The USAID/India Urban Health Program:
An evaluation of activities to date and 
recommendations for the future
OCTOBER 2005
This publication was produced by a USAID team with representation from USAID/India, the Bureau
for Global Health, the Bureau for Asia and the Near East, and the USAID BASICS and Environmental
Health Projects.
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Table of Contents
List of Acronyms
The Evaluation Team
Acknowledgments
Executive Summary
1.0 Background 
2.0 Purpose, Methodology, and Questions for Evaluation 
3.0 Findings
3.1 Technical assistance to the GOI
3.2 Technical assistance to States and cities
3.3 City demonstration and learning activities
3.4 Increased urban health knowledge for advocacy and planning
3.5 Urban Health Resource Centre capacity to support USAID and GOI objectives
3.6 Public-private partnerships
4.0 Recommendations for the Future
4.1 A revised Urban Health Results Framework
4.2 Relative roles of technical assistance, technical leadership, and city-based 
demonstration and learning activities, and 
4.3 City-based demonstration and learning activities
4.4 Niche for urban health within PHN and USAID
4.5 Role of public-private partnerships
4.6 UHRC organizational development
4.7 Complementary mechanisms to support USAID urban health programs
4.8 USAID management 
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4.9 Monitoring and evaluation
4.10 Additional activities to support urban health program development 
5.0 General Lessons Learned in Urban Health Programming
Bibliography
Annex 1: Contact List 
Annex 2: Evaluation Team Scope of Work
Annex 3: EHP-UHRC March 2005 staffing pattern
Annex 4: Presentation of initial findings to Mission staff, 18 March 2005
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List of Acronyms
ANM Auxiliary Nurse Midwife
AID/W USAID Washington
ANC antenatal care
ANE Asia Near East
APAC AIDS Prevention and Control Project
ARI Acute Respiratory Infection
AWW Anganwadi Worker
BASICS Basic Support for Institutionalizing Child Survival Project (USAID)
BCC Behavior Change Communication
BGH or GH (USAID) Bureau for Global Health
CBO Community Based Organization
CDM Camp Dresser & Mckee
CII Confederation of Indian Industry
CMO Chief Medical Officer
CSH Child Survival and Health
CTO Cognizant Technical Officer
DFID Department for International Development (UK)
DUDA District Urban Development Authority
EAG Empowered Action Group
EG Economic Growth
EGAT Economic Growth, Agriculture, and Trade
EHP Environmental Health Project (USAID)
EPI Expanded Program on Immunization
FCRA Foreign Contribution (Regulation) Act
FHI Family Health International
FICCI Federation of Indian Chambers of Commerce and Industry
FIRE-D Financial Institutions Reform and Expansion Project (USAID)
GOI Government of India
HIDN Office of Health, Infectious Diseases, and Nutrition (USAID/GH)
HIV/AIDS Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome
IAP Indian Academy of Paediatrics
ICDS Integrated Child Development Services
ID infectious diseases
IEC Information, Education and Communication
IFPS Innovations in Family Planning Services
IndiaCLEN India Clinical Epidemiology Network
IQC Indefinite Quantity Contract
IRMS Institute for Research in Medical Statistics
IT information technology
JBIC Japan Bank for International Cooperation
LHV Lady Health Visitor
M&E monitoring and evaluation
MCD Municipal Corporation of Delhi
MCH Maternal and Child Health
MCHUH Maternal Child Health and Urban Health (Division, USAID/India)
MOHFW Ministry of Health and Family Welfare
MOHRD Ministry of Human Resource Development
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MOUD Ministry of Urban Development
NACO National AIDS Control Organization
NFHS National Family Health Survey
NGO Non-Government Organization
NNF National Nutrition Foundation
NRHM National Rural Health Mission
OB/GYN Obstetrics and Gynecology
OD Organizational Development
OR operations research
ORS/ORT Oral Rehydration Solution/ Oral Rehydration Therapy
PACT-CRH Program for Advancement of Commercial Technology - Child and 
Reproductive Health 
PATH Program for Appropriate Technology in Health
PHC primary health care
PHN Population, Health and Nutrition
PHR Partnership for Health Reform
PMTCT Prevention of Mother-To-Child Transmission
PPP Public Private Partnership
PSI Population Services International
PSP Private Sector Program
PVO Private Voluntary Organization
RACHNA Reproductive and Child Health, Nutrition and AIDS Program
RCH Reproductive and Child Health (national program)
RUDO Regional Urban Development Office
SIFPSA State Innovations in Family Planning Services Project Agency
SO Strategic Objective
SOW Scope of Work
SUDA State Urban Development Authority
TA technical assistance
TB Tuberculosis
TBA Traditional Birth Attendant
UH Urban Health
UHP Urban Health Program
UHRC Urban Health Resource Centre
ULB Urban Local Body
UNICEF United Nations Children’s Fund
UP Uttar Pradesh
USAID United States Agency for International Development
WHO World Health Organization
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About the Evaluation Team
John Borrazzo is the Environmental Health Team Leader in the USAID Bureau for 
Global Health in Washington. He also served as team leader for the evaluation team.
Sonali Korde is a USAID Senior Technical Advisor based in Washington, specializing 
in private sector roles and partnerships in public health.
Dan Kraushaar was Director of the USAID BASICS III project, at the headquarters 
office in Arlington, Virginia, at the time this evaluation was undertaken. 
Rajiv Tandon is the Senior Advisor for Child Survival in the Division of Maternal and 
Child and Urban Health, in USAID/India’s Population, Health, and Nutrition Office.
Lehar Zaidi was a short-term Environmental Health Project / Urban Health Resource 
Centre consultant.
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Acknowledgments
The team is particularly grateful to Dr. Siddharth Agarwal of the Environmental Health 
Project / Urban Health Resource Centre for his time, frankness, and attentiveness to the 
team’s requests for clarifications and documentation. The EHP/UHRC team provided 
tremendous assistance in organizing and making available key documents, as well as in 
the preparation of summary presentation material and in discussion.
We thank all of those with whom we spoke for meeting with the Evaluation Team and 
providing their insights and perspectives. In particular, we appreciate the active interest 
and time of Mr. Prasanna Hota, Secretary for Health and Family Welfare, Ministry of 
Health and Family Welfare.
The Background section was largely drawn from the Scope of Work prepared by Dr. 
Massee Bateman, Chief of the Maternal and Child Health and Urban Health Division, of 
USAID/India, who was also very generous with his time in working with the evaluation 
team and in providing helpful insights into the history, current performance, and future 
directions of the USAID/India urban health program.
Finally, the team thanks all of those not already named in the GOI, State and municipal 
governments, non-governmental organizations, international partners, and USAID/India 
staff at all levels for their time, inputs, and feedback on this evaluation.
