HUP Midterm Evaluation Report Oct 2012 :: PFI Publication :: KNOWLEDGE MANAGEMENT CENTRE PORTAL, POPULATION FOUNDATION OF INDIA

Acronyms ................................................................................................................................................................................................ i

Executive Summary............................................................................................................................................................................. iii

Evaluation Purpose and Evaluation Questions ......................................................................................................................... iii

Project Background........................................................................................................................................................................ iii

Evaluation Questions, Design, Methods and Limitations....................................................................................................... iv

Findings and Conclusions.............................................................................................................................................................. iv

Overall Conclusions in response to SOW questions ............................................................................................................ vi

Summary of Major Recommendations..................................................................................................................................... viii

Recommendations for USAID................................................................................................................................................. ix

The Way Forward: Options for the Future......................................................................................................................... ix

Evaluation Purpose and Evaluation Questions............................................................................................................................... 1

Evaluation Purpose .......................................................................................................................................................................... 1

Evaluation Questions ...................................................................................................................................................................... 1

Project Background ............................................................................................................................................................................. 2

Evaluation methods & limitations ..................................................................................................................................................... 3

Methodology ..................................................................................................................................................................................... 3

Limitations ......................................................................................................................................................................................... 4

Measuring Evidence of HUP Project Achievements ................................................................................................................ 5

Findings and Conclusions ................................................................................................................................................................... 6

FINDINGS: Objective One (TA) ................................................................................................................................................. 6

HUP Project Design and the Provision of Technical Assistance...................................................................................... 6

Key Observations and Findings Pertaining to TA Provision ............................................................................................. 7

Conclusions Related to TA .........................................................................................................................................................10

Findings: Objective 2 (PPP)..........................................................................................................................................................11

Activities and Achievements Related to Public-Private Partnerships............................................................................11

Key Observations and Findings related to PPP..................................................................................................................12

Conclusions Related to PPP ........................................................................................................................................................14

Findings: Objective 3 (Convergence) ........................................................................................................................................14

Activities and Achievements Related to Convergence ....................................................................................................16

Findings Related to Convergence..........................................................................................................................................19

Conclusions Related to Convergence ......................................................................................................................................20

Findings: Objective 4 .........................................................................................................................................................................21

Activities and Achievements Related to Demonstration Models.......................................................................................22

Findings Related to Demonstration Models ............................................................................................................................22

Conclusions Related to Demonstration Models ....................................................................................................................25

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Findings: Objective 5 (Management and Government).........................................................................................................26

Activities and Achievements Related to Management and Governance......................................................................26

Findings Related to Management and Governance ...........................................................................................................27

Conclusions Related to Management and Governance........................................................................................................29

Summary Conclusions.......................................................................................................................................................................31

Recommendations..............................................................................................................................................................................34

Recommendations Related to Technical Assistance .............................................................................................................34

Recommendations Related to Public-Private Partnerships..................................................................................................35

Recommendations Related to Convergence...........................................................................................................................35

Recommendations Related to Technical Assistance for Water, Sanitation, and Hygiene............................................36

Recommendations Related to Demonstration Models ........................................................................................................36

Recommendations Related to Management and Governance of the HUP Project .......................................................37

Recommendations for USAID ....................................................................................................................................................38

The Way Forward: Options for the Future ............................................................................................................................38

Exit Strategy ....................................................................................................................................................................................39

Annex I: Evaluation Statement of Work.......................................................................................................................................41

Annex II: Evaluation Timeline and Calendar ................................................................................................................................50

Annex III: Key References/Documents Reviewed ......................................................................................................................53

Annex IV: Individuals and Organizations Consulted/Interviewed ...........................................................................................56

Annex V: Current Performance Indicators Used by the HUP Project..................................................................................61

Annex VI: Selected Preliminary Indicators from 2012 HUP Baseline Survey in Jaipur, Bhubaneswar, and Pune ........65

Annex VII: Stages in the Evolution of Urban Health Programming ........................................................................................67

Annex VIII: Mapping of TA Provided by HUP .............................................................................................................................68

Annex IX: Comparison of the Change in Urban Rich Budgets of HUP and Non-HUP States, 2010–2013 .................69

Annex X: Public-Private Partnerships............................................................................................................................................70

Annex XI: Key Government Programs for the Urban Poor in India .....................................................................................77

Annex XII: TA to Water Supply, Sanitation, and Hygiene (WASH) ......................................................................................78

Annex XIII: Framework of the HUP Demonstration Model Program ..................................................................................81

Annex XIV: Key Stakeholders for the HUP Project ..................................................................................................................83

Annex XV: HUP Project Partners..................................................................................................................................................84

Annex XVI: HUP Project Management Structure ......................................................................................................................86

Annex XVII: Summary of Findings on Management and Governance....................................................................................87

Annex XVIII: Stakeholder Interview Forms: PFI and HUP Partnering Implementing Agencies .......................................88

Annex XIX: HUP Indicators by Effectiveness Areas ..................................................................................................................95

Annex XX: MCH/RCH Approach to TA .....................................................................................................................................97

Annex XXI: Capacity Building (CB) Efforts of HUP...................................................................................................................98

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ACRONYMS

ANC

ANM

AOTR

ASHA

AWW

BCC

BCT

BMC

BSUP

CBO

CEDPA

COP

CSR

DFID

DEA

EHP

GOI

GoO

GOV

GRC

HFW

HIV/AIDS

HUP

ICDS

IEC

IIHMR

IIPS

INR

JNNURM

JSY

MAS

M&E

MCH

MCH Star

MCHT

MIA

MOHFW

MOHUPA

MOUD

MIS

Antenatal care

Auxiliary Nurse Midwife

Agreement Officer’s Technical Representative

Accredited Social Health Activist

Anganwadi Worker

Behavior Change Communication

Bhoruka Charitable Trust

Bhubaneswar Municipal Corporation

Basic Services for the Urban Poor

Community Based Organization

Centre for Development and Population Activities

Cluster Coordinator

Chief of the Party

Corporate Social Responsibility

Department for International Development (UK)

Department of Economic Affairs

Environmental Health Project (USAID)

Government of India

Government of Odisha

Government

Gender Resource Center

Health and Family Welfare

Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome

Health of the Urban Poor

Integrated Child Development Services

Information, Education, and Communication

International Institute of Health Management and Research

International Institute for Population Studies

Indian National Rupees

Jawaharlal Nehru National Urban Renewal Mission

Janani Suraksha Yojana (Incentive scheme for promoting institutional deliveries)

Link Worker

Mahila Swasthya Samiti (Women’s Health Committee)

Monitoring and Evaluation

Maternal and Child Health

Maternal and Child Health Sustainable Technical Assistance and Research

Maternal and Child Health Tracking

Micro Insurance Academy

Ministry of Health and Family Welfare

Ministry of Housing and Urban Poverty Alleviation

Ministry of Urban Development

Management Information System

Madhya Pradesh

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MTA

NFHS

NGO

NRHM

NUHM

OPD

PFI

PHED

PIP

PMG

PMTCT

PMU

POU

POUZN

PPP

QPR

RCH

RSBY

SOW

STI

TAG

UHC

UHI

UHND

UHRC

UHP

ULB

UNICEF

USAID

VISTAAR

WASH

WCD

WESNET

Midterm Assessment

National Family Health Survey

Nongovernmental Organization

National Rural Health Mission

National Urban Health Mission

Outpatient Department

Operations Research

Population Foundation of India

Public Health Engineering Department

Project Implementation Plan

Procurement and Grant Management Group

Prevention of Mother-To-Child Transmission

Program Management Unit

Point of Use

Point of Use for Zink

Public-Private Partnership

Quarterly Progress Report

Reproductive and Child Health (national program)

Rashtriya Swasthya Bima Yojana (National health insurance scheme)

Scope of Work

Sexually Transmitted Infections

Technical Assistance

Technical Advisory Group

Tuberculosis

Urban Development

Urban Health Center

Urban Health Initiative

Urban Health and Nutrition Days

Urban Health Resource Centre

Urban Health Post

Urban Local Body

Uttarakhand

United Nations

United Nations Children’s Fund

Uttar Pradesh

United States Agency for International Development

USAID MNCH Project (Hindi word=to expand)

Water and Sanitation Hygiene

Women and Child Development

Water and Environmental Sanitation Network

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EXECUTIVE SUMMARY

In India, the urban poor are among the fastest growing and especially vulnerable sub-populations, having

limited access to clean water, sanitation, and health care. Despite compelling need, urban health has not been

a priority issue and receives less attention than rural health care. Since 2001, USAID has engaged in an active

partnership with the Ministry of Health and Family Welfare/Government of India (MOHFW/GOI),

beginning with the Environmental Health Project-India (which in 2005 transitioned to a nongovernmental

organization [NGO], the Urban Health Research Center [UHRC]), in addition to providing long-term

assistance for improving water and sanitation in urban areas. In response to GOI’s proposed National Urban

Health Mission (NUHM), the Health of the Urban Poor (HUP) project in 2009 was designed to work at state,

municipal, and community levels to develop innovative policies and program strategies to better meet the

health needs of the urban poor.

EVALUATION PURPOSE AND EVALUATION QUESTIONS

The project’s main focus is on maternal and child health (MCH), and the improvement of delivery and

community-mobilization systems that could prove effective in reaching India’s rapidly growing urban slum

populations. Because the launch of the NUHM has been delayed, the technical assistance (TA) component of

HUP has been aligned with the urban health component of the existing National Rural Health

Mission/Reproductive and Child Health (NRHM/RCH) program. HUP is being implemented in the

following states: Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, and Uttar

Pradesh; in addition to five cities: Bhubaneswar, Jaipur, Pune, Agra, and Delhi.

The Cooperative Agreement (for the total sum of INR 513,601,582/US$10,778,627) was awarded to the

Population Foundation of India (PFI) to provide support to USAID/India’s Health of the Urban Poor

Program. HUP is the first USAID award made directly to an Indian NGO. GOI approval had not been

obtained prior to awarding the Cooperative Agreement for HUP in September 2009, thus delaying project

implementation for ten months. As a result, the project has been operational for a maximum of one year and

in most demonstration sites, for only six to eight months. The four-year project is scheduled to end by

September 30, 2013.

PROJECT BACKGROUND

This mid-term HUP evaluation was designed to provide an assessment of the project’s progress in addressing

five key components (i.e., TA, public private partnerships, convergence, demonstration models, and

management and governance) after one year of project implementation. The evaluation addresses the extent

to which HUP is developing and implementing innovative urban health interventions and models that can be

considered for replication and scale up, in India and possibly other countries as well. By addressing the key

questions listed in the scope of work (SOW) at the project’s mid-term, the evaluation should provide useful

guidance on how well the project has been rolled-out, what appears to be working or not working, and how

HUP might be best deployed to ensure positive results during the remainder of the project.

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EVALUATION QUESTIONS, DESIGN, METHODS AND LIMITATIONS

The evaluation, commissioned by USAID/India under a contract with Social Impact, was conducted by two

U.S. and three Indian consultants over a period of four weeks in-country during June and July 2012. During

field visits to four states and four city demonstration models, the evaluation team gathered data through

extensive review of documents and project reports, interviews with key informants, including GOI, state and

municipal government officials, PFI and its partners, NGOs, foundations, donor/UN organizations, health

facility staff and community workers and members. Analysis of these data forms the basis for the report’s

findings and recommendations.

FINDINGS AND CONCLUSIONS

The evaluation team found that the HUP project has several accomplishments and achievements, despite

encountering many challenges which include: on-going delay in the launch of the NUHM and thus, no clear

incentive for states to address urban health issues; a 10-month delay in HUP project approval by GOI,

resulting in a very short period (six to 12 months) for implementation of project activities to date; and

uncertainty about the remaining time period (one or two years) until project completion. Another

fundamental challenge is the nature of the project design, which includes a broad range of activities to be

provided through a TA approach in eight states and five municipalities representing diverse environments.

Also, the project’s performance indicators make it difficult to assess achievements in many areas. However, in

a relatively short period, the HUP project has helped to delineate national- and state-level policies on urban

health, in addition to broadening the participation of relevant stakeholders in the development of NUHM

policies, program priorities, and operational strategies (e.g., national- and state-level ministries and

departments).

The key findings related to project objectives follow:

Objective 1: Provide Quality technical assistance to the GOI, states, and cities for effective

implementation of the National Urban Health Mission (NUHM).

The HUP team has been successful in establishing relationships and providing a range of TA to

national-, state-, and city-level governments and been recognized as a valued partner in urban health.

At the same time, there is a need to develop a mechanism to increase involvement of state and

municipal governments in developing work plans. TA could be provided more comprehensively in

some areas, e.g., for an overall state urban health plan and nutrition program.

Objective 2: Expand partnerships in urban health, including engaging the commercial sector in

Public Private Partnerships.

Despite special challenges to establish public-private partnerships (PPPs) in urban health (e.g., in

urban health there are no policies, structures, or PPP cells and limited funding, unclear incentives,

and short time-frames), HUP has facilitated the launching of some PPP models and others are under

discussion. However, many states, and especially city, teams need more guidance from the project

management unit (PMU). Findings also include government preference for working with non-profit

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NGOs rather than the commercial sector, and a lack of clarity about the value of alternative

insurance models.

Objective 3: Promote the convergence of different GOI urban health and development efforts.

In India, the need to converge the many development initiatives implemented in urban areas (e.g.,

JNNURM, ICDS, and NRHM through its urban RCH component) through various ministries is

recognized. To date, HUP convergence activities have been focused more at state and city levels,

including engagement at the national level, rather than attempting to bring convergence with other

donors at national or state level, or with NGOs working in slum areas. Convergence in states that

have a clearer vision on ways to address urban health (e.g., Odisha and Uttarakhand) facilitated

progress on the policy front, and these consultations have led to recommendations on the formation

of Urban Health Cells and City Task Forces, micro planning at slum level, vulnerability assessments,

etc. Activities for WASH have been limited to three key sub-components (i.e., improving water

quality at POU, improving toilet use, and hand washing), in addition to activities designed to inform,

at state and city levels, on the status of urban water and sanitation, and to bring convergence with

health and other departments. However, the indicators required to capture the facilitation role of

HUP do not exist at present, and for WASH, the performance indicators are only related to

improved access, for which HUP activities have been limited to date.

Objective 4: Strengthen the evidence-based rigor of city-level demonstration models.

The HUP is undertaking urban health demonstration models in five cities, including 276 slum

communities covering 450,000 people. Eleven NGO partners are implementing the demonstration

models with a combined field staff of 205 people. The evaluation found that the demonstration sites

have been established and are functioning, although still at an initial learning stage. In these

communities, there appears to be an increase in access to health services, but not all key areas are

addressed under RCH. Although HUP is generating demand, there is less support for strengthening

service provision. Among the challenges is the variation in responsiveness of local government

resources across slum areas.

Objective 5: HUP management practices and systems.

The HUP project consists of a consortium of experienced partners (including three sub-

implementing partners and three technical partners), with PFI providing overall management

through the PMU (including specialists in each thematic area) to the eight state teams and five city

teams. The Program Management Group (PMG) is to provide program management oversight and

the Technical Advisory Group (TAG) is to provide strategic guidance. However, both groups meet

infrequently and irregularly. Project administration and financial management were found to be in

compliance with USAID regulations, and there is a system of communication and reporting to

USAID in place. The delay in project approval and appointment of state and city teams has limited

implementation activities. Although most appointed staff were found to be of high quality and had

benefited from prior experience with government, some lacked more senior expertise. In some cases,

interaction between the PMU and state/city teams was limited, with an expressed need for more

technical support and mentoring, including public health expertise. HUP state teams noted the need

for clear communication from GOI and for greater USAID support at state level “to open doors”

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with the government. Interaction and cross-learning between state and city teams and between states

was limited.

OVERALL CONCLUSIONS IN RESPONSE TO SOW QUESTIONS

How has HUP influenced GOI policy on urban health since 2009 and what opportunities currently

exist for USAID to influence policy-level changes through HUP?

Despite the challenges, and in a relatively short period, the HUP project has helped to delineate

national and state-level policies on urban health, in addition to broadening the participation of

relevant stakeholders in the development of NUHM policies, program priorities, and operational

strategies (e.g., national and state-level ministries and departments). The HUP project has

demonstrated mechanisms for strengthening urban health systems within varying environments and,

therefore has the potential to frame strategies for addressing urban health needs and priorities, as well

as to accelerate the implementation of NUHM when it is officially launched. HUP is working to

develop a comprehensive urban health vision for the country, giving USAID a unique opportunity

among donors to make major contributions to the NUHM design and implementation process and,

ultimately, improve health and living standards in India’s most disadvantaged urban settings.

To what extent has the project contributed to the operationalization of the urban health program at

national and state levels? What were the strengths and weaknesses of its implementation?

Although the project’s implementation approach has been hampered by the delay in approving the

NUHM, HUP has developed operational tools for enhancing access to urban services, strengthened

behavior-change communication (BCC) initiatives for urban health, and prepared systematic

community mobilization guidelines, in addition to producing many policy documents, research

reports and pilot project implementation plans (PIPs) that have helped to advance the urban health

agenda. Major strengths include: 1. strong policy capabilities and inputs at the national level; 2. HUP

staff members are generally well-connected with government health, urban development, and water

and sanitation departments; 3. the project is working to build a supportive environment for learning

and documenting results, and 4. the project has developed workable mechanisms for fostering

convergence across government and NGO partners.

How effective has the project’s technical assistance approach been in building synergies between

the public and private partners in implementation of key project strategies?

Developing productive PPP for urban health takes time (e.g., negotiating, officially approving and

activating PPP activities). Therefore, HUP’s results to date in developing PPP activities have been

mixed, owing in part to inconsistent interest in the PPP approaches across HUP’s eight states and

different levels of PPP expertise within HUP’s state and municipal-level teams. However, some good

models have been developed during HUP’s first year, e.g., in Uttarakhand, and other models are

being developed, e.g., Odisha, Pune, Rajasthan.

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What lessons can be drawn for future designs from the program governance system, especially its

role in promoting convergence strategies of different GOI programs?

The HUP project is making important contributions to improving the “governance system” for

urban health through its efforts to engage relevant public-sector and NGO stakeholders in

addressing urban health needs and strategies for reaching the urban poor. The project’s efforts to

promote greater interministerial and interdepartmental convergence in delivering MCH services,

enhancing WASH infrastructure in urban slums, and nutritional services are now underway in all

eight states, but it is premature to judge the effectiveness of the project’s convergence. This work has

been well received at state and municipal levels and the MOHFW in Delhi noted that they were

especially interested in how different convergence strategies were working.

What has been the outcome of the slum demonstration activities under HUP? What are the key

strengths and weaknesses of these interventions and what is the opportunity for potential scale up?

The HUP project has made a good start in implementing the five city demonstration models.

Partnering NGOs have been engaged, field offices opened, field staff recruited (cluster and link

workers), slum communities mapped, household listings completed, baseline surveys implemented in

three cities, management information systems (MIS) developed, and the project’s maternal and child

health tracking (MCHT) systems deployed. HUP has also made good progress in working with local

community organizations, most notably the Mahila Swasthya Samiti (MAS) committees established in

all slum communities where HUP is working. Education and urban-health-demand-generation

activities (often undertaken in collaboration with the MAS committees) are also underway in HUP’s

demonstration sites. Owing to the short implementation period (six to eight months), demonstration

model potential for replication and scale-up will be difficult to determine without more time for

implementation and the gathering and analysis of evidence on results. Also, the focus thus far has

been on increasing demand, with less attention given to improving the access and quality of service

provision.

How effective are the HUP management systems, including project planning and review, grants

management, financial and procurement systems, in scaling-up project activities?

The HUP management system appears to be functioning reasonably well despite early problems

stemming from a change in leadership and slow recruitment procedures for state and city teams

(both initial hires and replacement staff). A system of written and verbal communication between the

PMU and USAID is in place. However, the infrequent meetings of the TAG were seen as limiting

opportunities for greater strategic program guidance and review. In addition, PMG meetings are held

irregularly. While HUP has taken steps to ensure good coordination within the project, there were

reports that communication between the PMU and state/city teams could be improved and greater

cross-pollination between state and city teams would be desirable. It was noted that the project

spends considerable time developing annual work plans that must be approved by the GOI’s

MOHFW and USAID. These lengthy clearance procedures can give rise to uncertainty over the

timely availability of funds needed to pay staff and procure equipment and supplies. A four-year

framework mechanism for all sub-grantee contracts might have been a more efficient approach for

ensuring smooth project implementation.

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Currently, HUP is facing a challenging situation in planning for the next annual work plan without

knowing whether a project extension will be feasible. If the project ends as scheduled in September

2013, the work plan needs to address close-out activities during the next year. If there is a no-cost

extension, then the work plan could build on and expand current activities.

SUMMARY OF MAJOR RECOMMENDATIONS

• Continue working to facilitate the development of a state urban health vision and plan.

• Build on what exists in the state to develop an urban health strategy to support implementation of a

comprehensive urban plan, e.g., use recently developed Madhya Pradesh as an example for other states.

• Where possible, support the development of a more comprehensive urban health model, beyond RCH.

• Systematically document the capacity of state and municipal health systems.

• Systematically track indicators derived from the MCHT system that document contact with

beneficiaries and the extent to which HUP is providing support to urban slum dwellers.

• Invest in an expanded, qualitative research program during the last year of the project to better assess

what the five-city demonstration models have achieved.

• Repeat the baseline survey during the last year of the project to measure change in basic output and

impact indicators over the life of the project.

• Engage in substantive dialogues with states in preparing specific PPP guidelines for urban health.

• Disseminate documentation on successful PPP models to different states and city governments to

encourage adoption of such models.

• Engage in advocacy for utilizing and strengthening PPP cells under NRHM in many states.

• Greater focus should be given to assisting state governments to expedite the formation of ward-,

city-, and state-level committees as priority structures for urban health.

• Strengthen information exchange between states on the development of urban health frameworks

and strategies.

• Make greater efforts to engage other NGO and donor organizations working in urban health.

• Revisit and prioritize the scope of WASH as listed in the Cooperative Agreement and rework

performance indicators to reflect the same.

• Utilize the strength of each partner in HUP by providing flexible strategies.

• Encourage an inter-team exchange program between HUP teams and staff for short periods to share

knowledge and skills effectively.

• State work plans need to be formally or informally agreed upon with state governments, which will

help align TA with state government priorities.

• Introduce state-wide progress ranking to encourage healthy competition between teams within HUP.

• TAG and PMG meetings need to be conducted regularly to provide guidance to the project that

pertains to its original design and objectives.

• Undertake operations research (OR) into meaningful incentives for MAS members that will help

ensure their sustainable engagement in urban health activities.

• Reduce the project’s internal reporting from a weekly to a monthly schedule (particularly for the

project’s demonstration models) in order to reduce management loads and allow more time for

project implementation.

• Reduce administrative burdens and streamline approval and budgetary procedures through

framework contractual agreements that cover the life of the project, rather than biannual contracts

with sub-grantees.

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Recommendations for USAID

• Maintain an urban health niche through HUP and provide leadership to the donor community by

escalating the urban health agenda in India.

• Continue strategic dialogue with GOI and states on ways to adopt evidence created through HUP, as

well as in other countries and regions.

• At a later stage, provide feedback to GOI and states on models and innovations based on the Indian

experience as documented by HUP, to be shared with Africa and other regions.

The Way Forward: Options for the Future

Due to the initial project delay, limited time was available for the project to demonstrate models and results

by the midterm. Going forward, the project has two options: (1) close out in September 2013 as originally

planned; or, (2) extend HUP beyond its planned close-out date in order to overlap with the eventual launch

of NUHM. As a sequel to option (1), there could be follow-on TA to NUHM once HUP has amassed a

larger evidence-base for how to operationalize urban health. The benefits and costs of each of these options

are summarized below:

Option 1: Close HUP in September 2013 as planned.

• Benefits include following the proposed timeframe and budget allocation.

• Costs include the removal of any capacities already built because of the delay in NUHM launch, as

well as the shortening of implementation by one year.

Option 2: Extend beyond original closure date to have an overlap with NUHM launch.

• Benefits include higher return on investments (ROI) and the recapture of time lost at the beginning

of the project.

• Costs include the requirement of a higher budget outlay and the additional effort needed to get

GOI/state concurrence for the extension.

Option 3: Plan a Phase II of TA to provide longer-term support to proposed NUHM.

• Benefits include the opportunity to scale-up successful models and look into increasing the

leveraging of resources.

The ROI from HUP could be increased if the project is extended at least for a year, in view of the time lost in

the start-up phase for reasons beyond the control of PFI. Moreover, additional time would also allow further

opportunity to present the successful models developed by HUP to government (and other potential donors)

in the future, once the NUHM is launched.

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EVALUATION PURPOSE AND EVALUATION QUESTIONS

EVALUATION PURPOSE

The purpose of this evaluation is to conduct an in-depth analysis of urban-health-support activities

implemented by the HUP projects in India. The evaluation team was instructed to focus on the main

components of the project:

• Technical assistance to the Government of India (GOI) and state, municipal, and community

organizations in eight states of India

• Convergence of relevant health and development programs (primarily within the public sector)

• Public-Private Partnerships in addressing urban health service provision and infrastructure

• Community-based demonstration models in slum areas of five cities (Delhi, Agra, Jaipur, Pune,

and Bhubaneswar)

• HUP management practices and systems

The objective of this mid-term HUP evaluation is to provide an assessment of how the project is addressing

these five components after one year of project implementation (six to eight months in the case of most city

demonstration models). The evaluation addresses the extent to which HUP is developing and implementing

innovative, urban health interventions and models that can be considered for replication and scale up in

India, and possibly other countries as well.

EVALUATION QUESTIONS

The Scope of Work outlines the main evaluation questions (in order of priority) for this evaluation as follows:

• How has HUP influenced GOI policy on urban health since 2009, and what opportunities currently

exist for USAID to influence policy-level changes through HUP?

• To what extent has the project contributed to the operationalization of the urban health program at

national and state levels? What were the strengths and weaknesses of its implementation?

• How effective has the project’s technical assistance approach been in building synergies between the

public and private partners in implementation of key project strategies?

• What lessons can be drawn for future designs from the program governance system, especially its

role in promoting convergence strategies of different GOI programs?

• What has been the outcome of the slum demonstration activities under HUP? What are the key

strengths and weaknesses of these interventions and what is the opportunity for potential scale up?

• How effective are the HUP management systems, including project planning and review, grants

management, financial and procurement systems, in scaling-up project activities?

Answers to these questions at the project’s mid-term should provide useful guidance on how well the project

has been rolled out, what appears to be working and not working, and how HUP activities might be best

deployed to ensure positive results during the remainder of the project.

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The evaluation was commissioned by USAID/India Evaluation Services IQC under Task Order RAN-I-00-

09-00019 with Social Impact. (See Annex I for a copy of the complete Scope of Work.)

PROJECT BACKGROUND

In India, the urban poor are among the fastest growing sub-population, with migration a major factor

contributing to this increase. The urban poor are especially vulnerable, owing to cramped living conditions,

low quality housing, and limited access to clean water, sanitation, and health services. The health services that

are available are often of poor quality, understaffed, and have insufficient medicines and outreach to urban

slum communities. Thus, it is not surprising that health indicators for the urban poor are low, and some

indicators1 are worse than the averages of the rural populations. Although such circumstances present a

compelling argument for addressing these needs, urban health has not been a priority issue and receives less

attention than rural health care.

USAID/India began developing an urban health programming strategy in 2001–2002 with the launch of the

Environmental Health Project-India (EHP/India). In 2005, EHP/India began the transition to become a

nonprofit NGO, the Urban Health Research Center (UHRC). USAID/India has focused on active

engagement and partnership with the MOHFW/GOI to effect improvements in urban health in India at

scale. USAID also has a long history of providing assistance for improving water and sanitation facilities in

urban areas. The agenda has focused on three principal areas:

1. Building knowledge on the extent and nature of health challenges among the urban poor and using

this information in advocacy efforts among the GOI, states, cities, and other stakeholders, e.g.,

NGOs and the private sector

2. Developing city-level programs to model creative, effective, multi-stakeholder approaches to address

urban health challenges

3. Providing technical assistance to the GOI, states, cities, and other stakeholders to promote policy

change, planning and implementation of new urban health initiatives

The GOI has responded to increased attention on health needs of the urban poor by forming the Urban

Health Task Force under the NRHM and in 2009, proposed the NUHM. In response to the anticipated

NUHM, the HUP project, the focus of this evaluation, was designed to work at state, municipal, and

community levels to develop innovative policies and program strategies to better meet the health needs of the

urban poor.

