Situational Analysis Report of Agra City

80 Pages·2007·0.65 MB·English

Draft Summary

Situational Analysis Report of Agra City
for
Guiding Urban Health Program

February 2005

Better Health in Underserved Urban Settlements
Draft Summary
Situational Analysis Report of Agra City
for
Guiding Urban Health Program

December 2004

Key USAID Contact: Dr Massee Bateman, Senior Child Health Advisor

USAID-EHP URBAN HEALTH PROGRAM

Supported by
United States Agency for International Development
through a contract with
Camp Dresser & McKee International Inc.
ii
Acknowledgements
We gratefully acknowledge contribution of many urban health stakeholders of Agra, for
their active help, support and insights without which it would not have been possible to
compile this short situation analysis report.

We wish to express our gratefulness to Shri Nitishwar Kumar, I.A.S, District Magistrate;
Dr. Roshan Lal, Chief Medical Officer for providing information on various subjects and
supporting the process of obtaining and analyzing information. Many thanks are due to Dr
Deoki Nandan, Principal S.N. Medical College for helping start the situation analysis
process through the first stakeholders meeting in Agra. Dr. Shamsher Singh, Deputy
Chief Medical Officer, Dr. Anita Gupta, Senior Medical Officer and all Lady Medical
Officers (Urban), Health Visitors and ANMs were very helpful in understanding the
Urban Health Delivery system and analyzing the difficulties and possible options.

Shri A.K. Singh, Municipal Commissioner, Shri S.K. Singh, Former Municipal
Commissioner, Dr. R.S. Jaiman and Dr. P.K. Agarwal, Senior Municipal Health Officers,
Ward Councilors and Sanitary Inspectors are gratefully acknowledged for sharing their
perspectives and providing information on different aspects particularly important
insights on Agra slums.

We would also like to thank District Project Officer, C.D.P.O., Supervisors and
Anganwadi Workers of the Department of Women & Child Development; Project Officer
- SIFPSA; Project Officer - DUDA; Project Officer - CARE; SMO - NPSP, WHO, Shri
Ravi Kashyap, SNBI, General Manager, Jal Sansthan, Director, ESI, Agra, Director,
JALMA, Agra Iron and Foundry Association, Dr. P.S Mehra, Relief Hospital, Dr. Irshad,
Meena Charitable Hospital, Presidents, Jatav Panchayat, Mahila Utthan Samiti for their
active participation during the stakeholders’ consultations and individual interactions.
Learnings gained from these meetings helped in building the situational analysis and are
reflected in this document.

Our special thanks go to Dr. Massee Bateman, USAID India for his active interest and
constant guidance during the entire course of the study.

Untiring efforts of EHP colleagues Ms. Kirti Ghei, Mr. Anuj Srivastava, Ms. Madhvi
Mathur, Mr. Pravin Jha, Shivani Taneja and Dr. Sainath Banerjee are greatly valued.
Support, encouragement and comradeship of Mr. S.K. Kukreja, Arti Bhanot, Sandeep
Kumar, Prabhat Jha and Rajeev Nambiar have been of immense value.

This report has been prepared by Karishma, Dr. Rajesh Dubey, Anju Dadhwal, Srinivas
Varadan, Mani Gupta and Dr Siddharth of the USAID-EHP Urban Health Program team.

We hope that this report will be able to extend its reach as it is used by various
stakeholders and program implementers. We look forward to comments and suggestions
from its readers.
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Table of Contents

1.1. City Profile
1.2. Urban Poverty in Agra
1.3. Existing Public Sector Health Facilities
1.3.1. Public Sector Health Facilities
1.3.2. Other Central Government Facilities
1.3.3. Private Health Facilities
1.4. Health Scenario Among the Urban Poor in Agra
1.5. Other Development Programs in Agra
1.5.1. Swarna Jayanti Shahari Rozgar Yojana
1.5.2. Integrated Child Development Services
1.5.3. Early childhood Care for Growth, Survival and Development Project
(ECCD)
1.5.4. SIFPSA Supported Projects
1.5.5. CARE
1.6. NGOs and CBOs Working in Agra
1.6.1. Current activities of NGOs and CBOs
1.6.2. Implementations and Existing Options for EHP
1.7. Private Industry
1.7.1. Footwear Industry
1.7.2. Foundries
1.7.3. ESIS Registered Units
1.8. Need Analysis and Pointers for Improving the Health Delivery System
1.8.1. Location of the Health Facilities
1.8.2. Targeting of the Vulnerable slum population
1.8.3. Public private partnership
1.8.4. Strengthen and optimize Use of Infrastructure
1.8.5. Regularity in Services
1.8.6. Integration of development programs in the city

