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Urban Health in Developing
Countries
Live Talk 2
Urban Health Issues
14 April 2009
2
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
3
Part 1
Pam Lynam and
Stuart Merkel
Jhpiego – Kenya Program
4
HEALTH IN THE URBAN
SLUMS: Let the people lead the
way
Pamela Lynam MD
Stuart Merkel, MBA
April 2009
5
Photo by Madhav Pai. Creative Commons BY.
6
Jhpiego Overview
Photo by Jhpiego staff.
•  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
7
Jhpiego’s Work in Urban Slums
Photo by Stuart Merkel.
•  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
8
sustainability
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.
9
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
10
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.
11
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,
Photo by Stuart Merkel.
community & ethnic support
structures
–  Prostitution, addiction, domestic
violence, etc.
12
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.
13
Nairobi slums - Emerging Evidence
Selected Data:
•  Data generally hard to find on health in slums
•  Expected higher MMR, prevalence rates for HIV,
TB, etc
14
Two Key Messages
“So Close – Yet So Far”
Proximity ≠ Access
in Slums!
Photo by Stuart Merkel.
Bridging the
CommunityClinic Divide is Key!
Photo by Stuart Merkel.
15
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
16
PQI Framework
17
17!
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
18
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
19
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
20
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
21
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
22
PQI Results
Community-Inspired and Owned Interventions
–  Anti-rape self defense training
–  Community Theatre
–  Peer Education
–  Community Mapping
–  Village Health Committees
–  Community Gardening
Photo by Stuart Merkel.
–  Free medical camps
–  Vastly improved attitude between clinics and
slumdwellers - Painted Health facilities, garden etc.
23
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
24
Photos by Stuart Merkel.
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.
25
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.
26
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
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Photos by Stuart Merkel.