HEALTH AND IMMUNIZATION SERVICES FOR THE URBAN POOR IN EAST ASIA Case studies from seven countries in East Asia on access by the urban poor to health services
Cover image: UNICEF Mongolia 2016 UNICEF East Asia and Pacific Regional Office 19 Phra Atit Road Bangkok 10200 Thailand Email: eapro@unicef.org www.unicef.org/eapro
HEALTH AND IMMUNIZATION SERVICES FOR THE URBAN POOR IN EAST ASIA Case studies from seven countries in East Asia on access by the urban poor to health services UNICEF East Asia and Pacific Regional Office
FOREWORD The East Asia and Pacific Region is undergoing significant social changes, fast growing economies, demographic transitions, and rapid urbanization. Rapid urbanization specifically has the potential to bring both opportunities and challenges to the development of its social systems. Everyday in our region, families leave their rural homes, with dreams of a better life and future for their children, moving into cities, or places where urbanization is under way. In a rapidly changing world, children are the most vulnerable group in a society. Children need special care and protection including adequate access to essential health, sanitation and social services. The public health emergency of measles and diphtheria outbreaks in certain cities in our region is causing deaths and suffering to many children. This rings loud bells for the development community. The phenomenon of vaccine preventable disease outbreaks indicates an increased public health risk for urban populations. This may only be the tip of the iceberg. There are many other public health and development challenges for the urban poor that are affecting the well-being of millions of children and families. Among them are pneumonia and diarrhea. Considering the important transition the East Asia and Pacific Region is undergoing, I am pleased to introduce our work on HEALTH AND IMMUNIZATION SERVICES FOR THE URBAN POOR IN EAST ASIA. The Summary Report and two detailed reports share existing evidence and analysis to examine how effectively health systems are responding to rapid urbanization in the region. They also map out policy and service gaps to close, and recommend strategies to reduce inequities of access to health care in urban settings. They clearly articulate the complexity of urban development systems. It shows the essential need for public and private sectors to work collaboratively to respond to the rapidly changing social conditions in the region. UNICEF in East Asia and the Pacific is committed to protecting the rights of every child in the region, and leaving no one behind. We are also committed to working tirelessly and cooperatively with national and local governments, international partners and civil society agencies, to enhance social development systems to meet the needs of children and families. It also provides the opportunity to offer special support to those most suffering deprivation in what is a rapidly urbanizing region of the world. We count on you to address the urgent need to tie down accountability for management and financing of health services for the urban poor. Karin Hulshof UNICEF Regional Director, East Asia and the Pacific
SUMMARY REPORT Health and Immunization Services for the Urban Poor in East Asia BACKGROUND TO THE STUDY Urbanization, along with rapid economic growth and persistent or widening inequality, is the dominant demographic and social trend in Asia. By 2030, it is projected that the proportion of the population living in urban areas in South-East Asia will reach 56 per cent, and in East Asia it is expected to reach 72 per cent. 1 This presents a major challenge for governments and their civil society partners, who are struggling to adapt vital public services and social protection systems to meet the social consequences of this rapid demographic transition. The modern health sector, which has been traditionally based on a rural model of primary health care (PHC), is also endeavouring to adapt governance, financing and service delivery arrangements to meet the needs of these rapidly expanding urban populations. Among the health programmes tasked with responding to this rapid transition are the national immunization schemes, which, for the last 30 years, have been highly successful in administering rural-based programmes for the prevention and control of vaccine preventable diseases. But the recent increase, between 2014 and 2016, of disease outbreaks in major cities of the region, and the emerging evidence (cited in this report) of substantial coverage gaps between wealth quintiles in urban areas are now raising questions about the effectiveness and equity of immunization schemes in regions that are undergoing rapid urbanization. So just how are countries responding to the emerging rapid urbanization, and how are they adapting their programme policies and plans to meet the realities of this rapidly changing social context? Through an examination of published literature, country policy and planning documentation, as well as relevant survey databases, this review describes the policy and planning responses of countries to urban health and immunization in seven countries in East Asia (Cambodia, Indonesia, Mongolia, Myanmar, Papua New Guinea, the Philippines and Viet Nam), of the region, and makes recommendations on potential next steps for improving coverage and equity of access to services. Health and Immunization Services for the Urban Poor in East Asia l 1
