all major decisionsof programmeimplementationat the community levelandalsosupervisescommunityworkers:cleanersandcommunity healthworkers.Salaries of theseworkers are paidthrough monthly fees contributedbyeachfamily.

ASHA ‘s slumupgradationprojecthasbeen made possibleby the uniquerelationshipthe NGO haswith theDDAauthoritiesandtheurbanpoorandprovideimportantlessonsfor futureprogrammes.However the various stagesof thecommunityorganisationprocessand the

Mapping of Slum Communities - A useful tool

period required is oftenunderestimatedand needsto be betterunderstoodbygovernmentauthorities if expansionofsuch an initiative isdesired.

Provision ofHealthSer~ccs

A four tiered refer-ral system hasbeen establishedthrough the Com-munity HealthWork-ers(CHWs), HealthCentre, ASHA’spolyclinic (Diag-nostic centre) andHospital.

*informal leadersin the communityareselectedfor a 3-4 month training byASHA, responsiblefor preventive,

promotive and cura-tivecareofupto200families in theirzone.Shereceives

anhonorariumofRs350/month from

ASHA which is sup-plementedby Rs 2per casethat in-cludesdispensation

of drugs (upto 10 es-sential drugs forcommonproblemsareusedbeingpro-

• vided free forcharge from

ASHA) as required.TheseCHWs who

ASHA’s slum upgrada-tion project has beenmade possible by theunique relationship theNGOhaswith the DDAauthoritiesand the ur-

ban poor andprovidesimportant lessonsforfuture Programmes.

CommunityHealthWorkersoftenthe

A dynamic dialogue with Government ofllcials holds the key to ASHAs progress

4~U&~LT~fl

*

numberaround46 in the21 areaswitha populationof 1,15,412 are eachaccountableto a teamleader(ANM orRNRM) whoattendsto referralcasesaswell as the family welfareandUnderfives clinic at the healthcentre. Theteam leaderalso assiststhe physicianduringtheweekly/biweeklygeneralclinicand is assistedby 1-2 paramedicalworkers.

The facilitationoftimely referralcareremainsan important role for healthworkers. Non participation of men inhealthservicesbeing providedand thecurativebias, multiplicity of agencies

providing healthcareand free services,Illicit Alcohol, TobaccoandDrug abusecoupledwith increasingviolenceamongcommunitiesand ongoing suspicionfrom local politicians comprisemajorchallengesin community organisingactivities.

TuberculosisControl

Case detection is the primaryresponsibility of CHWs. Suspectedpersonsarefirst given a Mantoux testwhich if positiveis followed by a chestX-ray at the Polyclinic.EachTB caseistreatedthrough weekly dispensationof

The Health Team at Kanak Durga Camp ASHA

L~14nubi~air

ugs at the healthcentre. If patientsdonot collectdrugspersonallyhomevisitsaremadeto follow-upandmotivatethemfor drug compli-ance. Familymembersarealso screenedfor the disease.In 1993 in theslum populationsbelow 5000,38% of TB pa- .

tientshavebeenbrought to curewith a compliancerate found to be49%. However ..

in the project costs.areas with alarger slumpopulation theregularcompliancerateis lower(37.5%)with only 17.9% of the patientshavingcompletedtreatment.

In theDelhislumsnonspecificfevershas been reported as the most commoncomplaint followed by diarrhoeaandrespiratory diseases (Vishwakarma1993). A recent morbidity survey inKanak Durga revealed a substantialdecrease in acute respiratory illnesses.In Devi Nagar a control area withoutASHA’s intervention,diarrhoea,acuterespiratoryillnessesandfever comprise83 % of all illnessesin contrastto 52%in Kanak Durga where the healthprogrammewasinitiatedin 1990.Betterenvironmentalconditions and regular

*garbagedisposal,improvedwatersupplyandlatrinesandpersistenceby theCHWswith regularvisits and preventivehealth

carehaveresultedin bettercommu-nity awarenessand has no doubtcontributed to-

wards thesefind-ings.

Although

the beneficiariesof ASHA’s pro-

grainmewill bearonly partof the pro-grammecosts,sub-

stantial capitalcontributionsfrom public au-thorities, NGOparticipationand

communitybeneficiarieshaveminimizedprogrammecosts.(Booth 1994) Severalimportant factors in the ASHA projectareas can be consideredresponsibleforenhanced coverage and an effectivereferral systemsuchas a manageableratioofhouseholdsperCIIW, closeandregularsupervisionby team leaders,close proximity of populations,acomputerisedinformation systemthatenlists targetpopulations(pregnantwomen andunder five children) andmonitors coverage,easy transportationwithin the city, trained and committedhealthpersonneland an efficientdiagnosticcentreat the third level.

Although the beneficiariesoIASHA‘s programme willbear only part of the pro-grammecosts,substantialcapital contributions frompublic authorities, NGOparticipationandcornmu-nity beneficiaries haveminimized programme

VUVA*

(YOUTH FOR UNITY AND VOLUNTARY ACTION)

Evolufion andSfruclure

E~ormallystarted in August 1984,

YUVAis committed to organising

and empoweringpeople in the poorurban sections of society for the struggleagainstinjustice. Their approachesdevelopedovera decadeemphasisethedevelopmentofa movementthatwouldbe a catalyst for social transformation.

