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Urban Health in Developing Countries Live Talk 2

Urban Health Issues 14 April 2009

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Overview of Live Talk

•  Our course has three planned live talk sessions

•  Each session will be divided into two parts – First we will have a guest speaker who will

share some experiences – Secondly we will take questions and

comments from the BBS and respond to them •  As time allows we will encourage

additional questions for our guests and about the current Module

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Part 1

Pam Lynam and Stuart Merkel

Jhpiego – Kenya Program

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HEALTH IN THE URBAN SLUMS: Let the people lead the

way

Pamela Lynam MD Stuart Merkel, MBA

April 2009

6 Photo by Madhav Pai. Creative Commons BY.

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Jhpiego Overview •  A non-profit affiliate of

Johns Hopkins University •  Funded through

governments, international donors, private corporations and foundations

•  Strengthens the performance of health workers and health systems to provide quality health care services in low-resource settings

•  Started in Kenya in 1973 Photo by Jhpiego staff.

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Jhpiego’s Work in Urban Slums •  Korogocho & Viwandani Slums,

Nairobi, Kenya •  A variety of technical

interventions: –  HIV –  Reproductive Health –  Family Planning –  Safe Motherhood

•  Focus on: –  Facility-based improvement in

quality of services –  Community empowerment for

increased access to services –  Community-facility linkages for

sustainability

Photo by Stuart Merkel.

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The Facts: Urbanization

•  The World is increasingly Urban – 3 in 5 people will live

in cities by 2030

– 95% of urban growth will be in the developing world, creating as many as 10 new large cities each year (UNFPA)

Photo by Stuart Merkel.

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The Facts: Growth of Slums •  Most urban growth is in informal settlements, or

slums –  1/3 of urbanites live in slums (=~1.2 billion) –  72% of African urbanites are slum dwellers. Africa is

the fastest urbanizing continent –  Asia has the largest number of slum dwellers

•  554 million total •  60% of all slum dwellers worldwide

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Broad Characteristics of Slums

Poor Health Conditions •  Services:

–  Poor access to – and quality of – health services

•  Hazardous Environment: –  Deficient access to water and

sanitation, toilets –  Waste, garbage

Cash-Based Economy: Many competing factors: –  Example: paying for food,

clothing, shelter vs. health services

Photo by Stuart Merkel.

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Nairobi Slums (1) Insecurity and severe overcrowding

–  60% of Nairobi residents live on 5% of land (slums)

–  Land/housing tenure –  Crime and sexual assault –  Heterogeneous populations

Breakdown of social cohesion –  Complex power relationships –  Disruption of traditional family,

community & ethnic support structures

–  Prostitution, addiction, domestic violence, etc.

Photo by Stuart Merkel.

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Nairobi Slums (2)

Inadequate Health Services –  Lack of Respect and Trust

+ Insecurity and Neglect –  Illegality and abuse

+ Unhealthy lifestyles –  Breakdown of traditional

structure –  Water and sanitation

issues ____________________________

= Poor Health Indicators Photo by Stuart Merkel.

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Nairobi slums - Emerging Evidence

Selected Data:

•  Data generally hard to find on health in slums •  Expected higher MMR, prevalence rates for HIV,

TB, etc

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Two Key Messages

“So Close – Yet So Far” Proximity ≠ Access

in Slums!

Bridging the Community-

Clinic Divide is Key! Photo by Stuart Merkel.

Photo by Stuart Merkel.

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Performance & Quality Improvement

•  Originally designed for facility-based programs –  Improve provider performance by focusing on

identified gaps and creating plans to address them •  Adapted for slums context

–  Not: “We the experts will give you what you need” –  Rather: “What are your needs? What solutions will

work for you?” •  Health facility level •  Community level •  Jointly

•  PQI = empowerment = ownership = sustainability

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PQI Framework

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Health Facility interventions

•  Built the capacity of health workers from NCC and NGO/FBO in the informal settlements in RH/FP.

•  Service providers trained in Infection prevention, CTU, FANC, adolescent health, reproductive health, FP, HIV counseling testing, and treatment

• Held meetings with service providers to create linkages with community

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Health Facility interventions

•  Production of training manuals in RH/FP • With the cascading approach triple the

service providers trained in all the above •  Supportive supervision for health facilities

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Community interventions

•  PQI to define gaps in RH/FP in community

•  Orientation workshops for community on RH/FP

•  Develop Community Own Resource Persons (CORPS) in RH/FP

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Community interventions Cont

•  Form Support groups in community for mother-baby groups

•  Assist CBO and FBO in the community to support this intervention

•  Link community to quality Reproductive health care

•  Developed maps and directories for easy referrals and networking

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RESULTS

•  Improved health /family planning / HIV knowledge/skills at health facilities

•  Increased knowledge on healthcare services including where to get them in the community.

•  Increased uptake of health services •  Reduced mortality among women due to

unsafe practices

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PQI Results

Community-Inspired and Owned Interventions –  Anti-rape self defense training –  Community Theatre –  Peer Education –  Community Mapping –  Village Health Committees –  Community Gardening –  Free medical camps –  Vastly improved attitude between clinics and

slumdwellers - Painted Health facilities, garden etc.

Photo by Stuart Merkel.

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Key Lessons Learned •  Building trust can improve health

– This takes patience and time •  Enthusiasm and energy is

already present in both communities and among healthcare workers

•  Communities know their health challenges and must be consulted when designing solutions.

•  Sustainable results come from involving all stakeholders

Photos by Stuart Merkel.

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Implications for Future Projects •  PQI Works!

–  Local ownership = empowerment

•  Monitoring and evaluating PQI Interventions is challenging – Not pre-programmed – Example: self-defense

•  Requires flexibility on the part of donors and policymakers

Photo by Stuart Merkel.

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Acknowledgements

•  Communities of Korogocho and Viwandani

•  Healthcare workers in Korogocho and Viwandani

•  City Council of Nairobi •  Rockefeller Foundation •  Wallace Global Fund •  Co-Authors:

–  Jane Otai –  Julia Perri

Photo by Stuart Merkel.

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THANK YOU!

Pamela Lynam, MD Jhpiego Country

Director, Kenya

Stuart Merkel, MBA Jhpiego Program

Officer, Kenya Photo by Stuart Merkel.

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Visit our Website!

www.jhpiego.org/whatwedo/urbanslums.htm Photos by Stuart Merkel.