World Resources 1996-97
(A joint publication by The World Resource Institute, The United
 Nations Environment Programme, The United Nations Development
 Programme, and the World Bank)
(Data edited by Dr. Róbinson Rojas)

2. Urban Environment and Human Health

Box 2.2 ASHA Works To Improve Health in Delhi

Many health problems of the urban poor arise from the poverty and the degraded environment in which they live. However, conventional health delivery systems in most cities provide curative services to people, whereas environmental improvements or social services are the responsibility of different government departments. Because these departments tend to work in isolation, they seldom make a coordinated effort to improve the quality of life of the poor. Even existing health care systems are often beyond the reach of the poor because of cost, inconvenient locations, and overcrowded conditions (1).

In Delhi, India, a local nongovernmental organization, Action for Security Health for All (ASHA), has spent the past 6 years trying to improve the health of poor residents through community-based programs that address both poverty and the environment. The challenge is daunting: more than 1 million of Delhi's residents live in jhuggie shelters, temporary structures made of mud, thatch, plastic, and other discarded objects. Jhuggies are small and devoid of ventilation or natural light; many are susceptible to fire, dust, smoke, and noise pollution. The streets of jhuggie settlements are heaped with garbage, attracting dogs, pigs, flies, and mosquitos. One study found that although latrines were available in 46 percent of the settlements, most were poorly maintained, and nearly 41 percent of the residents still defecated in the open. Jhuggies are often located near garbage dumps, power plants and factories, and roads, exposing residents to risks from chemical residues, toxic wastes, and car exhaust fumes.

Not surprisingly, jhuggie residents--particularly women and children--are especially prone to respira- tory and waterborne diseases. The infant mortality rate in jhuggie settlements is 100 per 1,000 live births, compared with 40 per 1,000 live births for the city as a whole. Roughly 40 percent of children under age 2 have not received all immunizations; 40 percent of women and children suffer severe malnutrition; just 17 percent of pregnant women receive at least three prenatal checkups; and 80 percent of all deliveries are conducted by untrained midwives.

ASHA began in 1988 as an emergency health clinic in a slum in south Delhi to deal with a serious cholera epidemic. During this period, the clinic staff observed that although treatments were effective in curing patients, the incidence of disease remained unaffected. Indeed, there were repeated recurrences of preventable illnesses. Realizing that the community's health problems were intricately linked to poverty, pollution, and environmental degradation, ASHA began to focus on a broader approach to dealing with health, directing its efforts toward improving the environment, empowering women, increasing the literacy rate, and educating residents about the links between environment and health.

ASHA began by forging a partnership with the public agency responsible for delivering services to squatter settlements. Acting as mediator between the public agency and community members, ASHA managed to get the government to implement site and service improvement projects. ASHA also helped community members form cooperatives. T he cooperative objectives were to improve local environmental conditions by acquiring land rights and establishing long-term leases, providing home improvement loans, maintaining and repairing common spaces, and extending coverage of basic services such as water and sanitation facilities and roads.

These initial efforts were marred by difficulties. The site and service upgrading schemes had mixed results as news of slum improvement attracted additional settlers and increased land market values, displacing the original residents. Local power struggles arose over access to the improved facilities, and the cooperatives ultimately dissolved after ASHA decided to withdraw from the daily tasks of running them.

Through this experience, however, ASHA learned that women play a far greater role than men in managing households and the community. Women's health is a decisive factor in the well-being of their families; thus, they have a much larger stake in improving the living conditions in the community. A clear disadvantage of the first cooperative structure was that it had excluded women from an active role in community decisionmaking.

In response, ASHA helped form Mahila Mandals within some of the Delhi jhuggies. Mahila Mandals are community-based women's groups that meet once a week to talk about community issues and that also serve as a forum for health education sessions, income- earning activities, and loans. ASHA acts as a facilitator, helping to inform the community about relevant government policies and serving as a communication link to the formal system.

Recognizing that women play a key role as health care providers, ASHA set up a training program for female community health workers called basti sevikas. Selected through a process of community consultation and aptitude testing, basti sevikas are trained to provide basic health care treatment for colds, fevers, coughs, and diarrhea, and for more serious diseases such as malaria, scabies, and worms. Each sevika is responsible for 200 families and charges a small fee for visits. Basti sevikas also provide health education about environment-related issues such as hand washing and boiling water, encourage pregnant women to go for prenatal care, and maintain health records for households in the settlements. In exchange, the basti sevikas also receive a monthly honorarium.

The use of basti sevikas has proved to be an effective way of improving health care delivery to the urban poor. By selecting women from the community, ASHA ensures that health care is available to the community at all times. Basti sevikas reduce the load on the formal health care system by taking care of illnesses not requiring the attention of a doctor or hospital. Although the basti sevikas charge a small fee for their services, they are much more affordable than formal medical care for the urban poor.

Even now, ASHA's work is not obstacle free. Factors such as heavy workloads, resistance from husbands and families, and personal inhibitions prevent women from participating in Mahila Mandals. Residents resist paying fees to basti sevikas because they are not formally trained. Still, by approaching health care at the community level and encouraging residents to take charge of their environments, ASHA has helped to improve the health of many jhuggie residents. Between 1988 and 1993, ASHA increased its reach from 1 slum and 4,000 people to 21 slums and about 115,000 people. Empirical data are lacking, but a community survey shows that through ASHA's programs, child morbidity and malnutrition have decreased, residents are more likely to seek treatment for minor ailments, and overall environmental conditions in the slums have improved.

References and Notes

1. This box was taken from Pratibha Mehta, "Action for Securing Health for All," Mega- Cities Urban Environmental Poverty Case Study Series (Mega-Cities Project and National Institute for Urban Affairs, New York and New Delhi, India, 1994), pp. 1-40.

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