Urban Health Resource Centre (UHRC)

Urban Health Resource Centre

(UHRC) is a non-government organization that works towards socio-economic empowerment, improved quality of life, health, nutrition, well-being and empowered social organization among disadvantaged urban communities through – (i) demand-supply improvement, community-provider linkages, and demonstration programs that use a consultative and partnership based approach, (ii) technical support to government and non-government agencies and (iii) research, advocacy and knowledge dissemination. The UHRC’s demonstration programs utilize community organizing to establish women’s community groups consisting of slum-dwelling women who advocate for community-level infrastructure improvements.

History and outline of UHRC operations

UHRC was established in 2005 as a registered non-profit company under India’s Companies Act, 1956 with the aim of working towards socio-economic empowerment, improved quality of life, health, nutrition, and general well-being for urban disadvantaged families. Its startup was supported by USAID between 2004 and 2005, but as of 2009, the UHRC no longer receives USAID financial support.

UHRC implements demonstration programs among slum-dwelling populations in cities (Indore, Agra, and more recently North-East Delhi) with the intention that they be adapted, replicated and up-scaled by other government and non-government agencies. These demonstration programs focus simultaneously on community empowerment to enhance demand for services and on working with the service providers to improve supply side responsiveness to meet the increased demand. Since slum-dwellers are usually not connected to the mainstream population, part of the UHRC’s ground work involves proactive community mobilization, encouragement and outreach to identify vulnerable populations and facilitate their connection to social and economic sector service providers such as healthcare, living environment services, house improvement services and employment programs.

UHRC programs facilitate the formation of women's and children's groups to strengthen the social cohesion in slums and to address gender inequity. The program works toward building their capacity to take charge of processes that affect family economics, health, education, nutrition, housing improvement and overall social well-being. UHRC provides targeted trainings and workshops to community groups on topics such as a) acquiring knowledge, b) building negotiations skills (such as sending collective application to civic authorities) and, c) interfacing with diverse government agencies to improve slum living environments and access to health, nutrition and social entitlements. Slum communities in UHRC program cities participate in health education and promotion sessions facilitated by UHRC field workers on topics such as maternal and child health, nutrition, hygiene, and environmental health.

As the number of community groups in a local region reaches a critical mass, they are networked into a larger congress or cluster-team of women's groups, consisting of democratically agreed-upon representatives from each group. Cluster-level teams of women's groups and slum-level groups receive regular supervision, mentoring support and materials (such as steel containers to store registers, charts, behaviour promotion materials, floor mats to sit during meetings) from UHRC teams to carry out meetings and activities working towards improved health and well-being. UHRC partners with participating community groups and federations to help them access available services, schemes and resources. Groups and cluster-team members are also coached on negotiation skills and provided trainings on how to effectively negotiate with healthcare providers and other civic authorities through dialogue and formal applications to obtain health services and environmental services such as road paving, drain installation, sanitation/water infrastructure, garbage removal, and other entitlements.

Along with running the demonstration programs, UHRC also provides technical support to the government (at national, provincial, and city levels) and non-government agencies in the form of research, advocacy, and knowledge dissemination. Additionally, the UHRC central and field offices provides trainings, internships, and volunteer options for students from different universities in India and abroad. All interns and volunteers, who in the past eight years have included Masters and PhD students, have learnt from field based participatory action research in UHRC's program sites.

UHRC programs

Health outreach, service access, and behavior promotion

Some of the first activities the UHRC encourages slum women to discuss and analyze health, well-being challenges faced by their families and the community as a whole. UHRC helps a new slum women’s group with are health activism training and advocacy of healthy household practices. Through workshops and training sessions, women’s groups are encouraged to begin promoting healthy practices and health seeking behaviors in their communities, such as going to the hospital when a woman goes into labor. This process involves training women’s group members to become social health activists so they can conduct preventive and promotive health workshops and sessions for their peers. An aspect of this training is encouraging women’s group members to promote cultural and religious traditions that are relevant to their communities, while incorporating educational curriculums surrounding proper hygiene and healthy behaviors for new mothers. One example is that UHRC women’s groups often hold group Annaprashan ceremonies (a ceremony wherein a child is first fed food other than milk), incorporating curriculums surrounding ante-natal child care.