UNICEF EAPRO Health 2017
MAIN FINDINGS There are significant gaps in immunization coverage in some urban settings, mostly related to socio-economic disadvantage. These gaps have been identified, although in some settings, there is a lack of data and knowledge on the needs of the urban poor who live in informal settlements. Despite these data limitations, there is evidence in this report of coverage gaps between wealth quintiles within urban areas. In urban settings in the Philippines, in 2013, a gap of 15.5 per cent was observed between the highest and lowest wealth quintiles for DPT3 coverage for children aged 12-59 months, 2 and in Indonesia the gap was 18.9 per cent, with evidence of only a slight narrowing of these gaps over successive DHS surveys, the majority of which were conducted between 2012 and 2014. The latest DHS survey conducted in Myanmar in 2015 confirmed a 29.2 per cent gap between the highest and lowest wealth quintiles for DPT3 coverage for children aged 12-59 months (see Figure 1). Figure 1 Percentage of DPT3 coverage of children aged 12-59 months in urban areas, lowest and highest wealth quintiles, in six countries in East Asia from the most recent DHS/MICS 3 Percentage of of DPT3 in urban areas, lowest and highest wealth quintiles 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Cambodia (2014) Indonesia (2012) Mongolia (2013) Myanmar (2015) Philippines (2013) Viet Nam (2013) Lowest urban DTP wealth quintile 87.1% 65.1% 90.7% 58.8% 77.3% 46.9% Highest urban DTP wealth quintile 99.3% 84.0% 95.1% 88.0% 92.8% 58.4% Health and Immunization Services for the Urban Poor in East Asia l 3
These findings reinforce the importance of socioeconomics as a primary determinant of the risk of not being vaccinated. The evidence of vaccine preventable disease outbreaks in Asia over the last five years points to the potential for underestimating immunization coverage in urban areas, and signals increased public health risks in urban settings. There was a diphtheria outbreak of 105 cases in 2015 in the Philippines, with one third of cases reporting to San Lazaro Hospital in Metro Manila. 4 In Viet Nam in 2014 there was a measles outbreak, with 150 deaths reported at the Vietnam National Hospital of Pediatrics in Hanoi. 5 In Mongolia, there was a measles outbreak, with the first cases reported in Ulaanbaatar City, which was also the most affected location. There were 105 fatalities from 23,000 reported cases nationwide. 6 Of concern is the likelihood that the populations most affected by such outbreaks are those with the least capability to access health services for treatment and rehabilitation. There is also concern that highly concentrated and poorly nourished populations, living where environmental conditions elevate public health risks, are at significantly greater risk of disease transmission and face more severe outbreaks. Table 1 Data on vaccine-preventable diseases in urban areas from six counties in East Asia, 2012-2017 Location Year Disease outbreak Indonesia 2014 There have been annual measles outbreaks in slums in North, East and West Jakarta Districts, making up two thirds of annual confirmed measles cases 7 Mongolia 2016 Measles outbreak, with outbreak first reported in Ulaanbaatar City where most cases were reported. 23,000 cases and 105 fatalities nationally 8 Myanmar 2012 Measles outbreak nationwide with immunization campaign activity in urban areas 9 2016 Diphtheria outbreak in Yangon 10 Papua New Guinea 2013 Measles cases 308 laboratory confirmed cases 11 Philippines 2014 Measles outbreak with highest caseload of measles in the National Capital Region 12 2015 Diphtheria outbreak with 105 cases, and one third of these cases reporting to San Lazaro Hospital in Metro Manila 13 Viet Nam 2014 Measles outbreak, 150 deaths reported at Vietnam National Hospital of Pediatrics 14 4 l Health and Immunization Services for the Urban Poor in East Asia
Increasing urbanization with agglomerations of urban poor is increasing the public health risk of disease outbreaks in expanding slum areas in East Asia. Recent migrants from rural to urban areas are particularly at risk, especially in large agglomerations of peri urban-poor populations. Available demographic data demonstrates that the social conditions giving rise to lower access to health services by the urban poor are set to continue. Two out of the seven countries (Indonesia and Mongolia) will be more than 50 per cent urbanized by 2025, and Indonesia was already mostly urbanized by 2015. 15 In five out of the seven countries (Cambodia, Indonesia, Mongolia, Myanmar and Viet Nam), urbanization trends are still on the increase. A substantial proportion of these urban populations are living in slums (see Figure 2). In fact, of the seven countries under study, an estimated 64.6 million are living in urban slums, most in Indonesia, Viet Nam, and the Philippines. 16 In Cambodia for example, more than 50% of the urban population are residing in slum areas. Figure 2 Number of slum dwellers in six countries in East Asia, 2015 (in millions) 17 30.0 Number of people living in urban slums (in millions) 25.0 20.0 15.0 10.0 5.0 0.0 Mongolia Cambodia Myanmar Viet Nam Philippines Indonesia Health and Immunization Services for the Urban Poor in East Asia l 5
