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

Section Two - Nine AUICK Associate City (AAC) Reports

11. Chennai, India


Summary and Abstract

Urbanisation in the World and India

Health Sector in India: Public vs. Private

Reproductive Health Services: A Glance into the History of Tamil Nadu with Special Reference to Chennai

Problems of the Study

Data Source and Methodology

Status of Health/Reproductive Health in Chennai

City Budget for RH Services

Views of City Leaders

Conclusion and Summary

Limitations of the Study

Annexes

References


Ms. Sudha Yadav
 
Research Associate, Vellore I.T. (Institute of Technology) University, Tamil Nadu 
Ms. Tinsy Rose Tom 
Ph.D. Student at Vellore I.T. (Institute of Technology) University, Tamil Nadu

Chennai Map

Abbreviations 

AIDS: Acquired Immune Deficiency Syndrome 
ANC: Antenatal Care 
CBR: Crude Birth Rate 
CDR: Crude Death Rate 
CHC: Community Health Centre 
DANIDA: Danish International Development Agency 
EOCs: Emergency Obstetric Centres 
FW: Family Welfare 
GDP: Gross Domestic Product 
HIV: Human Immunodeficiency Virus 
IFA: Iron and Folic Acid IMR: Infant Mortality Rate 
IUD: Intrauterine Device 
MCH: Maternal and Child Health 
MMR: Maternal Mortality Rate 
MTP: Medical Termination of Pregnancy 
NACO: National AIDS Control Organisation 
NFHS: National Family Household Survey 
NGO: Non Governmental Organisation 
NRHM: National Rural Health Mission 
NUHM: National Urban Health Mission 
PHC: Primary Health Centres 
PHC: Public Health Care 
RH: Reproductive Health 
RCH: Reproductive and Child Health 
SRS: Sample Registration System 
STD: Sexually Transmitted Diseases 
STI: Sexually Transmitted Infections 
TFR: Total Fertility Rate 
TN-HSDP: Tamil Nadu Health System Development Project 
TNVHA: Tamil Nadu Voluntary Health Association 
USAID: United States Agency for International Development 
VES: Vital Events Survey 
VHS: Voluntary Health Services 
WHO: World Health Organisation 

I. Summary and Abstract

Aim: Due to rapid urbanization and boosts in the numbers of slums and migrant population, the deliverance of health services in the urban areas has become meek. This study peeks into the health care profile of Chennai City and thus strives to find out the lacunae in the RH care services and urge some policy implication to improve the same. 

Methodology: The study employs desktop research and interview methods via primary and secondary data from various published and unpublished sources. To know the present RH conditions in the city more closely, the city leaders were the key informants who were interviewed using a structured questionnaire. 

Findings: The study divulges that notwithstanding the fact that the existing RH condition in the city is satisfactory, the government ought to take added care to amplify it to cater to the needs of the swelling urban poor population in the future. 

II. Urbanisation in the World and India: An Introduction

Projections of the United Nations Population Division expose that by 2030, more people in the developing world will live in urban areas; by 2050, two-thirds of its population are likely to be urban. The world’s population as a whole is expected to grow by 2.5 billion from 2007 to 2050, with the cities and towns of developing countries absorbing almost all these additional people (USAIDS, 2008). India also is witnessing an unpredictable escalation in urban population. It is estimated that nearly 30% of India’s population, or about 300 million people, live in towns and cities. This population is estimated to reach 534 million by 2026 (USAID). Rapid urbanization has given space for rapid growth of slums too. It is estimated that nearly one-third of India’s urban population (nearly 100 million) dwell in slums and nearly 80.8 million persons in urban areas live below the poverty line (NFHS-3). 