UHRC also trains group members on reaching out to private and public healthcare providers such as Auxiliary Nurse Midwives (ANMs) and Anganwadi centers to run health camps in their communities. At the 13th World Congress on Public Health, the UHRC reported improvements in slum residents’ access to health services and information and adoption of healthy behaviors in intervention areas. Furthermore, they noted that as of 2009, 70% of children in intervention areas were completely immunized as opposed to 28% in areas that had not yet developed UHRC programs [https://wfpha.confex.com/wfpha/2012/webprogram/Paper10702.html]

In addition to advocacy and education, UHRC women's groups also play a direct role in linking women in urban slums to health services. Women's group members frequently escort married adolescent migrant girls to hospitals for safer deliveries when they go into labor, and to ante-natal services which they may not otherwise be familiar with [Ministry of Health and Family Welfare. Government of India. Guidelines for developing city level urban health projects, New Delhi: Government of India: 2005].

Collective savings/social resilience funds

Once groups have developed a regular meeting schedule and have undertaken some basic health outreach activities, the UHRC proposes to groups that they could form a collective savings fund. These collective savings funds are essentially a method of risk pooling. Groups decide upon a certain monthly or weekly contribution that each member needs to make to grow their fund. All contributions to the pool are recorded by a treasurer who is elected by the group. The women are facilitated to establish standards for mutual accountability. The UHRC aids in establishing a record keeping system and in training the women to keep these records up to date – trainings cover how to track and record collective savings, loans given from the savings pool, interest received along with the principal amount, and essential elements of managing savings and loans. When a member or even a non-member family is in need of a loan, women’s groups can provide low to zero interest loans (for example one group in Agra, Saraswati Mahila Swasth Samiti, has adopted a 2% interest rate). Collecting payments, managing the fund, and administering all loans is facilitated by women’s group members with support from UHRC's team members. These funds play a crucial role in reducing the burden of health care costs on poor families, particularly during health emergencies. Loans are given for a variety of needs: a) Maternal and Child Health, b) Health emergencies, c) Prevention of school drop-outs, d) House improvements, e) Food insecurity, f) starting or strengthening women's small enterprise from home or nearby market, g) starting or expansion of men's small enterprises, h) Repaying debts from money-lender, and i) Social and family expenditures.

Petition writing and infrastructure improvement

Based on its initial experience with the program in Indore, and Agra, beginning November 2009, UHRC program strategies have evolved towards a broader development of the urban slums/vulnerable populations goal. UHRC has found educating communities about government resources and services to be particularly effective. As groups bring municipal problems forward, the UHRC will suggest that communities begin writing applications and letters to service providers, and holds trainings and workshops where group members can practice writing applications and learn about the importance of making and filing copies of all applications and letters that submitted. Field workers encourage groups to write highly specific, concrete requests that focus on a single issue rather than multiple issues to increase chances of success. They are also encouraged to have all members sign each request or petition to show consensus.

Usually the first few petitions or letters written are followed by a period of struggle or stagnancy. Municipal service providers and government officials tend to be initially unresponsive and uncooperative. Group members are therefore trained to write reminders following up on requests and to seek formal receipts from civic authorities for any communications sent. For example, group members are trained to send reminders through the government postal system, which automatically provides receipts to senders.

Women’s groups also learn to recruit the support of democratically elected ward representatives who can help in interfacing with municipal corporations. UHRC social facilitators guide women's group members to start by pursuing simple tasks, such as getting a street drain cleaned, before moving on to more ambitious projects such as road paving and water supply installation.

