The urban poor population of India is rapidly increasing, has health indicators that are   similar to or worse than those in rural populations, and faces a per capita availability of public primary health care services that is much lower than in rural areas. India’s urban population was 17% of the total in 1950, 25% in 1990 and 28% in 2001. However, this apparent slow pace of urbanization is misleading, as the urban population has grown at a high rate in India , just not at a rate dramatically higher than growth in rural areas. There are indications that this is changing with the current growth being a 2-3-4-5-6 phenomenon: all- India growth is about 2% per year, urban India 3%, megacities 4% and slum areas 5 to 6% per year. The urban poor currently constitute 25% of India ’s poor.  

USAID/ India Evaluation Document  

EHP-UHRC has been particularly effective in advocacy efforts at the local level and identifying “urban health champions” that have had the ability to influence and commit to

an urban health agenda. In Indore , EHP-UHRC worked closely with the recently elected mayor who remains committed to urban health and continues to work with the project. Officials from the Municipal Corporation in Indore and the Chief Medical Officer in

Agra both expressed their satisfaction and continued desire for EHP-UHRC’s technical assistance and coordination.  

4.0 Recommendations for the Future

The team considered several areas for recommendations within the overall framework of the questions listed in Section 2.0, including:

·  a revised Urban Health Results Framework; ·  the relative roles of technical assistance, technical leadership activities, and city demonstration and learning activities;
·  recommendations for city-based demonstration and learning activities; 
·  the niche for urban health within PHN and USAID 16 
·  the role of public-private partnerships 
·  organizational development of the Urban Health Resource Centre;
·  complementary mechanisms to support USAID urban health programs, including linkages with USAID/Washington programs;
·  USAID management, including considerations of flexibility; 
·  monitoring and evaluation; and 
·  additional activities to support urban health program development.

4.1 A Revised Urban Health Results Framework

The evaluation team felt that a revision of the results framework is required to guide future strategic development of USAID/ India ’s  urban health program. The draft results framework presented here is based on the team’s evaluation findings, recommendations, and guidance from the USAID/ India PHN office. Specifically, guiding principles for developing the results framework and recommendations for the urban health strategy included: 
·  USAID’s resources for India vis-à-vis the government and the magnitude of the target population are relatively small. Therefore, direct service delivery is not a strategic use of scarce resources or a means to achieve health impact for the urban poor on national or state level. Therefore, any direct service delivery components must have a defined strategic purpose such as demonstration models or pilot projects from which lessons learned can be drawn or policy and resource allocation decisions influenced. 
·  Technical assistance and support in the health sector must be designed to influence policy at scale and leverage other resources, e.g. RCH 2. 
·  Proposed interventions, demonstration projects, research, capacity building activities must be designed with an intent and ability to be scaled up. 
·  The urban health program strategy should be designed to work through and strengthen local India n institutions in both the public sector and private sector. 
·  Sustainability and a clear exit strategy is a primary consideration in the development of the urban health program strategy.

The team proposes the following urban health program objective:

Improved Health and Nutrition of Underserved and Poor Women and Children in Urban Areas 
with two supporting results and a common sub-result, depicted in the results framework below: 17

Urban Health Strategy Results Framework 
To date, the urban health program has focused exclusively on a select basket of child survival interventions. These interventions included improved immunization coverage, ANC, improved community practices on home deliveries and neonatal care, nutrition education, and household hygiene practices for diarrhea prevention. The team recommends that the urban health strategy expand its mandate in the near term to include reproductive health, a full package for maternal and child health, and nutrition. This  recommendation is based on several factors:

·  Needs in urban slums: The health needs of women and children in poor urban areas are comprehensive and include, at a minimum, reproductive health and family planning, diarrhea prevention and treatment, ARI treatment, and combating malnutrition. Nutrition is explicitly stated to highlight that it is managed by a separate GOI agency—ICDS, not the Ministry of Health and Family Welfare. Although the EHP-UHRC implementation to date has been successful in linking target beneficiaries to some of these services, the project did not explicitly measure impact or coverage in these areas. Expanding the technical intervention focus to include RCH 2 interventions as well as nutrition would be expected to have a greater impact on reducing morbidity and mortality among women and children. 

·  Scope of RCH-2: The EHP-UHRC has been highly successful at positioning its role in supporting the national government to implement RCH-2 in poor urban areas.