III. Health Sector in India: Public Vs Private

India has a vast health care sector, estimated worth of Rs. 126.27 billion in the year 1998. Health of the urban poor is noticeably shoddier than the urban middle and high income groups, and is as inferior as the rural population. Only 42% of slum children receive all the recommended vaccinations. Over half (56%) of child births take place at home in slums risking the life of both mother and child. The health care sector in India is broadly divided into the public and private sectors (one of the largest in world). Private expenditure on health care in India ranges between 75% and 85% of the total budget. The total health expenditure in India was 5.2 % of the GDP in 2008, of which only13 % was spent by the government. What does this mean in a country where at least 26 % of the population is still fighting for subsistence (below the poverty line)? Poverty and ill-health go hand-in-hand, and limited income means a limited capacity for health spending. Public health services in India consist of the following 'step-up referral' network of sub-centers, primary health centers, community health centers and district hospitals: 140,000 sub-centers manned by two multipurpose health workers; 23,000 primary health centers. (PHCs) with a medical officer, 14 staff and 4 to 6 patient beds, with each PHC acting as a referral unit for six sub centers; 3,000 community health centers (CHCs) with four medical specialists, 21 staff, 30 beds and basic surgical and lab facilities, with each CHC a referral unit for four PHCs; 550 district hospitals and 1,012 at the sub-divisional level. 

Chennai Budget for RH Services (2009)IV. Reproductive Health Services: A Glance into the History of Tamil Nadu with Special Reference to Chennai.

(a) RHS: A Definition 

Reproductive health is defined within the frame work of the World Health Organization (WHO) as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity”. 

(b) History of Tamil Nadu, Chennai 

The Family Welfare Programme (earlier known as the Family Planning Programme) shifted emphasis from fertility reduction to protection of the health and survival of mothers and children. The target–driven, method–specific approach that dominated the scene before 1995 has since moved towards what is popularly known as “the MCH route to family welfare”. When compared with All-India statistics, health status in Tamil Nadu is considerably above average and has also seen noteworthy augmentation of which Chennai is the best performing city in terms of RH services. Health infrastructure in Tamil Nadu has also been fairly good with Chennai having the maximum number of hospitals and clinics. Tamil Nadu also has 11 teaching hospitals, 26 district headquarters hospitals and 227 taluk and non-taluk hospitals, with a total of 8,000 doctors and 28,000 paramedical personnel. With reference to RH conditions, Infant Mortality Rates (IMR) have declined in the last ten years from 80 per 1,000 in 1980 to 58 in 1992 for Tamil Nadu (Chennai, 17.40), appreciably lower than the all-India rate of 79. The figures again showed a steep decline in Tamil Nadu (31.0) as well Chennai (11.68) in 2008, much lower than national figure of 53 (Table 1). The Total Fertility Rate (TFR) in Chennai has also declined manifestly from 3.9 in 1971 to 2.02 in 1990 and, further, to 1.7 in 2008; similarly, the Crude Birth Rate (CBR) is also on a downward curve, falling from 31.0 in 1971 and 17.3 in 1992 to 16.43 in 2008. However, the Death Rate (DR) and Maternal Mortality Rate (MMR) which were (3.00) and (0.20) respectively in 1992, increased to 3.69 and 3.0 respectively in 2008, but were still much lower than state and national figures (Table 1). In the context of family planning and reproductive health services in the city (including both private and public sector), tremendous encouraging renovations have taken place in terms of permanent (male vasectomy and female sterilization (tubectomy and laparoscopy)) and temporary methods (IUD, OP and condoms) of contraception, Abortions (MTP) and all types of immunization over the past 44 years (from 1964 to 2008) (Table 2). 

State government expenditure on health also was relatively high, at 5.6% of the total revenue expenditure in 1999- 2000. 

V. Problems of the Study

As we witness from the above discussions on mounting urbanization and swelling slum population in India with a sparse provision of health services, it is indispensable to solicit that though RH conditions in Chennai are quite passable now, will it be able to cope with the swelling population due to urbanisation, increase in slums and migration in the future? And many other questions crop up, like what is the trend of RH services in the city? How seriously does the government view the problem of reproductive health services in the city? What are the problems that the city is facing due to the swelling population? What is the intensity of the problem, what are its causes and how the city is reacting to the above problem? 

To answer the above questions, with the intention of studying the trends of condition and provision of RH services in the city of Chennai, and to peep into the policies, facilities and services benefiting the poor, slum dwellers and migrant population (especially women), this project sets its objectives as the following:

- To study the profile of RH services to the slum, migrant and urban poor population, especially women. 
- To study the views of the city leaders about the provision and condition of RH services in the city. 
- To explore in the future policy prospects of RH services in the city. 