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Executive Summary
To meet the health challenges faced by the rapidly growing urban poor population in 
India, and based on strategic planning decisions made in 2000-2001, USAID/India 
launched a new Urban Health Program (UHP) activity in March 2002. While other PHN 
activities contribute to UHP objectives, such as the urban components of USAID 
activities in HIV/AIDS, TB, polio, or social marketing, initial UHP implementation has 
primarily been through the USAID Environmental Health Project (EHP), scheduled for 
completion at the end of October 2005. In preparation, the EHP Delhi office began the 
transition of becoming a not-for-profit NGO, the Urban Health Resource Centre 
(UHRC).*
USAID's original objectives for the urban health program have evolved considerably 
since the 2002 launch. These changes primarily reflect the active engagement of and 
partnerships with the GOI Ministry of Health and Family Welfare in the program. This 
has led to the wholesale integration of the assistance provided by the EHP-UHRC into the 
Ministry's plans and activities under the second phase of the GOI Reproductive and Child 
Health project (RCH-2).
At this critical programmatic juncture, USAID/India decided to solicit a fresh look at its 
UHP activities to date, partly from an evaluation perspective but mainly to provide 
forward-looking thinking for possible future program directions. A five-person 
evaluation team, consisting of a mix of USAID/W, USAID/India, and contractor 
personnel, undertook this evaluation and design exercise from March 7-18, 2005, visiting 
field sites and policy-level organizations and individuals as well as the current 
implementing partner, EHP.
There are three principal lines of work in the current scope of the EHP-UHRC￾implemented activity:
· building knowledge for advocacy to the GOI, States, cities, and other stakeholders 
(e.g. NGOs and the private sector, communities); 
· providing technical assistance to the GOI, States, cities, and other stakeholders; 
and 
· developing city models to enhance programs.
 
*
The naming and branding of the EHP office is in flux, changing from “EHP” to “Urban Health Resource 
Centre (UHRC).” This change is about more than just a name, but rather reflects the evolution of this 
institution from a local USAID project office to an independent Indian NGO. The team has recommended a 
period of co-branding to take advantage of the recognition and existing brand value of “EHP”, while 
allowing the “UHRC” to begin to be recognized. In this report, we have attempted to reinforce this by 
using “EHP-UHRC” throughout, which also reflects this report's dual nature in looking backwards at EHP 
as well as looking forwards towards UHRC. “UHRC” is also used in this report and is equivalent to “EHP￾UHRC”. The term “Urban Health Program” or “UHP” is used occasionally in this report to refer to the 
broader USAID program and objectives in urban health, which go beyond support for and working through 
EHP-UHRC, though this area of activity dominates.
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In 2003, EHP organized the first national consultation on urban health, working with 
government and non-governmental stakeholders. In 2004, EHP-UHRC was designated 
as the nodal agency for urban health by the Ministry of Health and Family Welfare. In 
summary, the current position of the Urban Health Resource Centre appears to very 
strong in ongoing advocacy and technical assistance at all levels.
Through review of written materials, background briefings by EHP-UHRC, key 
informant interviews, and field visits to sites in Indore and Agra, the evaluation team 
broadly considered the roles within USAID’s urban health program of:
· support to the GOI;
· technical assistance to states and cities; 
· city demonstration and learning activities;
· generation and use of urban health knowledge for advocacy and planning; and
· building Urban Health Resource Centre capacity to support USAID and GOI 
objectives in urban health.
Overall, the team had a positive impression of the accomplishments of the EHP￾UHRC-implemented component of the Urban Health Program to date. Considering 
the relatively short timeframe since activity inception, there has been significant progress 
in advocacy and policy development, as well as in the demonstration of practical 
operational models for both implementation and technical assistance at city level.
EHP-UHRC has proven itself to be very effective in supporting USAID’s objectives 
in urban health, particularly in the programmatic mode which has dominated, namely to 
use very limited USAID resources to influence the much larger expenditures by the GOI 
under the RCH program. 
The evaluation team made the following key recommendations:
Focus future USAID support on achieving two key results: better targeted policies 
and increased allocation of resources to improve the health of the urban poor; and 
improved program approaches at municipal level. The role of city demonstration and 
learning activities would be to support these results, not achieving city-level health 
impact as an end in itself.
Support technical assistance at city, state, and national levels; city demonstration 
and learning activities; and technical leadership activities (e.g. conferences and 
publications), since all three are important legs to support USAID/India urban health 
objectives. The emphasis in terms of level-of-effort and funding should be first on TA, 
second on technical leadership, and third on city demonstration and learning 
activities, although it is important to maintain flexibility to adjust this balance to adapt to 
any changing circumstances at the policy level which may arise.
Focus UHRC technical assistance at the State level, which can link resources available 
at the center to the needs of the municipalities. UHRC TA needs to be coupled to 
sufficient capacity at the recipient end (i.e. State level) to be effective, and USAID 
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should consider how best to support increasing this capacity (probably by placing long￾term UHRC advisors at the State level, although the sustainability of this approach was of 
concern to the team).
At all levels, the UHRC should diversify the partners with whom it works, moving 
beyond RCH-2 to include ICDS, the Urban Development Authorities (SUDA and 
DUDA), and NGO or parastatal platforms such as CARE or SIFPSA. While UHRC has 
undertaken limited efforts in such outreach to date, building such partnerships will in 
some cases require considerable advocacy for the urban health agenda. The focus should 
be on developing long-term mutual commitments to this agenda, with UHRC providing 
technical assistance.
City demonstration and learning activities should be focused on cities with distinct 
socioeconomic, environment, or health characteristics or that present a special 
policy, leveraging, or learning opportunity. Where it becomes involved in operational 
aspects of urban health programs (such as in the current efforts in Indore), the UHRC 
should enter into such arrangements with a clear exit strategy laying out its level of 
support, the timeline within which it will be involved, and how quickly and in what 
manner it will reduce its inputs.
UHRC should place emphasis on mining existing program experience for best 
practices, tools and methods. The UHRC has the opportunity to identify and work with 
organizations, projects and programs that already exist on the ground but lack technical 
focus, effective programmatic approaches, appropriate or proper evaluation. Effective 
models can probably be built from these “platforms” more quickly than creating new 
city-level activities. As a line of work, the UHRC should aggressively identify these 
platforms and work towards influencing their health content and approaches.
The ward coordination model appears to be a viable approach for achieving greater 
scale, at least as implemented in Indore, including dimensions of both population 
addressed and the range of service which can be effectively and cost-effectively 
delivered. Further evaluation of the inputs required for given outputs is required, 
however. In contrast, the NGO/CBO model approach appears to not to be scaleable and 
should not be further evaluated.
Continue to focus on maternal and child health but improve links to and 
coordination with other USAID-supported health activities, especially in reproductive 
health, HIV/AIDS, TB, and malaria.
Improve internal Mission communication and coordination between PHN and EG
on urban health issues, but focus these on a limited set of issues. These include: 
potential investments by JBIC that could relate to urban health, the development of the 
Agra City Development Strategy, and possible water and sanitation activities under 
FIRE/D in Agra and Madhya Pradesh.
Exploit opportunities to provide technical assistance to UHRC from USAID projects 
already on the ground in the India on other short- or long-term activities (e.g. BASICS). 
Specific TA requirements will need to be defined in dialogue with UHRC, which was 
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beyond the scope of this evaluation, and this will allow USAID to effectively leverage 
these opportunities.
