A recent review of developments in urban health over the last 30 years identified four perceptual shifts . First, more than health service inputs are necessary to improve health. Of particular interest are community participation and formation of partnerships with community-based organizations. Second, the emphasis should shift from individuals to communities. Third, there was a growing interest in multi-level determinants of health, including work on poverty, social interactions, the physical environment and services. Fourth, initiatives must go beyond the public sector. Informal settlement communities are heterogeneous [2, 3], and health care often involves the private and informal sectors [4–7].
The Society for Nutrition, Education and Health Action (SNEHA), a Mumbai-based non-government organization (NGO), works to improve the health of women and children in disadvantaged communities. We have addressed health care from two directions: on the demand side, by attempting to create informed users of health services who expect higher quality; and on the supply side, by working with public sector health providers (in our city, the Municipal Corporation of Greater Mumbai) to improve the quality of health services .
A National Urban Health Mission (NUHM) is due to merge with the existing National Rural Health Mission of the Government of India. It seeks to address the health care needs of the rapidly growing urban population, with a focus on the disadvantaged. A significant change in the proposed strategies is a move from the provider perspective to a more collaborative approach. There is an emphasis on building local capacity and engaging communities in delivery of health care, and on building public-private partnerships to enhance quality of care. Any potentially scalable intervention should fit the National Health Mission agenda: training of link-workers and women’s health committees to carry out community health promotion activities, strengthening linkages between service providers and the community, especially vulnerable groups, regular outreach services to address low access by disadvantaged groups, and public-private partnership.
We have become interested in the potential of community resource centers as nexuses for improving family and community health. There is a tradition of NGOs basing their community work at local resource centers. In some cases the NGOs are small and the resource centers are their headquarters. In others, they are satellite nodes linked with larger central offices: the structural arrangement we aim to test. We estimate that there are about 60 major NGOs working on urban informal settlement development in Mumbai. Prominent groups, including Society for Promotion of Area Resource Centres (http://www.sparcindia.org), Akanksha Foundation (http://www.akanksha.org), Apnalaya (http://www.apnalaya.org), DoorstepSchool (http://www.doorstepschool.org) and Pratham (http://www.pratham.org), have run local community resource centers since the 1980s. These have served purposes as varied as provision of preschool, non-formal and remedial education, vocational training, recreation activities (khelwadis), health clinics, care centers for people with disabilities, family counseling, collective savings and loans, and physical space for community interaction. Some organizations, including Apnalaya, Stree Hitkarni, Committed Communities Development Trust (http://www.ccdtrust.org), and Navjeevan (http://www.navjeevan.org), have focused on community health. Their resource centers occupy a range of locations: individual homes, leased spaces, or sites provided by community-based organizations. They are staffed by a combination of volunteers and salaried cadres and are open from 8 to 24 hours daily.
Our previous trial of community mobilization through women’s groups suggested that women were eminently able to articulate their experiences, identify problems and suggest local solutions, but that they hit a wall when they tried to move to community action . To some degree this is a feature of what we call the urban paradox: despite the density of informal settlement populations, contact with people outside one’s immediate area, cultural or kinship group is limited. While women’s groups in rural areas seem to be able to pull together communities for collective action [10, 11], groups in urban informal settlements - though probably less poor and more ‘modern’ - often feel that they lack the power to push their agendas with neighbors and health-care providers.
Our idea is that satellite resource centers located in vulnerable areas could be formalized sources of health information and bases for community outreach work. Workers at each center will be members of the SNEHA team, backed by the experience, knowledge, connections and skills of project coordinators and directors: a decentralization in the non-government sector that answers calls for decentralization in the government sector. Information, training, awareness and advocacy events will be cascaded out through the resource centers. The centers will coordinate services such as community-based contraceptive distribution, outreach camps for immunization, counseling services for women facing violence, and day care with supplementary nutrition for malnourished children.