HUP project objectives include the following: (1) Provide quality TA to the GOI, states, and cites for

effective implementation of the NUHM; (2) expand partnerships in urban health, including engaging the

commercial sector in PPP activities; (3) promote the convergence of different GOI urban health and

development efforts; and (4) strengthen the evidence-based rigor of city-level demonstration and learning

efforts in order to improve program learning. The project’s main focus is on maternal and child health, the

improvement of water and sanitation facilities, and nutrition. One of the project’s primary objectives is to

design and field test new service delivery and community mobilization systems that could prove effective in

reaching India’s rapidly growing urban slum population.

1 Proportion of households with access to piped water at home; proportion of stunting, underweight, and anemic children; immunization (completely immunized,

measles coverage); proportion of children with diarrhea receiving ORS. Source: reanalysis of NFHS-3 data.

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Because the launch of the NUHM has been delayed, the TA component of HUP has been aligned with the

urban health component of the existing NRHM/RCH program. Consistent with the MOHFW priority of

providing focused attention to underperforming “Empowered Action Group” states, HUP is being

implemented in the following states: Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan,

Uttarakhand, and Uttar Pradesh, in addition to five cities. The city demonstration models were initially started

in Bhubaneswar, Jaipur, and Pune, with Agra and Delhi added later.

The Cooperative Agreement (for the total sum of INR 513,601,582/US$10,778,627) was awarded to PFI to

provide support to USAID/India’s HUP program. (Approximate budget allocations are listed as follows:

62% for TA; 12% for PPP; 14% for convergence; 11% for city demonstration models). HUP is the first

USAID award made directly to an Indian NGO. GOI approval had not been obtained prior to awarding the

Cooperative Agreement for HUP in September 2009, thus delaying project implementation for ten months.

During this time, PFI was not permitted to implement activities, including staffing for the PMU and the eight

state and five city projects. As a result, the project has been operational for a maximum of one year and in

most demonstration sites, for only six to eight months. The four-year project is scheduled to end by

September 30, 2013.

EVALUATION METHODS & LIMITATIONS

METHODOLOGY

The evaluation was conducted by two U.S. and three Indian consultants over a period of four weeks in-

country during June and July 2012. During the first week, team members met to plan the evaluation strategy

and clarify with USAID the meaning of specific questions and other evaluation issues. The main information

sources included project and partner documents, key informant interviews, and site observations. Prior to the

evaluation, site selection was made by the USAID Health Office and PFI, and later amended by the

evaluation team in consultation with USAID’s Program Office. Each team member had primary

responsibility for specific project components that matched the consultant’s areas of expertise (refer to

Annex II, Evaluation Calendar).

Document Review: The evaluation was informed by an extensive review of key HUP project

documents, including three research reports (produced by HUP’s technical partners), in addition to

reports from the GOI, state and municipal governments, USAID, and other international

organizations (documents reviewed are listed in Annex III) .

Interviews: The gathering of field evidence largely was guided by interviews with stakeholders

involved in the HUP project, including the following: (1) senior officials from the Ministry of Health

and Family Welfare, Government of India, in New Delhi; (2) state-level Ministries of Health; (3)

municipal health offices; (4) state ministries and municipal offices working in development sectors

convergent with urban health, e.g., Ministry of Urban Development, the Ministry of Women and

Child Development, Municipal Departments of Water and Sanitation, and the Ministry of Education,

etc.; (5) Population Foundation of India (including the former PFI executive director and first HUP

chief of party), and HUP partnering organizations; (6) community organizations and health facilities

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in urban slum areas; and (7) bilateral and multilateral organizations and foundations working in urban

health (a complete list of interviews conducted is found in Annex IV). Examples of the interview

forms developed for state and municipal health offices, PFI and HUP-partnering NGOs, and

community health workers and facilities used for collecting evidence are presented in Annex XVIII.

Site Visits: Because of time constraints, the Evaluation Team was only able to visit four of the eight

HUP states (Madhya Pradesh, Odisha, Rajasthan, Uttarakhand) and four of the five city

demonstration models (Bhubaneswar, Delhi, Jaipur, Pune). These sites provided a representative

depiction of HUP activities and progress to date. Additional information was sought from states not

visited by the evaluation team.

Data Analysis: The findings of the evaluation are based on an analysis of the data collected from

several sources, including detailed notes from interviews and site visits, in addition to extensive

document review.

The evaluation methodology utilized by this evaluation also includes an assessment of quantitative

results generated by the project’s MIS over the first year of implementation and extensive data-

gathering in the field through group discussions and in-depth interviewing. Quantitative results are

largely drawn from the HUP MIS system that has been established for the project.

At the end of the in-country evaluation, the midterm assessment (MTA) presented preliminary findings to

USAID/India and PFI. Feedback from these debriefing sessions was taken into consideration when writing

the HUP Evaluation report.

LIMITATIONS

Prior to the evaluation team’s arrival in India, a detailed schedule for visiting HUP field sites had been

organized, although without prior consultation with the evaluation team. This delayed the beginning of field

work, since discussions about the criteria for site selection based on evaluation objectives and reconfiguration

of the visitation schedule was necessary. The evaluation team visited as many sites as possible; however,

additional time could have been allocated for some sites (e.g., Madhya Pradesh, Uttarakhand).

Although USAID and PFI had assembled many documents as background prior to the evaluation, during the

time in-country there were some delays in providing requested HUP documentation, pushing the timeline

back further than anticipated. In addition, all documents requested during visits to the state and city sites had

to be cleared by the PMU before being provided to the evaluation team, delaying access to this information.

The midterm evaluation was undertaken at a time when the project had been in operation for a little more

than a year. Hence, many of the activities are either at an early stage of operation (e.g., convergence) or are in

the process of development (e.g., PPP models), making it difficult for the project to disseminate evidence-

based models for adoption at state or city levels.

Another limitation pertains to quantitative indicators. The indicators are primarily administrative process

measures reporting on activities being implemented by the project. It is therefore not possible to compare

project outcome and impact indicators with baseline measures in the city demonstration models, since

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activities in these sites only began in late 2011 and early 2012 (see below for a more detailed discussion on

measuring project achievements).

MEASURING EVIDENCE OF HUP PROJECT ACHIEVEMENTS

The HUP project has developed an MIS for the project that addresses the four main objectives of the project

(technical assistance to national, state and municipal government; convergence activities; public-private

partnerships; and demonstration models in urban slums). At the present time, the project is reporting on 35

process and outcome indicators (see Annex V) that report on annual and quarterly activities undertaken by

the project. This information is used to report to USAID and the GOI’s Ministry of Health and Family

Welfare on progress in implementing the HUP project.

Many of these indicators pertain to administrative initiatives for assessing project activities. For example,

there are indicators that report on the number of meetings, training sessions, study tours, and reports

produced by HUP over various reporting periods. While it is important to track such activities, they do not

provide much information on the relevance and effectiveness of these initiatives. The current MIS has not set

“planned versus actual” expectations for individual indicators, which makes it difficult to determine whether

the project is on track for achieving key objectives and influencing urban health policy and program

outcomes.

Indicators currently being reported by the project’s MIS cover the period from June 2010 through July 2012.

They show that the project is actively engaged in working to achieve its four main objectives. However, since

the project is still in its start-up phase, some results are fragmentary. Some state and municipal activities are

still under development (e.g., states and cities developing and implementing urban health plans with HUP

assistance). These may not yet appear in the project’s MIS as an activity that has been formally inaugurated,

let alone completed. In addition, many of the process indicators in the project’s current MIS only provide a

partial picture of what the project is attempting.

Additional information that the project will be generating promises to give a more complete accounting of

HUP program outcomes, as well as demographic and health impacts. For example, HUP has been busy

establishing demonstration models for urban health in five cities over the past six to eight months. While

participating slum communities have been identified, field offices established, and frontline workers recruited,

the project is still working to establish and regularize its community-based record keeping and reporting

systems. The MCHT system, managed by the project’s cluster and link workers (LWs), is currently deployed

in all demonstration cities. This information is only now beginning to report on contact information with

households, assistance provided to beneficiaries (including immunization services at Anganwadi Centers and

other government facilities), community-based initiatives to address local health needs (like the UHND

activity), and support provided to government outreach (auxiliary nurse midwives [ANMs], and accredited

social health activists [ASHAs]) and facility-based health workers. Once this information is systematically

reported and measured over time, interested stakeholders will be better informed on what difference HUP is

making to the lives of women and children in its demonstration sites.

Another important data source for HUP is the Baseline Survey, implemented by the International Institute

for Population Studies (IIPS). This survey has been conducted in three of the project’s five demonstration

cities (Bhubaneswar, Jaipur, and Pune). The Baseline Survey questionnaire essentially is a slimmed-down

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version of the Indian Family Health Survey (IFHS) questionnaire. It collects information on household

characteristics; pregnancy histories for deriving fertility and infant/child mortality rates; family planning use,

contacts with health personnel; pregnancy, delivery, and postnatal care; immunization and health; gender

relations; and STI/HIV vulnerability. The survey covers urban slum communities where the HUP

demonstration models are working and non-slum urban settings that can be used to assess levels and trends

in slum and non-slum urban settings.2

It is worth noting that quantitative performance indicators are only capable of telling part of the HUP story.

There is also an important role for more qualitative research approaches that collect evidence from the field

on the effectiveness of HUP activities. Undertaking one-on-one or small group interviews with beneficiaries

in slum communities, members of community organizations such as MAS Committees, as well as government

outreach workers (e.g., Anganwadi workers, ANMs, and ASHAs) and facility-based health workers can add

considerable richness to the interpretation of quantitative indicators. In order to generate a solid evidence

base for HUP achievements by the end of the project, investments will need to be made in program research

that will encourage the inclusion of qualitative insights into what worked and what didn’t during the life of

the project.

FINDINGS AND CONCLUSIONS

The findings of the evaluation are presented below, organized by the five major project objectives, in addition

to a discussion of overall project conclusions.

FINDINGS: OBJECTIVE ONE (TECHNICAL ASSISTANCE)

Objective One: Provide quality technical assistance to the GOI, states and cities for effective

implementation of the National Urban Health Mission (NUHM)

HUP Project Design and the Provision of Technical Assistance

The Health for Urban Poor (HUP) Project is a response to the growing needs of the urban poor. The

programmatic and research efforts of bilateral, national and international agencies have generated evidence

pertaining to the growing urban need and demonstrated models of providing health care. Parallel

developments through the Jawaharlal Nehru National Urban Renewal Mission (JNNURM) and its sub-

component, Basic Services for the Urban Poor (BSUP), have begun to address the developmental

infrastructure needs and critical health determinants like water and sanitation in the urban areas of the

2 Preliminary results for several key impact indicators from the three city Baseline Survey are presented in Annex VI. The complete Baseline Survey report was not

available to the MTA team during the period of this evaluation. Preliminary results show that residents of urban slum communities are generally disadvantaged

compared to non-slum urban residents, particularly with respect to household living conditions, water and sanitation facilities, utilization of safe delivery services,

child immunization, TB incidence, and HIV awareness. However, it was also found that slum residents were not notably deficient with respect to family planning

use, Vitamin A supplementation, and the practice of exclusive breastfeeding. It is worth noting that the Baseline Survey does not differentiate between authorized

and non-authorized urban slum communities. Residents in non-authorized slums are generally considered to be living in more difficult circumstances in terms of

access to health services, reliable electricity supplies, and WASH infrastructure. In many cities, non-authorized slums constitute the majority of all slum

communities (and in cities such as Dehradun in Uttarakhand, it is roughly 90 percent of all slum areas).

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country. Similarly infrastructural inputs and mechanisms to address nutrition of the urban poor have been

universalized through the Integrated Child Development Services (ICDS) scheme.

However, the core of any health policy or plan, the delivery architecture, does not exist in the urban areas to

utilize the evidence or leverage complementary support. The proposed National Urban Health Mission not

only addresses this gap, but envisions the delivery of urban health care within the context of urban

development. This gap, the absence of the health delivery architecture, while it presents a challenge to the

HUP program, also presents a great opportunity for informing the design and implementation of NUHM

once it is approved.

The HUP project was designed with the objective of providing TA to the proposed National Urban Health

Mission. However, in the absence of NUHM and a clear incentive for states to address urban health issues,

HUP took up the task of facilitating the creation of demand for urban health services, as well as the

institutions and structures in partnering states and cities. The expectation of NUHM and its subsequent delay

from the expected launch in 2008 has kept many states waiting for guidelines on structures, systems, funds

and functionaries for addressing urban health. HUP had the difficult task of working against this inertia in

some states while trying to utilize the vision of other states to facilitate advancement of policy and

implementation frameworks. Therefore, the project picked-up momentum late because of the delay in

approval of HUP by the government, the time needed to establish HUP teams in different states, and changes

in PFI and HUP leadership early in the project.

The design of the HUP project is largely geared to MCH interventions (e.g., antenatal and safe delivery

services for pregnant women and child immunization), water and sanitation infrastructure, and nutritional

services. This focus largely circumscribes the range of TA initiatives that can be supported through HUP.

However, a comprehensive public health approach to urban health would be far broader in conception than

HUP’s current RCH/MCH strategy and include both infectious and non-communicable disease. For

example, a broader public health focus would address infectious diseases such as malaria, TB, polio,

meningitis, sexually transmitted infections (STI) (including HIV and AIDS), and newly-emerging infections

(e.g., avian flu). Chronic conditions such as cardiovascular disease, diabetes, and metastatic disease that occur

more commonly in adults would also be admissible as part of a comprehensive urban health strategy. These

broadened agendas will need to be addressed in the NUHM framework when it emerges. While it is beyond

the scope of the HUP Project to field-test a more comprehensive public health approach to urban health, the

project will need to reflect on how future demand generation and service delivery strategies can best support

a public health as opposed to RCH/MCH approach to serving the urban poor.

Key Observations and Findings Pertaining to TA Provision

The key findings and results achieved under objective one are discussed below. Also presented is an ‘urban

health potential matrix’ which identifies the stages (health systemic) of the evolution in urban health

programming; juxtaposes that with activities carried out by the HUP; and, delineates potential for action

within the context of varying state level environments. The matrix is followed by a brief discussion on the

impeding and facilitating factors; and the prerequisites for realizing the opportunities presented to the HUP

team. Either by design or fortuitously, HUP’s presence in eight diverse policy environments presents an

opportunity to demonstrate actions required to accelerate the development of urban health programming at

each stage of the evolution.

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The stages in the evolution of UH programming and the mapping of TA provided by HUP against this

background are illustrated in Annex 7.

There are highly variable policy environments for urban health across the states where HUP

is deployed: All states are at different stages of the ‘urban health programming evolution’. While

states like Uttarakhand have not only articulated their priority for urban health and introduced

interventions, but also been innovative with expanding Rashtriya Swasthya Bima Yojana (RSBY)

universally to the urban poor, states like Rajasthan await the arrival of NUHM before developing a

clear vision for their urban program.

The national level TA provision is strategic in nature: The impetus to establish relationships and

relevance of urban health programming is evident at the national level. A series of consultations and

advocacy efforts have resulted in a strategic position for the TA team at the national level. The

support provided to NUHM (e.g., multi-stakeholder consultations; substantive contributions to the

development of the NUHM document; and support to technical review of the urban RCH

component of the NRHM PIPs, are valued by GOI.

HUP is recognized as an urban health partner by state governments: HUP teams have

established a functional and/or valued partnership with the state governments. The HUP teams at

the state and city demonstration level are continuously responding to the needs of the state and

program management requirements. Initial orientation and advocacy consultations have been

uniformly appreciated by the recipient states. Common feedback at all levels of government was, “we

were not aware of the various schemes that this department could leverage from other sectors to

strengthen our programs.” The acknowledgement of HUP as a partner differs from state to state.

Similarly, the state ownership of HUP varies as well. The most common impeding factor cited for

fostering relationship and ownership is the perceived absence of any communication from GOI or

advocacy by USAID to establish HUP as the preferred partner in urban health programming.

HUP has provided a wide range of TA: HUP has provided a wide range of TA to the national,

state and city level governments in a short span of time. These include guidelines for tools, policy

papers, policy drafts, memorandum of understanding for partnerships, development of PIPs,

monitoring models and capacity building for implementation. A map of TA support provided at the

national, state and city level is provided in Annex VIII.

A detailed description of TA efforts provided by HUP for capacity building is presented in Annex

XXI.

There is no mechanism and advocacy effort in place yet to develop a comprehensive urban health

plan (with the exception of Madhya Pradesh (MP) where this was an explicit request from the

government to HUP for assistance in developing an urban health framework), which could serve as a

precursor to NUHM and facilitate the participation of all available partners, including HUP towards

a collective vision.

Budgets for urban Reproductive and Child Health (RCH) have increased in some HUP

states: An attempt was made to analyze the urban RCH budgets and expenditure for HUP and non-

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HUP states from 2010-13. While some HUP states have increased budgetary plans for urban RCH,

others have decreased it over the same period. The data gleaned from a web search for the non-HUP

states indicated that urban health budgets have often decreased in recent years. However, interaction

with the HUP staff supports the view that their presence may have facilitated broader urban health

planning and an increase in urban RCH budgets. Annex IX presents a table which captures the

budget analysis conducted by the evaluation team.

TA is currently fragmented – Project work plans do not emanate from an overall state urban

health plan: Despite the consideration of state-level needs and state government input into HUP

plans, no structural mechanism exists to formally involve state governments and partners to develop

the work plan. However, analysis of the urban RCH program implementation plans in Rajasthan,

MP, Uttarakhand, Odisha reveals an opportunity to work in tandem with state governments on

urban health planning.

TA to promote nutrition is focused on developing policy briefs, advocacy for convergence,

guidelines for implementing urban health and nutrition days (UHND), implementation of UHND,

PPPs for strengthening nutrition interventions in urban slums and establishment of nutrition

rehabilitation centers. (The UNDF strategy and its effectiveness are discussed in the section on

Demonstration Models.) Gaps like limited physical space in Anganwadis (Jaipur); non-availability

outreach ANMs (Delhi); and, non-availability of IFA/deworming tablets and salter scales (Jaipur and

Delhi) limit the implementation of the range of activities delineated in the UHND guidelines.

TA to promote WASH: This issue is discussed in the section on Convergence.

TA to promote gender equity and male engagement as articulated in the project work plan is

limited to re-analysis of National Family Health Survey (NFHS) data and the gender gap analysis, the

former completed and the latter initiated. The MCH/RCH focus of the project lends itself to

addressing gender equity in health outcomes. Male engagement was not observed in the community.

There are no specific activities to engage the men in the community and the groups facilitated by

HUP do not have male participation.

Opportunities for leveraging potential areas of growth not currently optimized: The mapping

in Annex VIII indicates the participation of HUP across the various levels of urban programming.

However, several opportunities to address critical programming gaps have not been utilized and

opportunities to leverage potentials that exist are not on HUP’s radar. Public Health support to the

states and cities are defined by the capacities within the state teams. Indicative examples of

opportunities as observed and discerned during the field visits include:

Table 1: Potential Matrix for HUP

STATE LEVEL

CITY/DEMONSTRATION LEVEL

• Development of a comprehensive urban health

vision in Odisha and Uttarakhand

• Delineation of service norms for primary care

(Rajasthan), secondary care (Uttarakhand/Odisha)

and referral mechanism (all three states)

• Mapping of slums and health facility assessments (Rajasthan and Delhi)

• Analysis of parameters of service provision quality (Jaipur/Bhubaneswar)

• Identification of primary health structure and promotion of preventive

outreach (Delhi)

• Coordination with Municipal Health Officer to improve primary care (Delhi)

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• Rationalization of services provided by varied

urban facilities – dispensaries, urban health posts,

urban health centers

• Policy inputs on the transition of health from

department of health to Urban Local Bodies

• Utilization of data for decision making (all three

states)

• Structured inputs to three key departments on

gaps in service provision

• Advocacy/TA for making water supply and

sanitation accessible (key performance indicators)

• Line Coordination with ULBs/facilities to improve service provision

(Jaipur/Bhubaneswar)

• Expanding scope of urban RCH to include family planning, adolescent and

reproductive health, STIs, RTIs, PMTCT (Odisha/Rajasthan)

• Promotion of Intra health convergence to improve access to non-RCH

services (malarial prophylactics in health centers, information about nearest

DOTS center, promoting linkages between facility and DOTS/ICT centers

(Jaipur/Bhubaneswar)

• Coordination and advocacy for critical supply issues - chlorine tablets, IFA,

deworming tablets, salter scales

• Delineation of roles for front line workers – ASHAs, LWs and Anganwadi

workers (Odisha)

• Convergence of critical community level groups

• Operations research on models of urban community participation –

incentives and disincentives

CONCLUSIONS RELATED TO TA

HUP’s Influence on Urban Health Policy: HUP has contributed to the delineation of GOI policy

on urban health by generating participation of multiple stakeholders to inform the NUHM. HUP has

helped GOI draft the NUHM mission document through evidence generated by earlier USAID

programs. HUP is in the process of generating evidence, which has the potential to inform revisions

(if required) in the mission document. However, HUP’s contribution at the state level is limited to

operationalizing urban RCH as mandated under the project log frame.

USAID has a unique advantage in the form of HUP phases, which are at varying degrees of maturity

in the evolution of urban health programming. HUP provides a fertile ground for demonstrating

operational mechanisms within varying environments – a potential for influencing accelerated

implementation of NUHM by the Indian states upon its inception. Furthermore by facilitating the

development of a comprehensive urban health vision in HUP states, USAID has the opportunity to

create additional demand for NUHM.

HUP’s Contribution to the operationalization of the urban health program at the national

and state levels: The scope and range of HUP assistance is limited to RCH/MCH/WASH. Several

opportunistic interventions enabled by the environment are being attempted. However in the

absence of an overarching urban health plan/vision in the states, HUP will benefit by redefining its

approach to TA; namely, to one which creates a favorable and capable environment for the

implementation of NUHM in its broadest conception as a public health program. A series of

discussions with USAID and HUP reveals an operational reluctance to expand the current

MCH/RCH scope. While current efforts are fragmented, the urban RCH PIPs 2012–2013 indicate a

maturing urban health programming in the HUP states. The budgetary requests from states and

approvals by GOI have increased in some HUP states (Jharkhand and Odisha). It was not possible to

assess whether this can be attributed to HUP. However, This could provide an opportunity to

support the operationalization of a focused urban RCH program. Indicative interventions in the PIP

include: rationalization of health facilities in Rajasthan, strengthening secondary level services in

Odisha, and convergence of other national health programs in Uttarakhand and MP.

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Assessing TA Effectiveness: The MTA Team observed that the HUP project is currently not

addressing several relevant TA opportunities that could strengthen the delivery and utilization of

health services to urban slum communities. Performance indicators that could track these additional

activities are not well-developed by the project. Several additional TA initiatives that could be

assessed include the following:

• Undertaking greater in-depth analysis of urban health needs and profiles of service

availability and utilization in each state participating in the HUP Project.

• Organizing and conducting more comprehensive health facility assessments in each state.

• Preparing policy assessments on the scope of urban health services beyond RCH/MCH, as

has been done recently in Madhya Pradesh.

• Developing an integrated MIS framework for capturing both RCH and other indicators for

urban health.

• Working to identify priority needs for strengthening secondary level services.

• Developing guidelines for the referral of beneficiaries to higher levels of care.

• Identifying institutional mechanisms for promoting community level convergence in the

delivery of health services and required health infrastructure.

• Designing program research studies to generate evidence on incentives for community

action/mobilization for urban health.

FINDINGS: OBJECTIVE 2 (PUBLIC PRIVATE PARTNERSHIPS)

Objective 2: Expand Partnerships in Urban Health, including engaging the commercial sector in

Public Private Partnerships (PPP)

The draft report3 on the Urban Health Task Force under the MOHFW, GOI recognizes that contracting the

delivery of health services to the private sector is a viable option to consider as government health facilities

do not have adequate reach in urban slums leading to low demand and poor utilization.

The project had a specific objective of harnessing the capacity of the private sector that includes both the

NGO and the for-profit sector, as expressed by its Objective 2. For PPP, the success of models depends on a

variety of factors ranging from the presence of a structure to administer contracts in the government,

willingness to tap non-government resources, identification of proper opportunities to leverage such

resources and clarify roles and incentives of each partner. In the absence of the NUHM, none of these

success factors for PPP existed when HUP was launched. The efforts of the HUP team to create demand in

state governments for urban health strategies, structures and systems has been continuing in this difficult

context.

Although there are many challenges, the HUP was successful in facilitating some positive change in the policy

and organizational attributes for PPPs, even though there is still much that needs to be done.

Activities and Achievements Related to Public-Private Partnerships

3 Draft Final Report of the Task Force to Advise the National Rural Health Mission on “Strategies for Urban Health Care”. May 2006. Source:

http://www.mohfw.nic.in/NRHM/Task_grp/Report_of_UHTF_5May2006.pdf. Accessed 15 July 2012.

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Considering the limited time the project has been operational and the different levels of interest in the

partnering states, progress in developing PPP models ranged from advanced to nascent. States that had

already launched PPP models at their own initiative (e.g., Uttarakhand) were supported by the HUP team

with enthusiasm. In others, more time was required to lay the groundwork, as well as generate interest in state

governments for supporting potentially effective PPP models. The MTA team considers the very effort of

integrating PPP into state plans for addressing Urban Health laudable, regardless of the achievement as

outcomes in the field. Some of the indicators on which the project reports (mostly on PPP workshops and

meetings held), are reported in Annex 5.

Facilitation of PPP models by HUP

The PPP models in HUP that are in implementation or at discussion stages at present are either a

Government-NGO model or those that involve the Corporate Social Responsibility (CSR) wing of an

organization. HUP is discussing development of PPP models with a number of potential partners, e.g., Bharti

Vidyapith and Kirloskar Foundation in Pune, Lupin and Narayan Hrudayalaya Hospitals for Rajasthan,

Ambuja Foundation and Titan Industries in Dehradun. However, most of these models will require more

time to be finalized, as the roles and incentives of each partner are still unclear. The types of models being

developed by HUP are noted in Table 2 (below) with the details of each model discussed in Annex X.

Table 2: PPP Contracting Models with HUP Assistance in States/Cities

STATE/CITY

MODEL IN HUP

ARRANGE- SERVICE PROVIDER

MENTS

DESIGN SELECTION

Urban Health Centers GOV-NGO

in slums4

Mapping potential

partners in

Commercial sector

(e.g. Kirloskar-Pune;

Lupin – Rajasthan, MP;

Sea-shore – Odisha)

HUP–

Commercial

Partner

GOV

Commerci HUP

al Partner–

HUP

SERVICE

INFRA-

FINANCING

MANAGEMENT STRUCTURE

/ MONITORING

GOV-HUP

GOV

Commercial

Partner–HUP

GOV

Commercial

Partner

Adopted from: Loevinsohn, B. (2008)5

Bolded black text in specific boxes denote scope for further involvement of HUP in future.

Key Observations and Findings related to PPP

Limited funds for Urban Health PPPs in NRHM: In the absence of a National Urban Health

Mission and appropriate structures for delivering public services in health in urban areas, a small

percentage of funds allocated for the urban RCH program in the states often remains largely unutilized.

However, the lack of substantial funding dedicated to urban health issues at the state departments of

Health & Family Welfare also limits the ability to contract NGOs for rendering service in urban slums.