UHRC should comprehensively and systematically catalogue other urban health 
activities, with a focus on identifying critical success factor and constraints, particularly 
for city-based efforts.
UHRC should remain the key implementing partner for USAID’s Urban Health 
Program. Complementary support to urban health cells at the GOI central and State 
levels is also required, but would best accomplished through UHRC-supported long-term 
consultants.
Track key UHRC organizational development and technical capacity-building 
issues which need to be addressed before UHRC can be a successful independent NGO, 
including: branding issues; broadening of management capacity; improved definition of 
the roles of Delhi-based and city-level UHRC staff; and technical capacity.
UHRC needs to have more clearly defined and reported indicators for inputs, 
process, and outputs/outcomes. Current reporting does not concisely communicate 
clear messages about what is being accomplished. There needs to be continued 
emphasis on strengthening the evidence base that the guidelines and approaches 
advocated by UHRC “work” – i.e. have public health impact at manageable cost and are 
sustainable. Building this capacity within UHRC will not result from a few technical 
assistance visits by an external contractor. Rather, it is likely that some kind of strategic 
partnership over the long term with another organization with more experience in 
monitoring and evaluation will be required. 
UHRC needs to develop clear “how-to” modules at central, State, and municipal level 
for the GOI-issued urban health Guidelines. A process to connect UHRC’s growing body 
of experience to continual refinement and improvement of the Guidelines and modules 
needs to be in place.
Though the UHRC has done a commendable job of documenting its city-level work to 
date, the UHRC should make sure that documents communicate effectively, are 
targeted well, and are as short and concise as possible. Recognizing that 
documentation is expensive, in the future, more attention could be placed on the “how￾to” modules, on results of monitoring and evaluation activities, and on advocacy pieces, 
with less emphasis on documenting inputs and processes.
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USAID/India should consider channeling its support to UHRC through a 
cooperative agreement mechanism, rather than a contract, since the way that USAID 
has tended to work with this partner is more reflective of a cooperative agreement rather 
than a contractual relationship, especially in light of the desired advantages of ongoing 
flexibility. Central Leader with Associate cooperative agreements may be helpful, 
perhaps with initial support with field support to an AID/W Leader award “graduating” to 
a Mission-based Associate award.
Public-private partnerships (PPP) should receive greater emphasis in UHRC 
program support. PPP were expected to be significant components in urban health 
programming by all stakeholders, and there is a high demand for technical assistance in 
this area. The evaluation team recommends that UHRC build upon existing 
infrastructure and facilitate partnership between the municipal corporation/district health 
office and the private sector rather than directly engaging in service delivery PPP, e.g. 
contracting out models or franchises. In addition, there are numerous larger initiatives on 
PPPs that are currently underway within the RCH-2 implementation plan and the 
USAID/India PHN office. Therefore, the team recommends that the urban health 
program strategy and UHRC coordinate with these efforts, leveraging existing resources 
to the fullest extent possible.
The team also identified several key gaps which require further investigation and thinking 
but were beyond the scope, available time, or timeframe for this evaluation, including:
· A detailed evaluation from a public health perspective of the initial city proposals 
which were developed using the EHP-UHRC guidelines, with recommendations 
for revision of the guidelines, including their application, as necessary.
· Including consideration of the health systems issues for the urban poor being 
explored by PHR under an ANE Bureau and EGAT/Urban Programs comparative 
analysis in Indore and Manila.
· Exploring links to microfinance institutions, self-help groups, etc.
· Tightening linkages to address environmental sanitation, water supply, and 
hygiene issues as part of the urban health planning process, and developing viable 
solutions to these critical issues.
· Conducting a cost-effective analysis of the ward coordination model, using best 
estimates of public health impact.
· Identifying TA needs of UHRC and developing a plan to help meet these needs.
· Establishing criteria for city-level TA support and cataloging likely candidate 
cities.
Each of these is recommended for follow-up action by USAID/India.
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1.0 Background 
This document is the product of a USAID and USAID contractor team tasked with a 
“forward-looking” evaluation of the urban health program supported by USAID/India 
since 2002. This is not an oxymoron. Rather, the approach has been to use lessons 
learned from what has taken place to date, set these within the context of the current 
policy and program environment faced by USAID, and provide recommendations on how 
best to proceed in the future. The focus of the evaluation was the Urban Health 
Resource Centre, based in New Delhi, which has been supported through a USAID 
contract, the Environmental Health Project, since its inception. The program that 
USAID supports as well as the national programs with which USAID interacts have 
evolved significantly over this period, and continue to do so. These developments as 
well as the motivations and objectives of the program are described in this background 
section.*
Historically, India has largely been a nation 
of rural villages, but that situation is rapidly 
changing. Considering the burgeoning 
population and attendant public health 
burden of the urban poor, USAID/India 
developed and implemented a strategy to 
address the health needs of the urban poor in 
India. Public health programs in India, 
either supported by the central government, 
state governments or external assistance 
agencies, have primarily targeted rural 
populations. The authorities for assuring 
basic health services for urban populations 
are complex, a situation that has resulted in 
inconsistent and generally very low levels of 
public primary health care services in cities. 
Much care is provided by private providers, 
who are often unqualified and provide poor 
quality services. Preventive services are 
generally weak. Poor environmental 
conditions, especially sanitation, are a 
hallmark of urban slums and the living 
conditions of the urban poor. The result is a 
population with poor access to quality 
services and poor health indicators. 
Recognizing the emerging importance of the health of the urban poor in India, 
USAID/India developed a new activity to develop experience in this area and to provide 
the basis for further development of a longer-term program. A team developed the first 
USAID/India Child Survival Strategy in late 2000. This strategy identified four 
 
*
 The audience for this document is primarily intended to be internal to USAID. Nevertheless, it 
is expected that USAID’s development partners in India may also find it valuable.
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.
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intermediate results, introducing urban health into the USAID/India portfolio for the first 
time. The four intermediate results were:
I.R. #1: Improved nutritional status for children under three years of age
I.R. #2: Improved health and survival of newborns 
I.R. #3: Reduced morbidity and mortality from the major childhood illnesses in 
older infants and children under five
I.R. #4: Improved child health and nutrition among the urban poor 
Following the identification of improved health and nutrition of children among the urban 
poor as a result under the 2000 Child Survival Strategy, a team developed an urban health 
strategy to guide the development of this new area of work. This strategy was drafted in 
June 2001 and stated the following goal and objectives:
“The broad goal of USAID/India’s Urban Health Program (UHP) is to improve the 
health of the slum dwelling urban poor in selected areas of India. To accomplish this, 
the mission has identified the following four objectives:
· Effective community-based programs: Improve health in selected urban poor 
communities by linking community level activities to existing municipal and private 
sector systems;
· Improved municipal planning: Address the needs of the urban poor through better 
use of essential information and reform of health systems;
· Pro-poor policies: Support the development and adoption of policies that overcome 
obstacles and enable improved health of the urban poor; and
· Advocacy for urban health: Increase the attention given to improving the health of 
the urban poor at the community, municipal, state, and national levels in India and 
within USAID.”