YUVA’s initial activities weredirected at the community organisationproject in a geographical slum areataking up the issues of communities:Basic amenities: sanitation, rationsupplies, increasing accountabilityofexisting political structures etc.

Today a decade later the organisationhasevolvedamulti issueapproachbasedon a decentralisedstructurethatis rootedin an ongoing process of dialogue andreflection to evolve responses andstrategies to current issues andproblems.

Acivides

Presently activities among over a 10,000population with 34 Slum PavementCommitteesarein placewith extensiveactivities in Jogeshwari, Ghatkopar andDharavi slum areas and contactprogrammesin otherareas.During the1990 action reflection process whichemergedout of a searchfor relevance,YUVA sought to shift implementation

of projects towards a more issue basedapproachand also worked towardsreorganisingtheirorganisationalinternalstructure.Various ‘Rights’ groups fordifferent targetpopulationstissuesarenow in place ; (Housing, Children,Youth, Women)aswell asforumsat thecommunity level comprising ofcommunity membersencouragedandfacilitatedby YUVA staff. Shortlyafterthis the organisationparticipatedin amassive Eviction Spree as a response tothe emergencyissue of large scaleevictions which threathenedslumdwellers’ basic rights to housing andlivelihood connected to these areas.Acoalition of NGOswas formed andYUVAprovided leadership anddirectionto the Committeeto the Right to Housingfor around4 years. The networkingfunction of YUVA is an importantoneandhasresultedin the formation of theNationalCampaignfor HousingRights,TheCampaignAgainstChildLabourandthe Development CollaborationFoundation.In addition,theProgramme

Support Group gives inputs andresourcesrelatingto training, research,media,legal expertiseanddocumentationto YUVA’s variousprogrammes.

A. HousingRights Group

The focus of the housingrights grouphas been on the slum and pavement

~nub~mrE~fl

*dwellers, Streetchildrenand youth anddestitutewomen.The objectivesof thisgroup are:

• to raise awarenesss andconsciousnessamong communities,community baseorganisationsandNGOswith regardsto humansettlementissues,alternativesand housing rights.• to promotepeople’s organisationsandfederationsto workonhousingrightsissues.• to trainhousinganimators to workat differentlevels.• to promote information and action

network against demolition anddisplacement.Threemajorissueshavebeenaddressed:• Work in Workers colonies ofJogeshwari that has led to thecomprehensivearea involvement ofcommunityand the strengtheningof theJogeshwariPeople’sOrganisation.(SeeBox 1)• Work with pavementcommunitiesand its process developing anorganisationof PavementDwellers(PDO) including efforts to developanaggressivecampaignto seeklegal status

YUVA’s Vision\ “TI,e vision of a society w&efl ea4,inI’ivi~iiial, womanai~~maii livesin i)igi1ity. Wljcre\ eaci, can participatein ti,e social, cultura(, economic an~political ôecisioi’is t!,at affect\ tljeir lives. W~ierewomani man is a controller of ~~er/~~isenz ron~nent - a sufject of

~evelop~iie~itrather tbathn anol~jcctA societynA~ereallin~vi~aLsiive injsestice,equalityan~peace.”

yuw~’sevolutionintoit’s ~.trriousprojectsèeve(ope~outof siti~ationsof nee~expresse~\ ~ people L~eingaffectet) ~ particular problems, a major event èeinan~)fngattention (eg

\ ~,ousing)or witilj,in the organisation itself requiringcertain supportfacilities to respon~ to\ grassroot levelneeès.

\ T~ei~eologica(frameworkof ~uvi’tis the important basis that provi~es?ñrection\ wi~ilealso maintaininginterconnecte~nes&(YUvA I99o~

YUVA’s major objectives incluae worl~ngwith yo~ti~,c~iil~rcnan~women from workers\ coloniesan~pavementsettlements to or(~niset1~emto take responsiblestan~san~action

on problems/issues atthecoi’nmiinity an~city levels. r~eprincipleofresponsiveness!,as\ been a key factor in~etenniningthe growth of the orpiisation.

YUVA strives thy~sevolving programmes basedon a more analytical un~)erstan~ingof\ the relevantissues affecting setecteô poor urban secticns of societ~

w~JRofthe casewosThatiti,ftS c4ecJarerithat theVET hoh

- ~ ~ tE~meiiaous~oösUo

0~

*

for pavementdwellers as well asestablishan identity.• Influencing policies, data buildingandstudywork.

B. Wonien’s Rights Group

The Women’s Rights group has takenup two major issues:• The public distribution systeimandits impacton women

• Issuesof Single womenThe Ibodration issuehadto bedealt

with not only at the shopkeeper’slevelbutalsoat theFoodCorporation of India(Central)andStateMinistry ofFoodandCivil Supplies.

The ration Jagruti Samiti wasdevelopedat the city level with otherlike mindedorganisations.