4 In Uttarakhand

5 Loevinsohn,B. Performance-Based Contracting in Developing Countries. A Toolkit. The World Bank. 2008.

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PPP model development and contractual arrangements are in initial planning stages and would

require time to bring clarity regarding the roles of each partner: In most states, the project activities

started only a year ago; hence, the time available for project teams to discuss and agree on effective PPP

models with government or private partners was limited. A number of PPP initiatives are still under

discussion in Pune, Jaipur, Dehradun, and other areas. It takes time to establish a clear delineation of the

roles and incentives of each partner, followed by creation of contractual arrangements and arrangement

for financing. Almost all government and private sector officials met the requested assistance on

contractual documentation and administration.

Lack of specific PPP policies in urban health in states: Some states, like Odisha and Uttarakhand,

have a state level PPP policy and all government departments, including Health and Urban Development,

are expected to remain within this framework. Therefore, although a PPP policy specifically for such

departments does not exist at present, the HUP teams in some states (e.g., Rajasthan, Odisha) have

initiated dialogues for assisting governments in creating department-specific PPP Guidelines.

Need for PMU guidance on PPP: Development of PPP models are largely left to the initiative of HUP

state and city teams, under the monitoring of the PMU in Delhi. However, owing to the delayed

recruitment in mid-2012 of the PPP Specialist in the PMU, guidance for this thematic area to the state

HUP teams was limited.

City teams do not have dedicated PPP resource: City teams lack a dedicated PPP specialist. Pune has

only a city model (and no state team), while Jaipur and Bhubaneswar have both state and city teams,

although the latter does not have a PPP specialist. It appears that cross-sharing of experiences and skills

across state and city teams has been limited, resulting in reduced support for multiple themes, including

PPP. The Odisha state and city teams, however, seem to have attained better convergence between them,

perhaps due to the prior experience of the PPP specialist in NRHM functions and good integration of

actions within both teams.

Knowledge products on PPP have not yet received government attention: A draft PPP study,

“Public-Private Partnership in Urban Health,” was published by the HUP team in December 2011, but

has not yet been reviewed by the government. The study describes a number of PPP models, including

urban health slum centers; mobile medical units; hospital management through partnerships; partnerships

with individual providers; and out-contracting of diagnostic facilities.

Government prefers NGOs to commercial sector for PPP: At the national as well as state levels,

government officials have shown decidedly more inclination towards including NGOs in PPP, rather

than the commercial sector. Interviews conducted with the commercial sector during field visits reveal

that most of the CSR initiatives of for-profit organizations also prefer to work with NGOs and have

limited or no interaction with government functionaries beyond the front-line workers.

Lack of clarity on value of alternative insurance models: PPP models in community insurance have

not been developed yet in the HUP project, perhaps due to the lack of a clear understanding with all

stakeholders regarding the value of such an approach, and compared to the public health insurance

scheme for the poor advanced by RSBY. Although the project supported a draft study, “Micro Health

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Insurance Schemes in Urban India: A Compendium” in March 2012, which discusses the different

models of insurance, it has not been disseminated.

Need for a dedicated PPP structure in government for urban health: PPP cells exist in most states

under NRHM, but an equivalent structure for urban health has yet to be established. Until states and

cities decide on whether the Health Department or Urban Development Department in the state

governments takes the leadership role in addressing urban health issues, cells for themes like PPP are not

expected to be created. Discussions with government officials in Bhubaneswar and Pune reveal that,

although there is a felt need for such a dedicated Cell to deal with PPP issues, it is still not clear which

department would house it.

CONCLUSIONS RELATED TO PPP

Absence of substantial funds and limited state attention on urban health affects development of

PPP models. Since most states allocate a small fraction of the NRHM budget for urban health, the

attention provided to urban health issues varies by state. Uttarakhand has had better success focusing on

government-led models to address urban health, perhaps due to a higher allocation of urban funds in

NRHM. Other states and cities appear to be waiting for dedicated funds from the proposed NUHM

before deciding on substantive actions on urban health.

Addressing incentives of each PPP partner is imperative for success and can work well through a

facilitator like HUP. The HUP team in Bhubaneswar has successfully addressed the incentives of the

private and public sector to harness the combined strengths into a good PPP model. It seems unlikely

that such a fruitful collaboration would have been established without the active facilitation of the well-

experienced HUP team.

Developing scalable PPP models through involvement of the commercial sector is possible when

business interests of the organization lie in the same domain. Although a number of CSR initiatives

are running in many states across the country (e.g., Kirloskar group assisting community schools on

WASH issues), these are mostly stand-alone examples and the scalability of such models is often

questionable. Creating scalable PPP models requires integration of CSR initiatives with business interests.

The Seashore example in Bhubaneswar, or the possibility of Lupin’s engagement through the HUP

project to run Urban Dispensaries in Rajasthan, exists primarily because of a strong business presence in

the field of healthcare.

Low-cost community health insurance models can be developed only if there is clarity on the

design of particular models that can be adopted in specific areas. The complementarity of

alternative insurance models to the national RSBY program is not clear at government or project levels.

The study on micro-insurance models does explain the different models existing in the country, but

advocacy to adopt particular models based on an actual needs assessment of specific areas is still not

available.

FINDINGS: OBJECTIVE 3 (CONVERGENCE)

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Objective 3: Promote the convergence of different GOI urban health and development efforts.

A number of national development programs are implemented in urban areas through various ministries.

Notable among them are JNNURM, ICDS, and NRHM (through its urban RCH component), which focus

on poor and vulnerable populations and (except for NRHM) have a slum-centered approach. If the proposed

NUHM is launched, it will take the lead role in urban health issues. However, because these programs are in

organizational “silos” under different ministries and departments, approaches to provide services in a

collaborative fashion are still far from optimum (refer to Annex XI: “Key Government Programs for the

Urban Poor in India”). Promoting convergence among all these different initiatives through joint planning,

demonstrating city-based models, and creating evidence is a key component of HUP.

A schematic representation of these areas covered by government departments and where HUP interventions

are targeted is shown in Fig. 1 below.

Fig. 1: Convergence Objectives of HUP

Convergence between

HFW and Nutrition

through: policy,

planning, health and

nutrition days,

connecting urban

ASHAs and AWWs,

hiring link workers in

urban slums to bridge

gaps etc.

Health

(DoHFW)

Convergence between HFW and

UD through: policy, IEC,

connecting municipal health

personnel with ANMs and ASHAs,

covering unregistered slums etc.

Nutrition

(DoWCD)

Water Sanitation

& Hygiene (urban

local bodies

under DoUD)

Convergence between

Nutrition and UD through:

IEC for hand washing and

other hygiene metrics.

Convergence of MNCHN

and WASH activities through

Mahila Arogya Samiti,

creating joint declaration

through the Secretaries of

three departments, etc.

The urban slums thus provide a unique opportunity to converge services at the beneficiary level, which are

delivered through multiple public agencies. Inclusion of convergence as one of its major objectives was a

strong advantage for HUP, as the need for such an intervention in India has been acknowledged. Reforms at

the urban, local-body level, a major objective of the JNNURM program of the national government, would

necessitate policy convergence between the different public agencies working for the common beneficiary,

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i.e., the urban poor. The JNNURM Overview6 states, “While several reform initiatives have been taken, e.g.,

the 74th Constitutional Amendment Act and model municipal law, there is potential for further reform-

oriented steps in order to meet the development objectives.”

The Request for Application (p. 17) of the HUP project recognizes the importance of planning coordination

for all these efforts at district level. It argues that “[c]oordinated, multi-stakeholder consultations to get buy-in

from multiple stakeholders and avoid duplicating such efforts, coordinated slum situational analysis to

prioritize and optimize resource allocation from multiple initiatives, and use of shared geographic information

systems for planning purposes are examples of common efforts” that could benefit the government programs

focused on urban poor.

The inclusion of WASH in HUP was a continuation from USAID’s Point of Use for Zink (POUZN) Project,

which aimed to reduce one of the leading causes of illness and death among children worldwide—diarrhea—

by using two proven methods: (1) preventing diarrhea by disinfecting water at its point of use (POU); and (2)

treating diarrhea with zinc therapy.

Activities and Achievements Related to Convergence

The performance indicators for convergence, as measured under Objective 3, include process indicators like

the number of consultation workshops, number of letters issued jointly by the departments of Health and

Family Welfare, Women and Children Development, and Urban Development (HFW, WCD, UD), number

of exposure visits held, etc. Neither annual nor quarterly progress reports reflect progress on the basis of

“planned versus actual” for any of the components and thus do not allow for clear assessment or

measurement of progress. HUP’s key indicators to measure progress on convergence included: meetings held

with stakeholders at GOI, state, and city levels with respect to convergence, coordination committees formed

and meetings held, letters and circulars jointly issued by health and other related departments, consultations

and workshops organized to bring in convergence and trainings and exposure visits to successful

coordination programs.

It was discussed during the field visits that the states that responded positively to these initiatives are planning

to move ahead through actions such as: transfer of NRHM urban health budget to municipalities, linking

WASH indicators to NRHM’s monitoring framework and planning to create separate budget lines for urban

health in the Urban Development Department. Even if the state government’s vision is the key factor in

initiating such long-term changes, HUP undoubtedly has contributed to such development in the limited time

it has been operational. However, the indicators required to capture the facilitation role of HUP for such a

paradigm shift in policy and institutional framework in states does not exist at present. The summary of

activities at process level that are being pursued by HUP at present is shown below:

Fig.2: Convergence activities in HUP at different levels

6 Source: !! !" ! !%#$$!#$! , p. 6. Accessed July 17, 2012.

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Workshops/Consultations

Joint statements from

HFW, WCD and UD

Exposure visits to states

Lessons adopted by

NRHM (urban)

Ward Committee

STATE

CITY

WARD

SLUM

City Committee formation

and meetings held between

stakeholders

UHND Days

Demonstration Model

MAS formation

Table 3: Convergence platforms attempted in HUP

MAJOR PLAYERS

National government

agencies: MOHFW, UD,

WCD and PHED.

NATURE OF ACTIVITY DESIRED INCLUDED IN HUP?

Joint policies, planning, and resource

allocation.

Included in principle. National level

consultations were held in 2010.

State (and city) government

agencies: HFW, UD/PHED,

WCD

Joint policies, planning, resource allocation,

and sharing of functionaries.

Started. Joint declaration of HFW,

WCD and/or UD in Odisha with

HUP facilitation.

Donors other than USAID

Policy frameworks, sharing of international

and regional best practices, sharing program

details, harmonization of efforts.

Limited or none in sites visited.

USAID financed projects like

MCH-STAR, VISTAAR,

POUZN etc.

Related activities influencing outcomes;

utilization of presence in states.

Tried in first year.

NGOs implementing

programs in slums

Implementation of IEC/BCC activities,

distribution of resources, service delivery,

capacity building, etc.

No formal collaborative effort

observed. However, some informal

collaboration happened in some

slums.

At present, HUP convergence activities are more focused at state and city levels, apart from continuous

engagement at the national level. However, attempts to bring convergence with other donors at national or

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state levels, or with NGOs working on different aspects in urban slums, have not been observed. States

possessing a clear vision regarding methods to address urban health, especially Odisha and Uttarakhand, have

made progress on the policy front. Consultations in these states have led to recommendations on the

formation of urban c and city task forces, micro-planning at slum levels, vulnerability assessments, etc. Such

progress was not observed in all states, perhaps due to the delay in starting the HUP project, different

priorities at state level, and different levels of experience with the HUP team.

The WASH approach under the HUP project is well defined and presented in the Cooperative Agreement

between USAID and PFI.7,8 However, the performance indicator set captures only the indicator related to

improved access. Thus far, the HUP project activities in WASH have been limited to three key sub-

components: improving water quality at point-of-use, improving toilet use, and improving hand washing. In

addition, activities were undertaken at the state and city level to inform the status of urban water supply and

sanitation and to bring convergence with health and other departments. These activities are summarized

below:

At the national level:

• HUP assisted in organizing the national consultation on NUHM in July 2010, to bring together the

ministries of Health and Family Welfare (MOHFW), Housing and Urban Poverty Alleviation

(MOHUPA), and Urban Development (MOUD) to address the urban health challenges in the

country. A similar consultation was held in November 2010 involving MOHFW and MOUD. HUP

also engaged in policy analysis on WASH and provided recommendations for Women and Child

Development, Urban Development and Health and Family Welfare departments.

• The HUP team engaged with the national government on proposed NUHM discussions and has

supported the urban health division of the MOHFW by providing data, information, and helping in

organizing the consultations. It also supported MOHFW in drafting an MOU between MOHUPA

and MOHFW to improve the health of the urban poor.

• HUP contributed to the chapter on urban WASH for the UN India Water Development Report.

At the state level:

• Exposure visits were made to USAID’s POUZN program and meetings were organized with their

staff to understand the activities and adaptability to HUP strategies.

• Meetings with UHI and representatives from the Commission on Urgent Relief and Equipment

Program were held in Agra to shortlist potential slums, map objectives and strategies of the

programs, and initiate health collaborations in slums.

• Consultation on “Basic Services to the Urban Poor in Odisha: Issues and Challenges,” WESNET

meeting in Jharkhand, advocacy event in Rajasthan and stakeholder consultations held in Pune,

Bhopal, and Chhattisgarh were some of the activities that highlighted the importance of convergence

among different stakeholders.

7 This includes improving provision through adoption of shared financing arrangements by the ULBs and Private Sectors (market financing using the debt-equity

model or through the Build operate and Transfer models) with community paying an affordable price for usage; BCC on hygiene practices; evidence based

decision-making and improved planning and implementation of water and sanitation interventions targeting the urban poor; and making local government more

responsive to water, sanitation and hygiene issues

8 Source: Cooperative Agreement (dated September 25, 2009), Pg. B-18 to B-25.

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• WASH activities covered in HUP included:

- Building context and information: needs assessment and stakeholder mapping; preparation of urban

WASH profile in the state and analysis of water supply and sanitation policies; contribution to

the women’s policy and 12th five year perspective plan on water and sanitation (in Jharkhand)

- Capacity building: point-of-use approach paper; WASH indicators incorporated in NRHM’s urban

health component for monitoring in ODISHA

- Implementation/demonstration: conducting World Water Day (at both state and city levels)

At the city level:

• Building context and information: preparation of urban WASH profile in the demonstration city;

documentation of best practices

• Capacity building: WASH manual for urban local body (ULB) functionaries; and preparing WASH

manual for ULB front line workers (in progress)

• Implementation/demonstration: partnership with Mission Convergence, an initiative by Delhi

government9 to promote WASH through its two district resource centers and 124 Gender Resource

Centers (GRCs) across Delhi10; WASH awareness through HUP project staff and MAS members;

and information, education, and communication (IEC) materials developed on WASH and

distributed; wall paintings on WASH at the demonstration slums in Bhubaneswar

Findings Related to Convergence

The HUP team has been able to promote convergence agendas at state and municipal levels.

The HUP team has advocated for the convergence agenda at national, state, and city levels through

involvement of departments of Health & Family Welfare, Women and Child Development and Urban

Development. The efforts were more successful in states that already possessed a clear vision regarding

urban health issues (e.g., Odisha, Uttarakhand), or in cities where the municipal corporation (or the

Public Health Engineering Department [PHED] in Rajasthan) was eager to drive the agenda (e.g., in

Bhubaneswar and Pune). A number of states have issued joint declarations for convergence through

involvement of the three departments mentioned above. State-level steering committee formation, to

unify the vision of different public agencies as stakeholders, is at a discussion stage in some states. Certain

states hosted Urban Health and Nutrition Days (UHND), an additional good practice.

The opportunity to bring convergence at ward and city levels has been understood by most

stakeholders. The strategy of leaving behind institutions or formal and informal rules of engagement is

appreciated by some government departments. The project’s focus on defining the structure and

functions of ward-level committees and city-level committees is appreciated. In Rajasthan, the Chief

Engineer of PHED took the lead on bringing convergence with other departments, which evolved as an

alternative model.

State and municipal government demand for city demonstration models and action plans for

urban health are increasing. In most states and cities visited, the realization for the need to have

urban-specific policies and strategies seemed to be very much part of the government’s vision. Although

9 A flagship program of the Delhi government seeks to strike the right balance between various government departments, community-based organizations, and

people, towards improving governance and empowering the vulnerable populations of Delhi.

10 HUP provided technical support to Mission Converge, Delhi on formats, trainings, manual, and IEC materials on WASH to leverage its network of NGOs and

CBOs to promote WASH

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it is not possible to determine the extent to which the HUP team’s efforts can be attributed to this, the

MTA team feels that the constant supply of TA is a positive catalyst.

Activities related to donor convergence, working in different sectors or bringing the “critical

mass” of experts together, have not occurred in a structured fashion through HUP, until

recently. Although the HUP team tried to establish connections with other USAID projects in the first

year of operations (e.g., MCH-Star, M-CHIP, VISTAR, etc.), there has been no perceivable effort to

utilize the technical assistance group effectively, or to bring other existing and potential donors together.

HUP assisted in building resources for enhancing capacities of urban local bodies (ULB) and

other departments. Manuals developed for ULBs and frontline workers on WASH are useful to build

capacities for ULB functionaries and front line workers of urban development, health, WCD, and NGOs.

This will be useful as available material for all the states to enhance capacity for delivery of BCC.

Insufficient effort has been made to increase access to water supply and sanitation at

demonstration sites/cities. Visits to some slums in demonstration cities suggest that inadequate effort

has been made to increase access to services. This also mutes the effort made through BCC to enhance

toilet use, especially in the absence of access to toilets. Similarly, even though POU has been the focus,

limited efforts were observed by the MTA team in the slums visited to ensure chlorine tablets were

available; tablets were not found at most sites visited. Although the scope of work listed in the

Cooperative Agreement is much wider, the WASH activities undertaken in HUP relate largely to three

key components, i.e., water quality at POU, toilet use, and hand washing.

Limited engagement with JNNURM program. Potential convergence with JNNURM and its sub-

missions has been articulated as one of the key elements to extend the urban health agenda in the draft

NUHM policy. The Cooperative Agreement between USAID and PFI reiterates the same for HUP.

However, there has been limited engagement observed by the MTA team in the states and cities visited.

This may also be the reflection of a limited understanding of the HUP team on complementarities of

JNNURM sub-mission, such as basic services for urban poor (BSUP) and Rajiv Awas Yojna (RAY),

which is mandated to provide infrastructure (housing and other basic services) to the urban poor, and

complements HUP’s interventions like BCC on WASH. Also, community- and ward-level institutions

under JNNURM and its sub-missions present a unique opportunity to converge for taking forward the

urban health agenda.

CONCLUSIONS RELATED TO CONVERGENCE

Until NUHM is launched, the differential priorities assigned by states to urban health can

only be pushed further with documentation of evidences in HUP. The project is still at an early

stage, but it needs to be recognized that such documents are clearly going to make a positive

difference in the states’ prioritization for urban health. Cross-learning between different teams could

also be an effective catalyst for enhancing project coordination.

HUP team has acted as a “convergence agent” in the states and has successfully connected

the departmental silos, in most cases, to start the dialogue. The MTA team observed the

inclination in most stakeholder departments to create a convergence agenda, but an appropriate

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convergence agent was needed to do this. The HUP team has filled the gap appropriately in most

cases. The joint declaration on convergence by the departments of HFW, WCD, and UD in Odisha

is an excellent example of such an initiative.

Even though HUP enjoys a unique position by being active in state-level urban health

programs, it requires a monumental effort to drive the agenda without the help of reputed

experts or potential donors in urban health. The Gates Foundation’s Urban Health Initiative

project, earlier efforts by the European Commission in “Model RCH Project” and the World Bank’s

policy notes on urban health are some of the examples of explicit or latent interests of potential

partners in India. Moreover, there are many other programs funded by donors in water and

sanitation, nutrition, and other sectors that have a correlation to urban health. There has been little

effort by the HUP team to bring these forces together.

City demonstration models helped to involve the municipal structure in addressing urban

health issues(e.g., Pune and Bhubaneswar) in the slums. The PHED, as an alternative to a

municipal government structure, led the efforts on convergence in Jaipur. HUP’s efforts to cater to

the varying capacities and incentives of municipal and health departments to lead urban health

matters in different states have been largely successful.

HUP performance indicators for WASH cannot be achieved without working on other

components of WASH. In the absence of related activities in WASH for improving “access,” the

impact of HUP interventions are likely to be limited. The MTA team felt that if slum dwellers do not

have access to adequate water supplies, promoting toilet use through BCC/ IEC initiatives would

result in limited benefits.

FINDINGS: OBJECTIVE 4

Objective 4: Strengthen the evidence-based rigor of city-level demonstration and learning efforts in

order to improve program learning.

The HUP project is undertaking urban health demonstration models in 276 slum communities in five cities of

India covering 450,000 people. The objective of these demonstration sites is to generate demand for urban

health services and enhance the accessibility, quality, and utilization of services—the “supply provision”

component of the model. Demand generation is to be addressed through home visits by project link workers,

the formation of MAS, and awareness events on health, WASH, and nutrition organized in slum

communities. Supply provision objectives are to be undertaken through TA to state and municipal

departments, public-private partnerships, and convergence activities designed to strengthen program

outreach, the capacity of primary health care providers, and referral mechanisms in urban slum areas (see

Annex XIII, “Framework of HUP Demonstration Model Program”).

Eleven NGO partners are implementing the demonstration models with a combined field staff of 205 people.

The city demonstration model structure consists of a HUP project coordinator for each NGO partner, HUP

cluster coordinators (CCs) for every 12,500–15,000 urban slum dwellers, LWs for every 2,500–3,000 slum

residents, and MAS committees for every 200–250 households.

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ACTIVITIES AND ACHIEVEMENTS RELATED TO DEMONSTRATION MODELS

Even though the five city demonstration models have been operational for only six to eight months, much

has been accomplished in this short time in terms of operationalizing the demonstration sites. Field offices

have been established by HUP’s partnering NGOs implementing the five city demonstration models. The

sites visited by the evaluation team are up and running and fully staffed with project coordinators, CCs, and

link workers. Training modules have been developed covering HUP project goals and objectives, maternal

health, and newborn and child health. HUP’s field personnel have received training from HUP project staff

and appear to be well oriented to their work routines and responsibilities.

In collaboration with state and municipal government departments, slum communities have been chosen for

the demonstration models. These communities are often “unauthorized” slums that tend to be more

inaccessible, lack good access to health services, and have little water and sanitation infrastructure. HUP LWs

are visiting homes, identifying beneficiary and community needs, providing information on the prevention

and treatment of disease, and referring (and often accompanying) beneficiaries to health facilities to obtain

care.

Demonstration sites have been mapped and household listings completed. An MIS for the model

demonstration sites has been established for reporting on administrative process and a limited array of

outcome indicators. The MCHT system has recently become operational in the five demonstration areas. A

“daily planner” calendar for HUP LWs is also being distributed in all demonstration sites, which will allow for

more systematic tracking of contact with beneficiaries.

The IIPS has run surveys in three demonstration cities (Bhubaneswar, Jaipur, and Pune) to establish baseline

indicators and identify program gaps. The final survey report has not been released by IIPS as of July, 2012. It

is anticipated that this survey will be repeated in the last year of the project to assess change in outcome and

impact indicators.

FINDINGS RELATED TO DEMONSTRATION MODELS

Demonstration sites have been established and are beginning to gain traction. HUP’s field

personnel have received training from project staff and appear to be well oriented to their work

routines and responsibilities. The MAS committees organized by HUP have also participated in

training programs focusing on health needs in their communities. MAS members in several locations

said they had received useful training about the importance of antenatal care for pregnant women,

institutional deliveries, child immunization, and personal hygiene and sanitation. They seemed

especially appreciative of information they received on health entitlements. For example, in Jaipur,

HUP cluster workers were helping to organize health camps and transport medicines for local health

posts and ANMs working in the community.

There is an apparent increase in access to health services. For example, in slum communities

served by HUP in Jaipur, there has been a 100% increase in immunization uptake during March–

April, 2012. Similarly, the HUP cluster and link workers in Jaipur have helped to increase the number

of beneficiaries going to health posts and hospitals for antenatal and delivery services and child

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health care. MAS members have been working to encourage more women (and their children) to

attend health camps organized for urban slum dwellers in their coverage areas. The MAS members

indicated that they received inputs about the importance of institutional deliveries, immunization,

and hygiene from HUP and appreciate them, especially the information pertaining to the health

entitlements of beneficiaries. This gain was ascribed in part to HUP community education and

mobilization efforts. However, it is difficult to ascribe such gains to HUP project activities alone.

While the number of children being registered for immunization has increased in areas where HUP

LWs have been working, government health departments have also been running immunization

campaigns, so it is not clear to what extent the HUP project may have contributed to this increase.

HUP has introduced an urban birth-planning intervention for pregnant women in Bhubaneswar.

Birth planning is discussed with women on first contact, but activates more fully at the seventh

month of pregnancy. The birth plan helps in scheduling necessary antenatal visits (including the

provision of tetanus toxoid) and access to modern obstetric care at the time of delivery. The birth

plan includes the name and number of a “skilled birth attendant” in cases where delivery is forced to

take place at home.

Not all key areas of RCH are addressed. The primary focus of the HUP project appears to be on

antenatal care, safe delivery services, post natal care, and child immunization. Several key

reproductive health components, including family planning and the diagnosis and treatment of

sexually transmitted diseases are not being given priority attention in HUP’s demonstration areas,

although there was evidence of some activity on these issues in Bhubaneswar and Dehradun.

HUP currently is not addressing facility gaps in service provision in a systematic manner.

Several deficiencies were observed in the provision of health services. At the Bhala Basti Anganwadi

Center in Jaipur, visited during an Urban Health and Nutrition Day, HUP LWs were busy providing

health education to the women in attendance at the site. However, no growth monitoring was

performed, as the AWC lacked salter scales. The ANMs also lackd blood pressure meters. Both the

Anganwadi worker and ANM reported that the AWC had no iron supplementation (IFA),

deworming, or chlorine tablets, although the site did have ORS and paracetamol. Antenatal care

(ANC) services were limited to registering the woman, providing health education (with HUP LW

support), and referral to a higher facility level. HUP has made no systematic attempt, as yet, to

address these issues. Even in states like Uttarakhand, where the health facilities operate on the basis

of clear-cut guidelines, chlorine tablets were not found in the health facilities visited.

Community mobilization efforts are underway. HUP has developed procedural strategies for

working with city and ward committees on addressing health needs among the urban poor and

promoting more effective convergence efforts within slum communities. As part of this effort,

several NGOs partnering with HUP are investigating how the Anganwadi Centers, LWs, and health

posts are interacting with urban slum populations.11 HUP has also developed operational guidelines

for MAS committees, aimed at better defining their roles and responsibilities. MAS committees

11 One senior health professional in Pune noted that Anganwadi Centers need to be reinvented as part of any effort to mobilize health resources in urban slum areas. This

respondent thought that Anganwadi centers currently were underutilized, poorly staffed, and often lacking in essential health supplies and equipment. He also noted that

Anganwadi workers are poorly supervised and are underutilized resources in many slum communities.

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collaborating with HUP have already participated in training programs focusing on health needs in

their communities.

While these various community-level initiatives hold considerable promise, serious implementation

challenges remain. For example, informants from a HUP-partnering NGO in Pune observed that the

municipal government still is not working well with the HUP project. The MTA team was told that

there should be better engagement with city and ward coordination committees. The city

coordination committee in Pune is still not fully operational. This committee was considered an

important nexus for municipal convergence activities in Pune’s demonstration slum areas. However,

HUP does appear to have some influence with ward committees in Pune. HUP’s recent ward

committee presentations on personal hygiene, sanitation, and the social and health needs of

adolescent girls were reasonably well attended.

HUP has developed guidelines for implementing Urban Health and Nutrition Day (UHND)

activities and has started implementing these in the project’s slum communities. UNHDs are

convergent activities of health nutrition carried out primarily in Anganwadi Centers (AWCs). HUP

LWs encourage mothers to bring their children to Anganwadi Centers to meet with ANMs and

Anganwadi workers (AWWs) who provide health checks/immunization services and to receive

information on personal hygiene and nutrition. Nutritional supplementation products are also often

distributed at UHND events.

Currently, the entire complement of services envisioned under UHND is not yet being implemented.

