Designing Healthier Urban Environments for a Healthier Urban World August 2012 – June 2013 Sandra Plaza, DI Fellow
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SNEHA’S MISSION •
To work in partnership with communities and health systems building effective and replicable solutions, empowering women and their families in urban slums to improve their health
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To work at the community level to empower women and slum communities to be catalysts of change in their own right
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To target four large public health areas - Maternal and Newborn Health, Child Health and Nutrition, Sexual and Reproductive Health and Prevention of Violence against Women and Children
SNEHA Program Overview
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Prevention of Violence Against Women • Offer counseling services for survivors of rape, sexual assault and child sexual abuse, women with disabilities, sex workers, and women suffering from mental illnesses •Train staff of police and hospitals on how to properly address violence
Sexual and Reproductive Health • Empower adolescents 11-19 yrs. to make informed decisions about their health • Offer education sessions on a skill or vocation that can make them economically self-reliant • Offer family planning through doorstep awareness, delivery of contraceptives and referral services
SNEHA Program Overview
Child Health and Nutrition • Provide Day Care Centres for Malnourished Children 0 – 3 years • Administer Medical Nutrition Therapy (MNT) • Offer Home Based Care and Nutrition Counseling
Maternal and Newborn Health • Ensure availability of antenatal clinics at health posts • Set up referral links for hospitals and maternity homes • Mentally prepare women in any case of emergency during deliver of their baby through birth preparedness counseling
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Location: Mumbai India occupies 17.5 percent of the world's population
Mumbai Population: 20.5 million (Total Metropolitan Area) Financial capital The wealthiest city in India Over 50% of the population lives in a slum
Mumbai Overview
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URBANIZATION Urbanization is taking place at a faster rate in India. 40.76% of country's population is expected to reside in urban areas.
Mumbai Overview
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URBAN POPULATION Current population of Mumbai is estimated to be around 20.5 million
Mumbai Overview
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SLUM POPULATION More than half of Mumbai’s population lives in a slum with little or no access to public infrastructure, resources for clean water and toilet facilities.
Mumbai Overview
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Project Summary •
Our initial proposal was to look at developing a sustainable business model in which new services would offset the costs to deliver existing SNEHA service
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We soon realized the costs to deliver SNEHA services was high so we altered our focus to improve the delivery and quality of existing services
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We began by familiarizing ourselves with the work of SNEHA
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We conducted interviews with SNEHA staff and Program Directors to understand the different processes and strategies used
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We visited various project site locations to review SNEHA’s programs
SNEHA Program Overview
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Conducted General Field Observations Participated in public health awareness campaigns and rallies throughout Mumbai’s urban slum communities.
Conducted Community Site Visits
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Identified People To Speak With Spoke with employees of SNEHA responsible for delivering health services to beneficiaries.
Met with Program Officers, Community Organizers and Program Directors
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Hosted Workshops With Facilitators Of Adolescent Programs Met with community organizers to understand dreams and aspirations of the youth.
Conducted Facilitator’s Workshop
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Visited Vikhroli Parksite – A Suburb of Mumbai A potential project site located on a hill slope where most residents migrate from villages to work in small scale industries, driving rickshaws, etc.
SNEHA Project Overview
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Documented Community Concerns Area has limited water access and open drainage systems which negatively impact residents’ health. Conflicts occur due to alcohol and drug abuse. There is a high rate of unemployment.
SNEHA Project Overview
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NEXT STEPS •
Selected M East ward, one of Mumbai’s poorest wards, to conduct our work and research
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Reviewed costs to deliver SNEHA services and worked with an existing SNEHA Centre community trial project, in which more than 20 community centers have been inaugurated to deliver SNEHA’s services
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Worked closely with staff responsible for administering best feeding practices for infants and young children, maternity care, family planning, immunizations, child development and adolescent health
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Selected to work in the community of Sanjay Nagar
SNEHA Project Overview
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Percentage Breakup of SNEHA Centre
Case Study: SNEHA Centre SNEHA Model Centre Overview
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Sanjay Nagar
Project Site Selection: Sanjay Nagar Catchment Area Per Centre • 600-650 Households • 400-450 Families • 2250 Est. Population M East Ward • Lowest literacy rate (66%) • Highest infant mortality rate (66.4%)
Case Study: Centre SNEHA locations Centre locations SNEHA Project Site Selection
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Visited Various Centre Locations Throughout M East Ward We selected a centre based on location, size, periphery to a main street, and per staff rapport with the community.