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List of Abbreviations
AMC Agra Municipal Corporation
ANM Auxiliary nurses midwife
ANC Ante-natal care
ARI Acute Respiratory Infection
AWW Anganwadi Worker
BCG Bacillus Calmette Guerin
BPL Below Poverty Line
CBD Community Based Organizations
CBO Community Development Society
CDS Community Development Society
CMO Chief Medical Officer
CPR Couple Protection Rate
DDK Disposal Delivery Kit
DoMHFW Department of Medical Health and Family Welfare
DPT Diphtheria Pertussis Tetanus
DTHC D Type health centre
DUDA District Urban development Agency
DWCUA Development of Women and Children in Urban Areas
ECCD Early Childhood Care for Survival, Growth and development
Project
EHP Environmental Health Project
ENT Ear, Nose & Throat
ESIS Employee State Insurance Services
FGD Focus Group Discussion
FICCI Federation of Indian Chambers of Commerce and Industries
GoI Government of India
GoUP Government of Uttar Pradesh
HIV Human Immunodeficiency Virus
ICDS Integrated Child Development services
IPPI Intensive Pulse Polio Immunization
IFA Iron Folic Acid
IFPS Integrated Family Planning Services
LHV Lady Health Visitor
LMO Lady Medical Officer
MCH Maternal and Child Health
MTP Medical Termination of Pregnancy
NABARD National Bank for Agriculture and Rural development
NFHS National Family Health Survey
NGO Non Government Organization
NHC Neighborhood Committee
NHG Neighborhood Group
NSS National Sample Survey
OPD Out Patient Department
ORS Oral Re-hydration Salts
PPC Post-Partum Centre
RCH Reproductive and Child Health
RCV Resident Community Volunteer
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RTI Reproductive Tract Infection
SIFPSA State Innovations in Family Planning Services Project Agency
SJSRY Swarna Jayanti Shahari Rozgar Yojana
SLI Standard of Living Index
STD/STI Sexually Transmitted Disease/Infection
TT Tetanus Toxoid
UFWC Urban Family Welfare Centre
UHC Urban Health Centre
UNICEF The United Nations Children’s Fund
UP Uttar Pradesh
UPAP Urban Poverty Alleviation Programme
USAID United States Agency for International Development

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Draft
Situation Analysis, Agra

1.1 CITY PROFILE

India is experiencing rapid and unplanned urban growth. Of India’s total population of
1027 million1, 285 million (27.8%) live in urban areas. The percentage decadal growth of
population in rural and urban areas from 1991 to 2001 is 17.9 and 31.2 percent
respectively. The slum population in 2001 is estimated to be tune of 60 million2,
comprising 21 percent of the total urban population. However, these estimates do not
reflect the true magnitude of urban poverty because of the “un-accounted” for and
unorganized squatter-settlements and other populations residing in inner-city areas,
pavements, constructions sites, urban fringes, etc. Undoubtedly, significant proportions of
the urban population live in slums or slum like conditions, which seriously compromise
health and sanitary conditions, putting them at a much higher morbidity and mortality risk
than non-slum populations.

Therefore, Urban Health Program for slum is one of the thrust areas in the 10th five year
plan, RCH II, National Population Policy and National Health Policy. In continuation to
this, GoI identified four cities, Delhi, Agra, Bally and Haldwani to develop sample urban
health proposal. In effect, Agra was taken up for the development of urban health plan.

Urban population in Uttar Pradesh constitutes 20.78% of the total population. While the
urbanization rate of the state is still well below the national average of 27.78%. In
absolute terms, this amounts to nearly 35 million people residing in 684 towns and cities3.
With nearly one in three city dwellers estimated to be poor, it amounts to approximately
10 million people4 living below the poverty line in the urban areas of UP. There is
increasing evidence that the urban poor, particularly those residing in slums and squatter
settlements, have health indicators comparable to or even worse than their rural
counterparts. Addressing health inequities within cities and providing quality health care
to slum dwellers has emerged as an issue of critical importance for Uttar Pradesh.

Agra city, which is spread over an area of 140 sq. km. along the banks of the river
Yamuna, is one of the major cities of Uttar Pradesh. The history of the city dates back to
1475 AD when Raja Singh Badal laid the foundation for the city. The post-independence
growth of the city was linked to the large scale influx of refugees as well as migration
from rural areas. This led to the congestion of the central part of the city, which to date
remains highly congested with very poor civic facilities. With planned industrial
development in the 70s and 80s, three important industrial areas of Agra, namely Nunhai,
Sikandra and Foundry Nagar were established. This led to the further growth of the city
in the north-western and north-eastern directions.