Social awareness and advocacy

UHRC women’s groups have also begun organizing rallies around community needs, such as ousting alcohol vendors to disincentivize alcoholism, demonstrating against gambling to protect household finances, advocating against domestic violence, or organizing public health advocacy campaigns. Groups have also orchestrated sit ins at government offices to urge them to be responsive to community needs and requests by providing services, such as slum street paving, drain installation, water supply and sewage system installation, health and nutrition services, food security services, and access to government's social welfare schemes such as education scholarship, widows' pension scheme, old-age pension scheme.

Government scheme awareness and application support

Through engagement with its target populations in Indore, Agra, and Delhi, the UHRC began focusing its efforts on helping slum residents attain proper identification documentation. Slum residents, and particularly migrant adolescents living within urban slums, who do not have proper documentation face barriers such as ineligibility for government welfare programs and education scholarships as well as housing insecurity. The UHRC assists women's group members to learn about and apply for various forms of picture ID, voter ID, proof-of-address, and other documentation.

Source: Montgomery, Mark R.; Balk, Deborah; Liu, Zhen; Agarwal, Siddharth; Jones, Eleri; Adamo, Susana (2016-01-01). White, Michael J., ed. International Handbook of Migration and Population Distribution. International Handbooks of Population. Springer Netherlands. pp. 573–604. doi:10.1007/978-94-017-7282-2_26. ISBN 9789401772815.

Policy advocacy & technical support to government/NGOs

In 2004, prior to its renaming from USAID-EHP to the Urban Health Resource Centre, the Ministry of Health and Family Welfare designated UHRC as “the nodal technical agency for ‘Urban Health Programme’”. UHRC continued to be designated as “the nodal technical agency for ‘Urban Health Programme’” in the Ministry's communications and in this capacity, the UHRC’s role has been to “provide further assistance to State Governments in formulating urban health proposals and to provide concrete examples for planning of health care delivery to the urban poor in different categories of cities” Source:Draft final report of the task force to advise the National Rural Health Mission on “Strategies for Urban Health Care. This technical assistance included recommendations for goals and objectives of the Urban Health Program, coverage criteria, and a workflow for the development of urban health proposals by cities eligible for support from the Ministry of Health. UHRC along with the Area Projects Division of Ministry of Health and Family Welfare, Government of India steered the series of meetings and consultations of the Task Force for Advising NRHM for Urban Health Strategies. These consultations contributed to the preparation of the first comprehensive report on Urban Health Strategies with a focus on the urban vulnerable, published formally by the Government of India as the Draft final report of the task force to advise the National Rural Health Mission on “Strategies for Urban Health Care. The UHRC also played a key role in shaping the National Urban Health Mission (NUHM), now a sub-mission to the National Health Mission (NHM) and launched in 2013, intended to consolidate, focus, and expand the Government of India’s initiatives for addressing the needs of the urban poor which were formerly operated under the NHRM (Corburn and Cohen 2012). Since its renaming to the UHRC, the organization has continued in its capacity of providing technical assistance to State Governments within India as they propose and execute urban health projects.

Technical Support to Government of Uttrakhand's Urban Health Programme

An example of the UHRC’s role in supporting state governments is its role in helping the Uttrakhand Health & Family Welfare Society to develop its Program Implementation Plan (PIP) under the National Rural Health Mission. Program Implementation Plan 2011-12 of UttarakhandHealth & Family Welfare Society mentions on pages 4-67 to 4-82 that the "Urban Health Resource Centre (UHRC) New Delhi have been involved for imparting training to NGO functionaries for the smooth functioning of the UHCs. Prior to this selection process the UHRC have done GIS mapping of these intervention cities which include the no. of slum, coverage and identification of location of UHCs. The UHRC New Delhi also developed BCC strategy for urban slums & guidelines for Mahila Arogya Samities (MAS) & convergence with other stakeholder. UHC staff has been trained on BCC strategy and on other modules by UHRC at state level. Besides this UHRC is providing technical support for implementation and monitoring of Urban RCH programme in the state". The UHRC provided technical support to run Urban Health Centres (UHCs) aimed at providing health care and support in slum communities and regularized outreach camps to vulnerable urban populations. The UHRC’s functions included coordinating NGO functionaries and collaborators and providing training to their staffs to help run UHCs, conducting GIS mapping of cities and slums to determine the most effective locations to place UHCs, and developing and piloting guidelines for women’s group programs through its experience in its other program cities such as Indore and Agra. Key activities of UHCs include providing maternal and child healthcare, providing antenatal and postnatal care, providing immunizations for newborns and children, care coordination through collaboration with other NGOs, behavior change education with regards to health and sanitation, resource awareness education for slum-dwelling families, and community capacity building through collective action initiatives.

