Sustainable urban health services: Transferring responsibilities to local government

SanitationCommunity health workers

by Martin Allaby and Christine Preston

The Yala Urban Health Programme (YUHP) was originally set up by the United Mission to Nepal to respond to urban health problems in the city of Patan, Nepal. However, in 1998 the key priority became the gradual transfer of responsibility for this successful healthcare programme to full government control. This article looks at the process of transferring responsibility and highlights the success factors.

In 1984, YUHP staff conducted a baseline survey of the city. They found there was little awareness of health and environmental issues in the city. The streets were dark and unpaved, and blocked by solid waste. Public wells were a main source of drinking water, but were often in bad condition and filled with contaminated water. Diarrhoeal diseases were very common. School attendance was low and literacy rates, especially among girls and women, were very low. Immunisation coverage and uptake of family planning was also low.

The government health system in Nepal provides basic health services for rural citizens, but not for urban populations. In the cities, public health is officially the responsibility of the city government. At that time there was just one government clinic and a district hospital in Patan. YUHP’s first priority was to fill the gap in essential services in the areas of the city where it worked. To improve health in Patan, YUHP began several initiatives:

Raising awareness Urban health staff raised awareness of sanitation, hygiene, health and environmental issues. Nurses went to public meeting places with a vaccination box as a first step towards improving mother and child healthcare. Mother and child health clinics were gradually introduced.

Improving wells After an outbreak of typhoid in the city in 1992, a programme of well-improvement began. Communities formed welluser committees to take responsibility for local fundraising and to recruit volunteers to maintain the well. Wells were rebuilt or repaired and the well water was treated with chlorine.

Women’s education A non-formal education programme began, which targeted women and factory workers.

Improved sanitation Improvements were made for many households with piped water and latrines with the support of the German agency, GTZ. By 2000, in six of the 22 city wards, all households had access to latrines and nearly 80% had access to piped water. During recent interviews, women who were young mothers in Patan 20 years ago noted that women today have smaller families and that children no longer die from diarrhoea or typhoid.

New direction

From 1995, with the appointment of a new manager to YUHP, the focus changed to ensuring that a sustainable primary healthcare system could be developed within local government by 2006. A formal partnership was agreed with the local government in 1998. The key factors in planning for successful handover were:

  • Credibility Over 15 years YUHP had gained the trust of both the community and of local government.
  • Evaluation To ensure an effective strategy for handover, YUHP looked at the strengths, weaknesses, opportunities and threats in their work. It took into account the activities and capacity of other organisations and local authorities. Following this evaluation, YUHP focused on community mobilisation and basic healthcare.
  • Extended coverage In 1995 YUHP were working in just eight of the city’s 22 wards. They agreed to extend their work to include any of the other wards that wished to develop local health activities.
  • Healthy Cities workshop This was organised in 1998 by YUHP for key government and community leaders to share the vision for strengthening Patan as a healthy city. It was a key event in building local commitment. After the workshop, the mayor signed the first partnership agreement with YUHP.

Building on the partnership agreement

From 1998 onwards, the focus of YUHP changed. They planned an eight-year handover process, to ensure there was enough time to develop local capacity. The agreement of senior government leaders was essential. However, YUHP recognised that developing the capacity of senior government staff was unlikely to be enough. A great deal of effort was therefore given to working at community level.

Building capacity at higher levels
A public health unit was established to manage nursing staff, co-ordinate health committees and ensure participation in national health campaigns. YUHP helped by providing a Nepali consultant and by sponsoring key staff to attend training.

Building capacity at middle level
Local health committees were established in each ward of the city. These were made up of teachers, traditional birth attendants and representatives of community groups. The initial priority of most committees was to open a clinic. During their first 12 months, the committees were supported by YUHP and local government who both sent a representative to attend each meeting. The committees chose volunteer health promoters from their members. The promoters were trained by YUHP to carry out an initial survey of all households in their area. This assessed people’s work, literacy levels, water and sanitation practices and their uptake of health services. YUHP staff helped the volunteers to analyse the results and to present the findings to the committee.

Based on the survey findings, the committees produce action plans to begin meeting local health needs. For example, they organise one-day health demonstrations. They provide posters with information about common health problems and display them in public places. People can have their height, weight and blood pressure checked. Nutritious foods are put on display. They also organise one-day health camps, where doctors are asked to donate their services for a day, to examine patients, provide minor treatments and arrange referral for complex problems. The most popular camps are for eye, dental and maternal health problems.

Building capacity at community level
Over 400 volunteers have been trained in hygiene, nutrition, family planning, immunisation, women’s rights, tuberculosis, HIV and AIDS and other health issues. Their aim is to raise awareness about health in Patan. Each volunteer makes contact with about 50 households every two months. They also help with health demonstrations and health campaigns.

Conclusion

YUHP still plans to complete the handover in 2006. At every stage in the handover of responsibility, donors and evaluators have been sceptical that this would work. However, local government now manages the team of nine nurses and community health workers, and provides almost 80% of their salaries. This article shares some of the factors that have led to success but perhaps the most important has been that leaders in both YUHP and local government have been willing to take risks. An attitude of service that values the work of others has helped to build success. 

Martin Allaby is a consultant in public health with Interserve. Christine Preston is programme unit director of the Yala Urban Health Programme.

United Mission to Nepal, PO Box 126, Kathmandu, Nepal
Emails:
chrisp@wlink.com.np allaby@wlink.com.np

This article is adapted from: Environment and Urbanization Vol. 17 No 1 2005 – Sustaining health services


Solving problems

YUHP has encountered several problems in handing over responsibility for community health. These include:

Dependency To tackle this, YUHP has encour aged more people to volunteer as health promoters, encouraged more initiatives from the health committees, and provided opportunities for developing capacity.

Ethnic tensions Many Nepalis have a strong sense of caste and ethnic identity. Migrants from rural areas may belong to different castes, speak different languages and dress differently. This can mean they are not easily accepted into the local community. In some areas, the health committee and clinic were led by different caste groups that were unwilling to work together. YUHP introduced several practical ideas to tackle these tensions:

  • All YUHP staff and volunteers wear the same uniform.
  • 10% of the volunteer health promoters must be from low-caste or migrant communities.
  • Volunteers and staff from different castes and professional groups must eat together at training events. This has resulted in friendships that cross social barriers.