At an Anganwadi Center in Jaipur, a review of the registers of the AWC revealed that all eligible

children were not being registered for services. The MTA was given to understand that an impending

training on nutrition is expected to bridge these gaps and clarify policies pertaining to public health

entitlements.

There is a felt need for strengthening the capacities of government employed LWs: NGO

partners in Bhubaneswar stressed the need for more training of LWs employed by the Odisha state

government. The MTA team was told that LWs were not always well supervised and were unclear

about their job responsibilities and daily work routines. The state government currently uses an

incentive payment system, similar to the system that has been in place for ASHA cadres for many

years, to motivate LWs to perform at a higher level. However, it is not clear whether this approach

has had much effect.

Unmet needs are being articulated by communities. Many cluster and link workers noted that

the provision of safe water and sanitation facilities was the number one priority in their area. For

example, many slum communities where HUP is working have no access to toilets and sewage lines

were often clogged or broken. These poor conditions had prevailed in many communities for a long

time. Additional needs included health services and community support for adolescent girls,

supplemental nutrition programs, and improved community outreach efforts by government ANMs,

ASHAs and Anganwadi workers.

In Pune, the strengthening of local funding schemes for health insurance and other self-help

programs was identified as an important community need. Some MAS groups are currently collecting

funds to support various community funding schemes, but there is no coordination between MAS

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and various insurance programs. There is still a major challenge ahead in bringing insurance systems

to local community levels, especially to pay for emergency care and hospital services.

CONCLUSIONS RELATED TO DEMONSTRATION MODELS

The HUP demonstration models are still at a learning stage. The problems being faced in some

areas include: (1) potential beneficiaries occasionally complain that HUP is not providing any tangible

benefits; (2) it is sometimes difficult to get community beneficiaries (residents) to participate in

project activities; and (3) introduction of effective coordination between government programs and

community organizations for improving the quality of health services and urban health infrastructure

remains a major challenge for the project. HUP field staff in several states also noted that

demonstration models are limited to the formal scope for the project (“what PFI recommends”),

rather than undertaking innovations that might more effectively meet local needs.

At the present time, the HUP project is not addressing the full range of reproductive health

needs that women face in urban slum areas. For example, there are no STI diagnosis and

treatment interventions at the community level, and family planning services are not always available.

In addition, not all women are being adequately served. For example, the sexual and reproductive

health needs of adolescent girls are typically being left out of the current mix of reproductive health

services offered in urban slum communities.

HUP is generating demand, but not adequately supporting the strengthening of service

provision—a missed opportunity. The HUP work plan identified activities pertaining to demand

generation; however the achievement of the articulated indicators requires that HUP support service

strengthening through negotiation, capacity building and TA. HUP is making progress in generating

demand for health services in the project’s demonstration sites. A major challenge for the project will

be to identify effective means for strengthening service delivery in demonstration sites and

coordinating with government agencies to improve health services, water and sanitation

infrastructure, and nutrition supplementation.

Partnering institutions were seen to have unique capabilities that should be more fully

utilized. In many community demonstration projects, there has been little feedback from senior

state and municipal health staff concerning HUP project activities. In some areas, “downstream”

participation has not happened.

The responsiveness of local government resources can vary greatly across slum areas.

Authorized slums tend to be better served with health facilities, community mobilization efforts

(including the formation of MAS and other self-help groups), and infrastructure than non-authorized

slums. In the five demonstration cities, non-authorized slums are generally larger than authorized

slums.

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FINDINGS: OBJECTIVE 5 (MANAGEMENT AND GOVERNMENT)

Objective five: HUP management practices and governance system in HUP

The HUP project brings together a set of experienced consortium partners to advance India’s urban health

programs. The prime implementing organization is the Population Foundation of India (PFI), known for its

policy advocacy work in India. PFI’s key sub-implementing partners include the Indian Institute of Health

Management Research (IIHMR), known for its research and work in the area of health systems management,

Plan India, a subsidiary of Plan International, one of the world's largest community development

organizations, and Bhoruka Charitable Trust (BCT), a respected organization in Rajasthan working for

community development for over four decades. There are eleven field implementation partners: two in Delhi,

two in Agra, five in Bhubaneswar, and two in Pune, (no specific field partner exists in Jaipur, as BCT is a

field-implementing agency). (See Annex XIV for a list of key stakeholders and Annex XV for a list of HUP

partner organizations.)

In addition to the implementing partners, HUP draws on the experience of its technical partners; the Centre

for Development and Population Activities (CEDPA), The Micro Insurance Academy (MIA), and IIPS also

provide specific research support.

Overall management of HUP is provided by the PMU located at the PFI office in Delhi, and includes

specialists for each of the four thematic objectives addressed by HUP, in addition to grants, financial, and

procurement experts. The PMU provides direction and support to eight state and five city teams.

Activities and Achievements Related to Management and Governance

Strategic direction is provided by the national TAG, which coordinates stakeholder inputs, determines

program priorities and overall implementation strategies, and serves as the guide for all consortium partners

in implementing the project in their respective geographic and technical areas. Although the TAG was

scheduled to meet every six months, there have only been three TAG meetings since its inception in February

2010, with a wide gap between the second TAG (in Sept 2010) and third TAG (in May 2012).

The Program Management Group (PMG), consisting of representation from each partner agency, was

established to provide oversight for managing the operational aspects of project implementation. In the initial

phase of the project, the PMG was to meet weekly, and then every two weeks.12 However, the PMG to date

has met only four times, in January 2010, September 2010, May 2011, and April 2012. Currently, partnership

management issues appear to be discussed at bilateral meetings between PFI and sub-partners.

Because of the initial delay (nine months to obtain the Department of Economic Affairs approval), followed

by additional delays for clearance of the work plan by GOI (in August 2010), the project effectively started in

September 2010. Upon project approval in September 2010, the primary activity for the ensuing six months

was to establish offices in each of the implementing states and cities, including recruitment and contracting of

sub-partners and sub-sub partners. During this period, financial, procurement, and grant management

systems were developed for HUP.

12 Cooperative Agreement document September 2009.

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Guidelines developed by PFI for implementing HUP’s financial and procurement system were adapted and

further modified to comply with USAID policies and reporting requirements. In addition to developing

management, procurement and grants manuals, a delegation system for managing the project’s finances was

approved and implemented. However, PFI’s implementing partners follow their own organizational norms

for internal management, but report back to PFI as per HUP’s agreed framework, in compliance with USAID

requirements. Rationalization of travel entitlement and benefits were done among partners, and it was also

agreed that all partners must follow the mandatory norms extended by USAID. By the end of June 2012,

36.7% of the total HUP budget had been utilized. (See Annex XVI, “HUP Project Management Structure”

and Annex XVII, “A Summary of Findings on Management and Governance.”)

Findings Related to Management and Governance

PFIs played an active role in articulating the need for the HUP project. PFI was actively

engaged, in association with USAID, in articulating the need for an urban health project like HUP to

the MOH and DEA, and the GOI, which aided in obtaining approval from DEA. Also, PFI helped

to encourage buy-in from GOI for approval of the HUP annual work plan.

Results of strategy implementation are mixed. The three-pronged HUP strategy of intervening at

national, state, and city levels has been effective in several respects, namely: (1) engagement at the

national level by PFI with Ministry of Health has improved; (2) there is evidence that the

demonstration models are gaining traction at city and ward level; and, (3) the assistance provided for

preparing models to utilize urban RCH funds of NRHM has resulted in the utilization of formerly

underutilized funds in many states, e.g., in Rajasthan, Odisha, and Madhya Pradesh.

However, cross-learning between sites has been weak and could be improved. In addition, interaction

with other donors working in the same state and thematic areas, e.g., urban development, WASH,

convergence, and PPP, has been limited, thus minimizing opportunities for cross-learning.

It was also noted that an overemphasis on HUP “branding” appears to have limited the leveraging

of internal resources from partnering NGOs engaged on the HUP project. Both Plan India and

IIHMR mentioned this issue.

The state teams have invested substantial efforts in positioning HUP with the state governments.

HUP state teams often noted the need for greater USAID support at the state level to “open doors”

with the government. Also, visits by USAID to HUP states were reported to be infrequent.

The strengths and uniqueness of program partners is underutilized. Although each partner has

a different strength, e.g., policy advocacy (PFI), community mobilization and implementation

(PLAN), and research (IIHMR), these are not recognized fully when pursing the urban health

agenda. For example, IIHMR could be better utilized to create documentation on evidence and

policy advocacy.

Cross-pollination between state and city teams remains limited. Learning opportunities

between state teams and from one city to another city team was found to be limited. The program

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could have benefitted greatly from opportunities, including transfer of knowledge from the Urban

Health Centre in Uttarakhand to other state teams, or an exchange of experiences between state and

city teams from Odisha to Rajasthan.

Interaction between PMU and states and cities is likewise limited. Interaction between the

National PMU and state/city teams was reported to be limited to three to four face-to-face

interactions in a year, largely on programmatic review, in addition to periodic reporting and

clarification through mail and phone. This has resulted in missed guidance from the PMU at critical

times of need by state and city teams. Some PMU thematic and programmatic specialists have

provided more frequent interaction, which was reported to be effective, e.g., in WASH.

Prior experience with government systems is beneficial. Prior experience with the government

system and programs (e.g., NRHM) was found to be beneficial in establishing relationships with

government as a TA agency, in most of the states visited. Staff with prior experience working with

government systems successfully connected with government officials and facilitated better

convergence outputs.

Limited skill sets available at state and city level. A public health specialist is available only at the

PMU in Delhi. Even though in many states the project director or convergence specialist brings

substantive knowledge of public health from their prior experience working in the sector (but not

trained as a public health person), often a gap is felt with the technical subject knowledge. The state

and city teams often reported needing guidance on best practices from a public health perspective.

Also, some city teams do not have a PPP specialist (e.g., Pune), although they are expected to initiate

PPP activities and reported needing guidance.

Delays in appointing TA teams affected all states. There has been considerable delay in staffing

the full TA team in some states and replacing staff in others. Analysis of staff deployment at PMU

and in various state teams suggests that on average, it has taken from one to five months from initial

recruitment to being in position, with some positions taking even longer; for example, the

appointment of MIS officers has been delayed for seven to 12 months in most states. The project

suffers from an 18–20% attrition rate and replacement of staff is also delayed. Analysis of available

information suggests that an average of four to five months is spent, both at national and state levels,

for replacements. This has certainly impacted momentum where attrition has been high, e.g., Madhya

Pradesh and Uttar Pradesh.

It is important to note that, irrespective of delays in recruitment and gaps in skill sets in some teams,

the professionals recruited so far are of high quality, which adds value in taking the HUP project

forward in each state.

Work plans are based on perceived need. Work plans for each state and demonstration city are

based on what team members perceive to be the need of the state/city government based on

interactions during the last year, and sometimes do not reflect actual state priorities. Hence, even

though some governments appreciate HUP’s efforts, they could have been more responsive if there

had been some form of consultation and agreement during the planning process.

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Delays in approval of activities from PMU results in lost time and relevance. Concept notes

are now being applied across states in order to promote consistency. However, this requires approval

from the PMU for all activities costing more than INR 5,000, which recently (May–June 2012) has

been revised to INR 20,000. It often takes more than a month to process PMU approval, resulting in

lost time and relevance for activities.

Weekly reporting is seen as “burden” by link and cluster workers. The required weekly

reporting by link and cluster workers is viewed as very time intensive, taking time from work

activities. An inadequate number of available computers further adds to the problem.

Limited incentives for MAS members and LWs. Visits to urban slums in Jaipur and Bhubaneswar

suggest that in the absence of monetary and/or non-monetary benefits for MAS members’ time and

energy, especially in a highly fragmented and heterogeneous slum population, concerns were raised

among project staff about issues related to retention and sustainability. MAS members noted that

they also have a limited say about the quality of service provision at community or facility levels.

Similarly, incentives or salaries (as the case may be in different states) for LWs and cluster workers

are often low, resulting in attrition problems.

Annual contracting instead of framework contracting with sub-grantees poses a risk to the

project. PFI, as the prime agency for HUP, has a signed agreement with USAID for the entire

project period (Cooperative Agreement signed on September 25, 2009). In addition, based on the

annual work plan, USAID obligates the necessary amount required for any given year. According to

USAID’s obligation and approval of the work plan by GOI, PFI signs contracts with its sub-grantee

for only one year (covering the work plan period) at a time. Similarly, the sub-grantees sign contracts

with sub-sub grantees based on the work plan period.

In the absence of any framework agreement like the Cooperative Agreement between USAID and

PFI, the sub-grantee or sub-sub-grantee is not bound to remain engaged with HUP for the entire

project period, and if any group chooses to withdraw from the consortium, there is no binding

agreement, MOU or contract—which poses a risk to the project.

TAG and procurement and grant management group meetings are irregular: Only three TAG

and four PMG meetings have been conducted since the initiation of the HUP project. This deviates

from the project design for semi-annual TAG meetings and bi-weekly PMG meetings.

Relationship with USAID and GOI: USAID is regularly informed about HUP’s progress bi-

weekly, through chief of the party to agreement officer’s technical representative (AOTR) meetings

or conference calls once or twice weekly, in addition to joint meetings with the Joint Secretary

responsible for NRHM and Urban Health, MOH/GOI every two months. The AOTR also attends

the TAG and PMG meetings of HUP when the meetings are held.

CONCLUSIONS RELATED TO MANAGEMENT AND GOVERNANCE

PFI’s role in grounding the HUP project has been commendable. Engagement of PFI, in

association with USAID, in articulating the need for an urban health project like HUP to the DEA,

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GOI, has been commendable and helped obtain approval from DEA and buy-in from government.

Approval of the HUP annual work plan by GOI puts HUP in a unique position, as government is

rarely involved in approving similar work plans of bilateral agencies or of NGOs.

HUP does not effectively utilize consortium strengths: Even though the consortium comes with

a rich experience in each of the HUP programmatic areas, partner strengths are not optimally

utilized.

Cross-pollination is not by design. The HUP project demonstrates only limited learning

opportunities between teams (state and city) and also from other donors who may have overlapping

program experience in health, nutrition, and water supply/sanitation in the same state. Project

implementation is not designed to facilitate cross-learning, nor have any specific efforts or

mechanisms been developed for this purpose.

HUP has capitalized on past experiences and staff contacts, rather than institutional

standing of PFI or USAID. A substantial leverage in terms of individual contacts and experience

working with the government prior to HUP has helped in establishing the project as a TA agency in

each of the states, even though this has taken a substantial amount of time. USAID’s presence in

states as a donor to “open doors” with the government could have helped reduce the time taken to

establish HUP in states.

Substantial amounts of time are being lost in filling staff positions. An average of four to five

months is lost every time any staff leaves and a new person is appointed to fill the vacant position.

Invariably, the process of recruitment starts after the staff member leaves, rather than when the

resignation is accepted. Such delays have had a negative impact on project momentum.

Substantial amounts of time spent in generating weekly reports without any feedback leads

to frustration among link and cluster workers. Weekly reporting takes considerable time for

information processing, especially by the bottom of the HUP project implementation pyramid.

However, insufficient time to process this information by middle or top level staff means the

feedback loop is not completed. The lack of feedback often leads to frustration among link and

cluster workers.

Limited incentive to MAS members and LWs poses issues of sustainability. The NUHM draft

document envisages MAS members as volunteers and presumes that they will draw their identity and

status in the community by promoting health. Limited incentives for MAS members—either

monetary or non-monetary—in addition to having no say in the provision of health care services at

community or at facility level, raises concerns about the future of volunteer services. This poses

sustainability issues and will be a future challenge for HUP, as well as NUHM if and when it is

approved.

Irregular TAG and PMG meetings undermine the initial design. The TAG and PMG were

designed and constituted in the HUP project to provide strategic and programmatic guidance.

Infrequent meetings of TAG and PMG undermine the basic design of the project.

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SUMMARY CONCLUSIONS

In addition to specific conclusions identified above for each of the main objectives of the project, the MTA

was able to reach summary conclusions for the six evaluation questions listed in the Scope of Work for this

assessment.

1. How has HUP influenced GOI policy on urban health since 2009 and what opportunities

currently exist for USAID to influence policy-level changes through HUP?

In a relatively short period of time, the HUP project has helped to delineate national- and state-level

policies on urban health. The HUP team has helped the MOHFW draft the current version of the

NUHM. The project has also worked to broaden the participation of relevant stakeholders in the

development of NUHM policies, program priorities, and operational strategies (e.g., national- and state-

level ministries and departments (see Annex XIV for a list of key stakeholders).

The HUP project has demonstrated mechanisms for strengthening urban health systems within varying

environments. The project therefore has the potential to frame strategies for addressing urban health

needs and priorities as well as accelerate the implementation of NUHM once it is officially launched.

HUP is working to develop a comprehensive urban health vision for the country. The project therefore

gives USAID a unique opportunity among donors to make major contributions to the NUHM design

and implementation process and ultimately improve health and living standards in India’s most

disadvantaged urban settings.

2. To what extent has the project contributed to the operationalization of the urban health

program at national and state levels? What were the strengths and weaknesses of its

implementation?

As noted, India still has no comprehensive, national urb- health program and the NUHM has not been

approved. During the design of the HUP project, it had been assumed that the NUHM would be in place

when HUP was launched. However, the project has helped to improve the utilization of NRHM

resources for urban health. To this end, HUP has developed operational tools for enhancing access to

urban health services, strengthened BCC initiatives for urban health, and prepared systematic community

mobilization guidelines. The project has also produced numerous policy documents, research reports, and

PIPs that have helped to advance the urban health agenda. As noted above, it is difficult to determine,

after only six to eight months, the extent to which HUP’s demonstration models have contributed to the

operationalization of a national health strategy.

Major strengths of HUP include: (1) strong policy capabilities and inputs at the national level; (2) HUP

staff members are generally well-connected with government health, urban development, and water and

sanitation departments; (3) the project is working to build a supportive environment for learning and

documenting results; and (4) the project has developed workable mechanisms for fostering convergence

across government and NGO partners. For example, the Odisha convergence experience developed

during the last year has considerable potential for replication in other states.

To some extent, the project’s implementation approach has been hampered by the delay in approving the

NUHM. Some states (Rajasthan and Uttar Pradesh) seem reluctant to undertake major initiates in urban

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health without clear directives from the national level and formal approval of the NUHM, while other

states (Madhya Pradesh and Odisha) are moving ahead with state-level initiatives in urban health.

Operating in different supportive environments for urban health has inevitably led to some unevenness

in the receptivity to HUP and the extent to which the project is addressing its main objectives.

3. How effective has the project’s TA approach been in building synergies between the public

and private partners in implementation of key project strategies?

Developing productive public-private partnerships for urban health takes time. Potential partners must

be identified, program objectives clearly articulated, interventions well designed, and activities adequately

resourced. To date, HUP’s results in developing PPP activities has been mixed, owing in part to

inconsistent interest in the PPP approaches across HUP’s eight states and different levels of PPP

expertise within HUP’s state and municipal-level teams. However, some good models have been

developed during HUP’ first year. For example, elements of the Seashore Project in Odisha and the

Ambuia Cement Foundation partnership in Uttarakhand have potential for replication in other settings.

Other models are under development with Bharti Vidyapith University and the Kirloskar Foundation in

Pune, Lupin and Narayan Hrudayalaya Hospitals in Rajasthan, and Titan Industries in Dehradun.

Given the long lead time often entailed in negotiating, officially approving, and activating PPP activities,

it is unclear how much HUP will be able to achieve on PPP during the remainder of its project life. It is

also too early to reach conclusions regarding the ability of HUP to leverage resources for public-private

partnerships.

4. What lessons can be drawn for future designs from the program governance system,

especially its role in promoting convergence strategies of different GOI programs?

Experience to date indicates that HUP’s efforts to improve coordinated policy and program design

between national and state/municipal bodies (e.g., through sub-allotment funding schemes in

Bhubaneswar and Pune) have helped to increase attention to urban health within the NRHM framework.

Convergence activities have also shown promise, although effective coordination at state and municipal

levels between health, urban development, water and sanitation, and women and child development

remain more promissory than realized at this stage of the project. WASH and nutrition convergence

efforts are less advanced than maternal and child health. However, HUP can take some credit for the

recent inclusion of WASH indictors in Odisha’s NRHM urban health framework. This seemingly modest

example of successful convergence could prove seminal in achieving better inter-ministerial/

departmental collaboration and implementing more holistic urban health programs.

5. What has been the outcome of the slum demonstration activities under HUP? What are the

key strengths and weaknesses of these interventions and what is the opportunity for potential

scale up?

The HUP project has made a good start in implementing the five city demonstration models. Partnering

NGOs have been engaged, field offices opened, field staff recruited (cluster and LWs), slum communities

mapped, household listings completed, baseline surveys implemented in three cities, MIS systems

developed, and the project’s maternal and child health tracking (MCHT) systems deployed. HUP has also

made good progress in working with local community organizations, most notably the MAS committees

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established in all of the slum communities where HUP is working. Education and urban health demand

generation activities (often undertaken in collaboration with the MAS committees) are also underway in

HUP’s demonstration sites.

Unfortunately, HUP’s demonstration models have only been operational for six to eight months. The full

complement of potential performance indicators that will be generated by the demonstration models

(e.g., from the MCHT system now being deployed) are only beginning to come on line and the final

report of the three-city baseline survey has not been released. Demonstration-model potential for

replication and scale-up will be difficult to determine without more time for implementation and the

gathering and analysis of evidence on results.

Despite these very real drawbacks, the MTA team was told by many respondents that HUP field activities

are beginning to have a positive impact. Mention was made of HUP’s role in promoting greater health

awareness and knowledge among potential beneficiaries; stimulating greater demand for health services;

increasing the utilization of health services; clarifying the roles and responsibilities of government

outreach and facility-based health workers; implementing referral mechanisms for improved access to

appropriate levels of care (e.g., for safe deliveries); and identifying weaknesses in urban health delivery

systems and supportive infrastructure for WASH, particularly in the non-authorized slum communities

where HUP staff members are present. It will be imperative for the project to document results for these

various elements of the demonstration models.

Despite the considerable promise of HUP’s demonstration models, the MTA team did observe some

weaknesses in implementation. It was not always clear whether the rational for the HUP project in terms

of goals and objectives was clearly understood at the community level. There was also doubt expressed

by some potential beneficiaries concerning the “tangible benefits” to be gained from HUP. This should

become clearer with greater household contact and educational outreach over the duration of the project.

Based on findings gathered from the field, it also appears that HUP is not giving reproductive health

(including family planning and STI/HIV diagnosis and treatment) high priority at the present time. The

project’s current emphasis is more oriented to the provision of safe delivery services for pregnant women

and the immunization of infants and children. It was also noted that efforts have been limited so far in

assessing the range and quality of services provided by facilities at different levels of the urban health

system (e.g., health posts, urban health centers, tertiary municipal hospitals and clinics). The situation

analysis study on health facilities undertaken by Plan India (HUP’s partnering NGO in Uttarakhand) at

the request of the state’s Ministry of Health is a notable exception.

Numerous HUP field staff reported that the reporting requirements for the project (especially in the case

of the demonstration models) are excessive. A monthly reporting system might work better and allow

more time for executing project activities. There is also some frustration among HUP frontline workers

in demonstration sites, who feel they are kept busy gathering evidence from the field, but receive little

feedback on their performance and how to become more productive. This important feedback in large

part is missing from the project at the present time.

6. How effective are the HUP management systems including project planning and review,

grants management, financial and procurement systems in scaling-up project activities?

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The HUP management system appears to be functioning reasonably well, despite early problems

stemming from a change in leadership and slow recruitment procedures for state and city teams (both

initial hires and replacement staff). In terms of administrative practice, the MTA team found that PFI

grant management, financial systems, and procurement policies are being effectively implemented and

appear to be in-line with USAID policies. A system of written and verbal communication between the

PMU and USAID is in place. However, infrequent TAG meetings were seen as limiting opportunities for

greater strategic program guidance and review. In addition, PMG meetings are held irregularly.

It was noted that the project spends considerable time developing annual work plans that must be

approved by the GOI’s MOHFW and USAID. These lengthy clearance procedures can give rise to

uncertainty over the timely availability of funds needed to pay staff and procure equipment and supplies.

A four-year framework mechanism for all sub-grantee contracts might have been a more efficient

approach for ensuring smooth project implementation.

Currently, HUP is facing a challenging situation related to planning for the next annual work plan,

without information about project extension. If the project ends as scheduled in September 2013, the

work plan would need to address close-out activities during the next year; if there is a no-cost extension,

then the work plan would build on and expand current activities.

While HUP has taken steps to ensure effective coordination within the project (e.g., by holding quarterly

progress review meetings for all state- and city-level partnering organizations), there is always room for

making improvements in how the project communicates internally. The MTA was told that currently,

there is limited cross-pollination between PFI’s PMU and state/city teams working on the project. At the

state level, sub-grantee partnering NGOs (usually working in demonstration model sites) did not have

sufficient contact with the prime NGO partner in their respective states. The MTA team concluded that

HUP could be doing a better job with internal communication. One obvious step would be to increase

the number and duration of field visits to HUP implementation sites to see the project firsthand and be

available to trouble-shoot implementation bottlenecks that will inevitably arise.

One managerial challenge for the project will be to develop incentives for MAS workers to remain

engaged with the project, as there are no incentives in place to encourage greater retention. The MTA

team was also concerned that the low salaries paid to HUP frontline workers (CCs and LWs) may cause

morale and retention problems for the project going forward.

RECOMMENDATIONS

The following recommendations are based on the findings of the evaluation.

RECOMMENDATIONS RELATED TO TECHNICAL ASSISTANCE

• Continue working to facilitate the development of a state urban-health vision and plan,

identify various stakeholders who can participate, delineate their roles, and include HUP as

a contributing partner. Generate HUP work plans, which incorporate and feed into state urban-

health plans and include activities which feed into HUP objectives.

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• Wherever the environment is considered conducive, support the development of a more

comprehensive urban health model. Provide a broadened public health perspective and

inputs to state and city teams. Use the recently developed Madhya Pradesh urban-health strategy

to support implementation of feasible components of a comprehensive urban plan. Use the

precedents in pioneer states to effectively advocate in more hesitant states.

• Redefine what ‘health’ means to HUP, articulate this vision, and reorient staff when

appropriate.

RECOMMENDATIONS RELATED TO PUBLIC-PRIVATE PARTNERSHIPS

• Engage in substantive dialogues with states in preparing specific PPP guidelines for urban

health. Since urban health requires convergence of health, urban development, WASH, and nutrition

sectors together, a specific PPP policy for this theme would help in identifying approaches to be

taken, funding requirements, mapping of potential partners, and creating contractual arrangements.

• Disseminate documentation on successful PPP models to different states and city

governments to encourage adoption of such models. The Urban Health Center example in

Uttarakhand and the Bhubaneswar Municipal Corporation-Seashore-HUP model in Odisha are good

examples of scalable models for the future. The HUP team should document these practices and

assist governments in other states and cities to adopt and implement these models. The national

government should also be briefed about such models for possible inclusion in the proposed

National Urban Health Mission draft. The project has also prepared a publication with a list of

existing best practices for PPPs in Urban Health through its partner CEDPA, which could also be

disseminated at workshops/conferences as an advocacy tool for adoption by districts/cities/states.

• Engage in advocacy for utilizing and strengthening PPP Cells under NRHM In many states.

PPP cells under NRHM typically do not consider urban health interventions to be part of their work.

Making greater use of NRHM’s existing PPP structures, especially in contracting with NGOs and

commercial partners, could be a way to ensure effective public sector engagement in working with

the private sector.

RECOMMENDATIONS RELATED TO CONVERGENCE

• Greater focus should be given to assisting state governments to expedite the formation of

ward-, city-, and state-level committees as priority structures for urban health. The formation

of these structures is an essential deliverable to prepare states for the introduction of NUHM. Unless

structures are formed, fund flow and reporting mechanisms will not take shape. HUP’s community-

level convergence initiatives (e.g., with ICDS, JNNURM, and PMC) are still in a formative stage.

These efforts will need to be intensified and carefully documented as the project unfolds.