An overview of some of the

TABLE A. Somecommunity basedwomen’sorganisations&their issuesof involvement

1. AvhaanMahilaMad~

NameofGroup Area No. ofmembers IssueofInvolvement

DadgiBldgDharavi

20

2 UtknishtaMahilaMandal

SakmabaiChawlDharav,

3 SangharshMalulaMandal

25

DisplacementRationingViolence agamstwomenUnemployment

Shiv ShaktsDharavi

10

4 lndiraNagarMahilaMandal

RationingViolenceagainstwomenPolice lethargy

IndtraNagarGoregaon

5 Indira MahilaMandal

30

Exploitation by employersSelf-employmentRapeof6 childrenIssuesofdesertedwomen

Rain NagarGhatkopar

30

CommunityToiletRation

6 VarshaNagarMahilaMandal

Ram NagarGhatkopar

7 VarshaNagarMahilaMandal

10

GoondaisaRationIMFPee-SchoolClass

VarshaNagarGhatkopar

8 IndiraNagarMalulaMandal

10

Adult EducationRation

IndiraNagarGhatkopar

9 PanchashilMahilaMandal

20

Support groupRation

JagnitiNagarGhatkopar

10 JagrutiNagarMahilaMandal

20

Issueof DalitsSelf-EmploymentWaler

JagrutiNagarGhatkopar

20

PoliceGoondiseRation

RationPoliceSelf-Employment

4111~

community based Women’sOrganisationsandIssuesofInvolvementcanbereferredto in TableA.

Under the Women’s Right Groupefforts are also made in the areasoftrainingresearch,networkingwith otherlocal women’s orgainsationsand issuesof violenceagainstwomen.

C. Youth RightsGroup:

The Youth Rights Group has focussedon thecampaignagainstunemploymentandits campaignhasbeenbasedon twomajor demands:The Right to workshouldbe a fundamentalright and theIntroductionof theUrbanEmploymentGuaranteeSchemein Maharashtra.

Voluntary Intervention of DeprivedChildren Project

This initiative emergedasa followup toUNICEF’s study onpavementchildrenand was undertakenin a crossmaidancommunity facing evictions whichtoday is the Children’s Rights Unit.Initiated as an informal open schoolin crossmaidanchildren communities.

*

andrecreationalactivitiesby collegesofyouth, this programmeculminatedinthe opening of 3 schools in differentareas.The fourth schoolwas initiatedby communities who selectedandprovidedthetwo volunteersto conduct

smiling, despite adversities

- __La~

w~I_ !~_

act-!- ~tt~~&____~

t~t44~gz~

•

a

the activites for children. Thisinitiative was then supportedbyYUVA through training and someadditional resources.

The focus of this project was toinitiate recreationalcum educationalactivities with thepavementchildrenanduse this asan entry point to overcomeproblems concerningthe pavementcommunityasa whole.

Work was also initiated with streetchildren not just issues of shelterand educationbut also activities tocounterpoliceharassment,(SeeBox2)as well as ilthealth through operatinga mobile van providing basichealthcare.

Theseandotherexamplesofchildrenin similar circumstancesraisednewchallengesfor the YUVA team : Theneed for increasedprotection forstreet and working children, theimportanceof enhancingthe role ofNGOs and the sensitivity of thegovernmentsystem.

Thus from educationYUVA movedto other areas:issuesof Children’sLabour, Healthand Sanitationandmobiisinghealthservicesfor childrenona regularbasis. Among the targetpopulationsit hasbeenfound thatexisting perceptionsof physical,emotionalandsocial well-beingarelinked up very closelywith selfidentityandfinancial stability. Traumaandinsecurityespeciallyamongchildrenarecommon and stem from frequentdisplacement,abuseandviolence.

0~

Through community organisationactivitiesYUVA alsoseeksto improveaccessto andaffordability to thehealthcaresystem.

Women’s Organisation

Although mitial activities were directedat the Youthin selectedareas,graduallythe womenbecameinterestedand withthis YUVA initiateda women’s forum -

MahilaMandal- to meetand interact on

general community issues water,sanitation, ration cards etc. then on tomoregenderspecificissues:reproductiverights, rape, healthservicesdeliverysystem.This also led to the involvementof governmentofficerson duty in issueslike rationsuppliestoprovideinformationand increaseawarenessaboutaccessto

services. A greater vigilance amongsuppliersandconsumersanda decreasein corruptionwas encouragingfor localcommunities and also providedopportunitiesfor community forums todialoguewith officials at thehigherlevelincluding theFAQ.

Efforts arebeingmade to increaseunderstandingof urbanslumwomenofmacroissuesbasedon specificproblemsencountered.

Thus,linkagesbetweenavailabilityofration supplies with dowry, familyplanning are being propagated. TheWomen’s Rights Group and theCollective Stree Manch both contributeto influencing and evolving women’sperspectiveand linkagesof micro levelunderstandingwith macroissues.

*• The action reflectionprocessis anongoingprocessat thecommunity leveltaking forms from mandals(of youth,mahila, tenants)to specific issuebasedcommitteesdealing with issue basedcommitteese.g. goondaism,rationsuppliesand a collective Stree Manch.Oneof YUVA’s pioneersshared:

‘Each time we go back to theMandals’.. .whatisthestrategyweshouldtake? We keepmovingbackand forth..When an issuecomesup we take it up,achievesomething,reflectupon it withthemanadals,takestockof inclinations,resources,contacts, come out withstrategiesthat canbemorerelevant.’

