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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

5. Summary and Implications


What can we learn from these reviews of urban reproductive health experiences? Let us begin with a summary of major findings and then discuss their implications. 

Regional Analysis: Correlations, Outliers and System Variability 

In the regional analysis we saw that overall RH conditions are very much a function of the wealth of a nation. Wealthier nations have resources for a more robust RH delivery system and people in wealthier nations have more resources to provide for their own health. Wealthier nations have also made more progress in moving through the demographic transition, which itself indicates progress in reproductive health. 

The more interesting observation, however, is how some countries are quite out of line in this general correlation. Two stand out in our countries: Pakistan and Vietnam. Pakistan’s Faisalabad has the weakest RH system and poorest RH condition, though it is wealthier than Vietnam’s Danang or Bangladesh’s Chittagong. Faisalabad’s condition can be related to its position in a series of highly destructive wars both of its own and on its borders. 

Weihai, China is also a slight outlier, but it is the country rather than the city which is the outlier. China is less wealthy than Thailand, but Weihai is considerably wealthier than Khon Kaen, and has greater control over government activities and expenditures than does Khon Kaen. Thus its slightly better RH conditions can be considered. 

We have argued that Danang’s and Weihai’s more favorable conditions can be traced in part to their revolutionary socialist background. In these systems primary health care and education have typically been given substantial priority, and have also seen some highly innovative approaches. China’s Barefoot Doctor program was undoubtedly responsible for rapid increases in reproductive health long before it changed its disastrous social economic strategy. 

The regional analysis also shows wide variance in the budgets for these health programs. As is demonstrated in the country analyses this results from wide variances in the development of local government and devolution of authority, responsibility and resources. China is the most decentralized system of our nine, and is also considered the most decentralized in all Asia. (World Bank 2003) Thailand is at the other extreme, with the central bureaucracy controlling and funding the great majority of local activities. The AUICK Workshop Action Plan experience shows that whatever the level of government decentralization, local administrators can always find ways to improve the quality of life for their citizens. 

What does this suggest for RH policy assistance? 

It seems clear that single, homogeneous strategies are not appropriate for international population and RH assistance. The most effective assistance will be tailored to the specific needs of a country, and especially of the cities in each country. Perhaps more important is the AUICK experience that local administrators are in a good position to conceive and carry out projects that directly improve the quality of life of their citizens. International assistance programs that mobilize local administrators will thereby tap into a great source of human energy to promote human development and reproductive health services and care. 

Assistance policies that mandate working through a Ministry of Health, or that promote “Integrated Services” (to cite two common examples) risk wasting time, effort and resources and slowing the development of an effective RH system. This seems so obvious a point that one is almost embarrassed to note it here. Yet we have seen many examples of international assistance weaken their impact precisely by promoting one homogeneous strategy for all countries. 

Country Analyses: Local Expertise, Data Systems and Regional Strategies 

1. Local Expertise. The individual city reports tell us a great deal. Problems vary immensely, and individual urban administrators can be moved to work out locally appropriate innovations to improve reproductive health specifically and the quality of life more generally. The AUICK Workshop strategy that led urban administrators to develop an Action Plan around a Workshop topic for implementation in their cities has been highly successful. This was first applied more generally to the Millennium Development Goals (under the UNFPA-AUICK agreement of 2004), and more specifically to the reproductive health goals more recently adopted. These individual Action Plans have had a substantial impact on the quality of life in AUICK’s Associate Cities. This is true no matter how the country administrative systems are organized. There have been as many effective local initiatives in Khon Kaen under a highly centralized national administrative system as there have been in Weihai or Danang, which work under more highly decentralized national systems. 

The point is a simple one, but one to which AUICK has been committed since its inception. Local administrators know their cities and their systems of governance. They know how to get things done. What the Workshops did was to address a problem (primary health care, primary education, reproductive health etc), show how one very successful city (Kobe) has addressed that problem, and also show how nine other cities define and face the same problem. This stimulated urban administrators to think of how they could make an impact at home. From this they developed highly successful programs for their own cities. 

In some cases, these Action Plans remained localized and simply made a small improvement in peoples’ lives. In most cases, plans are implemented citywide. Some are promoted at the state level, and in Danang’s storefront HIV/AIDS counseling program, the idea was so obviously significant that it became part of a national program. 