This strategy set forth initial target cities (Ahmedabad and Indore), details of each 
objective including problems to be addressed, USAID’s role, organizational 
arrangements and a draft workplan. The initiation of the activity was hampered by 9/11, 
delay in successfully recruiting a chief of party, and at the last minute, outbreak of 
communal violence in Ahmedabad. The latter led to travel and work restrictions and 
ultimately to Ahmedabad being dropped as the first city program.
In practical terms, this program began activities on 15 March 2002 when Dr. Siddharth 
Agarwal joined as country representative of the USAID Environmental Health Project 
(EHP), through which the main components of the Urban Health Program were 
implemented through October 2005, and a project office was opened soon thereafter, now 
the EHP-Urban Health Resource Centre (UHRC). Initial city-level activities began in the 
city of Indore.
The USAID urban health program, as reflected in the EHP-UHRC mission statement, 
aims to “improve child health and nutrition among the urban poor in selected cities by 
providing technical assistance to improve newborn care practices, coverage of 
immunizations and control of diarrheal diseases, prevention of malnutrition, and 
sanitation and hygiene practices.” 
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The objectives of the USAID-funded EHP-UHRC program through October 2005 are:
· Increased coverage of services and adoption of key health behaviors in neonatal 
survival, diarrheal disease control and other reproductive and child health priorities;
· Improved capacity of CBOs, NGOs, private and public sector health providers in 
health behavior promotion, use of health data, and building partnerships;
· Better targeted policies and increased allocation of resources to improve the health of 
the urban poor;
· Development of replicable models for urban child health programs and use of these 
models in other GOI activities, such as the Reproductive and Child Health (RCH-2) 
program of the GOI;
· Institutionalization of a non-for-profit independent Indian non-governmental 
organization focused on providing technical support to municipalities, States, and the 
GOI on urban health issues, i.e the Urban Health Resource Centre.
Over the past three years, the USAID/India program environment has continued to 
evolve. The former USAID South Asia Regional Urban Development Office (RUDO) 
was dissolved, and an urban development focus within the USAID/India Office of 
Economic Growth was created. Within PHN, there is an increasingly strong emphasis on 
PPP and working with the national RCH program. 
Within the GOI, there is a new urban health focus area within the national RCH program. 
The second phase of this program began on 1 April 2005 with an overall funding level of 
about $1.8 billion/year.
*
 The current Secretary of Health and Family Welfare has a 
special interest in the health of the urban poor and has been a strong supporter for 
inclusion of activities throughout his program, particularly within RCH, to better address 
these needs. This has led to a very sharp increase in demand for EHP-UHRC technical 
assistance services, and further increases are anticipated. 
2.0 Purpose, Methodology, and Questions for Evaluation 
To provide direction for future USAID/India investment in urban health, USAID/India 
requested a five-person evaluation team to assess the effectiveness to date of the program 
approaches used in implementing the Urban Health Program. The team, comprising 
specialists from different disciplines (child health, environmental health, health systems, 
and public-private partnerships) included both Washington- and India-based USAID and 
USAID project staff.
 
*While this evaluation was underway, the GOI elevated the political status of RCH by folding its objectives 
into the new National Rural Health Mission. Despite the name, the focus of this new initiative is on all the 
poor without access to adequate health services, not exclusively those in rural areas.
4
The team used interviews with key stakeholders, examination of key documents, 
extensive interaction with the EHP-UHRC team, including an extensive background 
briefing, and site visits to Indore and Agra to inform these recommendations. 
Stakeholders from the Indian government side were at all levels, including national level 
Ministries, State bodies, and municipal health officials. Other key informants were 
drawn from USAID and from international partners, including local representatives of 
intergovernmental organizations (e.g. World Bank, UNICEF) as well as other donors 
(e.g. DfID). A list of contacts made is attached as Annexes 1.
Early in the process, agreement was reached with USAID/India on a set of key questions 
to be addressed in guiding the recommendations of the evaluation team:
1. How should the main strategic elements of the urban health program be 
formulated? What are the primary results and indicators that should be tracked to 
measure performance? 
2. What should be the technical breadth and links of the program within the PHN 
portfolio, e.g. IFPS, PACT/CRH, CARE, etc? 
3. What nature and process for collaboration with other offices within USAID/India 
are recommended?
4. What linkages with USAID/W programs are recommended? 
5. What is the strategic niche for the USAID urban health program vis-à-vis other 
stakeholders, including government, development partners, NGOs, private sector? 
6. What is the strategic role within the overall program and proportionate level of 
effort to be applied in each of the following areas:
a. technical assistance at city, state, and national levels? 
b. city demonstration and learning activities, including recommendations on 
how many cities and the character (e.g. size, location, level of 
industrialization) of cities in which such programs be implemented? 
c. technical leadership activities, e.g. operations research, publication of 
technical papers, consultations and conferences, and support to resource 
centers? 
7. What are the recommended mechanisms to support these activities? Specifically, 
what activities can best be supported through the Urban Health Resource Center, 
and what activities may be supported through other mechanisms? 
8. What are the requirements for support for the organizational development of the 
Urban Health Resource Center – both from a strict OD point of view and from a 
technical capacity building point of view? What are the recommended 
mechanisms to support these activities? 
9. What options are recommended to maintain and manage flexibility, where it is 
required? 
10. What additional important activities can be recommended to inform the 
development of the urban health program – evaluations, analyses, research, 
tracking evolution of specific government programs and policies, and so on? 
Additional questions pertaining specifically to the evaluation of past performance are 
included in the Scope of Work, Annex 2.
5
3.0 Evaluation Findings
The team’s findings are organized around the major lines of work to date, as follows:
· support to the GOI;
· technical assistance to states and cities; 
· city demonstration and learning activities;
· generation and use of urban health knowledge for advocacy and planning; and
· building Urban Health Resource Centre capacity to support USAID and GOI 
objectives in urban health.
In addition, the evaluation team looked at the current exploitation of public-private 
partnerships to support urban health activities.
3.1 Support to the GOI
EHP-UHRC has been identified by the GOI as the nodal technical resource agency in 
urban health, and as such assists the GOI directly in day-to-day consultations, support for 
an urban health technical cell within the Ministry of Health and Family Welfare
(MOHFW), regional dissemination and training workshops in the application of the 
national urban health planning guidelines, and related activities. Assistance in the 
development of national urban health planning guidelines, now adopted and published as 
policy of the GOI, was an important achievement. These guidelines incorporated many 
of the tools and methods developed in city-based programs, highlighting a role that these 
demonstration and learning activities play in providing credibility for EHP-UHRC 
support to the GOI.
Urban health emerged as a priority in Government of India policies and plans over the 
last five years. Financial resources were allocated by the MOHFW towards the 
development of city-wide Urban Health Projects under the Tenth Five-Year plan (2002-
2007). Following this, a collaborative relationship between the Government of India and 
EHP-UHRC evolved over the past three years on urban health programming issues, 
culminating in the EHP-UHRC nodal agency designation.