VI. Data Source and Methodology

Both primary and secondary data forms the base of this study. Secondary data has been collected from various published sources like India Stat, NFHS - I, II, III, NRHM, NUHM and from the Municipal Corporation of Chennai. For the primary data, several city leaders, who are the links between the government and the laypeople, were interviewed and asked various questions relating to the provision of RH services in the city, problems in the provision of the same and their causes, and policies of the government taking care of these problems. For analysis, the data table was interpreted using percentages and graphic methods, and the responses of the key informants were summarized to have a better view of the RH services and conditions in the city. 

VII. Status of Health/Reproductive Health in Chennai

(a) Chennai: The Health Capital of India 

Chennai is India’s fourth largest city, with a total population of 5,031,183 and a slum population of 1,845,142 (2009). It has established itself as the health capital of the country. Estimates suggest that around five lakhs (hundred thousand) people from the rest of India, apart from 40,000 foreigners have visited the state for various medical treatments in 2008. 

(b) RH Conditions and Services in Chennai 

Table 3 reveals that the Infant Mortality Rate (IMR) for the city shrank from 15% in 2000 to 10.54% in 2005 but made a slight slog to 11.68% in the year 2009, which may be due to better reporting, but this rate is still far less than the IMR in Tamil Nadu (31% in 2009). The Maternal Mortality Rate (MMR) also decreased from 0.5% in 2000 to 0.3% in 2009. The contraceptive prevalence rate has also been showing an escalating trend from 67% in 2000 to 71.7% in 2009, and among the temporary methods of contraception, IUD was the most popular with credibility of 69% in 2000 and 66% in 2009, followed by the use of condoms. Among the permanent methods, female sterilization increased from 366,623 in 2000 to 469,443 in 2009, and male vasectomies decreased from 1,466 in 2000 to 750 in 2009. In the private sector, among permanent family planning methods, Tubectomy is the most popular followed by laparoscopy, whereas there is no data for male vasectomies, and among temporary methods of contraception, only IUD have significant data till 2007, but in 2009 some cases of oral pill cycles and contraceptive pieces were reported (Table 4). 

The number of abortions has decreased due to increases in the CPR, and the number of births has reduced due to low birth rates. The number of home deliveries in Chennai has also reduced from 1,405 in 2000 to 128 in 2010, because the figures for institutional deliveries are mounting (Table 5). The number of public hospitals providing RH services in Chennai has decreased from 51 in 2000 to 21 in 2010, because of mergers in wards. The number of beds for RH services has increased from 1,210 in 2000 to 1,330 in 2010. The number of private hospitals (363 in 2000 to 394 in 2009) and private clinics has also increased over the years (Table 6). 

Table 7 illustrates that compared to other districts in Tamil Nadu, Chennai has the minimum population per bed (393) and per doctor (2,309) including both public and private sector hospitals and doctors in the year 2008-09. Table 8 gives state-wise number of allopathic hospitals and beds by government, local and private ownership, showing that the government sector (282 hospitals, 37,935 beds) is higher than the private (119 hospitals, 10,366 beds). As stated in the data table though, this may be due to under reporting of private sector hospitals. Also, the number of doctors and nurses in public RH services has increased from 126 and 67 respectively in 2000 to 155 and 86 in 2009. The number of additional personnel providing RH services has also shown an increase from 562 (2000) to 588 (2010).Other staff working under family welfare have also increased from 581 in 2000 to 655 in 2009 (Table 9). 

From Table 10 it is obvious that the number of persons utilising public family planning services has been showing a downward trend (from 146,237 in 2000 to 97,344 in 2010). The number of pregnant women who have got prenatal care is 86,002 in the year 2010, of which only 80,515 (2010) got delivery services due to the migration of the other pregnant mothers to other regions, and 100% deliveries were given post natal care. In Chennai most of the children are getting all six vaccinations which show a decline trend due to a decline in the number of births. 

In Chennai, 205,431 (2010) people have been given HIV counseling, out of which 204,927 (2010) cases were tested and 2,227 (2010) were found positive. In terms of HIV counselling, testing and positive cases, all show an increasing trend, similar to the case of STI cases where, sexually transmitted cases were 35,987 (2010) out of which 32,878 (2010) cases were managed properly. The total number of pelvic examinations and cancer screenings done was 99,461 in 2010, as it started in the year of 2009 only (Table 11). Tamil Nadu is doing a great job in testing for HIV and controlling AIDS cases in all districts. The State’s work on handling HIV/AIDS cases is an example for the whole nation (Table 12). 