Thewholeprocessofactionreflectionis strengthenedby forums, regularactivities undertakenthought theseforums, and respondingto theseissuesthatcomeup.• The Multi-issue basedapproachis unique and has evolved basedon expressedneeds,major eventsdemandingattentionandfrom within theorganisationfor greaterrelevanceandeffectiveness.• Efforts towards ideologicalinfiltration intocommunityhaveatcertainlevels promotedconsciousdecisionmaking among womenthat havebeenempoweringandproductive.• YUVA’ s efforts at local networking

have promotedgreaterunderstandingamong likeminded groups. Strongrelationshipshavebeenestablishedwithother NGOs andactivities thatestablishlinkageswith other local forums, tradeunions, women’s organisations,educationalinstitutions, journalists,eminentpersonalities.• The formation of NGO Coalitiongroups: IBuilding coalition with otherwomen’scirganisationshasbeeneffectiveso that community problemscan beviewed more systematicallyexpandingandstrengtheningthegroup’svision andactivity.

challengesAhead

In such a multipronged issue basedapproach,it becomesdifficult to keepanissuealive with the mediaand takeit toit’s logical enddue to otherproblemsorpriorities which may be highlightedorcome up spontaneouslywithin thecommunity. The demandsat the urbanslum community level, and thedemandinginformal approachwithin theorganisationcan often lead to heavyworkloadsona few committedstaff. Sixmonthly reviewsof eachproject thatnotonly deal with reporting and measuringprogress and setbacks are alsoopportunitiesto strengthenstaff andbroadenandunify perspectivesevolvingon difficult or prospectiveissuesandstrategies.

ChristinaDe Sa

1~nubh~w

THE JAJMAU CHALLENGE

*

Background

~ anpuris a typicalexampleof citieswhich have becomeincreasingly

populous due to the forces ofindustrialization. With an averagedensityof over5000 personsperk.m.,the city is consideredto be oneof themostcongestedandheavily burdenedintermsof provision of basicservicestothe people.

Theleatherindustryinitially cateredto the demandsof the SaddelaryandHarnessFactory,which wasestablishedin Kanpurby theBritish in 1860. Slowly,due to erosionof textile industry andclosure of many big units, leatherbecamethe secondbestoption and themost lucrative occupation. In the pasttwo decades,therehasbeenanimmensegrowth in the numberof tanning unitsand Kanpur has becomethe secondlargestcentreof leathertanningin India.Now, with an openexport marketandincreasingdemandfor Indianleather,theindustry is growing at an even fasterpace.

Jajmauis the main industrialareaofleather processing.This area isapproximately8 kmsawayfromthecityandis characterizedwith alargenumberof tannerieslocated in a cluster alongtheSouthbankofriver Ganga.The areais mainly populatedby leatherworkersand their families.

Jajmau comprisesof 20 slum

pockets.It falls under ward no. 49 ofKanpurMaha Palika which hasgot 50wards under it. The oldest slum isapproximately100 years old and thenewestis 8 yearsold. On the peripheryof Jajmau industrial belt lie villageswhich still havefisheriesor agricultureas their main occupation.

Situatedat the banks of the riverGanga,the expansionof the city was aresult of growth of textile mills andrelated industrialization.The villageswhich weresituatedat theperipheryofthecity slowly mergedinto it andbecamea location for an every expandingindustrialbelt. Thesevillages,someofwhichgotconvertedinto industrialslumsaround 100 yearsback, housemigrantcommunitiesfrom Bihar and easternU.P.

Impactof SocialChange

Making of Jajmauinto a slum areahasnotbeenasuddenphenomena.It evolvedthroughstagesof social transformationin termsof industrialization,destructionoftraditionaloccupationsandgrowthoftechnology.

The forces of social changehavemediatedthroughthecasteequationsandhave changedthem significantly overtime. Consequently,in Jajmau thecompositionofpopulationshowsa verydistinct trend. Around seventypercentworkersin theleatherunits areMuslims

!~nubipvL~J

*and the rest thirty percentis a mixedpopulationof fishermen,traditionalleather workersand farmers.The risein Muslimpopulationis alsodueto socialandcommunaltensionswhich led to theformationof theseethnicclusters.

As mentionedabove,a few of theseurbanslumsstill retaintheir traditionaloccupationsof fisheriesandagricultureand peoplewho originally belongedtotheseerstwhile villages. This group ofpeoplebelongs to the communitiesofMallahs(fishermen),Kurmis (backwardagricultural farmers) and Chamars(traditional leatherworkers) who havebeenmarginalisedin the processoftechnological advancementsandresultantdestruction of traditional

occupations.The low socialstatusattachedto the

flaying of the dead animals, poorworking conditionsandthe reductionineconomicreturnshavealsocontributed

to the disappearanceof the traditionalvillage leather industries.At the sametime, therehasbeena rise in thenumberofmigrantlabourersjoining theindustry.The landless marginalised ruralcommunilies, unable to sustainthemselvesin the villages, seasonallymigrate lo the city in search ofemployment.