The first component of EHP-UHRC technical assistance to the GOI was a national 
consultation on “Improving the Health of the Urban Poor: Lessons Learned and the Way 
Forward” in June 2003. It provided a platform for governmental and non-governmental 
agencies to share experiences on urban health, to understand the strategies that had been 
effectively used in large-scale urban health programs in the country, and to identify 
challenges to wider adoption of these strategies.
Following this, EHP-UHRC worked with the GOI to identify several areas of activity to 
influence policy and program development at national and state levels. These included:
· Situational analyses using qualitative and quantitative research on health, 
socioeconomics, and stakeholders to identify gaps, critical implementers / 
decisionmakers, and priority interventions;
6
· Slum assessment and mapping to identify the vulnerable who did not appear on 
official lists of slums; 
· NFHS reanalysis of demographic trends, health conditions, and access to services to 
guide better targeted urban health programming;
· Preparation of baseline surveys at city level to guide intervention development;
· Follow-up surveys to gauge program outcomes and impact; and
· Collaboration with academic agencies (IRMS, IAP, NNF) to seek expertise and 
disseminate knowledge via journal publications and other respected channels.
These activities influenced the GOI national program in several ways:
ÿ GOI’s guidelines recommended that unlisted slums be identified and mapped and 
urban health proposals for four cities were developed to target unlisted slums.
ÿ The GOI established the need to focus urban health activities on EAG States, and 
more importantly, on poor and underserved urban populations in those States. 
ÿ The GOI directly applied the learnings from these activities to RCH II.
ÿ The GOI constituted an Expert Group on urban health.
The recommendations from the national consultation, ongoing proposal development 
activities, and learnings from urban health projects in select cities culminated in GOI 
issuance of Urban Health Guidelines to assist state governments in developing urban 
health proposals under RCH-II. EHP-UHRC additionally supported the GOI the 
development of sample state urban health proposals, organizing planning workshops for 
state governments and city authorities, and building capacity of state and local 
governments through regional workshops.
In summary, the team felt that EHP-UHRC TA to the GOI and the leadership activities 
advanced in partnership with GOI were valued and important in influencing the 
directions for urban health investment by the government. While the monitoring and 
reporting of the impacts of city-level activities have not been strong to date (see further 
discussion below), clearly the experience of working at city level provided the EHP￾UHRC was important to the quality, credibility, and influence of TA efforts. The theme 
of linkage of the city demonstration and learning activities to the TA and global 
leadership efforts undertaken by EHP-UHRC recurs as an important feature of the 
evaluation team’s examination of the work undertaken to date as well as the 
recommendations for the future.
3.2 Technical Assistance to States and Cities
The EHP-UHRC has rapidly developed into a respected technical resource for states and 
cities planning programs aimed at the health of the urban poor. In this capacity, EHP￾UHRC responded to requests from the government of Uttarhanchal to assist in 
developing urban health plans for three cities. Likewise it responded to a request from 
the GOI to assist four cities, one in each size class, in the development of model urban 
health plans for the national RCH program. To date, all Uttarhanchal plans and three of 
the GOI-requested plans have been completed. The program is assisting the state 
7
government of Uttar Pradesh in developing urban health plans for five cities, and has 
received a request from the government of Bihar for similar assistance. 
EHP-UHRC has directly provided technical assistance to the cities of Indore, Agra, 
Jamshedpur, Bally, and Dehra Dun to improve municipal planning for urban health, 
including improved capacity of CBOs, NGOs, private and public sector health providers 
in health promotion and service delivery, more effective use of health data, and the 
facilitation of partnerships amongst these various stakeholders to insure the connection of 
the most vulnerable populations to these efforts. The evaluation team had an opportunity 
to visit the city programs of Indore and Agra, which are the most advanced in terms of 
on-the-ground EHP-UHRC TA efforts, and the findings here are based on observations in 
these two cities and the examples of city-level proposals produced as part of the TA 
effort (and requested by the GOI as already discussed). 
EHP-UHRC has played an important role in 
facilitating broad-based, effective municipal 
planning to address the needs of the urban 
poor. One important manifestation of this 
assistance was the development of the RCH 
urban health proposals. EHP-UHRC’s 
technical assistance has also improved 
coordination for more effective service 
delivery. EHP-UHRC’s role has focused 
mostly on coordination, facilitation and 
development of the “Ward Coordination 
Model” in Indore (see also Section 3.3) and 
the “District Urban Health Center Model” in 
Agra. Both bring together a variety of 
stakeholders to address service delivery and 
improve service coverage (e.g. immunization) 
within a specific ward (the smallest unit of 
municipal administration). In Indore, for 
example, interviews with Ward Committee 
representatives revealed that EHP-UHRC’s role was catalytic in bringing together these 
disparate organizations to focus on underserved slums within Ward 5.
EHP-UHRC’s TA efforts were successful in engaging a wide range of stakeholders. 
Representatives on the Ward Coordination Committee included representatives from the 
Indore Municipal Corporation, Chief Medical Officer, DUDA, ICDS, Ward elected 
representatives, and the District Health Officer. In addition, other private sector 
stakeholders including Self Help Group NGOs and the local chapter of the Lion’s Club 
are also included in the Ward Coordination Committee. This partnership has proven 
particularly useful in leveraging resources—for example, the Lion’s Club has paid for 
some equipment and donated it to the district health center and mobilized volunteer 
private doctors to assist at immunization camps. 
Technical assistance has focused mostly on city-level planning, facilitation, and applying 
participatory tools and processes such as the slum vulnerability assessment, stakeholder 
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. 
8
consultation, and mapping of slum areas. These tools and processes were documented by 
the project and used in the preparation of city proposals. The key value of the mapping 
and vulnerability assessment tools seems to have been for advocacy and specific targeting 
of health services to underserved and previously unrecognized areas. Technical 
assistance was not directly provided to ANMs or district health centers on issues such as 
service delivery, quality of care, drug management, or logistics. Although these issues 
remain a concern, this type of technical assistance was viewed as being beyond the 
manageable interest of EHP-UHRC and sensitive since authority and supervision of 
service delivery resided with the Chief Medical Officer at the District. Technical 
assistance and training was provided to NGOs and CBOs on behavior change and health 
promotion messages.
In summary, the city-level technical assistance has been effective and led to improved 
municipal planning, including improved capacity of CBOs, NGOs, public and private 
health providers to better position their efforts to meet the needs of the urban poor. This 
is evident in the momentum behind the Ward Coordination model, multiple partnerships 
that have resulted in leveraged resources, and application of the mapping tools and 
processes documented in the project. 
Two areas of concern for these technical assistance efforts were identified by the 
evaluation team. First, there is a need to institutionalize the local-level planning process 
catalyzed by EHP-UHRC, either the Ward Committee model or something equivalent in 
terms of approach and objectives. Improved planning and capacity at the city level has 
been in part due to EHP-UHRC’s sustained efforts and the engagement of a core group of 
committed individuals at city level. Institutionalizing these committees and ensuring 
political commitment at the municipal level is challenging due to frequent turnover of 
government counterparts and staff. 