(c) RH Conditions in Chennai City: A Comparison between Slum and Non-Slum Areas 

All the RH rates (BR, DR, and IMR) are higher for the slum population (except MMR) than the total city’s rates (Table 13), signifying the need for enhanced health services, and the city is doing a good job to overcome these issues. Almost all mothers in slums (99%) and non-slums (100%) had at least three antenatal care visits for their most recent birth, but the consumption of Iron and Folic Acid (IFA) for at least 90 days was lower for women in slums (49%) than for women in non-slums (58%). Slum children are much more likely than non-slum children to have received all of the suggested vaccinations against childhood diseases (89% vs. 74%). The largest differentials for individual vaccinations are for the third dose of DPT vaccine (100% in slums and 91% in non-slums) and the third dose of polio vaccine (94% in slums and 87% in non-slums). The contraceptive prevalence rate is slightly higher in slums (72%) than non-slums (68%) and children in slums are more likely than broods in non-slums to be anaemic (72% vs. 60%). The fertility rate is also relatively low (1.6) compared to other cities. In Chennai, almost 78% poor women are using a modern method of family planning, and more than 80% of current contraceptive users are using sterilization. Figure 1 shows that the Infant Mortality Rate (IMR) was 28 per 1,000 live births in 2005, but according to the Municipal Corporation of Chennai figures, it was just 11.68 in 2009, and the mortality rate in children under five years of age was 35 in 2005. 

Infant and Under-Five Mortality in Selected CitiesFigure 2 shows that institutional deliveries were much higher than any other city in India and nearly universal in Chennai for slum, non-slum and poor (98%, slum and 100% for non-slum and poor). 

Live Births with Professional Assistance in Poor Areas

Figure 3 shows that with the exception of Chennai, a majority of even poor households usually seek treatment from the private medical sector. In Chennai, almost 63% of poor households seek treatment from the public medical sector. In most cities, public sector medical facilities are more likely to be utilized by poor households than slum households or other households. 

Percentage of Households Using Public Health Facilities in Poor Areas

VIII. City Budget for RH Services

The major donors of funds for health services in Chennai are city government (75%) and central government (25%). The city administrators trust that funds are quite sufficient to take care of the city’s health problems; in contrast the health administrators still sense some lacunae. 

Chennai Budget for RH Services (2000)

The total city budget for Chennai was 38,312 (Rs. in lakhs) in 2000, of which only 2,587.16 (Rs. in lakhs) was allocated for RH services, which is just 3.96% of the total budget. 

Chennai Budget for RH Services (2005)

The total city budget augmented to 58,425 (Rs. in lakhs) in 2005, of which only 1,824.88 (Rs. in lakhs) (3.12%) was allocated for RH services. 

The budget shows a rapid increase to 94,169 (Rs. in lakhs) in 2009 out of which 2,587 (Rs. in lakhs) was allocated to RH services, which was around just 2.75%. The expenditure on RH services in terms of absolute figures has increased over the years, but declined in terms of percentages.

IX. Views of the City Leaders and NGOs: Chennai

This section analyses the views of the city leaders and NGOs. The city leaders are divided into two groups: (a) City Administrators (responsible for overall development of the city) and (b) Health Administrators (responsible for the city’s health conditions). 

(a) RH Issues: Chennai 

Though anaemia in antenatal mothers is the major RH concern quoted by all the officials for the most important RH issues and conditions in Chennai, the views of the officials were blemished. Diabetes in antenatal mothers and pregnancy induced hypertension is also a significant hitch for RH. Separate programmes funded by the National Rural Health Mission (NRHM) for the above problems are there under which primary health care is given to all rural women free of charge. Some health officials also revealed that cervical cancer and higher order birth is also a problem in the city and to deal with it mass cancer screening is done by the city corporation for all the women above 35 years of age in the field as well as health posts. Five sanitary napkins are issued every month to take care of menstrual hygiene and thus control cervical cancer for all corporation school girls who attain puberty. Higher order birth in the city has also come down from a family size of five to four. Infertility is also considered a decisive trouble in the city, chiefly of the migrant population who come for infertility treatment in the city. The discussions also exposed that all parts of Tamil Nadu lack management of any emergency arising due to pregnancy (Dr. Vinay). City administrators considered Sexually Transmitted Diseases (STDs) also as a problem in the city, but only to a moderate level. However, some health administrators gave mammoth weight to safe motherhood and primary health care. They also emphasized that the local body should weigh up on preventive health care and all pregnant mothers should be given prenatal care rather than concentrating on just increasing the number of institutional deliveries. It was also stressed by the health administrators that the RCH programme should benefit at least 75% of pregnant mothers at the field level. Different from views of all others, Mrs. Saulina Arnold mentioned the prevalence of bribing for RH services at lower levels in the government hospitals, which is a brutal setback for the health services that undeniably needs attention for a healthier performance of the health sector. 