• Strengthen information exchange between states on the development of urban health

frameworks and strategies. Early sharing of thoughts on convergence mechanisms by leading

states would reduce the time for policy development in other states and give a head start to most

participants. Waiting to document such policies and frameworks until they are fully developed could

delay interventions in participating states.

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• The HUP project should make greater efforts to engage other NGO and donor organizations

working in urban health. Greater exchange of information on program approaches in different

regions of the country should strengthen urban health advocacy and program support activities.

RECOMMENDATIONS RELATED TO TECHNICAL ASSISTANCE FOR WATER,

SANITATION, AND HYGIENE

• Revisit and prioritize the scope of WASH as listed in HUP’s Cooperative Agreement and

rework performance indicators to reflect the same. Given the delay of the HUP project, it is

difficult to address all aspects of WASH listed in the Cooperative Agreement in all states/cities.

However, a comprehensive plan will need to be developed that can be executed by various partners

(including government, private sector, donors, and NGOs). Leveraging of partnerships with other

NGOs, ULBs, and other partners are required in order to expand the WASH agenda, including solid

water management and menstrual hygiene.

RECOMMENDATIONS RELATED TO DEMONSTRATION MODELS

• The HUP project should more systematically document the capacity of state and municipal

health systems. Such assessments would include municipal hospitals, urban health posts, urban

health centers, Anganwadi Centers, and facility-based and community outreach workers (ANMs,

ASHAs, cluster and LWs, etc.) to address the health needs of the urban poor. A situation analysis of

the urban health system was recently completed by Plan India in Uttarakhand. Similar assessments

should be completed in the remaining states and municipalities where HUP is working.

• HUP should systematically track indicators derived from the MCHT system that documents

contact with beneficiaries and the extent to which HUP is providing support to urban slum

dwellers. This information will be essential in determining the extent to which the project’s

demonstration models have been successful in generating demand and increasing the utilization of

services (e.g., antenatal care, safe delivery services, child immunization, and nutritional support). The

HUP Mother and Child Tracking System is not currently linked to the government’s facility-based

MIS tracking system. Mechanisms need to be explored to harmonize these two systems so that

beneficiary records maintained by HUP can be cross-linked with facility records. This would allow

the establishment of beneficiary contact histories with service providers and better document the

need for follow-up care.

• It will be imperative to have the HUP Baseline Survey repeated during the last year of HUP

to measure change in basic impact indicators over the life of the project. The HUP Baseline

Survey is the only tool available to HUP to measure potential impacts stemming from the project’s

field activities. Without this information, it will not be possible to adequately determine whether the

HUP project had a demonstrable impact on urban health conditions in the communities where it had

been working.

• HUP will need to invest in an expanded research program during the last year of the project

to better assess what the five city demonstration models have achieved. During the last year of

the HUP project, a systematic assessment will need to be undertaken to document the extent to

which the demonstration models have been successful and identify model components that should

be considered for scale-up under the NUHM. In addition repeating the behavioral baseline survey in

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the last year of the project and continuing to track MIS information, the HUP project should

undertake a more qualitative assessment that will obtain information from various stakeholder groups

on what the project has been able to achieve. Informant groups would include beneficiaries in slum

communities (both authorized and unauthorized slum areas), MAS members, HUP cluster and LWs,

Anganwadi and ASHA community workers, and facility-based government health workers. An

assessment report summarizing the outcomes of HUP’s five city demonstration models should be

the centerpiece of any formal end-of-project evaluation planned for the project. The HUP

demonstration models have only been operational for around 6-8 months. During this time, much

effort has been expended in launching the project in selected slum communities, including the

recruitment and training of field staff and the opening of state and local community offices. It is still

too early to assess the effectiveness of the community education, mobilization, and referral systems

that the project has setup in the project’s demonstration areas. It is recommended that the project be

given additional time (beyond June 2013) to assess the effectiveness of these interventions.

• Undertake OR on meaningful incentives for MAS members that will help ensure their

sustainable engagement in urban health activities. Options emerging from such research should

be piloted in selected demonstration model areas. This initiative will provide useful guidance when

NUHM is launched.

RECOMMENDATIONS RELATED TO MANAGEMENT AND GOVERNANCE OF

THE HUP PROJECT

• Utilize the strength of each partner in HUP by providing flexible strategies. Moreover, in

recognition of the differential capacities and preferences of each state, flexibility in strategies is logical

to maximize the returns on efforts by the HUP team.

• Encourage an inter-team exchange program between HUP staff for short periods to share

knowledge and skills effectively. The project could also develop a more fruitful method of

interaction between state teams through inter-team exchange programs for staff for short periods to

provide teams with skills and knowledge that currently are deficient.

• Framework contractual agreements that cover the life of the project, rather than biannual

contracts with sub-grantees, would reduce administrative burdens and streamline approval

and budgetary procedures.

• State work plans need to be formally or informally agreed upon with state governments,

which will help align TA with state government priorities.

• Introduce state-wide progress ranking to encourage healthy competition between teams

within HUP. It is possible that rankings based on annual achievements, when shared with the GOI

and individual states, will stimulate actions at public agency levels to excel in certain domains.

• TAG and PMG meetings need to be conducted regularly to provide guidance to the project

pertaining to its original design and objectives. A semi-annual meeting of TAG and quarterly

meetings of PMG would be useful.

• The project’s internal reporting should be reduced from a weekly to monthly schedule in

order to reduce management loads and allow more time for project implementation. This less

burdensome reporting system should be coupled with an improved feedback mechanism for HUP

sub-grantees to ensure that HUP staff on the ground, especially the project’s frontline workers, can

assess their work and suggest operational adjustments that improve the effectiveness of the project.

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RECOMMENDATIONS FOR USAID

• Maintain an urban health niche through HUP and provide leadership to the donor

community by escalating the urban health agenda in India. Organize workshops, conferences,

and meetings involving government and all potential donor partners to share experiences and views

on urban health.

• Continue strategic dialogue with GOI and states on ways to adopt evidence created through

HUP as well as in other countries and regions. Direct interaction by USAID at state and city

levels could help open doors at various government levels. Moreover, visits by USAID officials to

states should happen at least twice a year to: get feedback from government departments on

effectiveness of TA; develop models in project components; and assess the willingness of states to

engage in urban health.

• At a later stage, provide feedback to GOI and states on models and innovations based on the

Indian experience as documented by HUP, to be shared with Africa and other regions.

Providing evidence of the contribution made by HUP-led models to other countries (which could be

presented on USAID-administered websites and literature) could open avenues for future inter-

country learning and exposure visits. Such an exercise should also secure USAID’s standing as a

major partner in urban health.

THE WAY FORWARD: OPTIONS FOR THE FUTURE

Due to the initial project delay, there was limited time available for the project to demonstrate models and

evidence by the mid-term. Going forward, the project has two options: (1) close out in September 2013 as

originally planned; or (2) extend HUP beyond its planned close-out date in order to overlap with the eventual

launch of NUHM. As a sequel to option (1), there could be follow-on TA to NUHM once HUP has amassed

a larger evidence-base for how to operationalize urban health initiatives. The benefits and costs of each of

these options are summarized below.

CLOSE HUP IN SEPT

2013 AS PLANNED

Benefits: On time and

budget

Costs: Delay in NUHM

launch may take away the

capacities built already;

project gets 1 year less

for implementation

because of initial delay

EXTEND HUP BEYOND

ORIGINAL CLOSURE

DATE TO HAVE AN

OVERLAP WITH NUHM

LAUNCH

Benefits: ROI higher;

utilization of lost time at

project start

Costs: Higher budget

outlay required; effort

needed to get GOI/state

concurrence for

extension

PLAN A PHASE II OF TA

TO PROVIDE LONGER-

TERM HAND-HOLDING

TO PROPOSED NUHM

Benefits: Opportunity to

scale-up successful

models and "internalized"

by government; look for

higher leveraging of

resources

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The ROI from HUP could be increased if the project is extended at least for a year, in view of the time lost in

the start-up phase for reasons beyond the control of PFI. Moreover, additional time would allow further

opportunity to present successful models developed by HUP to government (and other potential donors)

once the NUHM is launched.

EXIT STRATEGY

It is important to manage the risk of creating unmet demands through HUP in partnering states in the event

NUHM is delayed beyond project closure. If HUP is successful in creating demand for urban health services,

USAID needs to develop a strategy to involve resources from government, donors, and the private sector so

as to meet the urban health demands in the absence of NUHM. While a long-term engagement strategy

would be the best option, interim measures could include extension of HUP or design of a follow-on project

to begin immediately after the closure of HUP.

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ANNEXES

II.

III.

IV.

VI.

VII.

VIII.

IX.

XI.

XII.

XIII.

XIV.

XV.

XVI.

XVII.

XVIII.

XIX.

XX.

XXI.

EVALUATION SCOPE OF WORK

EVALUATION TIMELINE AND CALENDAR

KEY REFERENCES/DOCUMENTS REVIEWED

INDIVIDUALS AND ORGANIZATIONS INTERVIEWED

CURRENT PERFORMANCE INDICATORS USED BY HUP PROJECT

SELECTED PRELIMINARY INDICATORS FROM 2012 HUP BASELINE

SURVEY IN JAIPUR, BHUBANESWAR, AND PUNE

STAGES IN THE EVOLUTION OF URBAN HEALTH PROGRAMMING

MAPPING OF TECHNICAL ASSISTANCE PROVIDED BY HUP

COMPARISON OF THE CHANGE IN URBAN RICH BUDGETS OF HUP

AND NON-HUP STATES, 2010-2013

PUBLIC PRIVATE PARTERNSHIPS

KEY GOVERNMENT PROGRAMS FOR THE URBAN POOR IN INDIA

TECHNICAL ASSISTANCE TO WATER SUPPLY, SANITATION AND

HYGIENE (WASH)

FRAMEWORK OF HUP DEMONSTRATION MODEL PROGRAM

KEY STAKEHOLDERS FOR THE HUP PROJECT

HUP PROJECT PARTNERS

HUP PROJECT MANAGEMENT STRUCTURE

SUMMARY OF FINDINGS ON MANAGEMENT AND GOVERNANCE

STAKEHOLDER INTERVIEW FORMS: PFI AND HUP PARTNERING

IMPLEMENTING AGENCIES

HUP INDICATORS BY EFFECTIVENESS AREAS

MCH/RCH APPROACH TO TA

CAPACITY BUILDING EFFORTS OF HUP

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ANNEX I: EVALUATION STATEMENT OF WORK

PROGRAM PROJECT INFORMATION

a. Program Project Title: Health of the Urban Poor (HUP)

b. Start-End Dates: October 1, 2009-September 30, 2013

c. Budget: $10,778,627

d. Program/Project Description:

Urban health issues have received little attention in the past as compared to rural health programs in

India. However, USAID/India has been active in the urban health sector since the 2002. In 2010, WHO

World Health Day theme, "1000 cities 1000 lives" have brought in the much needed focus towards the

much needed public health issues in urban health. The main purpose of the Health of the Urban Poor

(HUP) is to provide TA to the proposed National Urban Health Mission (NUHM), National Rural

Health Mission (NRHM) and the Reproductive Child Health II (RCH II). This TA is provided through

program learning, institutional strengthening, assistance in policy formulation and implementation

development of framework and guidelines, implementation, capacity building and strategic dissemination

of urban health knowledge. Through strategic pilot interventions and demonstration projects

highlighting comprehensive packages of maternal and child health and nutrition interventions, and the

promotion of safe water, sanitation and hygiene services, HUP is paving the way to improve the health

status of poor urban communities in India by working closely with GOI counterparts at center, state and

city level.

HUP’s primary objectives are:

1. Provide quality TA to the GOI, states and cities for effective implementation of the NUHM

2. Expand Partnerships in Urban Health including engaging the commercial sector in PPP activities

3. Promote the convergence of different GOI urban health and development efforts

4. Strengthen urban planning initiatives by the state through evidence-based city-level

demonstration and learning efforts

The HUP project is implemented by Population Foundation of India (PFI). The project works closely

with central, state, and city local authorities for institutional convergence of quality public health

services for the urban poor. The key strategies of the project include:

1. Need-based Technical Assistance for the operationalization of urban health programs within the

public health system at all national, state and city levels

2. Convergence at all levels for improved health, nutrition, water, sanitation and hygiene through

institutional capacity building

3. Capacity building for high quality accessible and sustainable health, nutritional and water and

sanitation services

4. Leveraging resources

5. Gender equity and male engagement

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6. Empowering community for improved negotiation

7. Fostering strategic alliances and partnership at all levels

8. Demonstration , documentation, systematic replication of successful urban health intervention

models

The geographical focus of the project is mainly at the national level and in the selected states of Bihar,

Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand and Uttar Pradesh. At a

national level, HUP supports the MoHFW to formulate the NUHM. The final draft and process for

NUHM has been finalized and communiqué from Ministry of Finance provides the budgetary allocation

for NUHM13.At a state level, the project provides technical support to state governments in

implementing urban health programs. In addition, the project has initiated model demonstrations in five

cities (Agra, Bhubaneshwar, Delhi, Jaipur and Pune). The project has also created opportunities for

dialogue and interaction amongst key stakeholders such as policy makers, managers, academicians and

civil society organizations on various issues related to urban health implementation and policy making.

Some of the key initiatives undertaken by the project are:

Technical Assistance at National and State level

- Organizing joint meetings among various ministries such as the MoHFW and Ministry of Housing

and Urban Poverty Alleviation.

- Contribute to the finalization of the NUHM Implementation Framework and State Program

Implementation Plans (PIPs) of NRHM

- Facilitating roundtable discussions among key state-level urban health stakeholders such as senior

government officials of health urban development departments and representatives of national and

international development agencies.

- Participation in MoHFW’s Common Review Mission to review NRHM progress, particularly the

urban health component.

Research and Advocacy

- Conducted a baseline survey and facility assessment in all three priority demonstration cities (Pune,

Jaipur and Bhubaneswar) to determine strategic inputs for effective program interventions.

Moreover, the study will bring in for the first time urban poor specific data at the city level.

- Completed the study of Disease Burden in Bhubaneswar, Jaipur and Pune which will specifically

inform community risk pooling/health insurance aspects of urban heath program

- Facility assessment of Urban Health Centers which are being operated under PPP mode in UP

- Commissioned a study on PPP models in all HUP states, conducted by CEDPA.

Slum Demonstration Program

- City Slum lists prepared/updated and vulnerability assessment process completed in Bhubaneswar,

Jaipur and Pune. Baseline studies have been done.

- Initiated the city demonstration program in Sanjay Gandhi slum in Delhi under a partnership MOU

with Hope Foundation.

$&!! !! *%#$%%'()

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- Strengthened efforts for maternal and child health service delivery to the urban poor community

through empowered women groups and convergence of service provider.

- More than 1,000 women benefitted from the regular health camps, water & sanitation awareness

campaigns organized in partnership with the city authority i.e. New Delhi Municipal Council

(NDMC) at the Delhi project site. Community members have benefitted from the outreach services

in the settlement.

- Over 8,000 individuals have benefitted from the efforts initiated to bring behavior change for safe

drinking water and access to improved sanitation facilities.

II. STATEMENT OF WORK

Evaluation Purpose:

The purpose of the mid-term assessment is to carry out an in-depth analysis of Urban Health support

activities implemented by the Health of the Urban Poor (HUP) projects in India. Specifically, the

assessment will focus on the following:

i. Technical Assistance to Govt. of India: Assess the process and effects of TA provided to the

GOI and its partners in the designated states and the cities. The assessment should be able to

document and substantiate the progress and process in the context of current GOI policies and

strategies on urban health.

ii. PPP and Convergence: The assessment will analyze the involvement of private sector

partnerships in urban health and convergence of various development and health programs in the

context of urban poor. The assessment should be able to provide insights on how the HUP

program strategies are aligned with and have contributed to the policy priorities of state

governments and GOI.

iii. Demonstration models: The assessment will also document the pilot models created under this

project for replication in terms of relevance, acceptability and credence as an immersion learning

model in Urban Health.

iv. Management systems: The assessment team will finally provide an objective overview of the

management practices followed by this project in meeting the intended objectives of the project.

a. Intended users and other audiences for the evaluation:

The primary intended users of this evaluation are the GOI at national and state levels, and

USAID/India. In particular the Health Office, Program Support Office, and Mission management are

interested in lessons learned concerning health innovations and partnerships as the Mission drafts the

2012-2017 Country Development Cooperation Strategy (CDCS). USAID/India will be particularly

interested in findings and recommendations concerning how innovations and public-private partnerships

can further this strategic plan.

USAID/India will also use this assessment to make mid-course corrections as recommended by the

assessment report. The recommendations will also be used to inform USAID’s new designs that

increasingly focus on innovations in health systems including technology, institutional capacity building,

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human resources for health, and health-related demonstration models that can be widely replicated and

scaled up in India and globally.

The secondary audience of the evaluation is local institutions, other donors, and perhaps

USAID/Washington and other missions worldwide.

c. Evaluation Questions:

This evaluation will answer the following questions, in priority order:

• How has HUP influenced GOI policy on urban health since 2009, and what opportunities currently

exist for USAID to influence policy-level changes through HUP?

• To what extent has the project contributed to the operationalization of the urban health program

at the national and state levels? What were the strengths and weaknesses of its implementation?

• How effective has the project’s TA approach been in building synergies between the public and

private partners in implementation of the key project strategies?

• What lessons can be drawn for future designs from the program governance system, especially its

role in promoting convergence strategies of different GOI program?

• What has been the outcome of the slum demonstration activities under HUP? What are the key

strengths and weakness of these interventions and what is the opportunity for potential scale up?

• How effective are the HUP management systems including project planning and review, grants

management, financial and procurement systems in scaling -up project activities?

III. TECHNICAL REQUIREMENTS FOR EVALUATION:

Data collection and Analysis Methods

USAID/India anticipates a ‘mixed method’ evaluation methodology that would include both quantitative

and qualitative approaches. Data collection methodologies will be discussed with, and approved by, the

USAID/India Health Office team prior to the start of the assignment. The evaluators should consider a

range of possible methods and approaches for collecting and analyzing the information which is required

to assess the evaluation objectives. The evaluators should also assess the performance of the project

against the baselines set by the project for key indicators. Data collection methodologies will be

discussed with, and approved by the USAID/India team prior to the start of the assignment.

The evaluation will address the key questions stated above, while articulating the framework that has led

to desired outcomes of the project. It is envisioned that this elaborated framework would then be used

as a guide to inform future replication strategies. We anticipate that the specific methodology will be

discussed at length and refined during the evaluation planning phase and the Team Planning Meeting.

Desk review of documents: USAID/India will provide the team with all relevant country and project

specific documents including proposals, evaluation reports, monitoring indicators and other relevant

documents for conducting this desk review. The evaluation team is expected to collect and collate

relevant international documents, reports, and data, and all team members are expected to review these

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documents in preparation for the team planning meeting. This desk review will help to organize the

materials for the external evaluation team analysis and review of progress to date, and facilitate their

utilization during the field work, analysis and report writing stages.

Data sources: Data sources that the team will be expected to utilize, review and analyze include the

project design documents, project proposal, annual work plans, M&E data including relevant baseline

information on project sub-components, evaluation reports, and other project-related documents and

reports. Additional relevant documents related to health programming in India may be utilized as

supporting documents, as well as relevant international standards.

b. Composition, Technical Qualifications and Experience Requirements of the

Evaluation Team

USAID seeks a five-member evaluation team (two international and three local experts) comprised of a

Team Leader (Senior Technical Advisor and Policy Expert), an Evaluation Methods Specialist

(International), a Senior Public Health Analyst, a Senior Private Health Sector Expert and a Management

and Governance Expert. All team members must have relevant prior experience in India, familiarity with

USAID’s objectives, approaches, and operations, and prior evaluation/ assessment experience.

Collectively, the team must have experience in evaluating urban health programs. The responsibilities

and technical qualifications and required experience of individual team members identified are given

below:

1. Team Leader (Senior Technical Advisor and Policy Expert) (International): The Team

Leader should have extensive experience in managing public health programs. S/he should have

proven experience in leading and managing large scale health evaluations both in the public and

health sector. S/he should have a good understanding of project administration, financial and

management skills, including an understanding of USAID functioning. S/he should have excellent

English language writing, editing and communication skills. In addition to proven ability to provide

this leadership role, involving a technically and logistically complex program, s/he should have

substantial and demonstrated expertise in evaluation techniques involving projects with TA, training,

advocacy, and partnership components. S/he should be familiar with the functioning of large donor

funded programs in India. The Team Leader will be responsible for coordinating evaluation activities

and ensuring the production and completion of a quality report, in conformance with this scope of

work. These reports may become a public document for distribution among the program’s key

stakeholders, including high-level U.S. government policy makers and officials, host country

government officials, private sector and NGO leaders, and other audiences. The person must have

ability to lead a diverse team of technical and management experts and to interface with various

stakeholders ranging from government to non-government organizations, donors and beneficiaries.

A minimum of 15 years’ experience in design, management and evaluation of health programs is

required. (LOE up to 34 days)

2. Evaluation Methods Specialist (International): This expert will have deep knowledge of

evaluation methodologies and their practical applications in public health settings and complex TA

programs. A minimum of ten years of experience in strategic planning, OR, and/or monitoring and

45 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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evaluation of global and national urban health programs is required. S/he should also have strong

experience in understanding of secondary literature reviews and developing evaluation

methodologies. Experience in presenting research publications and/or complex qualitative and

quantitative information will be an added advantage (LOE up to 30 days).

3. Senior Public Health Analyst (Local): This Senior Public Health Specialist should have

extensive and strong experience in designing, implementing, and evaluating public health programs

with a focus on maternal child health and water sanitation and hygiene projects. S/he should be an

expert in integrated public health programming in the context of urban health programs. S/he should

be familiar with the public and private actors in the health sector and have a good grasp of issues

related to the private sector. Additionally, a good understanding of the relevant national programs is

desirable. A minimum of 10 years of experience in the design, management and evaluation of public

health programs including urban and private health sector is required. Excellent writing and

communication skills are required. Having an excellent understanding of USAID operational,

management, and technical approaches including health systems strengthening will be an added

advantage. (LOE 30days)

4. Senior Private Health Sector Expert (Local): This expert will be responsible for assessing

private commercial sector involvement in the project and assess the public-private partnerships

(PPPs) piloted by the project. S/he should assess and analyze the processes of identification of

opportunities for partnerships and mechanisms to accelerate participation, as well as the

sustainability and scalability of PPPs. In addition, s/he should assess mechanisms to accelerate

participation as well as constraints faced in greater involvement. S/he should document lessons

learned and provide recommendations for strengthening the project partnerships as well as

suggestions for new directions for any future design. This expert should have extensive and proven

experience in implementing core health strategies including urban health in the private sector.

Experience in institutional capacity issues related to PPPs will be an asset. Additionally, s/he should

have exceptional conceptual, analytical and reasoning skills as well as the ability to analyze disparate

information. The expert should have at least 10 years of experience in the health private sector

specifically working on public-private partnerships. S/he should have an understanding of marketing,

promotion and consumer research. (LOE up to 30 days)

Management and Governance Expert (Local): This expert should have an extensive

experience in managing and governance of health and non-health programs. Specifically, s/he should

have an excellent understanding of project administration, governance and management in the health

and non-health sectors in India. S/he should be familiar with the functioning of large donor funded

programs in India. The expert should have at least 10 years of experience in the development

sector. This expert will assess the overall governance of the HUP project at the state and the

national level and must have a thorough knowledge of the project governance of large donor funded

programs which manage networks of NGOs and institutions; experience working with government

and various management issues related to such projects is required. (LOE up to 30 days)

Other Team Participants: This evaluation may include USAID/India, implementing partners’ staff

and GOI experts from Ministry of Health (MOH). USAID/ India staff (non-technical staff) may also join

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 46

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the evaluation team during the site visits. PFI staff may accompany the team on site visits as

appropriate, but will not be present during interviews with stakeholders or beneficiaries.

IV. EVALUATION MANAGEMENT

a. Roles and Responsibilities: The Health Evaluation Specialist in conjunction with the

Evaluation COR, the HUP AOR and Activity Managers, other key Health Office team

members and the Contracting Officer (CO), will provide overall direction to the assessment

team.

• The Contractor will be responsible for obtaining visas and country clearances for travel for

consultants.

• The Contractor will be responsible for coordinating and facilitating assessment-related TPM,

field trips, interviews, and meetings in conjunction with USAID and the HUP Project.

• The Contractor will be responsible for submitting an illustrative budget for all estimated

costs incurred in carrying out this review. The proposed cost may include, but not be

limited to: (1) international and in-country travel; (2) lodging; (3) M&IE; (4) in-country

transportation; and (5) other office supplies and logistical support services (i.e., laptop,

communication costs, etc.) as needed.

• The Contractor will be responsible for in-country logistics including transportation,

accommodations, communications, office support, etc.

b. Schedule:

The duration of the evaluation will be for five weeks, from late June to July 2012.

The evaluation team is expected to provide a schedule (in a tabular form) defining when specific

steps in the evaluation process will occur and when deliverables are due.

Team Planning Meeting (TPM): A two-day team planning meeting will be held by the

evaluation team at an offsite location before the evaluation begins. This will be facilitated by the

evaluation team leader, and will provide the Mission with an opportunity to present the

purpose, expectations and agenda of the assignment. The evaluators shall come prepared with a

draft set of tools and guidelines and a preliminary itinerary for the proposed evaluations. In

addition, the TPM will also:

• Clarify team members’ roles and responsibilities

• Establish the timeline, share experiences and firm up the evaluation methodology

• Finalize the methodology guidelines including tools and questionnaires to be used by the

team

• Discuss and finalize evaluation questions based on the SOW

• Review and revise the draft schedule proposed by USAID

47 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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Site Visits and Interviews: Conduct a thorough review of the Project through site visits and

interviews. Interviewees will include key members from all stakeholder groups, including

commercial sector partners, professional associations, health care providers, RNTCP staff,

USAID/India and its implementing partners and sub-partners, other donors, communication

agencies and beneficiaries. Interview guidelines will be prepared in advance and finalized during

the TPM. Site visits will be planned taking into consideration factors like geographical diversity,

representation of various beneficiary groups, and scale of interventions. After the TPM and

Delhi meetings, the evaluation team will travel to selected sites to conduct their research. The

team will travel together to two sites and will split up into two teams to conduct simultaneous

research at three sites. During visits to the two joint city demonstration/state sites, the team

will also split up for conducting interviews and making field visits.

c. Reports and Deliverables:

i. Draft Work Plan and Pre-Departure Briefings: The evaluation team will develop a

draft work plan prior to arrival in Delhi. The team will meet with USAID/India and other

relevant contractor staff for at least three working days prior to departure for the field.

ii. Mid-Point Review/Briefing: The evaluation team will provide a mid-point briefing to

the USAID/India team, including evaluation and technical members, to clarify any

outstanding queries that may have emerged since the initiation of the evaluation process. If

this is not feasible based on scheduled field work, the Team Leader will submit weekly

progress reports to the COTR via email by OOB beginning of the next week.

iii. Oral Presentation: The evaluation team will provide an oral briefing on its findings and

recommendations to relevant staff in the field, to GOI and state government officials, and

to USAID staff at the conclusion of the visits to the various project sites and implementing

partners. The team may be requested to do a presentation at the MOHFW attended by all

eight state representatives. The evaluation team will be required to debrief the Mission

Director and Deputy Mission Director separately on the observations and

recommendations.

iv. Reports: The evaluation will be required to submit the following reports:

a) Draft Report: The evaluation team will present a draft report of its findings and recommendations

to the USAID/India’s HUP AOTR and Activity Managers, Health Evaluation Specialist and Evaluation

COTR, and other key Health and Program Support Office staff one week after return to the United

States.

b) Final Report: The final report, with executive summary and in electronic form, must be received by

the Evaluation COTR, Health Evaluation Specialist and USAID/India HUP AOTR within seven working

days after receiving the final comments on the draft evaluation report from USAID/India team. The final

report should also be submitted to PPC/CDIE/DI. The final report should include an executive summary

of no more than three pages, a main report with conclusions and recommendations not to exceed 20 to

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 48

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30 pages, a copy of this scope of work, evaluation questionnaires used to collect information on each of

the program components, and lists of persons and organizations contacted.

d. Evaluation LOE and Budget:

i. Level of Effort:

LABOR CATEGORY

Team Leader (Technical Advisor/Policy Expert)

Evaluation Methods Specialist

Senior Public Health Analyst

Senior Private Health Sector Expert

Management and Governance Expert

LEVEL

MAXIMUM

PROPOSED METHODOLOGIES

The following data collection tools and interview guides will be used during the field visits. If necessary,

these will be revised in Jaipur and as needed.