One of the UHRC's key roles in influencing policy is in catalyzing local urban governments to recognize yet unlisted slums. Censuses often exclude the homeless and informal urban settlements as such settlements are often built on land that is not legally owned by the residents [Elsey et all 2016]. An analysis of five Indian cities conducted by the UHRC through field work and review of local records kept by UHRC community groups showed that 40% of slums were unlisted and thus not recognized by local governments. Further analysis revealed that unlisted slum residents made up about 36% of all slum residents in these cities. "Slum enumeration" techniques used by the UHRC rely on slum community members to draw upon their knowledge of their communities and to reach out to other households in their slum to collect information for the enumeration. Such activities and relationship building allow UHRC community groups to document additional information such as income flows, and make decisions about which slum-improvement initiatives to prioritize[Vlahov, Agarwal et al 2011].

Datasets and analyses of existing data generated by the UHRC have been used by UN organizations including the WHO and UN-Habitat.^[9] The UHRC's disaggregation and analysis of Demographic and Health Surveys (DHS) was highlighted in the WHO's "Hidden Cities" report page 84. Using India's National Family Health Survey (NFHS) dataset (an adaptation of DHS), the UHRC conducted an analysis of the poorest quartile of urban residents as compared to the rest of the urban population in Indian cities. The analysis revealed that the under-five mortality rate among the poorest quartile of urban residents in many provinces in India was nearly three times higher than for the rest of the urban population. Inter-provincial disparities also exist with Uttar Pradesh's under-five mortality more than twice as high as that of Maharashtra. The analysis also showed that among the poorest quartile: 60% of children had not completed immunization regiments and around 50% suffered from undernutrition, about half of all births were not assisted by health workers, less than 20% had a direct water supply, and more than half did not use a flush or pit toilet to dispose of waste [Satterthwaite, 2011]. This work has been referenced in numerous publications including UNICEF's State of the World's Children 2012 report, Draft final report of the task force to advise the National Rural Health Mission on “Strategies for Urban Health Care, 

Research and knowledge sharing

Secondary and primary research conducted by UHRC has been instrumental in shaping National and global documents and policy directions.

1. Health Disparities within urban areas unmasked:

a) David Satterthwaite in his editorial in Environment and Urbanization 2011 (http://eau.sagepub.com/content/23/1/5.full.pdf)  highlights the significance of UHRC's research. He states that UHRC's research provides "evidence of the lack of attention to the health of the urban poor. For instance, in 2004–2005, the under-five mortality rate of the poorest urban quartile in many states in India was two to three times that of the rest of the urban population. The evidence also points to considerable differences between states in this regard. The poorest urban quartile in Uttar Pradesh, for instance, had an under-five mortality rate more than double that of the poorest urban quartile in Maharashtra. For the poorest quartile of India’s urban population:

• 60 per cent of children were not completely immunized;

• 54 per cent of children were stunted and 47 per cent were underweight;

• only half of births were assisted by health personnel;

• less than one-fifth have water piped into their homes; and

• less than half use a flush or pit toilet to dispose of their excreta. One aspect of this lack of attention to urban health has been the use of inappropriate definitions regarding provision for water"

Sattherthwaite goes on to stress that UHRC's research exposes the "scale of health disadvantages experienced by the poorest quartile of India’s urban population and the large disparities in provision of health care, water and sanitation and in housing conditions in the urban population of seven states, between the poorest quartile and the rest of the population."