(b) Provision of RH services : Priority and Condition in the City 

Both city and health administrators notified that the city gives the highest priority to the RH services, excluding some health officials who critiqued that the priority to RH services is low, but it is basically solved by the routine procedures. Government hospitals are following hygienic methods on a par with private hospitals; hence for every normal delivery the doctors are given disposable kits worth Rs. 108, and for caesarean delivery worth Rs. 240. A gift pack containing towel, shirt etc. worth Rs. 180 is granted for every new born baby. The city administrators revealed that the RH condition is excellent but the health administrators revealed that it could be enhanced in future. 

(c) Resources for RH Services: Availability and Future Requirements

Discrepancy in the responses for the availability of resources for RH services in the city had little scope, as most of the officials deem that it is fully adequate in terms of personnel (numbers of doctors, nurses, health workers etc.), availability of space, funds and equipment etc., whereas some health administrators do feel that it is somewhat deficient and needs more improvement. Both groups of administrators felt that a major delimiting factor in the provision of RH services in the city is a lack of awareness among poor / slum people. People are not aware of the services available to them due to lack of education. Therefore for the better provision of health services, people have to be given education first, and awareness levels have to be increased with the help of field workers, which seems to be a lacunae (health administrators). Future requirements to increase RH services at the primary level are none but in order to cater to the secondary and tertiary needs, the city requires more funds and personnel (city administrators). However, some health administrators emphasized the need for infrastructure, equipment and vehicles in addition to funds and manpower for betterment of RH services. 

(d) Slums in Chennai: Availability of RH and Family Planning Services to Slum Dwellers. 

Chennai has one of the largest slum populations after greater Mumbai (54%) and Kolkata (32.48%). According to the enumerations of the Municipal Corporation of Chennai, there are presently 1,430 slums which cover nearly 16% of the area and nearly 36.7% of city’s population at present (1,845,142 out of the total city’s population of 5,031,183). The slum population in the year 2005 was 1,863,474 (38.4% of the total population), which shows that there is a dwindle in the slum population over the past 5 years which is a result of many poverty alleviation programmes (Mrs. Jothi Nirmala). However, the census 2001 data shows that the slum population was only 18.8% (820,000) of the total population of the city (4,344,000). The city aims at reducing the slum population to 14% by the year 2020, and to 10% by 2025. All the RH / Family Planning (FP) services introduced are basically for the slum / poor people, especially women. One hundred percent of RH services are available for slum / poor people, but due to lack of knowledge and education, not all people utilize these facilities. The health administrators also considered the non-corporation of the slum population as a drawback, and stated that the slum dwellers are more demanding. 

(e) Special Programme to Increase RH Services for Slums 

All the programmes and services provided by the government and City Corporation are essentially for slum people only. 

a. Major government benefit schemes for the slum/ poor are listed as follows:

i. Muthulakshmi Reddy Maternal Benefit Scheme: Rs. 6,000/- in two instalments of Rs. 3,000 is given to pregnant mothers for the first two pregnancies by the state government. 
ii. Moovaloor Ramamirtham Marriage Benefit Scheme: Rs. 25,000/- is given for the marriage of girls above 18 years old by the local government. 
iii. Janani Suraksha Yogna: Rs. 6,000/- is given to mothers who deliver in institutions. 
iv. National Maternity Scheme: This Scheme was implemented in 2001 by the Government of India; Rs.500/- is given to all pregnant women below the poverty line for the first two pregnancies, to enable them to avail nutritious food and medicine. This amount is given in one instalment 12-8 weeks prior to the delivery. 
v. Exgratia amount for sterilization failure and sterilization death: Rs.20,000/- from 29.11.05 is given in the case of failure of a sterilization operation. Rs. 25,000/- is given to the legal heirs of the deceased who dies due to a sterilization operation within 30 days. Rs.100,000/- is given from the insurance company to the legal heirs of the deceased if the death takes place within the hospital. 