SNEHA Centre Overview
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Centre 1 located on main street, highly visible
SNEHA Centre Overview: Shastri Nagar
View of inside lane
Visible street life
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Center 2 located in inside lane of community
Entrance from main road to the centre
SNEHA Centre Overview: Guatam Nagar
View of inside lane
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Centre 3 located on a main street and highly visible
Entrance to nearby health post
SNEHA Centre Overview: Raman Mama Nagar
Housing conditions in community
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Benefits of working at Sanjay Nagar Strong team support, good rapport with the community, residents asking for support for services, centre located on main street, highly visible
SNEHA Centre Overview: Sanjay Nagar
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Centre located on main street, highly visible
SNEHA Centre Overview: Sanjay Nagar
View of centre space
View of community inside lane
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NEXT STEPS • Closely examined the role of the community organizer and shadowed SNEHA’s staff • Developed frameworks and process maps to better understand the strategies and challenges in administering SNEHA’s community-based health interventions • Established interview protocols, conducted individual and group interviews, and organized and designed community workshops • Looked to determine which strategies resulted in positive health behavior
SNEHA Project Overview
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SRH
CHN SNEHA CENTRE MODEL CO
MNH
PVWC
SNEHA Centre Model: Staff responsible for administering all four programs verticals
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Shadowed The Work Of Community Organizers Conducted individual home visits to understand the strategies used in delivering home based interventions.
SNEHA Centre Overview
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Children enjoyed the Behavior Change Communication images
SNEHA Centre Overview
Visited the homes of pregnant mothers
25 year old mother with 4 children
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Conducted Workshops With Community Members Goal was to understand community values that impact the health of women and children
SNEHA Program Overview
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Desire to own her own home
SNEHA Program Overview
Education is a must
Honest doctors
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Hosted Value Exercises With Adolescents Important to identify dreams and aspirations of community youth members
SNEHA Program Overview
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Reduce child labour
SNEHA Program Overview
Education helps build a career
Doctors are important, villages have less doctors
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Conducted Beneficiary Interviews Discussed their vision for community centres
Community Workshop Overview
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Community Workshop Overview
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NEXT STEPS • Collected research and information •
Visualized entire process in one map, led to new conclusions and hypotheses about how to improve system’s design
• Identified “clusters and gaps” as places for potential ideation • Made suggestions to be more effective in the delivery of existing services and programs, increase coverage of beneficiaries • Facilitated the design and pilot of community based interventions
SNEHA Project Overview
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Conducted Internal Brainstorming Sessions Synthesizing collected data to better understand findings
SNEHA Program Overview
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PROCESS FLOW
Resist
Accept
Trust
Approach to home visits
Extracted Key Insights From Interviews With SNEHA Staff This allowed us to identify gaps and understand the process of delivering health services
SNEHA Program Overview
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Time Unhealthy Eating Habits
Migration
Distance
Religion
Identified Barriers And HealthChallenges Created buckets and themes Information Not Clear
SNEHA Program Overview
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Role of the CO
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Process Flow
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Barriers & Challenges
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Success & Success Drivers
Visualized Health Service Delivery Process Completed a cognitive walkthrough exercise with program staff
SNEHA Program Overview
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Observation: Mothers kept referencing the importance of their child’s health and well being. When the SNEHA centre was discussed they referred back to the DCC. Quote: “The most important thing in our life is our children. If they stay healthy we stay healthy, if they get ill or sick we also get ill or sick.”
Insight: Centering SNEHA Centre activities for children and adolescents will build trust and knowledge sharing amongst mothers, increasing presence of SNEHA services and information in the community.
