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


Annex I. Research Instrument: 
AUICK Research Project Outline


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

A Research Proposal: Examining Urban Administrative Capacity and Leadership

Historical Background

Appendix: Data Collection Protocols

I. 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. 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 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 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. And 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 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, Sexually Transmitted Diseases (STDs) and fertility control. Finally there are vast new urban slums, where Reproductive Health (RH) services often fail to reach the population. These migrants and slum dwellers represent a new highly vulnerable population. Too often, the most vulnerable of the 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. 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.

II. A Research Proposal: Examining Urban Administrative Capacity and Leadership

A. Proposal Summary 

In 2009, Nihon University Population Research Institute (NUPRI) supported a study of administrative perspectives and capacities to address the emerging aging problem that Asia now faces. (Ando and Ness 2009) That research utilized AUICK’s Associate Cities to determine how administrators viewed the current aging problem and what capacities the cities had to deal with the issue. Here we propose to use the same AUICK Associate Cities to ask how urban administrators view the issue of RH Services especially to the new vulnerable populations. The project will also assess the administrative capacities at the city level to provide RH services, again, especially to the vulnerable groups. Academic experts should play a role in the collection and analysis of data in each of the AACs, and technical experts of AUICK’s International Advisory Committee (IAC) will compile and assure the overall quality of the Project. We believe the Study will help national policy makers and international agencies to shape more effective policies and programs to provide the RH services that are widely needed to increase the quality of life of all citizens. 

B. Procedures and Schedule 

AUICK will make use of its AAC liaison persons, local university experts who have started working with their respective city administrations and members of the International Advisory Committee to collect data on the nine cities. AUICK will provide a draft protocol for data collection, share this with the field workers, and finalize the instruments (shown in Appendix I). The final analysis and report preparation will be the responsibility of the AUICK secretariat, with advice of the IAC. 

1) Data collection will be conducted from July - September, 2010. 
2) The complete data with a first draft of the Analysis and Report is to be submitted to AUICK from each city by 30 September, 2010. 
3) A completed Analysis and Report is to be sent from each city to AUICK by 31 October, 2010. 

C. Data to be Collected 

Two sets of data will be collected. Narrative qualitative data will describe the perspective of urban administrators on the importance of RH services and the specific RH conditions considered most important. Their views of the size and condition of the new vulnerable populations will also be elicited. The administrators to be surveyed will include the top urban administrators: Mayor, Deputy Mayor and Members of Urban Councils. In addition, data will be collected on the views of senior health administrators and social welfare programs in the city, and from leaders of local Non-Governmental Organization (NGO) service providers in the areas of RH. In addition, objective data will be collected on the actual services delivered under the RH rubric; on the numbers and types of facilities (clinics, hospitals etc.), care givers (nurses, MDs, midwives etc.), and recipients of family planning services, birth deliveries, abortion and disease control and prevention services (including vaccinations), and on the size and condition of the new vulnerable populations. These two sets of data collection protocols are provided in the appendix to this proposal. 

III. Historical Background

Please describe the historical background of RH in your City, if possible going to the 1970s, when the main component was essentially Maternal and Child Care (MCH) service, in not more than two or three pages. 

Appendix: Data Collection Protocols

I. Views of Urban Administrators and Non-Governmental Organization (NGO) Service Providers

Informants 

1) Mayor and Deputy Mayor 
2) Meeting with Urban Council members (organized as possible by field worker) 
3) City Health Director and Deputy 
4) City NGOs (head of city office) 

These are question areas on which we wish administrators to comment in as much detail as possible. We would like first a selection of one of the response categories listed, then a narrative description. 

1. What are considered the most important RH issues and conditions? 
List respondents views to probe: 
a) HIV/AIDS 
b) Sexually Transmitted Diseases 
c) Family planning for health of mothers 
d) Family planning for/ against population growth 
e) Infertility 
f) Safe motherhood Discussion/analysis: 

2. Overall, how is the level of the city’s reproductive health condition? 
a) Excellent 
b) Very good but could be improved 
c) Needs more improvement 
d) Seriously low and needs much improvement.

Discussion/analysis: 

3. Overall what priority does the city give to RH services? 
a) The very highest 
b) High 
c) Moderate: the problem is not serious 
d) Low: the problem is basically solved and procedures are routine 
e) Low: the problem is still very serious but due to other competing demands
f) Low: due to lack of political support or commitment 

Discussion/analysis:

4. Overall how do you feel about the resources available for RH services? 
a) Fully adequate 
b) Quite good 
c) Somewhat deficient 
d) Woefully deficient 

Discussion/analysis: 

5. What are the specific needs of the city to improve its RH services? 
a) None: services are now quite adequate, including the service by private sector 
b) Less than adequate services, more is needed in: 
1) Funds 
2) Personnel 
3) Equipment 
4) Facilities such as examination rooms 
5) Political support 
6) Others (please describe): 

c) Far less than adequate, more is needed in: 
1) Funds 
2) Personnel 
3) Equipment
4) Facilities such as examination rooms 
5) Political support
6) Others (please describe): 

Discussion/analysis: 

6. What is the size of the cities slum or below poverty level ($2 per day) population?
In 2000 (in actual number or % of total population): 
2005: and 
2010: 
Any future projection: 2020 or 2025? 

7. To what extent are city RH/ Family Planning (FP) services available to the slum dwellers? Are any factors impeding this availability? How could it be increased? (Please provide a rough percentage estimate and then discuss conditions) 

8. Are there special programs to increase RH services to slum dwellers? Is so, please describe them, especially in terms of the following: 
a) staff size and categories designated (e.g. MDs, nurses, midwives etc.) 
b) special features 
c) size of budget 

9. What is the estimated size of the city’s new immigrant population (the new floating population)? 
In 2000: 
2005: and 
2010 and/or annual growth rate 
Any future projection: 2020 or 2025? 
Will reproductive health services be sufficient for these projected populations? 

10. To what extent are city RH services regularly available to the migrants? 
Does this represent a problem for the city? 
Are there any special health and social programs to deal with this new floating population? What kinds of program are necessary? 

11. What is the breakdown of the total budget for RH services in terms of the following: 
a) Percentage of costs covered by city government 
b) Percentage of costs covered by national government 
c) Percentage of costs covered by other sources (eg. donors etc.)? 

Discussion/analysis:

II. Objective RH services data (from head of city health services and/or Management Information Systems (MIS)) 

(If the city produces an annual report of health services, please include the latest year, with translations of row labels and column heads in the statistical tables.) 

What services are considered part of RH services? 

Please make a separate list of the services, and then complete the following forms as much as possible. 

Objective RH Services Data Table

Objective RH Services Data Table (Continued)

References 

- Ando, Hirofumi, and Gayl D. Ness, 2009, “Aging in Asian Cities: An Exploratory Analysis: Experience of the Asian Urban Information Center of Kobe and its Associate Cities AACs,” Nihon University Population Research Institute, Research Paper Series No. 75. 24 pp.

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

- -----, 1993, “Population Environment Dynamics: The Long View,” in Ness, Brechin and Drake, eds., Population Environment Dynamics: Ideas and Observations, (Ann Arbor. MI: University of Michigan Press)

- ----- and Michael Low, eds., 2000, Five Cities: Modelling 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

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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