Harsh social conditions are extreme and all demand more comprehensive health and social policy responses. One of the main findings of this study is the extent to which the severity of social conditions can be hidden by administrative authorities. In many of the countries, access to services is regulated through systems of civil registration (Myanmar, Viet Nam, Mongolia, the Philippines). The question as to whether rural to urban poor migrants are being counted and included in health and local government registers is, therefore, an essential issue to be addressed in urban health policy. Compounding this problem of the hidden nature of the urban poor is the social conditions in which they reside. Of concern are the large agglomerations of peri-urban residents who relocate to areas where there is limited public health infrastructure and services, as in the peri-urban areas of certain cities in the case studies. Management arrangements for urban health and immunization are complex and involve multiple stakeholders, and the delivery systems are increasingly complex. In the 1970s and 1980s, many countries, including Myanmar, Mongolia and Viet Nam, developed PHC systems. These were based on rural health models, with clear command and control structures, and administrative boundaries with defined population catchments, linked to primary care centres and village volunteers networked into a social mobilization communication approach. This review Figure 3 Stakeholders in municipal health governance in East Asia 01 06 Public sector providers 05 Social sector agencies National programmes Urban populations, migrants and mobile populations 04 Civil society agencies 02 Local government 03 Private sector agencies 6 l Health and Immunization Services for the Urban Poor in East Asia
demonstrates that urban health has evolved in a significantly more complex way, with governance and service delivery mechanisms dispersed across a wide set of government, local government, civil society, and private sector actors. What these country case studies illustrate is that unless there is an overall strategy for enabling local government leadership and accountability for immunization programming, such programmes will always be reliant on external project financing, and on an out-dated rural command and control national programme management model with limited implementation capability in an urban governance context. There have been promising innovations in reaching the urban poor with immunization services, but there are challenges in transitioning from project initiatives to system-wide approaches. In the cases of Cambodia, Indonesia, Mongolia, Myanmar, the Philippines and Viet Nam, there are indications that concerted efforts are being made by national immunization programmes to develop a national urban strategy. Part of the problem seems to be that urban planning initiatives are often reliant on project financing, and have not been adequately integrated into local government planning, budgeting and accountability frameworks. In summary, there are promising innovations in operational immunization strategy in evolving urban settings, but strategic legal, policy and planning initiatives to tie down accountability and financing for urban health have yet to eventuate. Table 2 Overview of urban strategies in comprehensive multi-year plans for immunization for seven countries in East Asia 18 Country Documented urban strategy Cambodia High risk community strategy implemented nationally Indonesia High risk community project being implemented by Ministry of Health with partners Mongolia Reaching Every District (RED) Strategy implemented nationally Myanmar Special strategy being developed to reach urban poor (peri-urban and slum communities) Papua New Guinea Currently nationwide RED Strategy applicable to both urban and rural areas Philippines Reaching Every Purok (REP) Strategy being implemented nationally Viet Nam Reaching Every Community (REC) Strategy developed for urban settings Health and Immunization Services for the Urban Poor in East Asia l 7
UNICEF Philippines 2017