Second, the EHP-UHRC has not to date clearly communicated outcomes of technical 
assistance in terms of benchmarks or indicators to assess or measure progress in terms of 
health impact or improved service delivery, and these have not been effectively 
monitored. The intermediate process-level monitoring that has been undertaken, such as 
the number of immunization camps conducted in the identified vulnerable 
neighborhoods, is important and valuable. Nevertheless, it will be important that the 
planned evaluation monitor agreed impact-level indicators, such as actual changes in 
immunization coverage.
3.3 CIty Demonstration and Learning Activities
The city-based demonstration and learning activities have been a key component of 
USAID’s strategy for urban health since its inception, reflected in both the USAID urban 
health strategy as well as the work plan for the aborted efforts in Ahmedabad. 
9
Over the three years since initiation, EHP-UHRC established two city-based programs in 
Indore and Kolkata (Calcutta), with only the program in Indore currently active. Other 
programs in earlier stages of initiation are located in Delhi, Agra (Uttar Pradesh), and 
Jamshedpur (Jharkhand). The work in Indore, in particular, has provided the basis for the 
development and validation of a number of tools for urban health planning and provided 
credibility and visibility to the program. In addition, and very importantly, they have 
allowed collective learning (by EHP-UHRC, USAID, municipalities, and the GOI) of the 
strengths and weaknesses of diverse approaches to improving the health of and services 
for the urban poor. In this sense, they have been very useful and effective. Though it is 
clear that these initial efforts have had significant shortcomings, they will allow future 
demonstration and learning activities to be constructed against refined criteria, targeted at 
meeting some very specific gaps in knowledge and the programmatic evidence base.
Two approaches for implementation at city level emerged from an evolving dialogue with 
slum dwellers, municipal and district health officials in Indore. The participatory 
appraisal process that influenced model design solicited ideas from municipal workers, 
slum dwellers and other informants on the ground as to local problems and priorities, 
informed by secondary data review and analysis. The “NGO/CBO community model” is 
aimed at creating demand and changing community and household practices, while the 
General Criteria for the Evaluation of City-based Activities
1. Addresses demand, supply, and health systems. These three elements are both necessary 
and sufficient for comprehensively addressing all aspects of child health programming. 
Demand must exist for services to be effectively used. Supply must exist to meet demand, 
and system constraints to effective access, use and coverage must be identified and 
addressed.
2. Design based on data. Baseline data should inform program design. For urban health 
programming that addresses child mortality and morbidity, program design should be based 
on knowledge of morbidity and mortality patterns in the target population, knowledge of 
services that can address these and knowledge of system functioning (and bottlenecks) that 
inhibit or reduce coverage of these interventions.
3. “80/20” rule and phasing. Most of the benefit of a program (“80%”) is the result of only a 
few services and behaviors (“20%”). As such, the most important causes of morbidity and 
the most effective interventions should be the initial focus of activities and practices with 
gradual expansion of interventions and practices as time, money and capacity allow.
4. Simplicity. The program should be conceptually and technically simple, focusing on small, 
doable actions. The link between inputs, process, outputs and coverage should be 
absolutely clear and it should be understood readily by those whose job it is to accept/adopt 
behaviors and implement programs.
5. Affordability and replicability. The program should achieve the greatest gain for the least 
amount of effort and be able to be implemented within existing resources. Required 
technical and management skills should exist, or could be readily developed, for successful 
startup and implementation. Detailed and clear “how to” manuals are needed to guide 
implementation.
6. Evidence of effectiveness.There should be evidence that if implemented appropriately, 
the model can achieve the intended results – reduced morbidity and mortality – through 
evidence that the model directly increases coverage of interventions and improves relevant 
behaviors.
10
“ward coordination model” is a supply-side model attempting to improve the 
coordination of programs and more efficient use of existing resources. 
The common elements within these two models include promoting linkages between 
communities and service providers; use of community and other stakeholder consultation 
as a core element; a focus on process and inputs; service delivery by existing 
government programs (AWW, ANM), and; community-based services with referral and 
prevention. 
In terms of actual service delivery, it is a bit artificial to separate the ward coordination 
model from the NGO/CBO implementation model since they come together at the 
community level, for services such as child immunization. The evaluation team observed 
an immunization camp set up by the Ward Coordinating Committee. It was run by the 
NGO, lead and slum CBO members were providing counseling, ANMs were immunizing 
children, and AWWs were weighing children. 
The evaluation team used six criteria (see box on preceding page) to gain insights into the 
activities undertaken by EHP-UHRC in Indore:
Attention to demand, supply and health systems: In terms of service delivery, service 
utilization, and ultimately, improved health status of the urban poor, it is critical to 
address demand for services, supply of services, and systems issues (where health system 
is broadly interpreted to include all stakeholders, not just the public sector). Neither of 
the current EHP-UHRC approaches addresses all three aspects. The NGO/CBO model is 
mainly demand-focused while the ward coordination model is largely focused on service 
supply and coordination. Neither model addresses other key issues such as supply and 
logistics of commodities and supplies, supervision, and development of human resources. 
Both models rely primarily on services provided by the ANM, a cadre of worker which is 
undersupplied, overworked and frequently not available. Reliance on the ANMs was 
identified as the primary limiting factor to scale-up.
Design based on data: Program content emerged with consultation and experience and 
was based on an assessment of community felt need with some secondary analysis. A 
more thorough examination of the findings of the Maternal and Child Health Survey in 
the Slums of Indore (September 2004) may have allowed for a fine tuning of the program 
technical content. 
Phasing and range of services offered: It is important to note that neither model as 
currently implemented provides services that address all the major killers of slum 
children: pneumonia, diarrhea, malaria, and malnutrition. The only cause of mortality 
directly addressed by the ward coordination model is measles, since it is currently 
focused on immunization. Because EPI coverage rates are already relatively high, the 
marginal impact of measles immunization on decreasing mortality would be expected to 
be relatively limited. If the underlying objective is to reduce mortality, then the technical 
content needs to insure that the leading causes of child mortality and associated morbidity 
are directly addressed.
Simplicity: The ward coordination model is simple and effective for what it is designed 
to accomplish. The NGO/PVO model is somewhat more complicated and time-
11
consuming, and it relies more heavily on EHP-UHRC staff and paid NGOs and CBOs. 
Community assessments must be conducted, NGOs and CBOs identified and trained, 
community women’s groups developed, ANMs identified and so on. While these process 
inputs are important to the effectiveness and sustainability of community-based service 
provision, the time and effort required are impediments to scaling up this model. 
Affordability and replicability: There has been no costing work done for either model, 
so it was not possible to evaluate affordability. In addition, for the NGO/CBO model 
there are no utilization or coverage figures and the population served is unclear, although 
this may become clearer through the impact evaluation of the Indore models currently in 
progress. The evaluation team feels that the ward coordination model, if expanded to 
cover additional services, could be an affordable and replicable way for improving 
service coverage at district, municipal and ward levels but, again, it would be best to back 
up this impression by quantification of actual costs.
