The UHP has evolved over the last 25 years, passing through three distinct phases:
Phase I: 1983-1996
The first primary health care prototype was established in 1983 in a part of Orangi town, the biggest urban slum of Karachi, in consultation with the Orangi Pilot Project (OPP). In 1984, a baseline survey was conducted by the first batch of the University's medical students. Based on an assessment of health-related needs, the first UHP community centre was established in Orangi in 1985. Over the next five years, a new field site was adopted with each incoming class of the Medical College. These included Chenasar Goth, Grax Village, Essa Nagri, Karimabad, Azam Basti and Baba Island. Each primary health care module served a population of 8,000 to 10,000.
The primary health care programme concentrated on improving the health status of mothers and children under five years of age, and was later extended to include families. Women were selected from the community to be trained as community health workers (CHWs). Each CHW was assigned 100 to 150 families to whom they provided a variety of services: immunisation, antenatal care, family planning, diarrhoea control, nutritional counselling, growth monitoring and breast feeding, among others.
The Departments of Obstetrics/Gynaecology, Family Medicine and CHS jointly provided ambulatory facility-based curative services to the entire catchment population of 50,000. This inter-University collaboration resulted in the provision of health services to disadvantaged communities, while fulfilling the requirements of a community-based medical curriculum.
The programme demonstrated considerable improvements in coverage and impact indicators. The average infant mortality rate fell from 126 to 64 per 1,000 live births and the under-five mortality rate from 177 to 83. However, during a self-assessment conducted in 1992-93, it was pointed out that these programmes had no comparison or control populations, where the health status could be monitored without interventions. Developmental interventions, such as safe water supply, sanitation and income generation were also considered in order to have a continuous positive impact on health. These considerations led the UHP into its second phase, where the emphasis was on community involvement and socio-economic determinants of health.
* The phasic evolution of UHP is adapted from: Rabbani, F. (2001), "The Aga Khan University and the Urban Health Project. Global Conference: Universities and the Health of the Disadvantaged. Arizona USA, 1999." in Daniel, S., Blumenthal, Charles Boelen, (Eds.), Evidence and Information for Policy. Department of Organization of Health Services Delivery, World Health Organization, Geneva, WHO/EIP/OSD/2000, Vol. 10, pp 50-61. - www.who.int/mip2001/files/2362/UNISOL.pdf
Phase II: 1994-1999
In the second phase of the programme (funded by Aga Khan Foundation, CIDA and USAID), the UHP objectives included: organising ethnically diverse, marginalised communities with a population of 100,000, to seek new knowledge on community empowerment and mobilisation, develop basic primary health care services, while serving as a catalyst for change. Intervention sites included Rehri Goth, Sultanabad and Hijrat Colony, where the focus was on health, and Moinabad, Ibrahim Hyderi and Future Colony, where more development-oriented interventions were made. The two control sites were Khuldabad and Muhammadi Colony.
A comprehensive baseline survey was conducted in 1996, designed with special sensitivity to gender issues. The survey concluded that 49% of the children under five years of age were mild to moderately malnourished (38% at national level), while 12% were wasted. Prevalence of diarrhoea among children under five was 12%. Of the surveyed population, 70% women (majority of whom were between 24 to 29 years of age), and 60% men were currently married. The mean number of pregnancies per woman was 4.4, while 40% married women in the child-bearing age group were anaemic. Contraceptive prevalence was approximately 17% and among pregnant women, 70% did not receive any antenatal care, while 75% of the deliveries occurred at home. Women were mostly housewives with 79% being illiterate. Further analysis of this survey suggested that for certain health outcomes of interest, there were differentials in socio-economic status that could possibly help identify households which were poorest of the poor, and hence most vulnerable to an undesirable outcome. These households experienced greater childhood mortality and under-utilised preventive services like immunisation and family planning.
The second phase of the UHP focused on community mobilisation and the formation of Community Management Teams (CMTs), which worked together to identify problems, set priorities and develop plans for implementation. The health initiatives included facility-based curative and preventive services, which were provided through community volunteers (male and female) trained for vaccination, drug dispensing, and family planning, along with health education services through various NGOs and government agencies. Lady Health Workers (LHWs) from the government also attended these training sessions and a few worked as project volunteers. The project aimed at empowering mothers to influence case management practices of local health practitioners. Emphasis was given on improving the referral system for high risk pregnancies, decreasing maternal anaemia and providing appropriate antenatal care. Efforts were also made to involve men in family planning strategies. Outreach services like lane meetings, sub-centres, health posts and health awareness at schools were organised to provide health education to the population at large.
Socio-development initiatives included capacity building of communities through a series of workshops and trainings on proposal writing, financing and accounting, among others. Women received training on various income generating activities and learned about marketing products. Sewing centres were established where a local teacher hired by the community was in charge. Primary schools for girls were opened in collaboration with local NGOs. Various schemes to improve adult literacy, especially for women were also initiated. Efforts were made to improve the quality and quantity of water supply and concerned government authorities were involved in this process.
A mid-term survey showed positive changes in the intervention sites as compared to controls. At the sites with the development focus, more houses had water taps inside their premises, and fewer houses were using open fields as latrines. There was also a decrease in the percentage of households throwing garbage in the streets. At the economic front, ownership of cars or pickups and motorcycles increased. Relatively more women were involved in income generating activities and the growth of household structures built in concrete increased.
At the sites with a health focus, that there was significant improvement in immunisation coverage (appropriate for age), compared to control sites. There was also an improvement seen in the correct use of ORS and cereal-based ORS, and there was a better recognition of signs of dehydration in diarrhoea by mothers. Though not significant, there was also a rise in the contraceptive prevalence rate among married couples.
Phase III: Current Urban Health programme (January 2000 to date)
Phase III, conducted in Rehri Goth, Sultanabad and Hijrat Colony, consists of four major areas: education and training, capacity building, primary health care and research. Education and training is for undergraduate medical students, community medicine residents, MScN students, and national and international elective students and, in collaboration with AKU, community- based organisations (CBOs) and various stakeholders.
Examples of student participation includes:
- Participation in needs assessment surveys where students help in priority setting and planning for appropriate interventions.
- Contribution towards the instalment of a sewage line in Sultanabad, to provide households with a proper drainage system.
- Establishment of rehabilitation projects in Sultanabad and Hijrat Colony for handicapped children.
- Assistance in the provision of basic preventive and curative services.
- Help in the establishment of fellowship schools and school health sessions.
In the current phase, community representatives and members, volunteers, traditional birth attendants, Lady Health Workers, school teachers and other health care providers are offered assistance in various roles. A primary health care centre has been established to provide affordable, acceptable and sustainable preventive and curative health services at the field sites. Staff at the field sites also provides counselling for disease prevention, family planning and nutrition, and promotes healthy living by effective communication through sessions at various children's schools. An inter-sectoral approach has been adopted to have a continuous positive impact in health and social development by providing access to a safe water supply, sanitation, girls' education, and opportunities for income generation. All of these activities are conducted at the field sites, which also provide an excellent research environment for health systems research, epidemiology and other collaborative studies.