CONCLUSIONS AND RECOMMENDATIONS The critical cornerstone for promoting sustainability and reach of health and immunization services in urban settings is to tie down accountability for resourcing of the strategy, and to include the approach within the planning and budgeting procedures of ministries of health and local governments. In the shorter term, national programmes, international organizations and non-government organizations will need to redouble efforts to ensure that operational technical guidance for reaching every community is documented and disseminated across the region. In the medium to long term, in order to effectively tackle the challenges associated with rapidly changing urban settings, technical agencies and partner governments will need to focus on development of municipal models of PHC that have clear delegations of authority and shared networks of information. Given the scope of the problem, including demographic trends, and expanding slum and peri-urban populations, reliance on external partners and charitable institutions is not a viable option in the long term for urban poor strategies. What is required is scale up of known operational strategies through ministry and local government institutional arrangements, so that pro-poor health services become the core priority for urban planners. The following sets five action points for national governments on the development and implementation of an agenda for improved access to health services for the urban poor. 1. Conduct baseline research on immunization and health access for the urban poor. 2. Review and/or redefine governance arrangements in urban for health and immunization. 3. Develop or revise the urban strategy for improving immunization services, and link it to the wider urban plan for health. 4. Develop a monitoring and evaluation framework to effectively track progress in improving health and immunization outcomes. 5. Support sustainability, explore links between health strategy (immunization as an entry point) and social policy. The main elements of an urban immunization strategy should include a situation analysis outlining the main gaps in service provision, a stakeholder analysis of immunization service provision, and a baseline monitoring and evaluation framework and plan The legal and policy context for implementation should be specified, along with the operational strategy to enhance coverage and programme performance (e.g., Reaching Every Community Strategy. ). Governance arrangements and standards for management of immunization in urban areas should also be specified, with clear accountabilities for management (financing, service delivery, waste management, cold chain maintenance, surveillance and reporting) that are defined and agreed to by the main stakeholders. As outlined throughout this report, there is an urgent need to tie down accountability for management and financing of health services for the urban population in general, and the urban poor specifically. This will require the mobilization of political commitment, either through advocacy efforts with political leaders, or through demand side pressures from civil society. Developing a higher-level policy and regulatory approach to resolve urban health challenges (in addition to the dissemination of technical operational procedures and capabilities) will work towards reaching consensus on accountabilities for management and financing. Options to explore in this regard are holistic health policy, and inclusion of pro-poor health planning and financing within city master plans or urban health plans. Health and Immunization Services for the Urban Poor in East Asia l 9
REFERENCES 1 Save the Children, 2015: State of the Worlds Mothers 2015: The Urban Disadvantage. 2 WHO, Country profiles on urban health, <www.who.int/kobe_centre/measuring/urban_ health_observatory/uhprofiles/en/>, accessed 23 November 2016. 3 The DHS programme <http://dhsprogram.com/>, accessed 14 December 2016. 4 WHO, Lessons learned from recent diphtheria cases. <www.wpro.who.int/philippines/ mediacentre/features/lessons_learned_diphtheria_cases/en/>, accessed 30 August 2017. 5 National Preventive Medicine Centre Hanoi: National EPI Review 2015 Vietnam, page 59. 6 WHO, Measles outbreak in Mongolia FAQs, 5 May 2016, <www.wpro.who.int/ mongolia/mediacentre/releases/20160505-measles-outbreak-faqs/en/>, accessed 9 September 2016. 7 UNICEF Indonesia, May 2016. Presentation on Health Programmes, UNICEF Jakarta. 8 WHO, Measles outbreak in Mongolia FAQs. 9 IRIN, Myanmar to immunize 6.4 million against measles <www.irinnews.org/photo/ 201203221156030186/some-64-million-children-will-be-vaccinated-against-measlesacrossmyanmar>, accessed 16 August 2016. 10 As reported in Myanmar Times, 10 June 2016, https://www.mmtimes.com/national-news/ yangon/20789-diphtheria-outbreak-claims-six-lives.html. 11 WHO Western Pacific Regional Office Country Profile Measles Elimination <www.wpro. who.int/immunization/documents/measles_country_profile_apr2014_png.pdf?ua=1>. 12 Department of Health, the Philippines, Dulce C. Elfa Strategy: Addressing Immunity Gaps in Urban Communities, PowerPoint presentation. 13 WHO, Lessons learned from recent diphtheria cases, <www.wpro.who.int/philippines/ mediacentre/features/lessons_learned_diphtheria_cases/en/>, accessed 30 August 2016. 14 National Preventive Medicine Centre Hanoi: National EPI Review 2015, Vietnam, page 59. 15 UN Habitat, Urban population and urbanization by country 1990-2050: <https://unhabitat. org/wp-content/uploads/2014/03/table-1.2-urban-population-and-urbanizationbycountry-1990-2050.pdf> 16 WHO, Country profiles on urban health. 17 Ibid. 18 All Multi-Year Plans sourced from GAVI website at,<www.gavi.org/country/>, accessed 14 December 2016. 10 l Health and Immunization Services for the Urban Poor in East Asia
UNICEF East Asia and Pacific Regional Office 19 Phra Atit Road Bangkok 10200 Thailand Email: eapro@unicef.org www.unicef.org/eapro