Maternal and Newborn Health in Urban India A Monograph based on Literature Review Exercise Save the Children, India M a y 2 0 1 6 Maternal and Newborn Health in Urban India A Monograph based on Literature Review Exercise Save the Children, India May 2016 Contents Letter from Ministry of Health & Family Welfare 5 Message 6 Preface 7 Message from CEO 8 Acknowledgement 9 Acronyms 10 Executive Summary 12 Outline of the Report 15 I Introduction 16 II Methodology 20 III Findings 24 A. Service Delivery Mechanisms, Logistics and Supply-Chain Management 24 B. Governance 37 C. Human Resources 40 D. Financial Mechanisms 46 E. Health Infrastructure 49 F. Health Management & Information System (HMIS) 50 G. Community Interventions and Innovations 51 H. Innovative Approaches 57 IV Discussion and Conclusions 64 References 72 Annexure 1: Evidence tables of the literature reviewed 84 Annexure 2: Tables on citywise programmes, schemes and innovations 113 3 5 Message P ublic healthcare for the urban poor has lagged behind in India despite good intentions. It suffers from multiplicity of players, non-standardised structure and low investments. Above all, the rich-poor gap is staggering. It has therefore been a challenge to systematically plan priority maternal-newborn health (MNH) services in cities and towns. Not surprisingly, the National Urban Health Mission has lagged behind the National Rural Health Mission by almost a decade. One reason for this state of affairs has been a relative lack of reliable information and program relevant research in urban MNH. Diversity and dynamics of urban health system make the available knowledge difficult to comprehend and apply. In this context, Saving Newborn Lives (SNL), Save the Children, has made a tremendous contribution by synthesising available literature and research in MNH in urban India. This monograph is based on well-researched, painstaking review using robust methods. The credentials of the team are impeccable. The flow of the narrative (service delivery, infrastructure, human resources, etc.) follows the health system framework. Gaps and solutions are captured in precise text at the end of each chapter; and discussions and implications are well captured in the final chapter. This review brings out several facets of urban MNH. Analytic insights into lack of community processes in urban areas in the report are most insightful. Equally, interesting is the capture of most innovations in MNH in cities. The need to design and test next generation primary care models for urban India is a clear priority. Overall scene of urban MNH cries out for more investment, better governance and coordination, and more research. The recurring theme in the monograph is the paucity of actionable information and evidence. We need studies on urban MNH epidemiology and innovative interventions; we need implementation research to inform scale up of what is known to be effective; we need demonstration sites to showcase replicable models; and we need technical support teams to facilitate implementation and monitoring. The government, the Indian Council of Medical Research and the public health research community together have the responsibility to bridge the knowledge gap. The monograph provides highly valuable inputs on MNH for the National Urban Health Mission. MNH and urban health stakeholders would gain immensely by insightful repository of information that this review provides. A must read document for the public health community of India. Dr. Vinod Paul Professor & Head Department of Paediatrics, AIIMS, New Delhi 6 Preface Save the Children’s 2015 State of the World's Mothers Report, The Urban Disadvantage, brings into sharp focus the health inequities found within cities all over the world. Data from the report demonstrate that while great progress has been made in reducing under-5 mortality globally, in about half of the cities where data are available, the mortality gap between rich and poor children has grown. The poorest children, especially those living in urban slums, have alarmingly high risks of death. These inequalities also exist in cities in high- income countries such as Washington, DC, in the United States. Given Save the Children's commitment to reaching the most disadvantaged children and families and the growing rates of global urbanization, we believe addressing the challenges surrounding improving health – especially maternal and newborn health – in poor urban areas is increasingly important. We are keen to understand the root causes of these inequalities and to learn from the experience of others about addressing the needs of children and families living in urban slums. Save the Children's Saving Newborn Lives Program, supported by the Bill and Melinda Gates Foundation, is working actively with appropriate stakeholders and the National Health Mission to explore how the contextual factor differ in urban settings for maternal and newborn health service availability as well as care seeking behaviors. Who are the main service providers to poor urban dwellers? How are those services financed? Are they of sufficient quality to improve health outcomes? How have they targeted the most deprived and poorest families? A key step in this learning agenda was to undertake a literature review to explore the rich array of programs already in existence in India. The results remind us of how much work has already been undertaken and the rich set of lessons that have emerged. However, it also is evident that most urban health programs have been pilot projects, covering relatively small populations within a fixed time period, and that successful pilots have yet to be scaled up to benefit large population groups. The challenge for India and other countries is to learn how to shape large-scale, well-funded,and sustainable programs such as India's National Health Missions to target services to those who need them the most in varied urban environments. Further, while future investments in urban health must come from government, we must also tap into the vibrant private and corporate sector and involve the service delivery systems of government, nonprofit, and commercial sectors, because everyone has an equal stake in the health and well being of India's women and children. I would like to thank all of those involved in carrying out this important review and analysis as well as those who guided it. We appreciate the global leadership that India is providing for improving urban approaches to addressing the health of women and children. Joy Riggs-Perla Director, Saving Newborn Lives Save the Children, USA 7 Message from CEO Urbanisation is often thought of as being beneficial for economic and social growth, which is what prompts rural populations to migrate to the cities for a better life and better prospects. Being the world's largest democracy, the second most populous country (1.21 billion as per Census 2011) and the tenth largest economy (with a Gross Domestic Product of US$ 1377.3 billion in 2009), India has undergone extraordinary socio- economic and demographic changes. In the past 30 years, the geographically-wide, densely-populated and enormously-varied Republic of India has made remarkable efforts in the field of health, including development of a strategic framework on RMNCH+A in 2013 and the recently launched National Health Mission with a sub- mission (NUHM) on Urban Health as a key component. Save the Children's Saving Newborn Lives (SNL) programme works with governments and partners to put newborn health on global and national agendas. In India, the programme is working towards evidence- generation, consensus-building and supporting policy and programmatic processes on delivering Maternal and Newborn Health (MNH) in urban poor settings. As a part of this process, a need was felt to review both the published and the unpublished literature on mechanisms, programme platforms, service delivery systems, practices and innovations in MNH in the urban areas of India including, literature on scaling up pilots/ innovations and conceptual frameworks with a specific focus on the urban poor. It is important that the MNH programmes, though variably existing in the urban space of India, gets a thorough prioritisation and reboot. The whole service delivery mechanism is not in place when it comes to most of the cities in the country. Ambiguity on the information, data, role of departments, leadership, personnel, supply chains and logistics continue to remain. The findings of this review clearly reflect on the gaps in terms of current availability of health services to deliver MNH care along with the clearly defined paucity of service delivery platforms, governance and mechanisms inclusive of infrastructure, human resources, logistics, supply chain, partnerships and community, level efforts. It further draws our attention to the fact that the gaps with regard to the availability of literature and evidence from the research undertaken in all of the abovementioned aspects of health service delivery for MNH care should not be ignored. At Save the Children, we consider that both the policy and programmatic efforts along with commitment of working towards the betterment of urban poor mothers and newborns should be augmented especially at this juncture, wherein the country is attempting to understand, develop and formalize the mechanisms for delivering health care to the urban poor mothers and newborns. This review report affirms the overwhelming constraint of better availability of services for MNH care in urban areas and it distinctly provides a direction to future researchers and policy-makers as to what needs to be done to ensure that MNH care services are delivered to the urban poor. Thomas Chandy CEO, Save the Children, India 8