1 Census 2001
2 National Commission on Population, 2000, Ministry of Health and Family Welfare, GoI
3 Population Estimate, Census 2001
4 NSS Consumer surveys, Official Poverty Lines and Corrected Estimates from Deaton, 2001
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Table 1.1: Population Growth (Census data)
1991 2001 Growth rate
(in lakhs) (in lakhs) (1991-2001)
AGRA District 27.51 36.11 31.27%
AGRA Urban 9.43 13.31 41.14%

The total population of Agra urban agglomeration (which includes Cantonment areas,
Swamibagh and Dayalbagh) is 1,331,339; whereas the population under Agra Municipal
Corporation as per the 2001 census is about 12.75 lakhs. The city is now growing in the
western direction following the Delhi-Agra corridor in a linear pattern. The decennial
growth rate of Agra city (1991-2001) is 41.14% which is twice the national decennial
growth rate of 21.34%. Population density of Agra is 897 persons per square kilometer as
compared to the Indian average of 324. These data indicate the immensely overcrowded
habitat conditions in the city. According to the 1991 census, the sex ratio of the city is
852 females per 1000 males (Indian average is 933).

Administrative Structure

Agra city is governed by Agra Municipal Corporation, Agra Cantonment Board and
Dayal Bagh & Swami Bagh Nagar Panchayats. Majority of the slum clusters mainly fall
in the area of the Agra Municipal Corporation. The Agra Municipal Corporation was
constituted on 30th November 1975. The spatial area of Agra Municipal Corporation is
spread over 120.57 sq. km. The remaining area of 20 square kilometers falls within the
Cantonment Board and Swami Bagh and Dayal Bagh municipalities. The entire area of
the Corporation is divided into 80 electoral wards, while for the purpose of revenue
collection the area of Agra Municipal Corporation has been divided into 8 divisions. Each
of these divisions has been further divided into several zones. The 8 divisions are
Hariparvat, Lohamandi North, Lohamandi South, Rakabganj, Chatta, Kotwali, Ward No.
7, and Tajganj. Various governance functions are carried out by the Administration,
Engineering and Lighting, Accounts, Health, and Revenue departments of Agra
Municipal Corporation.

1.2 URBAN POVERTY IN AGRA

The Census of India 2001 estimates the population of Agra at 13.31 lakhs, while
unofficial estimates put the figure over 16 lakhs. The slum assessment process in Agra
shows that 8.41 lakh people live in slums, which is about 50% of the city’s population5.
and squatter settlements. However, official figures reported in the last census (1991)
indicate only 9.67% slum population.

The official slums list of DUDA in Agra records 252 slums6. During slum assessment
only 215 DUDA recognized slums could be found in the city and subsequently assessed.
And out of the remaining slums in DUDA list, some were found repetitive, while other
could not be located7. As part of slum assessment8 , slum list9 of other departments such
as Agra Municipal Corporation, Health Department (1st tear Facilities), Pulse Polio
Immunization Campaign, ICDS were also obtained to identify other slums. Other key

5 Refer Annex 1 the U.P Slum Areas (Improvement and Clearance) Act, 1962.
6 Refer Annex 2 for Official slum list of DUDA.
7 Refer Annex 3 for list of slums not found in DUDA list.
8 Refer Annex 4 for Vulnerability Assessment process.
9 Refer Annex 2 for official slum list of AMC, pulse polio, ICDS, Health Department.
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informants such as the Ward Councilor, ICDS supervisors, Sanitary Inspectors, Medical
Officers and ANMs of the 1st tier facilities were also consulted to identify other slum like
settlements in the city. The vulnerability assessment exercise carried out in the city
revealed a total of 393 slums.

There are six areas where these slums are concentrated in Agra namely Lohamandi,
Rakabganj, Bundu Katra-Gwalior & Deori Road, Tajganj, Shahganj and Trans-Yamuna
area. In addition, there are a substantial numbers of slums, which are scattered.

A large majority of these slums are situated along nalas and railway lines. Most slums in
the city are characterized by poor sanitation, drainage, and water facilities. Housing
structure is pucca (concrete) in most slums of Agra, unlike other cities. Access to basic
services in each slum is a major determinant of health vulnerability.

