This story originally appeared in the October 2011 edition of the Searchlight South Asia newsletter created by Intellecap for the Rockefeller Foundation.
By Nisha Kumar Kulkarni
Hyderabad, state capital of Andhra Pradesh, is the sixth most populated city in India and holds the same ranking for the country’s most populated “urban agglomeration.” The city also has a significant urban poor population. According to the Greater Hyderabad Municipal Corporation(GHMC), more than 33% of the city’s population lives in slums. The overall slum-dwelling population in Andhra Pradesh is approximately seven million people, and Hyderabad claims near two million. Regarding the growth of the city’s slums, the GHMC states: “Slum settlements have multiplied over decades and the living conditions of the poor have not improved. Environmental decline, vehicular pollution, inadequate basic services and infrastructure in the poor settlements hit the poor hardest.”
Targeting the Most Vulnerable
In 2010, the not-for-profit Kriti Sustainable Livelihoods launched the Vaaradhi pilot, a livelihoods and healthcare program for the urban ultra poor – those who live on less than US$1.25 per day – in the Film Nagar slum near Hyderabad. The project is part of the Sorenson-Unitus Ultra Poor Initiative (UPI), a three-year program by Unitus Labs, a U.S.-based international not-for-profit focused on poverty alleviation. The initiative also receives support from the Sorenson Legacy Foundation – also based in the U.S. – which aims to alleviate extreme poverty. The UPI supports partner organizations to design and implement interventions for the ultra poor and address the unique circumstances and challenges of this particularly vulnerable population. Of the five projects under the UPI umbrella, Kriti is the only partner organization not working in the area of microfinance.
“Since Unitus was experimenting with various models, it was keen to also work with social organizations that were not MFIs or their NGO arms,” says Sriram Gutta, Manager of the UPI at Unitus Labs. “Kriti is one of the first urban ultra poor pilots. [The] Unitus team was keen to work with them and see [what] an urban pilot would [be] like – what components of rural models could be replicated in urban areas and the challenges that practitioners face.”
When it comes to programs targeting the ultra poor, there are many organizations, such as BRAC, that cater to this population. However, these organizations focus on models for rural areas; too few organizations have emphasized catering to the ultra poor in the urban context. Kriti launched its Vaaradhi pilot in the organization’s home city of Hyderabad, and chose the Film Nagar Slum because it is a “notified,” or legal, slum.
“Kriti had to choose between working in a notified slum and potentially compromising on the level of poverty they could target [by] working in a non-notified slum where there [is] constant threat of eviction and migration,” explains Gutta. Since the Kriti team chose to operate in a legal slum, access to ultra poor populations may have been relatively lower than if the project was launched in an illegal, or “non-notified,” slum.
Areas of Intervention
In designing the Vaaradhi pilot, the Kriti team deduced that any effective program for the ultra poor must clearly address the issues of livelihoods and healthcare. The livelihoods program focused on home-based interventions for women. The initiative was designed based on local needs and circumstances, particularly the large Muslim population in Film Nagar, which prohibits many Muslim women from working outside the home. “Flexibility is important for the women,” states Gutta. “They need to do household chores, collect water and take care of children and elderly, among others. Livelihood activities had to be designed accordingly.” With that in mind, it was settled that the livelihoods program must be flexible and home-based; easy to learn; doable in small spaces; and able to generate adequate income. It is for this reason that Kriti decided to provide free training on agarbatti (incense sticks) rolling, microentrepreneurship, paper bag making and tailoring.
The other main component of Vaaradhi, healthcare, also needed to be made relevant to the urban ultra poor. In rural areas, healthcare is a question of access: on average, a person may travel 10 -15 kilometers to the nearest doctor. Because of that, innovations such as mobile health have arisen to serve these populations. In urban areas, the issue is different. Living in a large city like Hyderabad means that a person does not have to go far to gain access to healthcare. In fact, there are many practitioners serving these poor populations, though most are unqualified. The focal points, then, for any healthcare intervention in the urban context must be quality and affordability. To ensure sustainability, the Vaaradhi pilot was designed not only as a primary healthcare facility, but also as a healthcare education program that could work as a preventative mechanism.
Pilot Challenges
The livelihoods component of Vaaradhi did not meet all the Kriti team’s goals for the pilot, especially around participant retention. Theagarbatti rolling and paper bag making had especially high attrition rates. It was concluded that the primary reasons for attrition were long training periods, inadequate income generation after training, inability to attain a certain skill level and a general lack of interest and commitment from participants. Gutta elucidates: “[The] opportunity cost of doing that activity was perceived as too high. It is important that women earn more than what they could otherwise earn through daily wages or other activities.”
Rolling incense and making paper bags proved to be more manual-type labor, and the general perception was that more income could be generated by other activities. Even an activity like tailoring, which is not very difficult to learn, requires time and practice before it can be safely relied upon as a livelihood option. “Some women lost motivation as they couldn’t see immediate financial benefit,” says Gutta.
In addition to the attrition challenge, the Kriti team was unable to develop market linkages for its chosen livelihood activities, given the long lead times between training and income generation. Declining participant numbers only exacerbated the already long manufacturing times. It was not feasible to develop the business relationships that could have taken the activities of these women to the next level and ensure a steady supply-and-demand stream.
Vaaradhi’s healthcare component was more successful. The Kriti Health Center was set up in the Film Nagar slum whereby it is always staffed with one qualified physician, one clinic manager and three health care workers, as well as regularly visiting specialists. The clinic was stocked with popularly needed generic medications, which were dispensed as per the doctor’s prescription. The price of a doctor’s consultation was INR 20 (US$0.45). The other part of Vaaradhi’s healthcare component, healthcare education, was also successful and included modules on women’s reproductive health, pre- and post-natal care, child health, nutrition, hygiene, vision care and emergency care.
What were the challenges then? “The terrain of the Film Nagar slum affected the healthcare intervention,” answers Gutta. “The clinic was not accessible to all the houses in the slum resulting in [a] lower number of patients.” Because there are multiple entry and exit points in Film Nagar, it was difficult to guarantee that there would be enough pedestrian traffic near the clinic to grab the attention of future patients.
Going Forward
The Vaaradhi pilot concluded earlier this year, and with its close, there are clear lessons on how to implement a successful ultra poor initiative. With regard to livelihoods, Gutta notes that it is essential to incentivize participation. For example, had Kriti provided a small stipend during the training period – which BRAC does – this may have kept motivation levels up and the attrition level down. “You have to show [the poor] the benefit of this training now,” Gutta emphasizes. “If the benefit is perceived as too far into the future, [these initiatives] won’t succeed.”
More than that, the issue is about giving people the necessary skills to improve their livelihood options. “[The] government has made a start by setting up the National Skill Development Corporation,” Gutta goes on to say. “[There is need] to train people in the slum and provide them with a stable job.”
The lessons learned from Vaaradhi’s healthcare component boil down to location. Kriti was able to nurture the Film Nagar’s community interest and trust over several months, but that relationship-building did not automatically mean that people would come to the Kriti Health Center to meet their individual healthcare needs. “The location of a clinic is important.” As for the government’s role in healthcare delivery to the poor, Gutta has this to say: “[The government] needs to adequately staff public health clinics and ensure they have the necessary drugs. And it needs to drive away the ‘quacks’ and other unqualified practitioners.”
The opinions expressed on the Searchlight South Asia site are solely those of the authors and do not necessarily reflect the positions of the Rockefeller Foundation.
Sources:
http://www.citypopulation.de/world/Agglomerations.html
http://www.ghmc.gov.in/cdp/chapter%205.pdf