Evidence of effectiveness: Evidence of effectiveness is anecdotal and fragmented and 
cause-effect relationships are unclear. However, there is evidence indicating that both 
models are effective at increasing either demand for or supply of covered services. The 
EHP-UHRC team provided some documentation of increased coverage of interventions 
at the slum level and the evaluation team, through interviews and observations, was 
provided anecdotal evidence that mortality and morbidity has declined in Indore pilot 
areas and that consumer demand for services has increased. Anecdotally, community 
members’ knowledge and practices related to hygiene and care seeking have improved 
and knowledge and practices of community workers, including trained traditional birth 
attendants (TBAs), has increased. At district, municipal, and slum levels there is a 
growing sense of ownership in the program by community members, trained TBAs and 
health workers at district and municipal levels. Coordination across programs and 
responsible entities at district and municipal levels seems to have increased. 
Other issues
Tools: EHP-UHRC has developed several tools to assist in city-level implementation 
activities, such as those for vulnerability assessment, but in general, the tools that exist 
are not always clear, easy to digest or complete. Once the models mature and are found 
to be effective, considerably more work needs to be done to develop clear, concise and 
detailed “how to” manuals for all aspects of the program. 
Linkages to non-health sectors: Intersectoral linkages, particularly in the area of water 
and sanitation, were pursued but not particularly advanced. Although there were a few 
examples of the project’s impact on engaging the municipal corporation to build a toilet 
block or mobilizing a community to obtain a bore well in a peri-urban slum, dialogue 
between the two sectors is not formalized or systematic. Linkages to ICDS and nutrition 
could also be strengthened.
12
3.4 Increased urban health knowledge for advocacy and planning
EHP-UHRC has established itself as the key resource for information on health matters 
among the urban poor in India. It has collaborated with the Indian Academy of Pediatrics 
to produce a series of articles on urban health in India, which are being published in the 
journal Indian Pediatrics. EHP-UHRC is regularly requested to make presentations, or 
assist eminent public health figures in making presentations, at national pediatric, child 
health, and public health events. EHP-UHRC has reanalyzed NFHS II data to generate 
important and unique information on the health conditions of the urban poor in India. 
This information is the raw material for many presentations, articles and reports. For 
example, in response to a request from the GOI, the UHP is developing urban health 
situation analyses for eight northern states. All of these point to significant achievements 
by EHP-UHRC is providing leadership in urban health knowledge generation and 
dissemination, a role that has concurrently increased and reinforced the ability of EHP￾UHRC to undertake the effective advocacy and planning activities already discussed.
EHP-UHRC has taken dual tracks in knowledge generation and dissemination. One has 
been the compilation and sharing of existing urban health information, including program 
information, at national level – through both documentation and national conferences. 
Key events included organization of the 2003 national consultation on urban health 
(“Improving the Health of the Urban Poor: Lessons Learned and the Way Forward”), a 
symposium at the 2005 Annual Conference of Indian Public Health Association, and 
collaboration with the Indian Academy of Pediatricians.
A second track developed situational analyses at both state and municipal levels, with 
advocacy activities such as the state-level urban health workshop in Uttar Pradesh. The 
situational analyses have served as key planning documents which have directly fed into 
both city activities (already described) and the development of five-year urban health 
proposals under RCH-II for Agra, Bally, Dehradun, Haldwani, and Haridwar.
Overall, the quality of the documents produced has been very good, and they have been 
well-received by counterparts. 
There extent to which the successful advocacy has led to state and municipal ownership 
of the work and urban health issues generally varies. In Delhi, the MCD was the clear 
driver of the planning process, and EHP-UHRC played a key facilitative and consultant 
role, which is appropriate. In other locations, while the leadership of the local process 
was clearly in the public sector, full engagement was sometimes limited by the 
availability of personnel with sufficient time allocated to the planning process. 
13
3.5 Urban Health Resource Centre capacity to support USAID and GOI objectives
Because the institutional and management capacity of UHRC was the subject of ongoing 
technical assistance efforts by EHP-UHRC, through both international consultancies and 
local subcontractors, the evaluation team focused on this in less detail than for other 
areas, and a comprehensive institutional evaluation of UHRC was beyond the scope of 
the evaluation.*
 Nevertheless, the team reached several general conclusions.
· EHP-UHRC has proven itself to be very effective in supporting USAID’s objectives 
in urban health, particularly in the programmatic mode which has dominated, namely 
to use very limited USAID resources to influence the much larger expenditures by the 
GOI under the RCH program. In addition, the TA function has been well 
implemented by EHP-UHRC, which has also served USAID and GOI objectives.
· The short, variable lengths of the project cycle has been a constraining factor in the 
most effective evolution/ implementation of the program, including professional staff 
retention. The initial EHP-UHRC project cycle was through June 2004. This was 
initially extended until September 2004, and then extended again through the current 
Task Order which runs through October 2005. The anticipated transition of UHRC to 
a more independent status, less dependent on contract end dates, should help alleviate 
this.
· The allocation of staff and division of roles and responsibilities between Delhi-based 
and city program staff requires clarification, as well as rationalization of the 
deployment of city-based staff. For example, the Indore program appears to require a 
dedicated documentation officer, while Jamshedpur has excess support staff in view 
of its current suspended status.
· The role of the UHRC vis-à-vis skill building of the National Health Systems 
Resource Center of the GOI remains to be fully agreed, but this is a critical function 
which the UHRC is now well-positioned to fulfill. 
· Appropriate professional growth potential of UHRC staff needs to be ensured, 
through both a business plan that allows for promotion as well as the identification of 
short-term training opportunities. 
· A key factor in the successful efforts of EHP-UHRC to date has been the flexibility of 
USAID/India management of the activity to allow for changes in staffing and 
deliverables. This adaptability has been critical in allowing EHP-UHRC to take 
advantage of opportunities as they arise and to realign its strategy against a changing 
policy backdrop, such as the evolution of RCH and National Rural Health Mission 
(NRHM).
The evaluation team also examined the process of transitioning the EHP-UHRC USAID 
project into the independent Urban Health Resources Center (UHRC) from an 
 
*
 The staffing pattern of the UHRC as of March 2005 is detailed in Annex 3, but it should be emphasized 
that this was and is in flux. 
14
organizational development perspective. The findings and recommendations are based 
on a review of the institutionalization plan, existing staffing patterns, and an interview 
with EHP-UHRC Director Dr. Siddharth Agarwal. Based on this review, UHRC is well 
en route to becoming an established NGO with a vision and mandate in its own right. 
There is a well documented work plan outlining key steps and milestones. Steps towards 
legalization and obtaining the FCRA certification (enabling the acceptance of foreign 
donor funds) are underway and should have been in place by May 2005. Major 
organizational development issues such as governance, human resources systems, and 
financial management systems are being addressed through the use of specialized 
consultants. Key findings that may pose challenges or impact these developments 
include: 
· Communication and Branding Strategy: The project activities to date have been 
marketed and communicated under the EHP name and logo. UHRC may face 
challenges in re-branding its prior work and future mandate with a new name. In 
addition, USAID’s branding strategy requiring contractors to display the USAID logo 
may be challenging for UHRC as it builds a new identity and seeks to establish 
partnerships with the Government of India. 
