NB Health Care
Targeting the Urban Ultra Poor: Taking The Road Less Travelled
Editor’s note: Continuing our series (past posts may be found here and here) showcasing the challenges faced by practitioners in developing non-traditional poverty alleviation programmes for the “ultra poor,” this post looks at an organization focused on new innovations for urban ultra poor.
In India, the urban population has grown from 78.9 million in 1961 to 286 million in 2001 and is estimated to double in the next 25 years. This has led to the exponential growth of slums in many cities and towns. Most migrants come to the city in search of opportunity and a better life. Far too many find neither and become one of the millions living without basic services in the country’s slums. Apart from the problems of education, health, and livelihoods that most ultra poor face, those in urban areas have the additional burden of housing and shelter, sanitation, and social security. To give these people a better standard of living and a stable lifestyle, it is critical to develop interventions specifically targeting the urban ultra poor.
To help those urban poor that are left out of microfinance programs, Kriti Social Initiatives (Kriti) was founded in 2009 as a not-for-profit enterprise working with the urban poor in Hyderabad.
Traditionally, development practitioners targeting the ultra poor have focused on rural populations. One proven model is the BRAC graduation model (profiled here and here), an approach that combines subsidy in food security and housing with longer term benefits like job training, financial literacy, and livelihood development. However, the BRAC graduation model is particularly targeted toward rural ultra poor households.
While most rural ultra poor pilots lead with interventions in asset transfer and food security, the Kriti team had to adapt its pilot to suit urban populations. Based on learnings from other ultra poor pilots and through field research, Kriti determined that it was essential for the pilot to include program components addressing livelihoods and healthcare. These became the primary interventions of the Vaaradhi pilot, and were supplemented by additional interventions in financial literacy and supplemental learning. The team realized that even interventions like healthcare and financial literacy – common between urban and rural pilots – needed the necessary fine-tuning to make them relevant for urban populations. Let’s take a look at the approach that Kriti took in adapting these interventions for the urban setting and the challenges that it faced.
One of the most critical decisions that Kriti had to make while designing the Vaaradhi pilot was location. This has a large impact on the targeting and selection process, as well as on the overall success of the pilot. The Kriti team had to decide whether to work in a notified slum or a non-notified (illegal) slum. The team knew they would be more likely to find ultra poor populations in a non-notified slum, but residents in these areas are under constant threat of eviction and therefore have much more transient populations. Ultimately, the team chose to work in the notified slum of Film Nagar in Hyderabad, perhaps compromising the level of poverty that they could target for their interventions but ensuring that beneficiaries would not leave in the middle of the program.
The bulk of urban ultra poor are engaged in the informal sector with sporadic employment and low wages. They often lack both the skills and opportunities to enter the formal sector. The goal of this component of the program was to enhance household incomes by providing training in various activities that could supplement the income of the family’s primary earner. Since most of the primary wage earners were men, Kriti developed its livelihood activities to target women. The livelihood activities were: 1) flexible and home-based, 2) low-skill (easy to learn), 3) feasible in small spaces, and 4) able to generate adequate income.
Most of the activities including agarbathi (incense sticks) rolling, paper bag making, tailoring, and basic goods for retail, saw beneficiaries drop-out either during or immediately after the training. This lack of interest was due to long training periods, and lack of sufficient or timely income generation after the training period. The cost of living and need for cash is higher in urban areas when compared to rural places. It is critical that market linkages for the activities are established before the project begins so that there is no delay in generating income once the beneficiaries are trained.
“There are significant challenges in identifying suitable livelihoods for urban areas. In most rural ultra poor programs many beneficiaries receive livestock transfer to help generate income. For urban livelihoods, especially in a settled slum, there is little scope for livestock,” said Himani Gupta, co-founder of Kriti.
Here, too, the rural model of providing healthcare had to be altered to fit the needs and challenges of an urban population. In rural areas, long distances that must be travelled to arrive at clinics, and the opportunity cost associated with the loss of a day’s work drive the delivery model. Thus, rural models focus on delivering medical advice using technology like telemedicine and health workers stationed in the village. However, since Film Nagar was located in Hyderabad, access to doctors and clinics was not the biggest obstacle. Instead, the challenge was to create a model where slum dwellers had affordable access to physicians and specialists in the area where they lived.
To provide affordable, accessible, and high-quality healthcare to beneficiaries of the program, Kriti set up a healthcare clinic called Kriti Health Centre (KHC) within the Film Nagar slum. The main goal of the KHC was to provide a large number of slum dwellers (not just the selected beneficiaries) with access to trained healthcare professionals in an effort to provide preventive and curative health care, raise awareness on health and hygiene issues, and improve quality of life. Patients of KHC received detailed attention and a standard of care similar to that of any private institution. The team also leveraged the existing government and NGO initiatives to benefit the people.
” Initially, the clinic saw fewer footfalls even though people around the slum acknowledged the quality and affordability of the service. However, as people started seeing us for a while, they started trusting the service and visited the clinic regularly,” said Aparna Vishwanatham, Kriti co-founder.
Although there are important learnings from other program interventions – financial literacy and supplemental learning – these interventions, along with other details of the pilot, will be covered in a case study on Kriti set to be released later this month.
Although rural poor currently exceed the number of urban poor in India, those populations are expected to be equal by 2030. It is therefore imperative upon fellow practitioners to develop innovative approaches for the urban ultra poor. In the absence of innovation, millions of these people will continue to live in destitution and without any hope for a better future. Together we all need to collaborate to convert our dream of “achieving significant improvement in the lives of at least 100 million slum dwellers” into a reality.
- Health Care