Along with the changein the socio-economicandculturalenvironmenttherehas beena clear shift in the choiceofleatherprc’cessingtechnologyalso. Thetraditionalbio-de~radabletanningagentshave been replacedby hazardouschemicalagentssuch as chrome,resultinginto seriousenvironmentalandhealthproblems.Lack of safedrinkingwater and sanitationfacilities and ill-ventilated, overcrowdedhousing hasaddedto theseexisting problems ofwater-bornediseases,tuberculosisandmalaria.

Choking smoke and dust - additional bonus of industrialization

~1 4iub~mr

Health Servicesin JAPJMAU

Generallyspeaking,the healthservicesnetworkin Jajmauslum areacomprisesof threedifferenttypesof agencies:1. Governmenthospitals,dispensaries!

urbanPHCs2. Non-Governmentagenciesand

others

3. Private clinics/communitybasedhealthpractitioners.

Most of theseagenciesare curativein naturewith few exceptionse.g.someinitiatives from theNGOsor the generalpreventionfrom the governmentsideintermsofimmunisation.A descriptionofthenatureandthescopeof theseagenciesis as follows:

1. GovernmentServices

The ESI Hospital

The most prominentone amongstthegovernmentrun agenciesis the ESIhospitalandthedispensary.Thehospitalprovides mainly curativeservicesandcaters to the InsuredPersons(IPs,industrial workers) and their families.The hospitalhas a sprawling complexand has the in patientcapacityof 100.Most patientsare treatedfor generalhealthdisorders,minor surgeries andtuberculosis.The hospitalrecordsshowahigh incidenceof waterbornediseases,tuberculosis,wounds and lacerations,fevers and common colds. Besidescateringto thesediseasesthehospitalalsoprovides MCHand referral services.

*-~ i_• L IFaca~theco*a:SomtStO~*s

ROJLIIL hasbeEnwoddnèIn thetanneries:forthepastSyess:Hewa& two ight todieESI hospitalwk4~tEn protflat~sofbreaftdessnestanti cbughhtg~Rea~on$7Raju feVinto oneof the druflis~fflWsf~Wcgases &chEmicals. Hewaflentbfl4frrfintakt:Be:aid notcometo thetSe~yforwork for 2 days.OntheMfl adian&tomeethint og* aflk4e tWrneyy.‘tack to w4wk?so~sobn?ItSelt”stdt kn,blo,J.accidentkeepftaØpenløg.Onecantjustsit at hoffie, i irmjgdnglmtersoicamtbackforwork~t- Rcgu toldMt therearenoalternatives..~*ttsilIy~g$~j*qr‘)nc4jor’aresgctirelativecon eptr4vgflv4Ltnowofmanyofthosewho.w$$ataftfldhnqinto these arunszS~

Wilu. 70,woEtte4* Litannery (orsoyçartnesøned $$llonuhetig~of12yezn BecamepeSpia!114t*r25yeaadfwo* ~e~reUr$SMtbIffla andjoMtp�unsWh*everMWMOfltyberecdved*r4td~IStgot$OI1$�RISIcIncspitsnatureofwork Intee4wrn~t1ng~$assimchtnes$Ucket*ttudtfldwanestanproblemstoo tie hadartES?card, btit sSar4~wrtactflecewsthna1ugft~ytatis$&i~4th03ehoS$olfaobtIes uWh&~ha$ieeSmnzathØne$øaaddo*prngoverthepQst40yeawetrnnselfis bewfldere4vWh thefaz%awthoftahnerksIn theareawhich usedto bean agriculturalland AccorSqte4iitn this qrowt4hastakEnplaceonfr in the Øast2Gtecnugh..har4’ hactyassetsbesSme househeomwandhas~SätefltW~coimnhlgrantIabouretL-~:~r

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In termsof its outreachthescopeofthe ES! hospital has remained very

limited. Becauseof the dynamicandchangingnature of the work force,unstableemploymentpatternsandthesiphoningof fundsthatarecut from theemployeessalaries,the numberofpersonscoveredunderES!hasbeenverylow. On an averageES! catersto only20% of all theexisting work force.

Urban PHCs

BaiwantKaurFamily WelfareCenteratKrishnaNagarPHC is the urbanPHCin Jajmau,looking after mainly MCHservices.The focusof thehealthcentrehasbeenon curativeservicesandfamilyplanning. Lack of infrastructuralfacilities andmotivationof thestaffhasresulted in a poor health care delivery

system. Family planning andimmunisationserviceshavebeenmainlytarget orientedthereforein terms ofactual impact the performanceover theyearshasbeenmarredby suchpriorities.

Urban Basic Services Programme(UBSP) has had health interventionsthrough programmes such asAnganwadis, informal schools,Adultliteracy programmesand ICDS. Thefocus has been on education,communicationandmaternaland childhealth. The health interventionsaremainly in the areasof immunisation,nutrition andante/postnatal care. TheUBSP worked closely with the IndoDutch Environmentaland SanitationProject and the Urban Health careProject (UHCP) supportedby MemisaMedicusMundi, (Netherlands).