The assessment and plotting of slums was undertaken to understand slums from a health
perspective and accordingly grade them as per their level of vulnerability. The
vulnerability assessment criteria included social conditions, living environment – water
and drainage systems, sanitation facilities, access to public health services, health and
disease prevalence, economic conditions and organized collective efforts at the
community level, etc.

Status of Vulnerability in Slums10
Most Moderately Less Total
Vulnerable Vulnerable Vulnerable
DUDA Recognised Slums 90 88 37 215
Unrecognised Slums 93 85 0 178
Total 183 173 37 393

The slum assessment revealed that about 20 % of the slums exist in the Trans Yamuna
area and that the slums in this area are largely scattered. In contrast, the slums in
Rakabganj area, which is also part of the old city, are highly congested and the density of
population in these settlements is fairly high. Areas such as Trans Yamuna and Bundu
Katra have settlements that were largely rural and due to the rapid expansion of the city
have transformed into ‘new slums of the city’.

An analysis of the slum assessment findings revealed the following situation:

• A large number of slums are located near dirty, open ‘nalas’. This leads to higher
malaria, diarrheal disease incidence in these slums.
• Slum dwellers have individual sources of water (taps / handpumps) in most slums.
However, water supply is generally limited to 2-6 hours in a day. Water quality is
poor (yellowish, hard water, smelly) in a few slums.
• Sanitation is the most pressing issue in a majority of slums with situations varying
from existence of individual toilets which lead into open drains to a total absence
of individual or public toilet facility. Children defecate in drains in most slums.
• Drains are open and narrow, which remain blocked due to disposal of solid waste
and no regular cleaning. Regular cleaning is done in ‘better off’ slums where
residents pay monthly charges to private cleaning staff.

10 Refer to Annex 5 for list of slums in the three groups - highly vulnerable, moderately vulnerable and less
vulnerable.
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• A majority of slums have kharanja, a few have cemented roads. Kharanjas are
broken in places. A few slums also have katchcha roads.
• Slum dwellers prefer to access private health facilities due to better
attention/services or proximity of these services.
• Deliveries are conducted at home by untrained dais in a large majority of slums

1.3 EXISTING PUBLIC SECTOR HEALTH FACILITIES

Health services in Agra are provided by the Public sector, Department of Medical, Health
and Family Welfare, and Agra Municipal Corporation and Private sector (hospitals,
nursing homes, and clinics). In addition, there are several charitable hospitals, which
provide subsidized health services to the poor. Also, there are Central Government health
facilities, which include Railways hospitals, ESI hospital and dispensaries and
Cantonment hospitals and dispensaries.

1.3.1 Public Sector Health Facilities

1.3.1.1 Department of Medical, Health and Family Welfare

1.3.1.1.a First tier facilities

Primary health care in the city is provided through 15 D-Type Health Centers (DTHCs).
Of these 15 D-Type health Centers, nine are located in rented buildings of Agra
Municipal Corporation and one is located in the Red Cross Building, but all these six are
also run by DoMHFW. Lohamandi I, Shahganj I, Jeoni Mandi and Chatta D-Type health
centers (located in AMC buildings) also have dispensaries. D-type health centers of the
Yamuna Par has a maternity home providing obstetric care services. In addition, there are
2 post-partum centers run by the District Administrator-one located at S.N Medical
College and the other at Lady Lyall Hospital and the other at T.B Demonstration Centre
and a Medical Care Unit in Trans-Yamuna area, all of which are not functional as first
tier facilities.

The major services provided by the D-Type health centers include immunization,
antenatal care, and family welfare services through OPD and outreach activities. Each of
these D-Type Health Centers is headed by a Lady Medical Officer (LMO) and 3-4 para-
medical staff. In the five DTHCs located in AMC building, there is provision for a Health
Education Officer (HEO) and out of which, HEOs are present in 4 DTHCs, and fifth one
in Lohamandi-I has retired. These five D-Type Health centers, which are running from
AMC buildings are in very poor shape and have not been repaired for several years due to
lack of funds. The other 10 are operating as one to two room units in rented buildings,
which may not be the most appropriately located

D-Type health Centers are providing maternal and child health and family welfare
services to a normative population of 50,000. however, due to substantial increase in the
population of the city over time, each health center is now creating to a population of
70,000 to 100,00. Due to shortage of staff vis-à-vis the catchment area, it is evident that
the existing primary health delivery system is inadequate to respond to the health needs of
the burgeoning urban population, of which approximately 50% reside in slums or slum-
like conditions.

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