Source: Satterthwaite, David. "Editorial: Why is urban health so poor even in many successful cities?." Environment and Urbanization 23.1 (2011): 5-11. accessed on 23-9-2016 at http://eau.sagepub.com/content/23/1/5.full.pdf

b). UNICEF's State of the World's Children 2012, has substantiated intra-urban disparities in child nutrition by citing Urban Health Resource Centre's study of National Family Health Survey -3 on page 19 of the SOWC 2012 report:

" A study of the National Family Health Survey (NFHS-3) in India from 2005 to 2006 found that levels of undernutrition in urban areas continue to be very high. At least a quarter of urban children under 5 were stunted, indicating that they had been undernourished for some time. Income was a significant factor. Among the poorest fourth of urban residents, 54 per cent of children were stunted and 47 per cent were underweight, compared with 33 per cent and 26 per cent, respectively, among the rest of the urban population".

Source: Unicef. The state of the world's children 2012: children in an urban world. eSocialSciences, 2012. Accessed23-9-16 at http://www.unicef.org/sowc/files/SOWC_2012-Main_Report_EN_21Dec2011.pdf

c). Hidden Cities has used UHRC's example of using analysis of available data (Demographic Health Survey data which is available for several countries), called national family Health Survey in India. On page 84 of the WHO and UN-Habitat report using UHRC's research emphasizes how existing data can help better understand disparities within urban areas and better understand that all of urban is not necessarily benefiting from what is often taken as "urban advantage".

2. Under counting of urban vulnerable populations:

A report entitled "Roundtable on Urban Living Environment Research (RULER)" that evolved over a Rockefeller Foundation supported research conducted through working group of twenty-one researchers over one year highlights Urban Health Resource Centre's stellar research stressing that urban vulnerable (often called slum) populations are under-counted through administrative data sources.

The report states “ 'Slum' enumerations are also a means of mobilizing the population as the enumerators (who are residents, not outsiders) explain to every household why they are collecting the information. They help residents to better understand their settlement and capabilities. For example, they may encourage the formation of savings groups. Often they provide a household with the first written evidence that it lives there, as each house structure is numbered and each household receives a document showing the information collected about it during the enumeration. These are often useful for residents of informal settlements in seeking government entitlements. Enumerations can also document local income flows, giving residents an indication of what they can afford to invest in themselves and often leading to community-identified initiatives.

The example of community enumerations and assessments coordinated by Urban Health Resource Centre in India: Table 1 shows data from five Indian cities—the proportion of slums that are unlisted and therefore without recognition is staggering, representing about 40% of all slums and 36% of all slum residents."

Table 1

Number of listed and unlisted slums in five Indian cities

Source: Vlahov, D., Agarwal, S. R., Buckley, R. M., Caiaffa, W. T., Corvalan, C. F., Ezeh, A. C., … Watson, V. J. (2011). Roundtable on Urban Living Environment Research (RULER). Journal of Urban Health : Bulletin of the New York Academy of Medicine, 88(5), 793–857. http://doi.org/10.1007/s11524-011-9613-2 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191208/

3. Collaborative research on maternal and newborn health in slums:

a) Collaborative research of Urban Health Resource Centre with Johns Hopkins School of Public Health on Birth preparedness and complication readiness among slum women in Indore city, India

highlights that "Factors associated with well-preparedness were maternal literacy [odds ratio (OR) = 1.9, (95%) confidence interval (CI) 1.1-3.4] and availing of antenatal services (OR = 1.7, CI 1.05-2.8). Deliveries in the slum-home were high (56.4%). Among these, skilled attendance was low (7.4%); 77.3% of them were assisted by traditional birth attendants. Skilled attendance during delivery was three times higher in well-prepared mothers compared to less-prepared mothers (OR: 3.0, CI 1.6-5.4) Antenatal outreach sessions can be used for promoting BPACR. It will be important to increase the competency of slum-based traditional birth attendants, along with promoting institutional deliveries.