Training of Urban Community Health Workers Calls for innovative Approaches

~1 7\flU~T

TraditionalSystemsof Medicine

AyurvedicfUnaniDispensaries

JajmauhasagovernmentrunAyurvedicdispensary.This dispensaryis lookedafter by the Nagar Mahapalika.Alsofor curative services, the dispensaryis almost non-functionaland catersto a very small segmentof thecommunity.

2. Non Government Agenciesandothers

Panvartan (CSR)

Parivartan,sponsoredby Centre forSocial Research,Delhi is mainly anincome generationprojectaimedat thewomen of Jajmauslums. Parivartanidentified a need for a healthcenter which exclusively looks afterwomen’s health. Parivartanruns a bi-weekly dispensaryin the area forGynaecologicaldisorders,with thehelpof a specialist. -

Charity Hospitals

Besides the other health agenciesoperatingin the area, thereare a fewsmall dispensariesrunbypaidphysiciansonbehalfofafew tanneryowners.Theseare charity dispensariesaimed atproviding curativeservicesto thepoorworkers community at nominal fee orsometimeswithout any payment.

Urban Health Care Project(UHCP)

0~

a most successfulgovernment/non-governmenteffort in thesphereofhealth.Althoughthefocalareasarecurativeandpreventiveservices,yet the projecthastried to build anetworkwith thehelp ofotheragenciesin theareasof training ofhealth personnelsuchas CommunityHealth Volunteers (CFIVs), healtheducation,school healthprogrammesetc. Major areasof interventionhavebeenTuberculosispreventionandcure,immunisation,MCII servicesand thecontrolof waterbornediseases.A profileof the UHCPJajmauTanneryareamaybe referredto theTable A. Theprojectalso organizes health camps forimmunisationand family planningservicesanddistributionofORT packets.The project has a dispensarywhere aregular OP~I)is held. In terms of databasethe project datarecordingsystemis most well developedalthoughit hasits ownlimitations.In someprogrammessuchas immunisationand MCII theapproachis again target orientedalthoughwith its wide networkofhealthworkers the coveragehas beenmuchmore thanany otherhealthprogrammerun in the area. Initial activities wereundertakenin closecoordinationwith theKanpur Medical College but now itfunctions independently.

Initially the project had close linkswith the Indo-DutchProgramme,whohad already built a base in thecommunity.

VHAI’s involvementhasbeenrelatedto training aspectsboth for the UIICPIn termsof outreachtheUHCPhasbeen

0*0

core staff and community healthvolunteersincluding Asha andseveralothers (For details refer to Box 2 —

“Rampyari and Asha: Two sides of acoin”).

The long term objectivesof theUHCP are to strengthen urbancommunitiesto maintain and improvetheirhealthand to supportintersectoralactivities, which contribute toimprovementof urbanhealth.

3. PrivateClinics/Connuuiiitybasedhealthpracifioners

Private Practitioners

Inthepastfew yearsprivateclinicshavesprungup all overJajmau.Roughlytherearearound 40 private clinics in Jajmauarea.These clinics, mostlyrunby quacksare most sought after healthinstitutions. There are many factorsbehindtheproliferationof theseclinics.

One is, lack of faith from theconimunity’s side in the other healthinstitutions specially governmentinstitutionsdueto pooraccessandhealthcaredelivery system.Secondly thesepractitionershave a firm base in thecommunity and they are consideredapart of it becausemost of them comefrom the community itself.

Besidessuchclinics, other privateclinics are also beenrun in the area.Thes~areclinics ownedby specialised!traineddoctors.The treatmentis pricedvery high and is given for a rangeofdiseasescommonas well as specific.Theseprivate clinics rangesomewherebetweenthequacksandthegovernmenthospitals in terms of the community’spreferencein seekingtreatment.

Popular Beliefs and CommunityBasedHealth Practitioners

Besides a rangeof prevailing health

- TABLE A Profile ofJAJMAUTanneryArea

Total Population and family size in UHCP areaJajmau (Slum areasin Sector H~

Description Number Percentage

Total Slum Areas 30 —

Total Families 7,978 —

Total Population 42,054 —

Male 22,587 53 07

Female 19,467 46 29

AverageFamilySize 5 27 —

Total Births (per 1000) 1,805 42 92

TotalDeaths(per1000) 524 1246

InfantDeaths(per 1000) 205 114

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systemsand a network of quacks andprivate practitioners,there is anotherstreamof community basedhealthpractitioners in Jajmau. Thesepractitionerswho are usually intopracticesofbonesetting,distributionofmedicinesand herbs, witch crafts andrituals are widely popular among thepeoplein theslum areas.Thereasonforthis popularityis moreor less thesamewhichcompelsthecommunityto optforquacksi.e. thedisillusionmentbroughtforth by the failure of modemmedicalfacilities and active interventions. Thepreferenceis alsodeterminedby theirpopularlyheldbeliefsystemswhichhavebeentime andagainreinforced by thisfailure. The community resortsto suchtreatmentwheneverythingelsefails andsometimestheotheroptionsarenoteventried dueto lack of faith and poverty.The communitypractitionersaresoughtfor a variety ofminorandmajorillnessesandareheavily relied upon.