b. Other facilities / services for the slum population by state and local government

i. The Health Department is conducting a slum health programme regularly once a week to cover each slum. 
ii. A Health team headed by a medical officer and paramedical staff visits the slums and examines the slum dwellers for minor ailments.
iii. IEC activities are also undertaken to create awareness among the slum dwellers about prevention of communicable diseases and environmental sanitation. 
vi. Ultrasonagram examinations for those registered at Corporation Centres are done for free. It is to be noted that more than Rs.400/- is charged for the same test at Private Nursing Homes. Seventeen Centres are provided with ultrasonagram facilities. About 34,000 mothers are benefited every year. 
vii. All antenatal women who are registered get a minimum of 5 checkups before delivery either in field or health posts. viii. Free cancer screening for all women above 35 years of age.
ix. Every new born baby in the government hospitals gets a gift pack worth Rs. 180/- and a bed with protective net worth Rs. 325/-. 
x. Free four-meal diet (including breakfast, lunch, snacks and dinner) for all new mothers, costing Rs. 96/- per day, is given for 3 days for normal deliveries and 5 days for caesarean, of which the second day is a special diet for surgical cases. 
xi. Post natal services are provided to all new mothers.
xii. A follow-up is done by SMS to inform about the vaccination of the mother and child. 
xiii. 108 Ambulance service: A toll free number for a 24-hour emergency service for all causalities, including pregnant mothers if the patient requires. 
xiv. 1913: Phone number for any emergency. 
xv. 105 health posts are there to take care of all primary health care as well any emergencies, which are also taken care of. 
xvi. National Rural Health Mission (NRHM) and National Urban Health Mission (NUHM) provide funding for the RH services for the rural and urban areas.

Due to the above services provided, institutional deliveries in Chennai have reached the mark of 100%. 

(f) RH Services for In-floating Population in Chennai. 

Chennai is a health capital city of India and lot of new population floats in due to its excellent health services, which the present figures show is nearly 10 lakhs (1,000,000 people). There are no projections available for the migrant population of the city. The city administrators believe that the present facilities available in the city are sufficient to provide primary health care but for secondary and tertiary health care more resources are required. However, the health administrators consider that special attention needs to be given for this extra populace. All the services available for the city population are also available for the migrant population, but there are no special programmes for the migrant population alone. There are corporate hospitals for the elite migrants and government hospitals for the poor migrants, like construction workers, etc. Cancer screening and immunization, etc. are also done near bus stands and railway stations, also considering the migrants. All health workers take care of the migrant population too. However, the migrant population are not availing the services much, due to a lack of information about the services and the language problem, etc. The new in floating population as such now does not represent any problem to the city, as it has sufficient resources to cater for all. Migrant population health care needs to be developed, like multi lingual support that can be given to the migrants, as they have language problems in their new city. 

X. Summary and Conclusion

It is obvious from the figures and discussions that Tamil Nadu has had a long track record of innovations in the health sector and many different players have been involved, including non-governmental organisations, led by socially committed physicians such as Voluntary Health Services (VHS), bilateral donors such as DANIDA and USAID, and the World Bank. But it would be fair to say that it is the state's health administration that shaped many of these reforms and innovations and ensured their successful implementation. 

From the discussions and data available regarding RH services and conditions in the city in previous sections, we can perceive that according to the city administrators, the present situation of RH services in the city is excellent. Compared to other cities and states of India it is venerable, but according to the health administrators who witness these issues more closely there are some lacunae which need to be taken heed of. The city has attained 100% institutional deliveries; CPR is also quite high (71%) and is still mounting, while it is just 37% for India. The MMR (0.3), CBD (16), CDR (4), IMR (11.68) and TFR (1.6) are reasonably lower than other cities and are also abating. 