SNEHA Program Interviews Beneficiary Responses
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Observation: During the interviews women discussed the issue of the ration card and how SNEHA had mobilized a group of women to go to the ration office, but there was never any follow through from SNEHA Centre. Quote: “If one person from SNEHA can take 20 people with them and take them to the office for the work, success will take place.” Insight: Women are willing to mobilize themselves as a part of a ‘community action group’ which can allow other community members to come together to address other important issues if micro planning exercises are followed through.
SNEHA Program Interviews Beneficiary Responses
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Observation: Women would like to see income generating activities from the centre and had mentioned taking courses in stitching or embroidery. Quote: “Any type of work from which we can earn money. We finish our work in the morning at 10 a.m., after that for the whole day we do not have any work to do, so we let time pass throughout the whole day.” Insight: Women are looking for employment opportunities to help sustain their future.
SNEHA Program Interviews Beneficiary Responses
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New Conclusions To Improve Delivery Of SNEHA Services • Activate centre spaces to attract beneficiaries • Look at different models of teaching to deliver SNEHA services by focusing on a ‘learning by doing’ approach and actively engaging participants • Provide additional training material for staff so they are updated on best practices for delivering health information and services
• Address social needs and delivery of programs or activities desired by the community • Make data transparent to beneficiaries, staff and community
SNEHA Program Overview
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Piloted A Cooking Demonstration Demonstrated to mothers and young girls how to prepare healthy and nutritious meals
Intervention #1
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Staff Demonstrated Cooking Recipes To Beneficiaries Prepared biryani, a traditional rice based dish made with spices and vegetables and/or meat
Intervention #1
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Women And Children Participated In SNEHA Program More than 25 women and adolescent girls attended the cooking demonstration
Intervention #1
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Adolescent girls enjoyed the class very much
Intervention Cooking Demonstration #1 Beneficiary Responses
Tastings were passed around to everyone who attended
Mothers and children from the community participated in the cooking demonstration
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Piloted Puppetry Workshops With SNEHA Staff Workshop conducted with the Family Planning Association of India
Intervention #2
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Women Used Recycled Materials To Make Puppets Puppets are made using recycled paper, plastic bottles and coconut shells
Intervention #2
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Taught Staff How To Effectively Communicate Health Messages Beneficiaries can participate in creating their own street plays on health and nutrition
Intervention #2
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Intervention #2
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Summary •
Beneficiaries found the services to be helpful, good for the health of their child and themselves. Beneficiaries very much enjoy having a centre in their community where they can receive free medicine, immunizations and doctor check ups which saves them both in time and in money. They felt the centres should be open for everyone and not limited to a specific boundary. Some mothers use the information they receive from the centres and incorporate practices into their own lives but others feel the information they receive is not useful, feel their time is wasted, and do not want to accept the services. A couple of the beneficiaries stated that they knew very little of the centres. In two of the interviews they discussed the formation of a ‘community action group’ however there was no follow up or action taken place. The beneficiaries placed a strong emphasis on providing activities, programs or services for their children stating that, “the most important thing in our life is our children. If they stay healthy we stay healthy, if they get ill or sick we also got ill or sick.”
SNEHA Project Overview
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Summary • Beneficiaries provided recommendations on how to improve the success of the SNEHA centre and in two of the interviews they sought to use the centre as a place where they can earn a source of income by doing small jobs. One beneficiary stated “SNEHA can do small things to help the community. Success and growth will take place and people will start joining SNEHA. We and everyone will think, yes, all the work is happening here. Now if 25% of people are coming, then 50% of people can join in SNEHA.” Many of the women do have free time and suggested that they “can give half day for the family and half day for the work”. • SNEHA will continue to monitor and carry out interventions that will improve the delivery and quality of health based interventions • A list of additional recommendations have been provided per the request of the Program and Executive Director as interventions they may choose to carry forward in the future
SNEHA Project Overview
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Thank You Contact: Sandra Plaza sandra.plaza@d-impact.org www.d-impact.org
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