Interacion of the TradilionalandModernMedical l~aci1ifies

Points of DivergenceandConvergence

The abovementionednetworkof healthinstitutions in Jajmau, reveals veryinterestingtrends. There has beenatremendousgrowthin thenumberoftheagencieswhicharewilling to operateinthe areaof health interventions.Yet,therehasbeenalmosta parallel rise inthe number of people who areincreasingly seekingtreatmentoutside

thedomainofmodernmedicalfacilities.Similarly, thereis anotheranalysiswhichgoeson closelyto theabovementionedone. This throwslight on thetrend thatthe reliability on modernmedicineandhealthcaredeliverysystemhasbeenatits lowest despiteevery programmehaving a componentof ‘Education’ init. This failure of the programmesshows that the context in which thecommunitiesoperateis importantto beunderstoodin orderto setpriorities.The‘usage’ of health servicesis verynominallydeterminedby educationonly.Therearevarious factorswhichmediateanddeterminetheprocessofuse. Pooraccessibility,lack of enoughfaith, andpoorquality of healthservicesrenderedare some such factors which haveaffected the patternsof utilisation ofhealthservicesin Jajmau. There hasbeenvery little correlation betweenrising number of agenciescreatingawarenessandthe actualuseof medicalfacilities providedby them. Therehavebeenexceptionsbut with very limitedsuccess.

Onepointof divergenceis obviouslythe accessto medical facilities. Besidesthe UIHCP, there is no other agencywhich hasa fully functional outreachprogramme.Other efforts have beenvery minor comparedto the magnitudeof the existing health problems.Similarly, healthhasnot beentakenupin an integratedmanner.The problemof housing, water supply, properdisposalof sewageand problems ofsanitation arenot seenas parts of the

7\FIuWlmT

whole i.e. health. Thereforethe extentof the problemshasremainedmore orless the same over the years. EvenIIHCP with its total focuson healthhasnot beenable to bring the incidenceofwaterbornediseasesandTuberculosis,significantly down. The reasonsbehindthis are lack of an intersectoraldevelopmenteffortandtheunidirectionaloperationsof theagencies.

While some agencies/institutionshave direct links with the community,somefunction from a distance.TheESIhospitalfor exampleworks as a closedinstitution.Although it is ahundredbedhospital,theutilisationof healthservicesremainspoor becauseof the fundsnotreaching the Corporationon a regularbasis. Therehavebeenproblemssuchaslack ofstaff, infrastructure,drugsandabove all lack of motivation in thehospital staff which has made peopleseekotherservices.Thesameis thecasewith othergovernmentagencies.

0*0

Keepingin view theabovementionedpointsofdivergencethefollowing trendsemerge:i) Thereis a lack of holistic thinking

andintersectoralcoordinationin thehealth programmes run by differentagencies.

ii) Thereis also lack of accessof thepoorersectionsto the facilities dueto the abovementionedfactors andthereforethecommunityhasto bankupon alternative sources oftreatment,thetraditional onesbeingthe mostconvenient.Theonly point wherethetwo systems

convergeis that the traditional systemoften works as a supportsystemto anincreasingly failing health servicessystemin Jajmau.Thereasonbehindtheproliferationof the community basedhealthpractitionersis that, thereis stillscopefor aparallelsystemto run withor without its provenefficacy in termsof curativeservices.Usually the choice

Table B : HOUSING AND SANITATION~•-~•• ~

Description Number Percentage

Statusof Housesin JajmauKutcha 3608 45 22Pucca 2056 25 77SemiPucca 2315 2901Total 7978 1000Statusof LatrinesNo Latrines 3497 43 83Dry Latrines 0867 10 87FlushLatrines 3614 4530Total 7978 1000

Note 56 percent ofthe households surveyed are one room settlements, 29 97 percent are two room and 13 39 have twoor moreroomsSource UHCP, 1994

\nulrnaLTE~J

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is betweenthe devil and the deepblueseaandhencethe sea.

Role of lntcrvenlion

Water Supply & Sanitation

Intheareasofwatersupplyandsanitationfacilitiesin Jajmau,thefirst andforemostagencyis the Indo-DutchEnvironmentandSanitaryEngineeringProject(IDP).Thisbilateralprojectworkedcloselywiththe Mnstry of Environment(GOl), intheareasofcleanwatersupplyby cleaningthe‘critical stretchesof(3angariver’ asapartof ahighprofileGangaAction Plan.The project was launchedin 1988 andwas withdrawn in December 1993.Becauseof this long durationof staytheIDP is abetterknownintervention.Theproject was mainly directed towardstackling two problemsin Jajmau:i) Control of pollution through

interventionslike installation ofprimary andsecondarysewageandtannerywastetreatmentplants.

ii) Creating infrastructurefor safesupply of drinking water andcontrolling waterbornediseases.Besidesthesetwomajor interventions

the IDP also coordinatedwith otherexistingagenciesfor otherinterventionssuchashealth, training inputsfor healthandmaintenanceof infrastructureandemploymentgenerationfor womenetc.