1) Key Stakeholders for the HUP Project

2) HUP Analysis Workbook

3) Stakeholder Interview Forms:

• Ministry of Health and Family Welfare, GOI

• Ministry of Health, State Level

• Municipal Health Offices, State Level

• HUP Partnering Implementing Agencies

• Community Organization and Health Facilities

• Bilateral and Multi-lateral Agencies

Evaluation tools and questionnaires are available upon request and are uploaded to the Drop Box.

49 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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ANNEX II: EVALUATION TIMELINE AND CALENDAR

PERIOD OF PERFORMANCE: June 18 – August 31

SUNDAY

MONDAY

TUESDAY

Prep Week-US US

Day off

Contract Start Home-based doc

Date

review, drafting

Home-based

instruments

drafting instruments

and eval work plan

India 24

Week 1

Justice & Team

arrive Delhi (AM)

TPM in PM

Kantner arrives

New Delhi PM

New Delhi 25 New Delhi 26

Internal SI Team

Team planning

Planning meeting w/ meeting to develop

full team

tools and work plan

½ day USAID

Team Planning

Meeting (pm)

½ day USAID

Team Planning

Meeting (pm)

WEDNESDAY

Home-based

drafting instruments

and eval work plan

Expats travel to DC

am and

New Delhi 27

Full Team:

Meetings in Delhi

(with implementing

partner/s)

THURSDAY

SI HQ Briefing

New Delhi 28

Full Team: Meetings

in Delhi

FRIDAY

TRAVEL 22

Kantner travels to

NY for visa

Justice departs USA

for New Delhi

New Delhi 29

Full Team: Meetings

in Delhi

SATURDAY

New Delhi 23

Kantner travels to

New Delhi

New Delhi 30

Review & Analysis

Day

India

Week 2

Travel to Jaipur

Team Meeting

Jaipur

Meetings in Jaipur

Jaipur 3

Meetings in Jaipur

Sub-team travel to

Pune (PM)

Jaipur/Pune 4

Pune/Delhi 5

New Delhi 6

New Delhi 7

Sub-team : Meetings

in Pune

Sub-team : Meetings

in Jaipur

Jaipur team travels

to Delhi (PM)

Data

analysis/prepare for

debrief

Pune team travels

to Delhi (PM)

Mid-term debrief

with USAID

Review & Analysis

Day

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 50

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India 8

Week 3

Bhubaneswar 9

Full Team travels to Meetings in

Bhubaneswar

Bhubaneswar 10 Bhubaneswar 11

Meetings in

Bhubaneswar

PM: Call with Kerry

Pelzman, USAID

Health Officer

Meetings in

Bhubaneswar

MP/Dehradun 12 MP/Dehradun 13 Return Delhi 14

Sub-team

Travel to Bhopal

Sub-team travel to

Dehradun

Sub-team meetings in Sub-team meetings in

Bhopal

DehradunSub-team

travel from Bhopal to

Sub-team meetings

Dehradun

Delhi (AM)

Sub-team travel from

Dehradun to Delhi

India 15

Week 4

Day Off

India/US 22

Week 5

Day off

New Delhi 16

Data Analysis

New Delhi 17

Data Analysis

New Delhi 18

Data Analysis

New Delhi 23 New Delhi 24

Presentation to

Ministry of Health

(Urban)

Prepare for USAID

debrief (pm)

Oral Debrief for

USAID (am)

Team Departs India

(pm)

Travel to US

New Delhi 19 New Delhi 20 New Delhi 21

Data analysis

Presentation to

PFI and selected

partners (AM)

Data Analysis/Report

Writing

3 PM: Informal

debrief with

USAID

Report Finalization Report Finalization

51 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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US 29

Week 6

Day off

Week 7

Day off

TBD

Day off

Report Finalization Report Finalization Report Finalization SI Quality Assurance SI Quality Assurance

and Review

TBD

SI Submit DRAFT USAID Review

report to USAID the draft report

TBD

SI internal

review/editor

TBD

SI internal

review/editor

USAID provides

SI comments on

draft

Finalize report based Finalize report based

on USAID feedback on USAID feedback

TBD

SI Submits Final

Report to USAID

7 days after

comments

received from

USAID

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 52

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ANNEX III: KEY REFERENCES/DOCUMENTS REVIEWED

Bharati Vidyapeeth Deemed University. 2011. Annual Report, 2010-2011: Social Transformation through

Dynamic Education. Pune:BVDU.

Kirloskar Foundation. 2012. School Health. Clean Beautiful School, Annual Report 2011-2012. Pune:

Kirloskar Foundation.

Micro Insurance Academy (MIA). 2012. The Burden of Disease among India’s Urban Poor: A Study at Three

Sites. New Delhi: PFI and USAID/India, March 27.

Micro Insurance Academy. 2012. Micro Health Insurance Schemes in Urban India: A Compendium. New

Delhi: PFI and USAID/India, March 27.

Ministry of Health and Family Welfare (MOHFW) and Ministry of Housing and Urban Poverty

Alleviation, Government of India. 2010. Workshop Report: Consultation Workshop on National Urban Health

Mission. New Delhi: MOHFW and HUPA, July, 23.

Ministry of Health and Family Welfare (MOHFW). 2006. Draft Final Report of the Task Force to Advise the

National Rural Health Mission on “Strategies for Urban Health Care”. New Delhi: MOHFW, Source

http://www.mohfw.nic.in/NRHM/Task grp/Report_of_UHTF_5May2006.pdf., May.

Orissa Voluntary Health Association. 2011. 37th Annual Report, 2010-2011. Bhubaneswar: OVHA.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Point of Use (POU): An

Approach Toward Safe Drinking Water. New Delhi: PFI and USAID/India, June.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Water and Sanitation:

Statistics of State Series. New Delhi: PFI and USAID/India, March.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Urban Health Training

Module: Model 1 Orientation and Introduction. New Delhi: PFI and USAID/India.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Maternal Health Training

for HUP Field Staff: A Detailed Report. New Delhi: PFI and USAID/India, January.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Newborn and Child Health

Training for Field Staff: A Detailed Report. New Delhi: PFI and USAID/India, May.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Baseline Questionnaire.

New Delhi: PFI and USAID/India, June.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2010-2012. Minutes of the

Program Management Group (PMG) Meeting. New Delhi, India, September 9, 2010; September 24, 2010;

January 17, 2011; February 4, 2012; April 18, 2012; and May 15, 2012.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Health of the Urban

Poor (HUP) Program: Overview and Status. Powerpoint Presentation. New Delhi: PFI and USAID/India,

June 27.

53 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Health of the Urban Poor

Program: Rajasthan: Mid-Term Assessment. Powerpoint Presentation. Jaipur: IIHMR and USAID/India, July

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. City Demonstration

Program: Pune. Powerpoint Presentation. Pune: Plan India and USAID/India, July 4-5.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Health of the Urban Poor

Program, State: Odisha. Powerpoint Presentation. Bhubaneswar: PFI and USAID/India, July 4-5.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. City Demonstration

Program: Bhubaneswar. Powerpoint Presentation. Bhubaneswar: PFI and USAID/India, July 9-11.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Health of the Urban Poor

Program, State: Uttarakhand and Dheradun. Powerpoint Presentation. Dheradun, Plan India and

USAID/India, July 13-14.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Health of the Urban Poor

Program: Quarterly Progress Report, January 1-March 31, 2012. New Delhi: PFI, April.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2012. Quarterly Progress Report,

January 1-March 31, 2012. New Delhi: PFI, April.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2011. Orientation and Induction

Training for HUP Field Staff. New Delhi: PFI and USAID/India, November.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2011. Annual Work Plan:

October 2011-September 2012. New Delhi: PFI, September.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2011. Public Private Partnership

in Urban Health (draft). New Delhi: PFI and USAID/India, December 22.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2011. Health of the Urban Poor

Program: Annual Report, October 1, 2010-September, 30 2011. New Delhi: PFI, October.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2010. Health of the Urban Poor

Program: Annual Report, October 1, 2009-September, 30 2010. New Delhi: PFI, October.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2009. HUP Award Monitoring

Plan. New Delhi: PFI, December.

Population Foundation of India, Health of the Urban Poor Project (HUP). 2009. HUP Logical Framework.

New Delhi: PFI, December.

Population Foundation of India, Health of the Urban Poor Project (HUP). Nd. Operational Guidelines for

Urban Health and Nutrition Day (UHND). New Delhi: PFI and USAID/India.

Population Foundation of India, Health of the Urban Poor Project (HUP). Nd. Operational Guidelines for

Formation/Strengthening of Ward Committees. New Delhi: PFI and USAID/India.

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 54

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8.1 Page 71

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Population Foundation of India, Health of the Urban Poor Project (HUP). Nd. Operational Guidelines for

Formation/Strengthening of City Coordinating Committees. New Delhi: PFI and USAID/India, June.

Population Foundation of India, Health of the Urban Poor Project (HUP). Nd. HUP Performance Indicators

and Frequency of Reporting/Means of Verification. New Delhi: PFI, pp-1-4.

Population Foundation of India, Health of the Urban Poor Project (HUP). Nd. Operational Guidelines for

Mahila Arogya Samiti (MAS). New Delhi: PFI and USAID/India.

Population Foundation of India, Health of the Urban Poor Project (HUP). Nd. Map and List of HUP

States and Cities. New Delhi: PFI and USAID/India.

Population Foundation of India, Health of the Urban Poor Project (HUP). Nd. Organogram and Key

People. New Delhi: PFI and USAID/India.

Population Foundation of India, Health of the Urban Poor Project (HUP). Nd. HUP Performance

Indicators and Frequency of Reporting/Means of Verification. New Delhi: PFI and USAID/India.

Seashore Health Care. 2011. On People’s Friemdly PPP-CSR Health Initiatives in Odisha: PPP and CSR

Initiatives of Seashore Foundation. Cuttack, Odisha: Volume –II, Newsletter, November.

USAID/India. 2009. Request for Application #386-09-055 for USAID/India’s Heatlh of the Urban Poor

(HUP) Program. June 1, 2009

USAID/India. 2009. Cooperative Agreement No.386-A-00-09-00303-00. September 25, 2009.

USAID/India. 2011. FY 2011 Portfolio Review: Project/Activity Summary Sheet. Period of Review: October 1,

2010 to September 30, 2011. New Delhi: USAID/India, pp 1-5.

USAID/India. 2010. FY 2010 Portfolio Review: Project/Activity Summary Sheet. Period of Review: October 1,

2009 to September 30, 2010. New Delhi: USAID/India, pp 1-5.

West, Gary R, Sheila P. Clapp, Megan Davidson Averill and Willand Cates Jr. (2012). Defining and

Assessing evidence for the effectiveness of TA in furthering global health. Global Public Health: An

International Journal for Research Policy and Practice (Available online: 21 May 2012).

55 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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ANNEX IV: INDIVIDUALS AND ORGANIZATIONS

CONSULTED/INTERVIEWED

USAID/India

Elizabeth Callender, Program Officer, Evaluation

Charushila Lal, Program Development Specialist, Monitoring & Evaluation

Anand Rudra, Program Management Specialist, Urban Health and Water Lead,

Sanjay Kapur, USAID

James Browder, Deputy Director, Health Office,

Dr. Sachin Gupta, Project Management Specialist (Child Health, Health Office)

Patricia Ramsay, Acting Mission Director

Buzz Enroth, Acting Deputy Mission Director

Other Donor/International Organizations

Dr. Gita Pillai, Director/Chief of Party, Urban Health Initiative (BMGF)

Ramesh Govind Raj, Lead, Health Specialist, World Bank/India

Billy Stewart, Head, Health Unit, DFID/India

Dr. Sanjay Panday, UNICEF (Former Director, HUP/PMU/PFI)

Population Foundation of India (PFI)

Mr. Surojit Chatterji, Programme Director, HUP/PFI

Shipra Saxena, Water and Sanitation Specialist, HUP/PFI

Dr. Subrato Kumar Mondal, Director, - Knowledge Management and Research, HUP/PFI

Dr. Mainak Chatterjee, Public Health Specialist, HUP/PFI

Dr. Sainath Banerjee, Chief of Party, HUP/PFI

Guatam Chakraborty, Public Health Economist, HUP/PFI

Shekhar Waikar, Senior Public Private Partnership Specialist, HUP/PFI

Poonam Muttreja, Executive Director, PFI

Bijit Roy, Programme Officer, Community Monitoring, HUP/PFI

Dr. Swati Mahajan, Demonstration Officer, HUP/PFI

Mr. A. R. Nanda , IAS (Retd)(Former Executive Director PFI

HUP/PMU debrief at PFI:

Madhu Loehi, CEDPA/India

Aparajita Gopoi, Country Director, CEDPA/India

Ash Pachauri, Social Impact, India

Shipra Saxena, HUP-PFI

B. S. Singh, PD-HUP/Rajasthan

Smarajit Chakraborty, Project Director, HUP-PFI, Odisha

Ashok Lal Soni, PD-HUP, Jharkhand

Dr. Sneha Siddham, Plan India

RashmiSliehathi, HUP-Plan India, Pure

Ashish Kumar, PD-HUP/Plan-Bihar

Sainath Banerjee, COP, HUP-PFI

Dr. Swati Mahajan, Demonstration Officer, HUP-PFI

Shekhar Waikar, Sr. PPP Specialist, HUP-PFI

Gautam Charraborti, Health Economist, HUP-PFI

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Dr. Mainak Chatterjee, Public Health Specialist, HUP-PFI

Monica Sahri, Finance and Administration Manager, PFI-HUP

Jatin Dhingra, Consultant, City Demonstration, PFI-HUP

Shahid A. Anari, Grants Manager, HUP-PFI

Lalitendu Jagatdeb, IS Manager, PFI-HUP

Gaugam Sadhu, IIHMR, Jaipur

Dr. Pradeep Panda, Micro Insurance Academy (MIA), Delhi

Rajiv Saurastri, PD-UP, HUP-PFI

Anujesh Mathur, P.D., MP, PFI

Dr. Bharati Dangwal, PD-HUP, Uttarakhand

Dr. Subrato K. Mondal, Director, KMR, PMU-PFI

Poonam Muttreja, Executive Director, PFI

Partha Roy, City Coordinator, Bhubaneswar

Surojit Chatterji, Director, Program, HUP Delhi

Dr. Naresh, City Coordinator, HUP, Jaipur

HUP Consortium Partner Organizations

Dr. Pradeep K. Panda, Deputy Director Research, Micro Insurance Academy (MIA)

Dr. Sneha Siddham, Sr. Program Manager, Urban Health, Plan India

Mohammed Asif, Director Programs, Plan India

Dr. Aparajita Gogai, Executive Director, CEDPA

Government of India, Ministry of Health, New Delhi

Manoj Jhalani, Joint Secretary, MOHFW/GOI

Priti Pant, Director Urban Health, MOHFW/GOI

Delhi Municipality/City Demonstration Project

Medical Officers at NDMC Hospital (Chanakyapuri)

Dr. Alka Saxena, Medical Superintendent, Charak Palika Hospital, New Delhi Municipal Corporation

Lizzy Cherian, Senior Nursing Superintendent, Charak Palika Hospital, New Delhi Municipal Corporation

Amrita Valli, Project Coordinator, Hope Foundation

Saji Verghese, Project Director Hope Foundation

HOPE Foundation, MAS and Community in Sanjay Gandhi slum:

Amrita Valli, Project Coordinator, Hope Foundation

Saji Verghese, Project Director Hope Foundation

Leela Bhatt, Deputy Director, Samajik Suvidha Sangam, Mission Convergence, Govt of NCT of Delhi

Prachi Kaushik, Associate Program Officer, Mission Convergence

Kamlesh Singh, Specialist Urban Poverty Management, Mission Convergence

R. B. Prashant, Executive Director, Kalyanam, (GRC, Sangan Vihar Slum), New Delhi

Kanchan Gera, Project Cordinator, Kalayanam (GRC, Sangam Vihar Slum), New Delhi

Madhya Pradesh

Anujesh Mathur, Project Director, HUM/MP

Rambir Singh Sikarwar, Convergence Advisor, HUP/MP

Chandan Verma, Public Private Parnership (PPP) Specialist, HUP/MP

D. Johnson Rhenius Jeyaseelan, Water Supply & Sanitation Specialist, HUP/MP

Prabhu Nath Mishra, Finance & Admin Officer, HUP/MP

Chanchal Sur, MIS Officer, HUP/MP

Dr. Veena Sinha, Civil Surgeon, J. P. Hospital, Bhopal

Dr. K. L. Sahu, Joint Director, NRHM, Bhopal, Madhya Pradesh

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Dr. R. Shrivastava, Deputy Director, Urban Health, Bhopal, GoMP

Dr. Ajay Khare, Deputy Director, SPMU

Dr. Ravindra Pastor, Mission Director, NRHM, Directorate of Health Services Madhya Pradesh

Dr. Harendra M. Mishra, Officer on Special Duty (Training), Urban Administration & Development

Department, GoMP

Rakesh Munshi, Advisor, State Planning Commission , GoMP (earlier Jt. Director NRHM)

Pravir Krishna, Principal Secretary, Department of Health and Family Welfare, GoMP

D. S. Bhadauriya, Principal Programme Coordinator, Lupin Human Welfare & Research Foundation,

Bhopal

Odhisha and Bhubaneswar

Samarajit Chakraborty, Project Director, HUP-PFI, Odisha

Niladri Chakraborti, NGO-CBO Coordinator, HUP-PFI, Bhubanerswar

Biraja Kabi Satapathy, Water & Sanitation Specialist, HUP/PFI, Bhubaneswar

Basudev Panda, Documentation Officer, HUP/PFI, Odisha

Partha Roy, City Coordinator, HUP/PFI, Bhubaneswar

Dr. Hrudananda Mohanty, Convergence Advisor, HUP/PFI, Odisha

Shekh Nausad Akhatar,. MIS Officer, HUP/PFI, Odisha

Ranjit Kumar Nayak, Finance and Administration Officer, HUP/PFI, Odisha

Dr. Dinandhu Sahoo, MD (O&G), C.M.M.O Municipal Hospital, Bhubaneswar

Sunand Maharana, Project Coordinator, HUP/My Heart (Health Post)

Barita Mahaptra, Cluster Coordinator (Junta Nagar slum, Saliasahi, BBSR)

Manorama Nayak, Cluster Coordinator

Basanti Singh, Cluster Coordinator

Rashmi Rekha Barik, ANM, Coordinator of Urban Slum Health Post

Rashmi Rekha Sahoo, ANM, Urban Slum Health Post

Sabitri Moharana, MAS member

Bhasi Mohapatra, MAS member

Sarajini Bhiswal, MAS member

Jyotshna Rani Sahwo, MAS member

Pramoda Senapati, Anganwadi Worker

Ms. Sujata Kartikeyan, Director Social Welfare, Department for Woman and Child Development, GoO

Dr. BK Mishra, Special Secretary Health (Technical), Department of Health Medical and Family Welfare, GoO

Dr. BK Panda, Joint Director (Technical), NRHM, DoHMFW, GoO

Mr. Santosh Naik, PPP consultant NRHM, GoO

Mr. Srimanta Mishra, OAS-I, SIO cum-Nodal Officer, RAY and PO Jn NURM, Bhuvaneswar Municipal Corporation

Mr. Binoy Kumar Das, Slum Improvement Officer, Bhubaneswar Municipal Corporation

Dr. M. R. Mishra, Deputy Director, Seashore Health Care Foundation, Seashore Health Training &

Resource Centre, Cuttack, Orissa

Dr. Dushasan Muduli, MD, (C.M.O.), Seashore Health Care Pvt. Ltd. (Former Special Secretary to

Government (Tech), Health and Food Dept, GoO

Mrs. Sanshamih-Pattnaili, Seashore Health Care Pvt. Ltd.

Mr. Debabrata Mohortra, (M.M.), Seashore Health Care, (P) Ltd.

Sanjib Kumar Mishra, Addl Secretary, H&UD Department, Bhubaneswar, Orissa

Er. Dilip Singh, EIC-cum Special Secretary, H&UD Department, Bhubaneswar, Orissa

Meetings with Community Workers and Members

Shaktidhar Sahoo, Director, My-Heart, March of Youth for Health, Education, and Action for Rural

Trust, Bhubaneswar

Itishree Praharaj, Project Coordinator, HUP, OFI, OVHA, Bhubaneswar

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 58

8.5 Page 75

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Satyaram Beura, Project Coordinator, HUP, Bhairabi Club, Bhubaneswar

Laxanan Kumar Bamisal, HUP, Bhairabi Club, Bhubaneswar

Artatrana Behera, Secretary, Gopinath Juba Sansha, HUP, Bhubaneswar

Abhaya Subudhi, Project Coordinator, HUP, Family Planning Association of India, Bhubaneswar

Umakarita Behera, Project Coordinator, Gopinath Juba Sansha, Bhubaneswar

Ashok Kuman Samantareay, Branch Managen, Family Planning Association of America, Bhubaneswar

Sunand Muharana, Project Coordinator, My-Heart, March of Youth for Health, Education, and Action

for Rural Trust, Bhubaneswar

Subrat Kumar Bisoyi, Executive Director, OVHA, Bhubaneswar

Pune Municipality/City Demonstration Project

Rashmi Shirhatti, City Coordinator, HUP, Plan India

Lina Rajan, NGO/CBO Coordinator, HUP, Plan India

Jayanta Chowdhury, MIS Officer, HUP, Plan India

Vijay G. Naik, Secretary and Treasurer, Kirloskar Foundation

Dr. V.N. Karandikar, Direcotr, Health Sciences Education and Research, Bharati Vidyapeeth University

Dr. A.V. Paranjape, Executive Director, Community Aid and Sponsorship Programme (CASP

Dr. S.T. Pardeshi, Acting Medical Officer of Health (MOH), Pune Municipal Corporation

Rajasthan and Jaipur

Indian Institute of Health Management and Research (IIHMR):

Shivendra Kumar, NOG/CBO Coordinator, City HUP Team

Naresh Kumar, City Coordinator, HUP Team,

Dr. Himani Tiwari, Water and Sanitation Specialist, HUP-Rajasthan

Pooja Bharuch, Documentation & MIS Officer, HUP

Phanindra Hari Krishna, MIS Officer, HUP State Team

D. S. Bisht, Finance Officer, HUP

Prafull Kumar Sharma, Convergence Advisor, HUP

Dr. B. S. Singh, Project Director, HUP

Nisha Ameta, Project Coordinator, HUP

Madhur Mathur, Support Staff, HUP

Dr. S. D. Gupta, Director, IIHMR

Goutam Sadhu, Associate Professor, Associate Dean and Programme Coordinator of HUP (Rajasthan &

Chhattisgarh)

Amitava Banerjee, Executive Director, Bhoruka Charitable Trust, Jaipur, Rajasthan

Ms. Gayatri A. Rathore (IAS), Special Secretary and Mission Director, National Rural Health Mission,

Dept of Medical Health & Family Welfare, GOR

Visit to Community July 2nd – Jawahar basti – Tilla number 3

Observation of UHND, Interaction with ANM (Mani Radha), AWW (Shobha Rani), Link Worker

(Mamta)

Meeting with Jawahar Nagar Basti Till no 3 MAS members – Chairperson Shamim Begum

Meeting with Reproductive Child health Officer, Department of Health and Family Welfare: Dr. Rommel

Singh Pawar

D- Health Post Jawahar Nagar: Dr Satjeet Sondhi

Review of supplies in Government Dispensary Jawahar Nager with Dr. Sondhi

Cluster Coordinators

Kamlesh Dr. Jangid, Cluster Coordinator, BCT/HUP

Vinod Kumar, Cluster Coordinator, BCT/HUP

Hari Narayan, Cluster Coordinator, BCT/HUP

Umili Solanki, Cluster Coordinator, BCT/HUP

59 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

8.6 Page 76

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Visha Aamera, Cluster Coordinator, BCT/HUP

Pooja Bharuch, D. O., BCT/HUP

Virerendra Singh, Cluster Coordinator, BCT/HUP

Manoj Kumar Shiv, Cluster Coordinator, BCT/HUP

Renu Sharma, Cluster Coordinator, BCT/HUP

Mithlesh Arora, Cluster Coordinator, BCT/HUP East Cluster

Dr. Naresh Kumar, City Coordinator

Shivendra Kumar, NOG/CBO Coordinator

Dr. Anil Bhargava, Chief Engineer, Public Health and Engineering Department, GOR

Dr. Mala Airun, Medical Superintendent, Narayana Hrudayalaya Hospitals, Jaipur

Dr. Noopur Prasad, Joint Director, Reproductive & Child Health, Dept of Medical Health & Family

Welfare, GOR

Shikka Sharma, Consultant, RCH Services, URCH, GOR

Col. Murli Nair, Chief Program Manager, Lupin Human Welfare & Research Foundation, Bharatpur

Rahul Charterjee, Program Coordinator, Health, Lupin Foundation

Dr. S. M. Mittal, Additional Director, Department of Medical Health and Family Welfare, GOR

Dr. P. K. Sarda, Director (RCH), Directorate of Medical Health & Family Welfare Services, Jaipur

Loknath Soni, CEO, Jaipur Municipal Corporation, Jaipur

Uttarakhand

Dr. Bharti Dangwal, Project Director, Health of the Urban Poor (HUP) Program, Plan India, Dehradun

Merajuddin Ahmad, Water and Sanitation Specialist, Health of the Urban Poor (HUP) Program, Plan

India, Dehradun

Devraj Bhatt, Convergence Advisor, Health of the Urban Poor (HUP) Program, Plan India, Dehradun

Gaurav Joshi, PPP Specialist, Health of the Urban Poor (HUP) Program, Plan India, Dehradun

Dr. Umakant Panwar, Secretary, Department of Urban Development, Uttarakhand Secretariat,

Dehradun

Dr. Geeta Khanna, Consultant Pediatrician, Executive Director, KMS Hospital, Director Combined

School Health Care Services, Dehradun, Secretary Samarpan NGO

Samarpan managed UHC: Dr. Arunima Goyal, Medical Officer, Mr. S.P Pokhriyal, Project Manager,

Mr. Amit Negi, IAS, Additional Secretary to GoUK and Director ICDS

Mr. PK Bisht, Joint Director, Midday meal scheme, Department of Education, GoUK

Mr. Jagdish Sajwan, Senior Lecturer, MDM, DoE, GoUK

Dr. Sushma Dutta, Director, National Programs, DoHFW, GoUK

Mr. Piyush Singh, IAS, NRHM Mission Director and Additional Secretary Health

Mr. Vinod Chamoli, Mayor Dehradun

Social Impact

Anna Jacobson, Program Associate, Social Impact

Dustin Homer, Program Assistant, Social Impact

Paige Mason, Program Associate, Social Impact

Lee Briggs, Social Impact

Richard Blue, Vice President, Social Impact

Ash Pachauri, Social Impact India Coordinator

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 60

8.7 Page 77

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ANNEX V: CURRENT PERFORMANCE INDICATORS USED BY THE HUP PROJECT

PERFORMANCE INDICATORS

SOURCE

(PRIMARY/

SECONDARY)

TYPE (OUTPUT/

OUTCOME)

MEANS OF

VERIFICATION

JUNE

2010–

SEPT.

2011

OCT.

2011–

SEPT.