Source: Agarwal, S., Sethi, V., Srivastava, K., Jha, P. K., & Baqui, A. H. (2010). Birth preparedness and complication readiness among slum women in Indore city, India. Journal of Health, Population and Nutrition, 383-391. accessed on 23-9-2016 at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2965330/

b) Another example of collaborative research of Urban Health Resource Centre with Johns Hopkins School of Public Health demonstrates the significance of simple Human touch method to detect hypothermia in neonates in Indian slum dwellings.

This research shows that Hypothermia prevalence (axillary temperature <36.5 degrees C) was 30.9%. Prevalence varied by season but insignificantly. Hypothermia was insignificantly associated with poor suckle (31% vs 19.7%, p=0.21) and undernutrition (33.3% vs 25.3%, p=0.4). HT had moderate diagnostic accuracy when compared with ADT (kappa: 0.38, sensitivity: 74.5%, specificity: 68.5%).Human touch (HT) emerged simpler and programmatically feasible method of early assessment of newborn sickness. The research calls for the need to examine whether trained and supervised community-based health workers and mothers can use HT accurately to identify and manage hypothermia and other simple signs.  of newborn illness using minimal algorithm at home and more confidently refer such newborns to proximal facilities linked to the program to ensure prompt management of illness.

Source: Agarwal, S., Sethi, V., Srivastava, K., Jha, P., & Baqui, A. H. (2010). Human touch to detect hypothermia in neonates in Indian slum dwellings. The Indian Journal of Pediatrics, 77(7), 759-762. Accessed23-09-2016 at http://medind.nic.in/icb/t10/i7/icbt10i7p759.pdf

c) Technology Review: MIT's Magazine on Innovation: India Edition, July 2010 discussing issues for Maternal Health care describes Urban Health Resource Centre's collaboration research with JHSPH and CSMM University, India. The magazine  reports: "A household survey by Urban Health Resource Center (UHRC) in collaboration with the Johns Hopkins Bloomberg School of Public Health, USA and Chhatrapati Shahu Ji Maharaj Medical University, Lucknow, conducted between October 2007 and March 2008 in Meerut, found that only 60 percent pregnancies were registered with a health facility. The survey covered 15,025 women who had a live or still birth in the three years preceding the survey— referred to as recently delivered women (RDW). The women were drawn from 44,888 households across 45 slums within the city. Of the 60 percent registered pregnancies, 59.4 percent pregnancies were registered within first three months, 21.7 percent between 4-6 months and 18.9 percent after six months of gestation. Among those who registered, private facility was the preferred place of registration for more than 40 percent pregnant mothers. Around one-fourth of the mothers approached a government facility and another one-fourth of mothers registered with a NGO run health facility.

Early registration of pregnancy with a healthcare provider facilitates assessment of health and nutritional status of the mother and to obtain their baseline information on blood pressure, weight, and more. An early contact with a health provider also helps to screen for complications early and manage appropriately by referral as and where required. An important reason for not availing health services from government facilities was absence/poor functioning of public facilities in the vicinity. Service usage of public facilities by pregnant women was also low because of shortage of staff especially lady doctors; shortage of medicines including IFA tablets; lack of diagnostic services; poor referral system; unfavorable timings of the facility that does not suit the working slum women; long queues in the higher level facilities; impolite attitude of health center staff towards slum women; and lack of privacy.

Source: Technology Review: MIT's Magazine on Innovation: India Edition, July 2010 https://s3.amazonaws.com/files.technologyreview.com/p/pub/legacy/tr_07_10_01_low_res.pdf

Recognition and Awards[edit]

1. UHRC's initiative, Resolve-Flight-Zest (Sankalp-Umang-Udaan) for Education, was recognized in Aug 2017 by South Asia Education Summit with an award in the category "Innovative Strategy for Equitable access to Children's Education in Cities". http://ictpost.com/3rd- edition-of-south-asia- education-summit-award-2017/