The focus of IDP hasmore or lessremainedon creationof infrastructure.For water supply as a major area ofinterventioninstallationofbandpipeshasbeenthe thrustarea.Although someof

the studiesconductedby the IDP showincreasedaccessto safedrinking water,the reality is not the same.The flushlatrineswhich wereconstructedthroughthe project lie defunctdue to lack ofproper water supply and seweragefacilities. Thereforeevenif thecoverageis 45.30% (approx. 3614 families outof 7978families) coveredunderUIHCParea(Table B), the actual use patternshowsa downwardslide.

Lackof propersewagechannelshaskept the sanitationscenarioin theslumarea as poor anddismal. The area ischaracterizedwith overflowing drains,toxic water flow from the tanneries,heapsof garbageand water logging.Thesehavebecomea breedinggroundfor mosquitoesand flies compoundingto already existing healthproblems.Accordingto a roughestimatethemainhealthproblemsareasfollows:• Cough and fevers (including

TuberculosisandMalaria).• Gastro-intestinaldisorders• Skin Diseases• Eyeproblems.

Mostof thesediseasesarearesponseto failing environmentalconditionswhich haveremainedthe samedespiteinterventions.The situation is enoughto questionthe basis premiseof theseinterventions.Is it enoughonly to createinfrastructureormovebeyondit andsee

its sustainability in terms of fullutilisationandaccessof thecommunityto thesefacilities?

Dr. GunjanChaturvedir~J

7\flU&~ThLT

0<1

REFERENCES

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o ChakrabortyA (1990) Social stressandmental healthA social-psychiatricfield studyof CalcuttaSagePublications,N Delhi/NewburyPark/London.

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o HardoyI , SatterthwaiteD. (1989) SquatterCitizen. EarthscanPublicationsLtd London.

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O Mathur 0 M (1993) Respondingto India’s UrbanChallenge:A researchagendafor the I 990s.NationalInstituteof PublicFinanceDraft Paper,NewDelhi.

O Mathur 0 P (1993) TheImpactof Urbanisationon Children, in UrbanChild IssuesandStrategiesNIUA incollaborationwith PlanningComnIission,Minsty of UrbanDevelopment,UNICEFNewDelhi

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O National Instituteof UrbanAffairs (1988)Who the Poorare?What they do’) Wherethey live’)nationalInstituteof UrbanAffairs, NewDelhi

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*0O NationalInstitute of UrbanAffairs (1992) FactorsandProcessesof marginahzation,New Delhi.

Ii] PatankarV Mistry M andRampure M (1993) Securing a foothold: a casestudyof the TenantsofjanataColony(E) Bombay.Paperpresentedat Workshopon NGO-Iocalgovernmentcollaborationin managementof local develoipmentfor SouthAsianCountries,Dhaka,December1993.

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O Rossi-EspagnetA. (1984). PrimaryHealthCarein UrbanAreas: Reachingthe UrbanPoorinDevelopingCountries.A Stateof the Art Reportby UNICEF andWHO. ReportNo.2499M.WorldHealthOrganization.Geneva.

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0 YUVA 1990.ReviewReportAugust1984-1990.Youth for Unity and Voluntary Action, Bombay.

0 YUVA 1992. Life on the MeanStreets- experiencesof working with streetchildren.Youth forUnity andVoluntaryAction, Bombay.

E~Ji\nubliau

Alok MukhopadhyayChristina M. De SaBhavna BanatiAchinto, Christina M De Sa,Ganeve Raj Kotia, Padam Khanna,Soumi Das, The Pioneer and Stree HitkarniDr Gunjan ChaturvediDr Shobha A. UdipiAmar Singh Sachan & KannaTamal Basu (Front)Capt. J Luard (Back)

Other publication in this seriesVivekananda Girl jana Kalyana Kendra

Health for One MillionLok Biradari prakalp

Rural Development TrustRaigarh Ambikapur Health Association

Urmul TrustSeva Mandir

Indigenous People and Their HealthRangabelia Comprehensive Rural Development Project

Copyright © Voluntary Health Association of India, 199540, Institutional Area (Near Qutab Hotel)

New Delhi 110 016.

Reproduction, adaptation and translation is authorized worldwide fornon-profit educational activities and publications, provided that

permission is obtained from the publisher and that copiescontaining reproduced material are sent to

The Director, Anubhav Series,Voluntary Health Association of India.

Director, Anubhav SeriesAuthor

Editor & CoordinatorPhotographs

Contributions

ProductionCover Design

Voluntary Health Association of India (VHAI) isa non-profit registered societyformed bythefederationof Voluntary Association at the level of States and Union Territories. VHAIlinks over 3000 grassroot-level organisations and community health programmesspread across the country,VHAI’s primaryobjectives are to promote community health, social justice and humanrights related to the provision and distribution of health services in India.VHAI fulfils theseobjectivesthrough campaign,policy research and pressand parliamentadvocacy; through need-based training and information and documentation services;and through production and distribution of innovative health education materials andpackages, in theform of print and audiovisuals, fora wide spectrum of users - both urbanand rural.

VHAI tries to ensure that a people-oriented health policy is formulated and effectivelyimplemented. It also endeavours to sensitise the large public towards a scientific attitudeto health, without ignoring India’s natural traditions and resources.

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