2012

CUMULATIVE

ACHIEVEMENTS

Objective 1: Provide quality TA (TA) to the GOI, states and cities for effective implementation of the NUHM and/or urban components of

NRHM

No. of meetings of Technical Advisory Group

(TAG)

Secondary

Output

Annual Report

No. of meetings of State Counter Part

teams/Coordination forum

Secondary

Output

QPR

No. of training programs/ sensitization sessions

organized for staff and different stakeholders

Secondary

Output

QPR

No. of program planning and review

meetings/workshops at state level

Secondary

Output

Annual reports

No. of study tours organized for government/ and

other stakeholders

Secondary

Output

QPR

Number of local institutions identified/developed

to provide TA to NUHM/urban components of

Secondary

Output

Govt. Records

NRHM on sustainable basis

Number of state/ city Project Implementation

Plans (PIPs) prepared with recipient’s support

Secondary

Outcome

Govt. Records

Number of states provided TA through urban

health cells or consultants with recipient’s support

Secondary

Output

Govt. Records

Number of new cities developed and implemented

urban health plans.

Secondary

Outcome

Govt. Records

61 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

8.8 Page 78

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PERFORMANCE INDICATORS

SOURCE

(PRIMARY/

SECONDARY)

TYPE (OUTPUT/

OUTCOME)

MEANS OF

VERIFICATION

JUNE

2010–

SEPT.

2011

OCT.

2011–

SEPT.

2012

CUMULATIVE

ACHIEVEMENTS

Objective 1 (cont.): Provide quality TA (TA) to the GOI, states and cities for effective implementation of the NUHM and/or urban components

of NRHM

Number of reports / Program lessons,

documentation published/ disseminated

Secondary

Output

Reports

Number of dissemination events organized for the

key officials from MOHFW, MoH&UPA and

MoWCD with recipient’s TA support

Secondary

Output

Workshop

Report

Number of advocacy events/ symposiums/seminars

organized

Secondary

Output

Annual Report

Objective 2: Expand partnerships in urban health including engaging the commercial sector in PPP activities

Number of MOUs signed by state/city

governments with non-government and

commercial sector partners through recipient’s TA

Secondary

Output

Govt. Records -

MoUs

Number of service delivery models

developed/strengthened in collaboration with

Secondary

Output

MoUs signed

private/commercial sector

No. of consultations/meetings for sharing best

practices on PPP

Secondary

Output

Annual Report

No. tools (MOUs, EOI/ToR/evaluation criteria)

developed for establishing Partnership

Secondary

Output

Annual Report

No. of potential partners identified for resource

leveraging

Secondary

Output

QPR

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 62

8.9 Page 79

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PERFORMANCE INDICATORS

SOURCE

(PRIMARY/

SECONDARY)

TYPE (OUTPUT/

OUTCOME)

MEANS OF

VERIFICATION

JUNE

2010–

SEPT.

2011

No of USAID partners having convergent actions

in their work-plans

Secondary

Output

Submitted work

plans

Objective 3: Promote the convergence of different GOI urban health and development efforts

Number of consultations/workshops organized to

operationalized convergence

No. of letters jointly issued by Departments of

Health and Family Welfare, Housing and Urban

Poverty Alleviation and Woman and Child

Development

Secondary

Output

Workshop

reports

Govt. records

OCT.

2011–

SEPT.

2012

CUMULATIVE

ACHIEVEMENTS

Number of CRM/JRM/JMM of NUHM with

participation of officials from Housing & Urban

Poverty Alleviation and Women & Child

Secondary

Output

Govt. records

Development

Number of cities with models of convergence

between NUHM/Urban components of NRHM

Secondary

Output

Govt. records

and JNNURM/ICDS

No. of exposure visits and cross visits to

successful convergence models

Secondary

Output

QPR

No. of meetings of city multi-stakeholder

coordination committee organized

Secondary

Output

QPR

Lessons of community level convergence are

documented and adopted by NUHM/urban

Secondary

Output

Govt. records

components of NRHM

63 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

8.10 Page 80

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PERFORMANCE INDICATORS

SOURCE

(PRIMARY/

SECONDARY)

TYPE (OUTPUT/

OUTCOME)

MEANS OF

VERIFICATION

JUNE

2010–

SEPT.

2011

OCT.

2011–

SEPT.

2012

Objective 4: Strengthen the evidence-based rigor of city-level demonstration and learning efforts in order to improve program

learning

No. of cities where slum and facility mapping and

vulnerability assessment conducted

Secondary

Output

QPR

CUMULATIVE

ACHIEVEMENTS

No. of city demonstration and learning models

developed and documented

Secondary

Output

Annual Report

No. of baseline or feasibility studies conducted

Secondary

Output

Report

Number of new cities implementing city programs

with learning from USAID supported

Secondary

Outcome

Govt. records

demonstration and learning sites

Number of people in target areas gaining access to

improved drinking water supply as a result of USG

assistance

Primary

Outcome

Rapid

Assessment

4804

Number of people in target areas gaining access to

improved sanitation facilities as result of USG

assistance

Primary

Outcome

Rapid

Assessment

3404

No. of people in target areas with access maternal

and child health-care services

Primary

Output

Quarterly

Report

A Toolkit to undertake baseline research studies

developed

Secondary

Output

Annual Report

Toolkits developed with recipient’s support is

adopted by the national/state/city governments

Secondary

Output

Annual Report

Number of scientific articles published in peer

reviewed indexed journals

Secondary

Output

Scientific journal

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 64

9 Pages 81-90

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9.1 Page 81

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ANNEX VI: SELECTED PRELIMINARY INDICATORS FROM 2012

HUP BASELINE SURVEY IN JAIPUR, BHUBANESWAR, AND PUNE

INDICATORS

JAIPUR

BHUBANESWAR

Total

Urban

N=1997

Slum Non-

Slum

N=370

N=1627

Total

Urban

N=1839

Slum Non-

Slum

N=279

N=1560

PUNE

Total

Urban

Slum

Non-

Slum

N=1884 N=447 N=1437

Environmental Conditions (Water and Sanitation)

Percentage of

48.2 59.9 42.2

37.5 67.1

35.0

households using one

room for sleeping 3 or

more persons

53.3 69.8 49.7

Percentage of

households having

access to improved

toilet facility

94.1 86.4 98.1

94.1 71.3

96.0

98.2 93.8 99.3

Maternal Health Status

Percentage of

18.7 28.7 15.5

32.8 28.6

33.1

20.4 17.2 20.8

currently married

women not using any

method of

contraception

Percentage of

92.2 92.0 92.2

93.9 83.3

94.9

99.0 94.7 99.5

pregnant women who

had at least three

ANC visits for the last

birth

Percentage of

49.0 39.4 54.6

77.0 65.3

78.7

81.2 74.5 82.4

pregnant women

consuming IFA

tablets/syrups during

the 90 day period

before the last birth

Percentage of mothers 85.5 77.6 90.5

95.8 81.8

97.5

97.8 96.7 98.2

who delivered in an

institution for the last

birth

65 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

9.2 Page 82

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INDICATORS

JAIPUR

BHUBANESWAR

Total

Urban

N=1997

Slum Non-

Slum

N=370

N=1627

Total

Urban

N=1839

Slum Non-

Slum

N=279

N=1560

PUNE

Total

Urban

Slum

Non-

Slum

N=1884 N=447 N=1437

Child Health Status

Percentage of children 41.0 32.4 46.5

58.6 32.4

62.2

56.2 63.6 54.7

(12-23 months) fully

immunized

Percentage of children 46.2 42.4 48.5

80.1 85.4

80.0

75.8 74.4 75.8

(12-35 months) who

have received at least

1 dose of Vitamin A

Percentage of children 74.4 70.4 77.3

88.3 97.0

87.5

83.1 83.3 83.2

(0-5 months) who

were exclusively

breastfed

Percentage of children 52.8 42.9 59.0

67.9 68.4

65.0

72.0 85.7 64.7

with diarrhea in last

two weeks treated

with ORS

Other Health Burdens and Risk Factors

Percentage of

1.7

1.5

1.8

0.9

3.1

0.7

0.1

0.5

0.0

households having any

member suffering

from of malaria in last

two weeks

Percentage of

1.2

1.3

1.2

0.5

1.3

0.3

0.7

1.2

0.5

households having any

member suffering

from TB in last year

Percentage of women 78.3 67.5 83.1

64.5 46.2

66.0

63.5 48.8 66.7

aware that consistent

condom use can

reduce chances of HIV

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 66

9.3 Page 83

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ANNEX VII: STAGES IN THE EVOLUTION OF URBAN HEALTH

PROGRAMMING

Urban Health a need and prioritized

Policy environment restricted to

urban RCH

Policy environment conducive for

comprehensive urban programming

Clarity on needs & Gaps analyzed

Adequacy, accessibility and quality of

service strengthened

Partnerships leveraged for designing

health delivery architecture

HR/ Financial management/

Convergence/Partnerships delineated

Mechanisms for demand generation

developed and implemented

M&E systems established and

strengthened

Planning afoot to expand scope of

urban programming

Vision and Policy developed

Financing mechanisms delineated

(GOI/State/Private)

Service delivery areas prioritized and

mechanisms delineated

HR/ Financial management/

Convergence/Partnerships delineated

Mechanisms for demand generation

developed and implemented

M&E systems established and

strengthened

Forecasting future needs continuously

67 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

9.4 Page 84

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ANNEX VIII: MAPPING OF TA PROVIDED BY HUP

GOI

VISION AND

POLICY

FINANCING UH

HR AND

GOVERNANCE

SERVICE

DELIVERY

INFORMATION

SYSTEMS

PROCUREMENT

FINANCIAL

MANAGEMENT

DEMAND

GENERATION

-Draft NUHM

document -Evidence

generation -

Disease Burden Study;

Study on PPP, micro-

insurance schemes,

BCC

-Review of state PIPs

-NUHM

implementation

framework

Component of

NUHM

implementation

framework

Component of

NUHM

implementation

framework

NUHM budgetary

framework

Yet to be

completed –

successful

models for

demand

generation being

field tested

STATES

Evidence: Facility

Assessment- (JK,UK)

-Advocacy

&/government orders

for convergence

-Planning and mapping

tools

-Technical Resource

group (JK)

-Policy analysis of

WASH

Efforts for urban RCH

cell/PPP cell

Supporting an

increase in urban

RCH budgets

PPPs afoot for

secondary level

services – Odisha

and Rajasthan

-Mapping of

potential partners

for

WASH/nutrition/he

alth

Support for tailoring

RSBY to urban

areas (UK)

Drafting of urban

-Micro plans for

RCH component of immunization in

PIPs in 4 states

(JK)

Advocacy & Capacity Operationalizing

Building (CB) –

UHNDs (UK&JK)

training on

-Defining service

PPP/MNCH and

norms for URCH

WASH modules/visits centers (UK)

Mother and child

tracking tools (all

states)

HMIS formats and

tools

MIS for urban

services (Odisha)

Drafting MOUs for

NGO and

commercial

partnerships for

service delivery

Efforts afoot to

create budget line

for urban

programming at

district health

society

BCC tools for

demand

generation

CITY

City health plans

Advocacy for

convergence

City specific PPPs in

Pune – efforts afoot

Advocacy & CB of

front line workers,

‘Point of Use’ training

in WASH (Raj/Od)

Promotion of

Urban health and

Nutrition Days

-Facilitating

outreach

-Guidelines for

MAS/CCC/WCC

Implementation

of demand

generation

models– BCC in

health, nutrition

and WASH

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 68

9.5 Page 85

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ANNEX IX: COMPARISON OF THE CHANGE IN URBAN RICH BUDGETS OF HUP AND

NON-HUP STATES, 2010–2013

STATE

2010–2011 EXPENDI- SPENT

BUDGET TURE %

UNSPENT

BUDGET

2011-12

ADDITIONAL

AMOUNT

REQUESTED

CHANGE

IN %

BUDGET

2012–2013

CHANGE

IN %

Bihar

Jharkhand

Rajasthan

Orissa

Uttarakhand

Chattisgarh

Manipur

Punjab

Karnataka

153.32

108

80.1

768.82

293.81

1674.36

369.08

80.12

190.44

480.73

55.64

33.17

10.18

56.00

42.93

64.01

95.04

33.99

89.09

44.14

85.30

35.82

8.15

430.56

126.13

1071.81

350.76

27.23

169.67

212.2

68.012

72.17

71.94

338.26

167.68

602.55

18.32

46.13

101.35

436.59

236

108

23.5

567

275.64

2062.68

801.2

88.32

345.6

576

167.99

35.82

-48.45

228.74

107.96

1460.13

782.88

61.09

175.93

363.80

53.93

162.48

-71

-26.25

-6.18%

117.08

10.23

81.47

19.82

846

56.5

404.8

427

288.92

146.8

258%

-47.69

65.96

-28.61

54.91

-16.40

-74.51

Figures in INR Lakhs (Hundred Thousand)

69 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

9.6 Page 86

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ANNEX X: PUBLIC-PRIVATE PARTNERSHIPS

Knowledge Work and Information, Education and Communication on PPP

The project’s logical framework stresses the creation of documents and evidence, as well as mapping of

potential partners in the private sector. Due to the initial delay in the project and time taken to put

things together, not much could be achieved in the first year of operations in PPP, although the project

did consult with other USAID programs like MCH Star, VISTAR and POUZN. The project had also

established partnerships through an MOU with the Hope Foundation for improving access and

availability of health care services at the Sanjay Gandhi slum in Delhi. Orientation workshops held for

Urban Local Bodies (ULBs) and the private sector on PPP and governance, as well as completing a study

on disease burdens and micro insurance could also have implications for PPP models in the future. Some

important activities from the 2nd year (October 2011 onwards) included:

• A draft PPP study titled “Public Private Partnership in Urban Health” was completed by the HUP

team in December 2011

• HUP Program Management Unit (PMU) organized meetings of PPP specialists and their

representatives from different states on 25-26 March 2011. The meeting discussed the concept

of PPP in the context of urban health and the development of the operational framework for

PPP

• In Chhattisgarh a state level meeting titled "Public-Private Partnership on role of corporate

sectors and NGO’s in promoting health of the urban poor" was organized in Raipur on July 5,

2011. Representatives from corporate and nongovernmental organizations participated in the

discussion

• The Rajasthan team organized a two-day State-level workshop on “Capacity Building of

Municipal Representatives on Public-Private Partnership and Governance” at Jodhpur on 17th -

18th August 2011 in partnership with the Department of Housing and Urban Development,

Govt. of Rajasthan

• The Chhattisgarh team had organized a consultation workshop on PPP on 23rd Sept. 2011. Mr.

Rajendra Jani, Chairman, Raman Group facilitated sessions on the PPP models

• An exposure visit was organized by HUP Odisha to Bruhat Bengaluru Mahanagar Palike and

National Rural Health Mission (NRHM), Bangaluru to observe the urban health and public

private partnership initiatives undertaken by the Health and Family Welfare Department,

Government of Karnataka during 27th to 31st December 2011

PPP Models Showing Promise for the Future

Urban Health Centers (UHC): Government-NGO collaboration

Twenty-one Urban Health Centers rendering outpatient department (OPD) services in slums in

Dehradun are run by NGOs contracted through NRHM’s urban RCH funds. The Government of

Uttarakhand has identified 17 more locations for starting similar services this year. HUP conducted a

Needs Assessment Study for UHCs on the request of the state government and is currently assisting the

government in conducting a Performance Assessment as well as NGO contracting exercises.

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 70

9.7 Page 87

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Fig. 3: Urban Health Center Model

RFP, assessment,

monitoring

State Government

HUP

Involves

MAS as link

workers

Holds meetings

with community

and counsels

Urban RCH Funds

NGO to deliver services in

slum centers

Slum community

utilizing services

Patients

referred

Hospitals for

secondary

care

The UHC model is working well and seems to have raised health-seeking behavior of the urban poor

living in and around the slums. With 3 ANMs, 1 Pharmacist and helping staff, a doctor in the slums is

providing quality care through the UHC. The HUP team assists the government in creating monitoring

tools and generating demand through counseling the Mahila Arogya Samiti (MAS) members on

sanitation, ANCs, infection prevention, etc.

Incentives for all parties are positive in this model and seem to be a good scalable option for other areas

of the country.

Running of Primary Health Centers and dispensaries through CSR wings of commercial

organization

Seashore Foundation, the CSR wing of the Seashore group of Cuttack in Orissa, has been running seven

Primary Health Centers in rural areas for more than a year. HUP approached the organization and

discussed incentives for running government facilities in urban areas. With the agreement of Seashore, a

three-way Memorandum of Understanding between the Bhubaneswar Municipal Corporation (BMC),

Seashore Foundation and HUP-PFI is planned to be drawn up shortly to run two Urban Dispensaries at

Gadakana and Kapil Prasad in Bhubaneswar for five years. The contributions of each partner are shown

in the table below:

71 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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Table 3: Contributions of each partner in BMC-Seashore-HUP partnership

PARTNER

BMC

Seashore Foundation

HUP-PFI

ROLE

INCENTIVES

Provides infrastructure (dispensaries)

and rights to Seashore to run urban

dispensaries against MoU; policy

management and recurring support.

OPD services for the poor would be free; would be

designated as an RSBY hospital which poor can access

against insurance; plans to have accreditation of facility

under JSY for institutional delivery under NRHM.

Provides funds (Rs. 25 lacs per annum/

dispensary) for operations in 5 years

and charges user fees for diagnostics

and pathology services;

Image building through CSR as Seashore Healthcare

Private Limited is already running commercial facilities;

giving back to the society through funds and expertise;

potential earning avenue through commission as RSBY

facility; potential to utilize land for further expansion

into BMONC in future.

Brings partners together; jointly

prepares proposal; assists government

in monitoring and provides other

technical support; joint assessment of

dispensaries; acts as a bridge between

government and the commercial sector.

Leveraging funds from commercial sector as per

objectives of project; creating PPP models that are

scalable.

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 72

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Some PPP models being developed by HUP at present

Running of Urban Dispensaries in Rajasthan through Lupin

The Lupin Human Welfare and Research Foundation, the CSR wing of pharmaceutical company Lupin,

and Government of Rajasthan are developing ways to contract out Urban Dispensaries in Bharatpur in

Rajasthan, facilitated by the HUP. Lupin’s choice as a potential partner is due to its experience in running

Urban Health Posts in Bharatpur (as a CSR initiative). The crux of each partner’s contribution is detailed

in Fig. 4, below.

Fig. 4: Urban Dispensary Operationalization in PPP mode

Additional Staff: 1

ANM, staff for outreach

services

Additional Services: Outreach,

Child Health, Communicable

diseases, NCD, etc.

INPUTS: LUPIN

Vaccines,

Medicines,

Supplies.

Maintenance &

Coordination

INPUTS:

GOVT.

Urban Health

Dispensary /Center

Outreach

5000

OUTPUTS

Outreach

5000

INPUTS:

HUP

TA: Ongoing coordination,

monitoring and capacity

building

Referral to FRU/

Charitable Trust

Outreach

5000

Other PPP models that are being developed

A few other PPP models are being developed by different states/cities under HUP. Notable among them

are:

(a) Government of Uttarakhand-Ambuja Cement-HUP Partnership:

This initiative, proposed in Roorkee, is expected to deliver the following benefits:

• Address behavioral changes in the community and strengthen preventive health services

• Induce health-seeking behavior in the community leading to better health outcomes.

73 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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• Strengthen Govt. Service Delivery Mechanism

• Provide primary health care and reach to approx. 50000 slum population

Proposed contributions of each partner for a slum population of 50,000:

PARTNER

Government

of Uttarakhand

(DOHFW, ICDS) & HUP

Ambuja Foundation

HUP

PROPOSED CONTRIBUTIONS

Rs. 13 lacs (approx.)

Rs. 6.4 lacs (amount requested)

Technical assistance in developing MoU and connecting private partner with

government.

(b) WASH activities in PPP mode in Pune through Kirloskar Foundation

In recognition of Kirloskar Foundation’s CSR work in the field of school health, the HUP team discussed

and agreed with the Foundation to participate in WASH activities in slums through the involvement of

MAS. At the suggestion of Kirloskar, the All India Institute of Local Self-Governance, a policy advocacy

institute supported by the TATA group, was also proposed to be involved. The role of each proposed

partner is described below.

Kirloskar Foundation

• Overall coordination

with partners and PMC

• Organizing resources

for implementing the

activities in two slums

nearby the Kirloskar

school health

intervention area

HUP

• Implementation of the

activities in selected

two slums of HUP

through community

groups.

• Providing technical

support for the material

development, module

development, designing

tools etc.

• Coordination with

Pune Municipal

Corporation (PMC)

All India Institute of

Local Self Governance

(AILSG)

• Providing resource

material for the

training and capacity

building of community

groups.

• Designing and

developing

communication tools.

• Providing training to

the community groups.

Pune Municipal

Corporation (PMC)

Urban Development

Department

• Ensuring provision of

hardware component

for water and

sanitation where ever

needed.

The proposed partnership, a write-up of which has been submitted by HUP to the state government,

proposes to run as per Figure 5.

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 74

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10.1 Page 91

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Fig. 5: Schematic diagram showing proposed model with Narayan Hrudayatula Hospitals

75 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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The role of each partner, including HUP-IIHMR and HUP-BCT, is shown below:

DOHFW

Narayan Hrudayala

Hospital and Private

Nursing Homes

HUP-IIHMR with support

from HUP-PMU

HUP-BCT with

Support from HUP-

PMU

• Provision of two ANMs • Empanelment of private

to attend MCHN day

clinics

on rotation basis.

• Certificate of association

• Provision of vaccines

to empanelled

for children and

practitioners

pregnant women

• Provision of services in the

• Linkages with Vaccine

health camps on the

ILR point Provision of scheduled days through

contraceptives VG.

empanelled practitioners

Condoms, OCP

• Provide OPD, referral,

• Monitoring formats of outreach and specialist

MCHN day

services

• Beneficiaries register • Participate in monthly

• Nomination of one

person for monitoring

review meeting for quality

assurance

• Facilitating the Partnership

• Providing Technical support

for operationalizing,

monitoring of the proposed

Urban camps through

partner NGO.

• Provide technical

support in the operational

model

• Developing a monitoring

mechanism

• Partnership monitoring for

its successful

implementation

• Documentation of best

practices

• Community level

awareness and demand

creation for services

through MAS members,

LWs and CCs

• Logistic Support for

organization of the camp.

• Capacity building of staff

in essential package of

MCH services, MIS,

developing referral

linkages and community

mobilization.

• Maintaining MIS and

reporting data on

monthly basis

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 76

10.3 Page 93

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ANNEX XI: KEY GOVERNMENT PROGRAMS FOR THE URBAN

POOR IN INDIA

GOVERNMENT

PROGRAM

FOCUS

MINISTRIES

INVOLVED

JNNURM

- Improve urban

Ministry of Urban

infrastructure and Development

governance

- Providing basic

Ministry of Urban

services like shelter, Employment and

civic amenities to Poverty Alleviation

the urban poor

ICDS

- Nutrition and pre-

school education to

children aged zero

to six years as well

as Nutrition and

Health Education

Ministry of Women

and Child

Development

STATE PUBLIC

AGENCIES

INVOLVED

WHAT IS NOT

COVERED IN

PROGRAM

Municipal corporations Health aspects for

and Urban Local Bodies the poor

under Department of

Urban Development;

some states have

separate department for

Drinking Water Supply as

well as Public Health &

Engineering Department.

Department of Women

and Child Development

or Social Welfare

department in some

states like Bihar

(Three of the six

services are related

to health)

Civic amenities and

infrastructure in

slums

NRHM

NACP III

- All disease control

programs (except

HIV/AIDS) with

RCH as flagship

- HIV/AIDS

Ministry of Health &

Family Welfare

(MOHFW)

National AIDS

Control

Organization under

the MOHFW

Department of Health &

Family Welfare

State AIDS Control

Societies

Limited urban RCH

funds in

programme do not

cover aspects other

than health

Barring some

collaborations with

TB program, does

not cover aspects

other than

HIV/AIDS

77 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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ANNEX XII: TA TO WATER SUPPLY, SANITATION, AND

HYGIENE (WASH)

Water, Sanitation, and Hygiene (WASH) are pre-requisite contributions for good public health and

environmental outcomes. The majority of the urban poor in India suffer from having inadequate access

to or linkages with formal systems of water supply and sanitation service delivery. It is now globally

understood that more than 80 percent of the diseases are directly or indirectly related to improper

water and sanitation facilities. Thus, water supply sanitation and hygiene practices serve as key health

determinants.

The inclusion of WASH in HUP is a logical step forward from the USAID’s POUZN Project that aimed

to reduce one of the leading causes of illness and death among children worldwide—diarrhea—via two

proven methods: preventing diarrhea by disinfecting water at its point-of-use (POU), and treating

diarrhea with zinc therapy. Water treatment at the point-of-use, such as at households or schools, has

been found to reduce diarrhea caused by waterborne pathogens by 30 to 50 percent. POU water

disinfection makes contaminated water safe to drink through methods such as filtration, boiling,

radiation, or chemical treatment.

THE APPROACH

In order to act upon the WASH agenda set in the Cooperative agreement, it is important to look at

WASH services in a more holistic manner and map out the key components and potential activities, as

presented in the Table below, to guide the HUP project interventions.

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 78

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KEY

SUB

SUB-SUB

POTENTIAL ACTIVITY SET

COMPONENTS COMPONENTS COMPONENTS (WITHOUT CAPITAL INVESTMENT)

IMPROVING

ACCESS

IMPROVING

ARRANGEMENTS

IMPROVING

ADEQUACY

• Mapping of existing status of target areas/

locations

• Improving access and adequacy through building

linkages and influencing service providers’ e.g.

PHED, Water supply division of ULB etc.

• Improving provision through PPP initiatives

• Building community linkages with service

providers

IMPROVING

WATER SUPPLY

IMPROVING

QUALITY

AT SOURCE

• Water quality mapping sources in target areas/

locations by building linkages with service

providers’ e.g. PHED, Water supply division of

ULB etc. and/or through private sector initiatives

• Building community linkages and influencing

service providers for improving quality supply and

periodic quality testing

• Behavior change communication (BCC) through

front line workers of service providers, NGOs/

CBOs

AT POINT OF USE • Training and capacity development of LWs/CCs

and MAS members

• Providing incentives and building linkages with

service providers to ensure availability of Chlorine

tabs, other filters etc

IMPROVING

SANITATION

IMPROVING

ACCESS

IMPROVING

ARRANGEMENTS

IMPROVING

ADEQUACY

• Mapping of existing status of target areas/

locations

• Improving access and adequacy through building

linkages and influencing service providers’ e.g.

PHED, Sanitation division of ULB etc.

• Improving provision through PPP initiatives

• Building community linkages with service

providers to raise demand

• Instituting community management systems of

public toilets

IMPROVING TOILET USE

• Behavior change communication (BCC) through

front line workers of service providers, NGOs/

CBOs and HUP project staff

79 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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KEY

SUB

SUB-SUB

POTENTIAL ACTIVITY SET

COMPONENTS COMPONENTS COMPONENTS (WITHOUT CAPITAL INVESTMENT)

IMPROVING

IMPROVING SOLID ACCESS

AND LIQUID

WASTE

IMPROVING

ARRANGEMENTS

IMPROVING

ADEQUACY

• Mapping of existing status of target areas/

locations

• Improving access and adequacy through building

linkages and influencing service providers’ e.g.

ULB.

