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Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls

Section One - The New Urban Challenge for Primary and Reproductive Health Care

1. Background: Urban Growth and Urban Primary / Reproductive Health Services (PRHS)


A. Asian Rapid Urbanization 

Asian urbanization since 1950 represents one of the largest and most rapid population movements in probably all of world population history (1).  In 1950 there were a mere 234 million people living in urban areas in all of Asia, representing just 17% of the population. By 2010 the number of urbanites had grown to 1.8 billion, representing 42% of the Asian population. By 2050 the urban population is projected to be 3.2 billion, or 65% of the Asian population. Thus in just a century the Asian urban population has grown by a factor of 14! In contrast the urbanization of Europe took some 250 years and involved a growth of from 120 to 527 million, increasing by a factor of less than five (Ness 1993). 

Asian urbanization continues despite declining growth rates for the total population. Asian population growth rates peaked in 1965-75 and have been steadily declining since. Rural areas are actually declining in nine major Asian countries and by 2030 that number will be 14. While rural populations decline, urban populations will continue to rise. 

B. Urban Reproductive Health (RH) Services 

When modern population planning began in the less developed countries, roughly in the period 1952-80 (2), most of Asia was still rural. The major task for population programs and especially for primary and reproductive health services was reaching a highly dispersed and remote rural population. New social and physical infrastructures had to be created to reach those physically isolated populations. Roads, postal systems, health care facilities and schools had to be created. In addition to the physical isolation was a more debilitating social isolation reflected in low levels of education and literacy. At the same time those rural populations were organized into small villages with close personal relationships. If a village could be organized for PRHS and family planning, most villagers would find services provided in a personal and friendly situation. 

It is important to recall the highly innovative and successful programs that many countries established to reach the rural areas. Consider only the Chinese Barefoot Doctor Program, which reduced infant mortality remarkably in less than a decade. Consider also the South Korean, Indonesian, and Thai family planning programs that succeeded in increasing rural as well as urban contraceptive use, and reducing rural fertility in a decade or two. It should also be remembered that reducing fertility produced a direct and dramatic rise in the health and welfare especially of poor women and children. Promoting reproductive health meant primarily reducing fertility. There were many successes as Asian leaders took on the task. 

Since then RH has become more complex and its implications much broader. In addition the new urban setting presents population planners with a radically different environment in which to provide RH services. In one sense, this new environment is more supportive. People are more densely settled and more directly in communication with new ideas and with new services. Schools, neighborhood clinics and markets provide dense settings in which information and services can be quickly and easily provided. 

But urban populations also present new problems. First, they are centers of vast and complex transportation and communication networks. This facilitates rapid movement of ideas and goods, but also of the microorganisms that debilitate health, especially STDs and HIV/AIDS. In addition, the new fast growing urban centers have large numbers of young immigrants from rural areas, who often lack the kind of supportive social networks found in villages. They are the new “floating” populations that are not easily reached by public services. This is especially important in areas such as AIDS, STDs and fertility control. Finally there are vast new urban slums, where RH services often fail to reach the population. These migrants and slum dwellers represent a new and highly vulnerable population. Too often, the most vulnerable of these new populations are women and girls. These new vulnerable populations require new and innovative delivery systems. 

It is also clear that RH service delivery to these vulnerable groups varies greatly by country and within countries as well. While individual characteristics, such as individual wealth and poverty have some impact on this variance, much greater importance must be given to administrative capacities and leadership in sub national areas (3). States, provinces, and cities vary greatly in both their administrative capacities and in the capacity of their leaders to promote effective service delivery. We have seen a wide range of innovative service delivery innovations developed under the Action Plan program in AUICK Workshops. 

Thus this new, rapidly growing Asian urban population needs its own set of innovative policies and programs, especially for the provision of RHS to the new vulnerable groups. In large part those innovative programs will arise in the cities and provinces where national policies are turned into direct action. They are far less likely to be developed in “expert” centers, far away from the cities where the action lies. 

1. AUICK has produced two books that review this history: Ness and Low 2000 and Ness and Talwar 2005.
2. India became the first country to establish an official policy to reduce population growth by reducing fertility in 1952. It led Asia and then the rest of the world into the modern era of population planning to reduce population growth rates. In the 1960s the first new non-coitally specific contraceptive technology made its appearance, and UNFPA, and many bilateral population programs were established (Ness and Ando 1984).
3. See Ness and Ando 1984 for a quantitative analysis of the state-wise differences in administrative capacity in India. Quantitative assessments were also made of Asian national political systems. In both cases administrative capacities at state and national levels were directly related to family planning program success, fertility decline, and maternal and child health.

CONTENTS

Top

Foreword

Section One

The New Urban Challenge for Primary and Reproductive Health Care

Executive Summary

1. Background: Urban Growth and Urban Primary / Reproductive Health (RH) Services

2. An AUICK Research Project Report

3. Regional Findings

4. Individual City Findings

5. Summary and Implications

Section Two

Providing Primary / Reproductive Health Services in Asian Urban Areas with Attention to Vulnerable Populations, Especially Women and Girls:

Nine AUICK Associate City (AAC) Reports

6. Kuantan, Malaysia

7. Khon Kaen, Thailand

8. Weihai, China

9. Surabaya, Indonesia

10. Olongapo, Philippines

11. Chennai, India

12. Faisalabad, Pakistan

13. Danang, Vietnam

14. Chittagong, Bangladesh

Annex I.
Research Instrument: AUICK Research Project Outline

Annex II.
AUICK Research Project Participants


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