The city has the best government hospital in India and many other good public and private hospitals which attract tourists for health care. In terms of RH facilities, the city is taking a lot of initiatives to extend the services to all urban poor, especially women. The city is doing an epic job in the screening of cervical cancer among poor women above 35 years of age, and controlling it too. In terms of HIV and STI control also, the city is doing quite well, as all cases of deliveries are tested for HIV in public as well as private hospitals. All the health services are provided free of charge to the slum/ poor population, and the government also provides a lot of benefit schemes for them if they avail services in public hospitals. Still, however, due to a lack of information and education, the services are not availed by the most vulnerable groups, consequently demanding a boost in the education level principally among poor women. The discussions also revealed that out of the major issues of provision of RH services, with anaemia in pregnant mothers and cervical cancer, corruption is also an impediment which fetters the poor people from availing services in public hospitals. Subsequently, this unquestionably needs to be taken heed of by the government for the enhancement of the services to poor.

As far as the problem of RH services to the migrant population is concerned, they are free to avail all the services available to the slum / poor people. As of now there are no special programmes for them, but definitely there is a need to develop a few. Furthermore, initiatives are taken to increase and improve the RH facilities. Earlier only two 24 hour Emergency Obstetric Centres (EOCs) were there, but now 10 more are going to start. From the discussions above, we can presume that though the RH services and facilities are adequate now, there is a need for many improvements, so that it can cater to the new future projected population, i.e. RH services should be improvised according to the growing population. To wind up we can say that however the state government is taking tremendous pains to improve the health/RH services, still the private sector takes the cartel in the provision of health services for various reasons. However, the situation in Chennai is still much better. In the end we should also mention the momentous role of NGOs in the provision of health services, but over the past 10 years, the government has taken comprehensive control over the provision of health services. This has limited the role of NGOs in health care, which can be a hitch in the provision of better health services, as NGOs work at the grass root level which is difficult for local and state bodies. Hence, a holistic approach is indispensable for consummate results. 

XI. Limitations of the Study

The major limitation of the study was the lack of data regarding reproductive health services especially for the private sector. Time constraint was also a restraint for the study. Another limitation is that the study focuses on Chennai City only, and hence generalisation for the rest of the country may not be suggested. 

XII. Annexure

Comparative Vital Rates for Chennai, Tamil Nadu and IndiaChennai Family planning and RH ServicesChennai Family Planning adn RH Services (Continued)Chennai RH Conditions, Family Planning Methods and Types of DeliveryChennai Facilities Providing RH Services / Population, Beds and Doctors RatioState-wise numbers of Allopathic Hospitals and Beds in IndiaChennai Staff Providing Services / Number of Persons Utilizing Public FP ServicesChennai Case Management of HIV and STIAIDS Cases / Anti Retroviral Treatment in Tamil NaduChennai Area Wise Vital RH Rates / List of Key Informants

XIII. References

- Bhat, P.N. Mari (1996). Contours of fertility decline in India: A district level study based on the 1991. 

- Bontha V. Babu, Basanta K. Swain, Suchismita Mishra, Shantanu K. Kar “Primary Healthcare Services Among a Migrant Indigenous Population Living in an Eastern Indian City”, Journal of Immigrant Minority Health 2010, Vol.12, pp. 53–59 

- India's Health System: The Financing And Delivery Of Health Care Services, Report Of The National Commission On Macroeconomics And Health, 2004. 

- National Rural Health Mission “Meeting People’s Health Needs in Partnership with States – Journey so far – 2005 – 2010”, Ministry of Health and Family Welfare, Government of India. 

- P.K. Mony, L. Verghese, S. Bhattacharji, A. George, P. Thoppuram & M. Mathai “Demography, Environmental Status And Maternal Health Care In Slums Of Vellore town, Southern India” Indian Journal of Community Medicine Vol. 31, No. 4, October-December, 2006. 

- Reproductive and Sexual: Health of Young People in India, NFHS – I, II, III, WHO.

- Srinivasan, K. (1998). Population policies and programmes since independence: A saga of great expectations and poor performance. Demography India, vol. 27, No. 1. 

- The World Bank “The World Bank’s Reproductive Health Action Plan - 2010 – 2015”, April 2010. 

- Urban Health Resource Centre: Annual Report, 2006-07, USAID. 

- Vydyanathan Lakshmanan “A Statistical Insight into Health & Education in Chennai Slums” CCS Working Paper No. 177, Research Internship Program 2006-07, Centre for Civil Society. 

- World Development Indicators; www.worldbank.org. 

- www.indiastat.com

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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