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Urban Health in Developing Countries Live Talk 2
Urban Health Issues 14 April 2009
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Overview of Live Talk
• Our course has three planned live talk sessions
• Each session will be divided into two parts – First we will have a guest speaker who will
share some experiences – Secondly we will take questions and
comments from the BBS and respond to them • As time allows we will encourage
additional questions for our guests and about the current Module
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Part 1
Pam Lynam and Stuart Merkel
Jhpiego – Kenya Program
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HEALTH IN THE URBAN SLUMS: Let the people lead the
way
Pamela Lynam MD Stuart Merkel, MBA
April 2009
6 Photo by Madhav Pai. Creative Commons BY.
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Jhpiego Overview • A non-profit affiliate of
Johns Hopkins University • Funded through
governments, international donors, private corporations and foundations
• Strengthens the performance of health workers and health systems to provide quality health care services in low-resource settings
• Started in Kenya in 1973 Photo by Jhpiego staff.
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Jhpiego’s Work in Urban Slums • Korogocho & Viwandani Slums,
Nairobi, Kenya • A variety of technical
interventions: – HIV – Reproductive Health – Family Planning – Safe Motherhood
• Focus on: – Facility-based improvement in
quality of services – Community empowerment for
increased access to services – Community-facility linkages for
sustainability
Photo by Stuart Merkel.
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The Facts: Urbanization
• The World is increasingly Urban – 3 in 5 people will live
in cities by 2030
– 95% of urban growth will be in the developing world, creating as many as 10 new large cities each year (UNFPA)
Photo by Stuart Merkel.
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The Facts: Growth of Slums • Most urban growth is in informal settlements, or
slums – 1/3 of urbanites live in slums (=~1.2 billion) – 72% of African urbanites are slum dwellers. Africa is
the fastest urbanizing continent – Asia has the largest number of slum dwellers
• 554 million total • 60% of all slum dwellers worldwide
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Broad Characteristics of Slums
Poor Health Conditions • Services:
– Poor access to – and quality of – health services
• Hazardous Environment: – Deficient access to water and
sanitation, toilets – Waste, garbage
Cash-Based Economy: Many competing factors: – Example: paying for food,
clothing, shelter vs. health services
Photo by Stuart Merkel.
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Nairobi Slums (1) Insecurity and severe overcrowding
– 60% of Nairobi residents live on 5% of land (slums)
– Land/housing tenure – Crime and sexual assault – Heterogeneous populations
Breakdown of social cohesion – Complex power relationships – Disruption of traditional family,
community & ethnic support structures
– Prostitution, addiction, domestic violence, etc.
Photo by Stuart Merkel.
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Nairobi Slums (2)
Inadequate Health Services – Lack of Respect and Trust
+ Insecurity and Neglect – Illegality and abuse
+ Unhealthy lifestyles – Breakdown of traditional
structure – Water and sanitation
issues ____________________________
= Poor Health Indicators Photo by Stuart Merkel.
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Nairobi slums - Emerging Evidence
Selected Data:
• Data generally hard to find on health in slums • Expected higher MMR, prevalence rates for HIV,
TB, etc
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Two Key Messages
“So Close – Yet So Far” Proximity ≠ Access
in Slums!
Bridging the Community-
Clinic Divide is Key! Photo by Stuart Merkel.
Photo by Stuart Merkel.
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Performance & Quality Improvement
• Originally designed for facility-based programs – Improve provider performance by focusing on
identified gaps and creating plans to address them • Adapted for slums context
– Not: “We the experts will give you what you need” – Rather: “What are your needs? What solutions will
work for you?” • Health facility level • Community level • Jointly
• PQI = empowerment = ownership = sustainability
17 17!
PQI Framework
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Health Facility interventions
• Built the capacity of health workers from NCC and NGO/FBO in the informal settlements in RH/FP.
• Service providers trained in Infection prevention, CTU, FANC, adolescent health, reproductive health, FP, HIV counseling testing, and treatment
• Held meetings with service providers to create linkages with community
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Health Facility interventions
• Production of training manuals in RH/FP • With the cascading approach triple the
service providers trained in all the above • Supportive supervision for health facilities
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Community interventions
• PQI to define gaps in RH/FP in community
• Orientation workshops for community on RH/FP
• Develop Community Own Resource Persons (CORPS) in RH/FP
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Community interventions Cont
• Form Support groups in community for mother-baby groups
• Assist CBO and FBO in the community to support this intervention
• Link community to quality Reproductive health care
• Developed maps and directories for easy referrals and networking
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RESULTS
• Improved health /family planning / HIV knowledge/skills at health facilities
• Increased knowledge on healthcare services including where to get them in the community.
• Increased uptake of health services • Reduced mortality among women due to
unsafe practices
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PQI Results
Community-Inspired and Owned Interventions – Anti-rape self defense training – Community Theatre – Peer Education – Community Mapping – Village Health Committees – Community Gardening – Free medical camps – Vastly improved attitude between clinics and
slumdwellers - Painted Health facilities, garden etc.
Photo by Stuart Merkel.
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Key Lessons Learned • Building trust can improve health
– This takes patience and time • Enthusiasm and energy is
already present in both communities and among healthcare workers
• Communities know their health challenges and must be consulted when designing solutions.
• Sustainable results come from involving all stakeholders
Photos by Stuart Merkel.
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Implications for Future Projects • PQI Works!
– Local ownership = empowerment
• Monitoring and evaluating PQI Interventions is challenging – Not pre-programmed – Example: self-defense
• Requires flexibility on the part of donors and policymakers
Photo by Stuart Merkel.
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Acknowledgements
• Communities of Korogocho and Viwandani
• Healthcare workers in Korogocho and Viwandani
• City Council of Nairobi • Rockefeller Foundation • Wallace Global Fund • Co-Authors:
– Jane Otai – Julia Perri
Photo by Stuart Merkel.
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THANK YOU!
Pamela Lynam, MD Jhpiego Country
Director, Kenya
Stuart Merkel, MBA Jhpiego Program
Officer, Kenya Photo by Stuart Merkel.
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Visit our Website!
www.jhpiego.org/whatwedo/urbanslums.htm Photos by Stuart Merkel.