In all cases, however, the improvement in individual cities suggests important lessons. 

Strategies that focus on local administrators and lead them to address their problems can make major headway in improving the quality of reproductive health specifically and the overall quality of life in cities more generally. 

2. Data Systems. Faisalabad’s health information system is in much need of improvement. Chittagong has a new set of good data on its whole RH system, in large part from its recent exercise in developing a local Management Information System (MIS). Khon Kaen cannot really tell where it is in reproductive health in the city itself, because its data do not pertain to the city’s administrative boundaries. Danang has an RH information system sufficiently robust so that when a major typhoon approached in 2006, it could identify and locate the 42 mothers with new born babies and be sure they were relocated to a safe place. These examples illustrate some of the range of conditions found in the data systems of our cities. AUICK recognized this in a 2000 study of five cities, and proposed the development of a City University Partnership to help cities develop the kind of information systems that would show where they are on specific issues and help them to take appropriate actions. Some progress has been made in some cities: Danang, Olongapo, Khon Kaen, Chittagong and Surabaya, for example. The Olongapo experience is especially important since that city program has now been adopted by the UNFPA Philippines Country Office as a best practice model. 

It would be especially useful for international assistance agencies to help cities develop good data systems so they can more effectively address their own problems. This suggests a general strategy, not the specific steps needed in each case. It suggests bringing together organizations (universities and city governments) that have special capacities, and having them develop an information system appropriate to their local conditions. 

3. Regional Strategies. One of the striking things we find in these city experiences is how effective it is for cities to learn from one another. This was, of course, one of the major findings of the 1987 UNFPA Asian Conference on Population and Development on medium sized cities, held in Kobe. It is also the observation that led to the creation of AUICK. Urban administrators found a common ground and learned a great deal from one another. It also reflects the longer history of population policy development in Asia and the world. We have noted how India’s advanced capacities in demographic and economic analysis led it to proclaim the world’s first public policy to reduce population growth by reducing fertility in marriage. This was a revolutionary policy development. India led the rest of Asia in adopting such policies largely through the regional programs of the United Nations through its regional economic commissions. Regional programs advance the quality of life as more advanced nations set standards of quality of care and less advanced nations work to emulate those more advanced policies and programs. 

AUICK’s Workshops have similarly provided a highly stimulating situation in which urban administrators from different cities and countries can learn from one another. Regional programs, where countries come together to address common problems and share experiences, have proved very effective in leading to new capacities to address common problems. 

Regional Programs (like the AUICK program) can help countries learn from one another and improve greatly the quality of services they provide to their people. These programs can also be highly cost effective, since they are run by competent local administrators and do not need a great deal of external supervision or oversight. 

References 

- AUICK, Population Dynamics and Port City Development: Comparative Analysis of Ten Asian Port Cities (with Kanae Tanigawa, ed.) Asian Urban Information of Kobe, January 1992. 

- Knodel, John, Jiraporn Kespichayawattana, Chanpen Saengtienchi, and Suvinee Wiwatwanishm, 2010, "The Role of Parents and Family Members in ART Treatment Adherence: Evidence from Thailand." Research on Aging 32(1): 19-39. 

- Ness, Gayl D, 1993, The Long View, Population Environment Dynamics in Historical perspective, in Population-Environment Dynamics: Ideas and Observations, (with William Drake and Steven R. Brechin, co-editors), University of Michigan Press, 1993. 

- ----- and Hirofumi Ando 1984, The Land is Shrinking: Population Planning in Asia, (Baltimore; Johns Hopkins University Press). 

- -----and Michael Low, eds., 2000, Five Cities: Modeling Asian Urban Population Environment Dynamics, (Singapore: Oxford University Press). 

- ------ and Prem Talwar, eds, 2005, Asian Urbanization in the New Millennium, (Singapore: Michael Cavendish), 507 pp 

- Singha-Dong, Naruemol, 2004, Tuberculosis in Sisaket Province of Thailand, 2001, Unpublished Ph. D. Dissertation, School of Nursing (Ann Arbor: University of Michigan). 

- World Bank, 2003, East Asia Decentralizes: Making Local Government Work, (Washington, DC: The World Bank).

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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