• Improving provision through PPP initiatives

• Building community linkages with service

providers

IMPROVING MANAGEMENT SYSTEM

• BCC through front line workers of service

providers, NGOs/ CBOs and HUP project staff

on solid and liquid waste management

• Building community participation and monitoring

IMPROVING

HYGIENE

PRACTICES

IMPROVING HAND WASHING PRACTICES

IMPROVING MENSTRUAL HYGIENE

MANAGEMENT (MHM)

• BCC through front line workers of service

providers, NGOs/ CBOs and HUP project staffs

on hand washing

• BCC through front line workers of service

providers, NGOs/ CBOs and HUP project staff

on MHM

• Building community linkages and influencing

service providers including Health and potential

private sector initiatives

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 80

10.7 Page 97

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ANNEX XIII: FRAMEWORK OF THE HUP DEMONSTRATION

MODEL PROGRAM

Taken from Health of the Urban Poor Project: Overview and Status – PFI Presentation on June 27,

2012

81 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 82

10.9 Page 99

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ANNEX XIV: KEY STAKEHOLDERS FOR THE HUP PROJECT

National Level

Ministry of Health and Family Welfare

Ministry of Urban Development

Population Foundation of India (PFI)

USAID/India

Other Donors supporting Urban Health Programs

State Level

State Ministry/Departments

Ministry of Health and Family Welfare (MOHFW)

Public Health Engineering Department (PHED)

Urban Development

Women and Child Development

Municipal Corporations

Other State-Level Donors working on Urban Health/NRHM

State Partners and Sub-Recipients

Plan India

Indian Institute of Health Management Research (IIHMR)

Technical Sub-Partners

Micro Insurance Company (MIA)

Centre for Development and Population Activities (CEDPA)

Business Community Foundation (BCF)

International Institute for Population Sciences (IIPS)

83 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

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ANNEX XV: HUP PROJECT PARTNERS

LOCATION

ADDRESS

OFFICE

TEL. NO.

NAME OF

CONTACT

PERSON

Population Foundation

of India

B-28 Qutab Institutional

Area,

New Delhi 110016

011-

43834100

Ms. Poonam

Muttreja

Plan International (India

Chapter)

E-12, Kailash Colony, New

Delhi

011-

46558484

Ms. Bhagyashri

Dengle

Indian Institute of

3 Health Management

Research (IIHMR)

1, Prabhu Dayal Marg,

Sanganer Airport, Jaipur -

302100

0141-

3924700

Dr. S. D. Gupta

Bhoruka Charitable

Trust

1, Prabhu Dayal Marg,

Sanganer Airport, Jaipur -

302100

0141-

3191666

Amitava Banerjee

The Centre for

Development and

Population Activities

(CEDPA)

C-1, Hauz Khas, New

Delhi - 110016

011-

47488888

Aparajita Gogoi

Indian Institute of

6 Population Sciences

(IIPS)

Micro Insurance

Academy (MIA)

Govandi Road, Deonar,

Mumbai - 400088

52-B, 1st floor

Okhla Industrial Estate,

Phase III, New Delhi -

110020

India

022-

25563254/55

Prof. F. Ram

011-43799100

Mr. Dharmendra

Kumar

8 Hope World Wide

H-6/B, Hauzkhas, New

Delhi- 110016

011-

26515374

Saji Geevarghese

9 SMILE Foundation

V-11, Level - 1, Green Park

Extension, New Delhi -

110 016

011-

43123700

H N Sahay

Shri Niroti Lal Buddha

Sansthan (SNBS)

3/4 – P – 2A, Bank Colony,

Opp. Subhash Park

M.G.Road, AGRA –

282010, Uttar Pradesh

0562-

6534816

Ravi Kashyap

DESIGNATION EMAIL ID

Executive

Director

Executive

Director

Corporate

Director

Executive

Director

pmuttreja@populationfoundation.i

Bhagyashri.Dengle@planindia.org

sdgupta@iihmr.org

amitava.jpr@bctngo.org

Executive

Director

agogoi@cedpaindia.org

Director & Sr.

Professor

director@iips.net

Chief Trustee

Sr. Program

Director

(Operations)

President

dkumar@mia.org.in

saji@hopeww.in

hnsahay@smilefoundationindia.org

president@snbsindia.org

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 84

11 Pages 101-110

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11.1 Page 101

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LOCATION

Centre for Urban and

Regional Excellence

12 MY-HEART

Orissa Voluntary

13 Health Organization

(OVHA)

Family Planning

14 Association of India

(FPAI)

Gopinath Juba Sangha

(GJS)

16 Bhairabi Club

Community Aid and

17 Sponsorship Program

(CASP)

Family Planning

Association of India

ADDRESS

OFFICE

TEL. NO.

CAP Office, Room No.

313, 2nd Floor, Agra Nagar

Nigam, Agra - 282002,

Uttar Pradesh

R P 115, Pandav Nagar,

Tamkapani Road,

Bhubaneswar 18

Lokaswasthya Bhawan, Plot

No.165, Laxmi Sagar

Square, Bhubaneswar,

Khurda, Orissa – 751006

Plot No. 392, (Ground

Floor), B.J.B. Nagar,

Bhubaneswar - 751014,

Odisha

At.-Alisisisan,P.o.-

Darada,P.s.-Balipatan

Dist.-Khordha, Pin.-

752102, Odisha,

AT-Kurumpada, P.O.-

Hadapada, District –

Khordha, Odisha-752018

CASP BHAVAN, Survey

No.132/2, Plot No.3,

Pashan-Baner Link Road,

Pune- 411 021

202, “Western Court,”

1082/1, Ganeshkhind Road,

Opp. E-Square Cinema,

Pune 411 016

0562-

4007943

0674-

2430548

0674-

2572849

0674-

2436427

06755-

245001

0674-

2460521

020-

25862839

020-

25654148

NAME OF

CONTACT

PERSON

Renu Khosla

DESIGNATION EMAIL ID

renukhosla@cureindia.org

Mr. Shaktidhar

Sahoo

Director

Mr. Subrata Kumar Executive

Bisoyi

Director

myheartbbsr@hotmail.com

ovha2008@gmail.com;

subratovha@hotmail.com

Ashok Samantaray Branch Manager bhubaneswar@fpaiindia.org

Baikuntha Nath

Marth

Director

Mr. Aratatrana

Behera

Secretary

Dr. Anil Paranjape

Executive

Director

bhairabi_27@yahoo.co.in

secretary.gopinath@gmail.com

caspheadoffice@gmail.com

Mrs V. A. Tulpule Branch Manager Email-pune@fpaindia.org

85 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

11.2 Page 102

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ANNEX XVI: HUP PROJECT MANAGEMENT STRUCTURE

HUP PROJECT IMPLEMENTATION STRUCTURE

Technical Advisory Group (TAG)

Project Management Group

(PMG)

Technical Sub

Partners

HUP PROGRAM MANAGEMENT

UNIT (PMU)

STATE TA TEAMS

Bihar

Jharkhand

Madhya Pradesh

Chhattisgarh

Orissa

Rajasthan

Uttar Pradesh

Uttarakhand

CITY TEAMS

Bhubaneswar

Jaipur

Pune

Delhi

Agra

PFI Managed

Plan Managed

IIHMR Managed

BCT Managed

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ANNEX XVII: SUMMARY OF FINDINGS ON MANAGEMENT AND

GOVERNANCE

A summary of findings on management & governance using McKinsey 7-S Framework is presented in

figure below.

Staff experienced with government systems

proved to be beneficial and fared much

better in getting HUP a firm footing at a TA

agency

High quality and experienced professional

recruited

Considerable delay appointing full TA team

in some states has impacted progress.

Staff

Shared Value

PFI played active role in grounding HUP

along with USAID

Underutilization of strength and

uniqueness of partners e.g. policy

advocacy (PFI), community mobilization

& implementation (Plan),and research

(IIHMR)

Low incentive to MAS members and link

workers leading to dropouts

Engagement strategy with national level

improved

Demonstration models at city & ward

level seems taking off

Weekly reporting systems are a “burden”

on link workers and ccs

Assisting in preparing models to utilize

urban RCH funds of NRHM paying off

Annual performance reports or QPRs do

not report oCn polanntnineduivnsg. actual –

making measurement of success difficult

Annual work plan is based on perceived

needs – some time fail to reflect

government priorities

Systems

Irregular TAG and PMG meetings –

losing opportunity on strategic and

programmatic guidance

FINDINGS:

MANAGEMENT &

GOVERNANCE IN HUP

Strategy

Limited skill set available at state / city

level e.g. Public Health specialist only at

PMU; absence of PPP specialist at city

team – some teams misses opportunity

to get guidance

Skills

Structure

Style

Follow centralized style of management –

often causes delay

Delay in approval of activities from PMU

–resulting in lost time and sometime

relevance

87 USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT

8 states and 5 cities: but cross-learning

from each other needs to be improved

No platform for donor interactions in

substantive way planned – a major issue

To “open doors” with government,

USAID presence in states as donor has

not often felt. USAID and PFI visits to

state have not been frequent

Over-emphasis on HUP branding limits

partner in leveraging own resources

Cross-pollination between state and city

teams has happened in some place, not

all (e.g., Jaipur)

Interaction between PMU and states/

cities are lower than optimal—misses

guidance of PMU at times

11.4 Page 104

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ANNEX XVIII: STAKEHOLDER INTERVIEW FORMS: PFI AND HUP

PARTNERING IMPLEMENTING AGENCIES

State and Municipal Health Offices

General Observations on Local Area Health Status and the HUP Project

I. Local Area Health Status

1. What are some of the health problems among the poor pockets of your catchment area?

2. How do the health centers, municipal hospitals/district health office relate to each other?

3. How do the primary and secondary levels of care link with each other?

4. What is the scope of service provision of primary health structures?

5. How are the national health programs implemented in your city – who implements them,

what is the involvement of the municipal apparatus?

HUP Project

1. In your opinion, what are some of the main objectives the HUP Project?

2. Can you describe some of the main ongoing HUP activities in support of urban health?

3. Has the project been playing a useful role in support of urban health initiatives?

4. Are there areas in which HUP could be playing a more effective role?

5. In your view, what are some of the main urban health challenges that the HUP Project might

best address during the remainder of its current lifecycle (until 2013)?

II. HUP Technical Assistance to National, State, and Municipal Governments

1. Has HUP enabled better understanding of health needs of the urban poor? To what extent

has HUP been able to influence urban health care delivery under NRHM?

2. Can you describe the type of TA that the HUP Project has provided in urban health at the

municipal level?

3. What efforts have been made under HUP to promote joint planning by various state

departments and municipal corporations?

4. Are there cities and states that have developed city level urban health plans and how are

they being addressed in the absence of NUHM or leveraging of NRHM?

5. What efforts have been made by HUP in developing and disseminating methodologies for

city level health planning?

6. Can you suggest ways in which HUP TA might more effectively support initiatives in urban

health?

III. Sectorial Convergence in Support of Urban Health

1. How has the HUP Project collaborated in the development of joint urban health policy and

program formulation/planning? Can you cite a few examples?

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2. Has the HUP Project collaborated in improving the implementation of joint urban health

programs? How has this implementation been operationalized? Can you cite a few

examples?

3. To what extent have HUP’s efforts brought various State departments and ULBs

(Department of Health and Family Welfare, WCD, and PHED) and Municipal Corporations

to converge in planning and implementing urban health initiatives for the urban poor?

4. What effort has been made towards converging with the Jawaharlal Nehru National Urban

Renewal Mission (JNNURM)?

5. How has HUP worked with slum development committees? Have convergence programs

promoted by HUP been undertaken by these committees? If so, can you cite a few

examples?

6. In your opinion, what urban health convergence initiatives should be given greatest priority

in future years? For example, in the fields of maternal and child health, environmental health

(water and sanitation), infectious disease, non-communicable disease, and nutrition?

7. Are there ways in which future urban health convergence activities could be strengthened?

For example, through pooling of funds? Pooling of human resources?

8. Do you have any suggestion for ways in which the HUP Project might play a more useful

role in supporting joint urban health programs in the future?

IV. Private – Public Partnerships

1. How would you characterize the current status of Private – Public partnerships (PPP) in

urban health? What is the nature of current private-public relationships?

2. Can you cite some examples of how the HUP Project has built more effective urban health

synergies in PPP? In corporate social responsibility (CSR)?

3. To what extent have existing slum level committees/Busti Vikas Samitis under JNNURM

been engaged in improving access and utilization of health services and improved water

supply and sanitation?

4. Are there ways in which social marketing initiatives could be more effectively deployed in

support of urban health? What role could your foresee for the HUP Project in this area?

5. In your opinion, are current PPP activities being adequately assessed with respect to

effectiveness, the potential for replication, and scale-up?

V. Demonstration Models

1. What are the main features of the urban health demonstration models that are being

implemented through the HUP Project?

2. Can you describe how were they developed?

3. Do any other NGOs work in your demonstration area?

4. What are the main strategic objectives of these demonstration models?

5. How are the baseline household listings in demonstration areas being used?

6. Are MIS in place to monitor relevant process and outcome indicators for these

demonstration models?

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7. Has HUP made efforts to develop more effective referral mechanisms (linkages) between

the urban poor and primary and higher levels of the health care system in urban areas?

8. Has there been HUP collaboration with ANM (auxiliary nurse midwife) and Anganwadi

community workers in urban slum demonstration sites? If so, can you describe these

linkages?

9. How has the project developed operational guidelines for promoting and strengthening

Mahila Arogya Samiti (MAS) organizations in demonstration sites?

10. Can you describe the communications (BCC) component in the demonstration models

currently being implemented?

11. Have community organizations and other local NGOs participated in the implementation of

these models? If so, how has this happened?

12. In your opinion, what elements of HUP’s demonstration projects could best support the

operationalization of the National Urban Health Mission (NUHM) once it officially comes

into being?

13. Is it possible at this early juncture to draw some conclusions about what is working and not

working in these demonstration models?

VI. HUP Project Management Systems

1. In your opinion, has the HUP Project been well managed and effectively implemented?

2. Do you have any observations to make on the effectiveness of HUP’s (1) project monitoring

and review procedures, (2) financial and procurement systems, and (3) delegating roles and

responsibility, (4) team deployments and capacity building of PFI and its partnering

organizations?

3. Has the HUP Project developed an efficient MIS for monitoring project activities and

progress? Has the information been routinely utilized for purposes of project monitoring

and evaluation?

4. Do you have any suggestions for how to make the project’s MIS more effective for

monitoring and evaluating project activities?

5. Have HUP management procedures been effective in analyzing and resolving implementation

bottlenecks? If yes, can you cite a few examples?

PFI and HUP Partnering Implementing Agencies

I. General Observations on the HUP Project

1. Can you provide some background on how the HUP Project came into being?

2. In your opinion, what are some of the main objectives of the HUP Project?

3. Can you describe some of the main ongoing HUP activities in support of urban health?

4. Has the project been playing a useful role in support of urban health initiatives?

5. Are there areas in which HUP could be playing a more effective role?

6. Does the HUP project have a frame work for engaging with national, state, and municipal

levels of government?

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7. In your view, what are some of the main urban health challenges that the HUP Project might

best address during the remainder of its current lifecycle (until 2013)?

8. What do partnering organizations hope to achieve through HUP during the remainder of its

project cycle?

II. HUP Technical Assistance to National, State, and Municipal Governments

1. Has HUP enabled better understanding of health needs of the urban poor?

2. To what extent has HUP been able to influence urban health care delivery under NRHM?

3. What is the current practice in planning urban health initiatives?

4. Does NRHM cover all aspects of the health care needs of the urban poor? If not, what

additional priority health care needs currently exist for the urban poor?

5. Can you describe the type of TA that the HUP Project has provided in urban health at the

(national, state, municipal) level?

6. Has the TA from the HUP Project been appropriate for addressing health needs of the

urban poor?

7. Has this TA been provided in a timely and effective manner? If not, why not?

8. How have the special research studies undertaken by the project been utilized?

9. What efforts have been made under HUP to promote joint planning by various state

departments and municipal corporations?

10. Are there cities and states that have developed city level urban health plans and how are

they being addressed in the absence of NUHM or leveraging of NRHM?

11. What efforts have been made by HUP in developing and disseminating methodologies for

city level health planning?

12. Can you describe ways in which HUP is promoting greater health seeking behavior among

women in urban slum areas?

13. Can you suggest ways in which HUP TA might more effectively support initiatives in urban

health?

III. Sectorial Convergence in Support of Urban Health

1. How has the HUP Project collaborated in the development of joint urban health policy and

program formulation/planning? Can you cite a few examples?

2. Has the HUP Project collaborated in improving the implementation of joint urban health

programs?

3. How has this implementation been operationalized? Can you cite a few examples?

4. To what extent have HUP’s efforts brought various State departments and ULBs

(Department of Health and Family Welfare, WCD, and PHED) and Municipal Corporations

to converge in planning and implementing urban health initiatives for the urban poor?

5. What effort has been made towards converging with the Jawaharlal Nehru National Urban

Renewal Mission (JNNURM)?

6. How has HUP worked with slum development committees? Have convergence programs

promoted by HUP been undertaken by these committees? If so, can you cite a few

examples?

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7. In your opinion, what urban health convergence initiatives should be given greatest priority

in future years? For example, in the fields of maternal and child health, environmental health

(water and sanitation) infectious disease, non-communicable disease, and nutrition?

8. Are there ways in which future urban health convergence activities could be strengthened?

For example, through pooling of funds? Pooling of human resources?

9. Do you have any suggestion for ways in which the HUP Project might play a more useful

role in supporting joint urban health programs in the future?

IV. Private – Public Partnerships

1. How would you characterize the current status of Private – Public partnerships (PPP) in

urban health?

2. What is the nature of current private-public relationships?

3. Has there been a compendium made of different models of PPP initiatives for the health

sector?

4. Has the HUP Project undertaken mapping of potential PPP partners?

5. What advocacy efforts have been undertaken to promote PPP through potential partners?

6. Can you cite some examples of how the HUP Project has built more effective urban health

synergies in PPP? In corporate social responsibility (CSR)?

7. To what extent have existing slum level committees/Busti Vikas Samitis under JNNURM

been engaged in improving access and utilization of health services and improved water

supply and sanitation?

8. Are there ways in which social marketing initiatives could be more effectively deployed in

support of urban health?

9. What role could your foresee for the HUP Project in this area?

10. In your opinion, are current PPP activities being adequately assessed with respect to

effectiveness, the potential for replication, and scale-up?

V. Demonstration Models

1. What are the main features of the urban health demonstration models that are being

implemented through the HUP Project?

2. Can you describe how were they developed?

3. Has HUP undertaken systematic gap analysis studies of urban health needs in demonstration

sites to better prioritize project initiatives?

4. Do any other NGOs work in your demonstration area?

5. What are the main strategic objectives of these demonstration models?

6. How are the baseline household listings in demonstration areas being used?

7. Are MIS in place to monitor relevant process and outcome indicators for these

demonstration models?

8. Has HUP made efforts to develop more effective referral mechanisms (linkages) between

the urban poor and primary and higher levels of the health care system in urban areas?

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9. Has there been HUP collaboration with ANM (auxiliary nurse midwife) and Anganwadi

community workers in urban slum demonstration sites? If so, can you describe these

linkages?

10. How has the project developed operational guidelines for promoting and strengthening

Mahila Arogya Samiti (MAS) organizations in demonstration sites?

11. Can you describe the communications (BCC) component in the demonstration models

currently being implemented?

12. Have community organizations and other local NGOs participated in the implementation of

these models? If so, how has this happened?

13. In your opinion, what elements of HUP’s demonstration projects could best support the

operationalization of the National Urban Health Mission (NUHM) once it officially comes

into being?

14. Is it possible at this early juncture to draw some conclusions about what is working and not

working in these demonstration models?

15. In conclusion, what categories of activities/strategies have worked well, which may require

an amendment in approach, and have there been significant implementation impediments for

the project?

VI. HUP Project Management Systems

1. In your opinion, has the HUP Project been well managed and effectively implemented?

2. Do you have any observations to make on the effectiveness of HUP’s (1) project monitoring

and review procedures; (2) financial and procurement systems; (3) delegating roles and

responsibility; and (4) team deployments and capacity building of PFI and its partnering

organizations?

3. How would you characterize working relationships between PFI and its sub-partners?

4. Are there ways in which these working relations could be strengthened?

5. Has the HUP Project developed an efficient MIS for monitoring project activities and

progress?

6. Has the information been routinely utilized for purposes of project monitoring and

evaluation?

7. Do you believe current reporting requirements for the project are reasonable?

8. Do you have any suggestions for how to make the project’s MIS more effective for

monitoring and evaluating project activities?

9. Have HUP management procedures been effective in analyzing and resolving implementation

bottlenecks? If yes, can you cite a few examples?

Community Organizations and Health Facilities

I. At the Community Level

1. What are some of the major health problems of this community?

2. Where does this community seek curative care from? How far are these facilities?

3. Where does the community seek preventive care from? How far are these facilities?

4. Are there any other facilities nearby? Why they are not utilized?

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5. Who are the public providers visiting this community? (Probe for ANMs, health visitors,

TB workers, other NGO workers)

6. What are the health inputs being provided by the Aanganwadi centers in the

community?

7. When was the MAS formed?

8. Why did you want to join the MAS? What determines your continued participation in

the MAS?

9. What inputs have you received from the HUP program?

10. Can you give us some examples of how you have benefitted?

11. What are the other health inputs that if introduced by HUP, will benefit the community?

II. At the Health Facility Level

1. What is the catchment area of this facility?

2. What is the scope of service provision – only curative – combines preventive, combines

supervision to lower facility, or receives supervisory support from higher facility, has

referral linkage?

3. Timing of services and human resources available – are there any gaps?

4. Does the facility have chlorine tablets? What is the current stock?

5. What are some of the health problems among the poor pockets of your catchment area?

6. If the facility a primary level structure – what is the stock of malaria prophylaxis, ORS and

chlorine tablets?

7. What is your association with HUP – formal/informal? Scope?

8. What inputs has this facility received from HUP? Capacity building? Gap analysis? Outreach

strengthening, community mobilization, community awareness?

9. In your opinion which have been the most important contributions of the HUP? What other

inputs from HUP will make a difference to the state of health in your catchment area?

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12.1 Page 111

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ANNEX XIX: HUP INDICATORS BY EFFECTIVENESS AREAS

EFFECTIVENESS

AREA

HUP TA EFFECTIVENESS INDICATORS

INPUTS

PROCESSES

OUTPUTS

OUTCOMES

Timeliness

Is the TA able to keep pace

with reasonable and relevant

assistance needs of the

implementing agency?

Currently not measured by

any indicator

Relevance

Flexibility and

Responsiveness

Quality

• Number of advocacy events/

symposiums/seminars organized

• No. of exposure visits and cross

• visits to successful convergence

• models

• No. of cities where slum and

• facility mapping and vulnerability

assessment conducted

• No. of baseline or feasibility studies

conducted

• No. of meetings of State

Counter Part

teams/Coordination forum

• Number of state/ city Project

Implementation Plans (PIPs)

• prepared with recipient’s

• support

• No. of meetings of city multi-

stakeholder coordination

• committee organized

• Number of service delivery models

developed/strengthened in collaboration

• with private/commercial sector

• No. of city demonstration and learning

• models developed and documented

• Number of new cities

• developed (output)

and implemented

urban health

• plans (outcome)

• Number of new cities

• implementing city

programs

• with learning from

USAID supported

demonstration

• and learning sites

Currently not measured by

any indicator

No. of training programs/ sensitization

sessions organized for staff and

different stakeholders

No. tools (MOUs, EOI/ToR/evaluation

criteria) developed for establishing

Partnership

No. of program planning and

review meetings/workshops at

state level

No. of study tours organized for

government/ and other

stakeholders

Number of states provided TA

through urban health cells or

consultants with recipient’s

support

No. of consultations/meetings for

sharing best practices on PPP

Number of reports / Program lessons,

documentation published/ disseminated

Lessons of community level convergence are

documented and adopted by NUHM/urban

components of NRHM

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Sustainability

Number of local institutions

identified/developed to provide TA to

NUHM/urban components of NRHM

on sustainable basis

No. of potential partners identified for

resource leveraging

Number of reports / Program lessons,

documentation published/ disseminated

Number of dissemination events organized

for the key officials from MOHFW,

MoH&UPA and MoWCD with recipient’s TA

support Number of MOUs signed by

state/city governments with non-government

and commercial sector partners through

recipient’s TA

No of USAID partners having convergent

actions in their work-plans

Number of CRM/JRM/JMM of NUHM with

participation of officials from Housing &

Urban Poverty Alleviation and Women &

Child Development

No. of letters jointly

issued by Departments

of Health and Family

Welfare, Housing and

Urban Poverty

Alleviation and Woman

and Child Development

Number of cities with

models of convergence

between NUHM/Urban

components of NRHM

and JNNURM/ICDS

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ANNEX XX: MCH/RCH APPROACH TO TA

TA AREAS

TA INPUTS

Support Planning for

strengthening urban

MCH/RCH

programming

Support

Implementation of

urban RCH/MCH

interventions

Support M&E of urban

RCH program

• Gap analysis in delivering MCH/RCH services in urban areas

• How will primary and secondary care be provided? Which facilities will provide

them?

• What services will be provided?

• How will adequacy and utilization (quality of services) addressed?

• How will these be measured by the government?

• Rationalize all available RCH facilities (whether with health or urban development

department) to increase adequacy

• Address governance and human resource issues through PIPs

• Strengthen definition of MCH/RCH services - develop services norms

• Develop guidelines for quality of services

• Develop or strengthen M&E systems

• Support convergent activities

• Support additional financing through PPPs and insurance

• Support community mobilization to increase demand

• Rationalize and strengthen current MIS

• Design and implement operational research to demonstrate various models

• Support utilization of data for feedback and decision making

• Lay the ground for expanding urban health programming beyond MCH/RCH

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ANNEX XXI: Capacity Building (CB) Efforts of HUP

CB AREA

AUDIENCE

TOOLS

RESULTS

Orientation to Urban

Health

Key stakeholders of

states c- health, WCD,

Urban Development

departments; City urban

local bodies

Workshops with

presentations on

situation of urban health

and national best

practices

Effective; all stakeholders cited

this effort as the reason for

generating interest and

awareness about urban health

in the states.

The Odisha approach

discussed elsewhere in the

report was seen as an effective

approach to facilitating

leadership within the three

key departments.

Maternal and child

health

Providers of urban

health clinics

Project front line

workers

Health and nutrition

days

Implementers from

Health and WCD

departments

ANMs and ASHAs

AWWs

Project front line

workers

Training modules

covering areas of

antenatal, delivery, post

natal care; early

childhood interventions

including breast feeding,

immunization and

childhood diseases

Appreciated by workers;

capacities not assessed by

MTA team; continued hand

holding, refreshers and

training in managing (as

opposed to technical) MCH

delivery will be required

Health Entitlements

Guidelines for carrying

out HNDs

Comprehensive

guidelines covering all

anticipated technical

areas

Effective; front line workers

well versed in MCH technical

issues; additional efforts will

be required to facilitate critical

analysis of public health

delivery management to

strengthen MCH; For

example; organizing a place for

carrying out antenatal care,

identifying absence of chlorine

tablets at facility as a deterrent

to preventing childhood

illnesses.

NGO staff highlighted the

need to include them in CB

efforts as an approach to

sustainability.

Trained workers have the

knowledge about components

of HND; however face

implementation difficulties to

comprehensively provider

HNDs. Additional hand

holding will be required to

support capacities in

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Mother and child

tracking

Mother and child

nutrition

WASH

Orientation to health

department;

Training to providers of

urban health centers;

project front line

workers

Training on using the

tracking formats; hand

holding support

Providers of urban health Yet to be implemented

centers; AWWs, project

front line workers

management of HNDs

NGO staff highlighted the

need to include them in CB

efforts as an approach to

sustainability.

Analysis of a small sample of

filled formats indicates

differential capacities in HUP

states. Continued hand

holding will be required to

effectively track children and

utilize data. In addition

mechanisms for integrating

this within health

department’s HMIS will be

required.

Urban health programs Key stakeholders of the

three departments

CB through TA

Government

functionaries at all levels

Cross Learning Visits

Much appreciated by

stakeholders and frequently

cited as a highlight of UHP

during discussions. Palpable

understanding of urban health

among stakeholders indicates

to the success of some of

UHP’s CB approaches

Several efforts – from

research, to presentation

of evidence, negotiations,

workshops, drafting of

documents

The capacity building efforts

through technical assistance

are often unquantifiable and

attribution of results difficult.

However, MTA team feels

that the constant presence

and participation of HUP team

does contribute to increasing

capabilities within government

to do things differently.

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U.S. Agency for International Development

American Embassy

New Delhi - 110 021

Phone: 91-11-2419-8000

Fax: 91-11-2419-8612 / 2419-8454

USAID/INDIA HEALTH OF THE URBAN POOR MID-TERM EVALUATION REPORT 100