· Management: The leadership, management, and development of the EHP-UHRC 
project has been dependent on the Director, Dr. Siddharth Agarwal, to date. As the 
project scales up with increasing demands for technical assistance at the National, 
State, and City level, program management will become increasingly complex. 
During the team’s interview with the Ministry of Health and Family Welfare, 
Secretary Hota said that he expected UHRC to double its efforts in supporting the 
Ministry on urban health issues. Staff seconded to urban health cells at the national, 
state or city level will require supervision, mentoring and support from UHRC’s head 
office in order to be successful. UHRC is planning on hiring two senior staff to 
alleviate the management burden on the Director. However, this may take some time 
and impact program implementation in the short run.
· Organizational Structure: UHRC has developed an organogram that will be 
revised once the business planning process take place and the evaluation report is 
finalized. The functional staff positions are well articulated but technical roles still 
need to be reviewed. This may depend on whether UHRC ventures into new 
technical areas such as family planning and reproductive health. The staffing, roles, 
and responsibilities of UHRC staff in both the Delhi and field offices needs to be 
reviewed and rationalized. For example, Indore seems relatively understaffed 
compared to Jamshedpur, a relatively smaller city program. 
· Systems Transitions: The EHP-UHRC project was reliant on CDM for support on 
financial and human resources systems. UHRC is transitioning to its own financial 
and human resources systems and has hired the consultancy services of Bansal and 
Company (financial) and Ernst and Young (human resources.) There may be some 
issues when the financial management and human resources systems transition to 
UHRC. 
15
3.6 Public-private Partnerships
The evaluation team was asked to assess opportunities to incorporate public-private 
partnerships in the next phase of USAID’s urban health program. The private sector is 
defined as both for-profit actors (private providers, corporations) and not-for profit actors 
(NGOs, CBOs, associations, and PVOs). Interviews with nearly all GOI stakeholders 
revealed a high degree of interest and consensus on the importance of public-private 
partnerships in RCH 2 and in the implementation of urban health programs. It is clear 
that there will be a high demand to incorporate PPP models and approaches in technical 
assistance and planning on urban health issues. 
The majority of people in India, in all income groups, access health care in private 
sector—80% of health expenditures are out of pocket and only 20% is spent on primary 
health care. Moreover, government resources are overstretched. During the field visits in 
Indore, the evaluation team consistently heard that it was not uncommon for a single 
ANM to have responsibility for catchment populations up to 60,000. Slum residents also 
consistently reported their preference to visit a private doctor particularly when a family 
member fell ill. In most cases, slum residents chose doctors close to the basti and were 
not aware whether the doctors were qualified or registered providers. 
EHP-UHRC’s experience with public private partnerships has been ad hoc. In Indore, 
the project has successfully engaged a few private obstetrician/gynecologists to conduct 
ANC camps and worked with the Lions Club in the Ward Coordination model. They are 
also in the process of developing a contracting-out model in Agra where EHP-UHRC 
would initially fund an NGO to operate an urban health center on behalf of the district in 
an underserved area. In addition, EHP-UHRC has also begun to develop a relationship 
with the Confederation of Indian Industries (CII). While these efforts have been highly 
positive, the urban health program has the opportunity to meet the demand for expertise 
on public private partnerships and link with other PPP efforts both in USAID and other 
partners. 
Much of the work to document and analyze examples of public-private partnerships in 
India has already been done. There are several World Bank case studies on public￾private partnerships in Andhra Pradesh, Karnataka, and Calcutta. In addition, 
USAID/India recently conducted a comprehensive assessment of various public private 
partnership models in terms of their applicability within the RCH-2 context. 
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 Indian 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. 
EHP-UHRC will provide staff for an urban health cell that will provide support to the 
Objective: Improved Health 
and Nutrition of Underserved 
and Poor Women and 
Children in Urban Areas
Result 1 – Better 
targeted policies and 
increased allocation of 
resources to improve the 
health and nutrition of 
the urban poor
Result 2 - Improved 
program approaches 
implemented at the 
Municipal level / ULBs
Sub-result: Generation of evidence on best practices and 
innovative program approaches from city-level 
demonstration and learning activities.
18
Ministry of Health and State governments through the National Health Systems 
Resource Centre (a parastatal organization that will assist with the implementation of 
RCH 2). Expansion of the urban health mandate to RCH 2 interventions will enable 
the program to remain aligned with the goals of the GOI and have a greater impact on 
influencing policy. 
· Options for further expansion: In the medium term, the team recommends that the 
urban health program mandate remain open to identifying convergence points with 
other technical health areas including HIV/AIDS, tuberculosis and malaria.*
 
However, the team recommends that the program focus in the near term on RCH-2 
interventions plus nutrition given the capacity of the UHRC, GOI expectations, and 
upcoming launch of the RCH 2 program. 
· Flexibility of funding: Expanding the program focus beyond child health to include 
family planning and reproductive health will require USAID/India to invest CSH 
population funds in the urban health program. In addition, to the extent that the IFPS 
II project will also be mandated to support the implementation of RCH 2 in Uttar 
Pradesh, USAID/India may consider funding both projects with population, child 
survival and micronutrient funds. Adding HIV/AIDS, TB, and malaria foci to the 
program also could potentially introduce other sources of funding for urban health.
Result 1: Better Targeted Policies and Increased Allocation of Resources to 
Improve the Health and Nutrition of Urban Poor
This result builds upon the achievements of EHP-UHRC in improving municipal 
planning, providing technical assistance to the national and state government levels, and 
advocacy on urban poor issues. Illustrative activities supporting Result 1 include:
· support to the GOI at the national level and state level through the provision of 
technical advisors and urban health cells;
· technical assistance to cities on planning, program development, implementation 
and monitoring;
· dissemination of research, best practices and evidence on successful program 
approaches throughout India to policy makers; and 
· national, state, and city level advocacy efforts on urban health.
Indicators for measuring progress for Result 1 need to be developed further. Illustrative 
indicators include:
· Number of municipal plans targeting health service delivery to the urban poor 
developed
 
*
 There are promising avenues to pursue when it makes sense to further expand. For example, in a meeting 
with Dr. Quraishi, Director General of NACO, he discussed NACO’s initiative to set up PMTCT centers in 
various district health centers. In addition, the USAID/India PHN office is conducting a study to assess 
malaria prevalence in urban areas. The findings may help make the case to include select malaria 
prevention/treatment interventions in the urban health program. 
19
· Non-USAID funds ($ or rupees) mobilized/leveraged (GOI, private sector, 
donors) to improve health for the urban poor
Result 2: Implementation of Improved Program Approaches at Municipal/ULB 
Level Result 2 focuses primarily on the provision of technical assistance and capacity 
building at the municipal level including non-governmental stakeholders such as NGOs, 
private sector, medical colleges, and voluntary organizations. Illustrative activities to 
support this result may include:
· technical assistance, coordination, and facilitation of stakeholders at the municipal 
level to address urban health; 
· technical assistance to municipal corporations and district health officers (Chief 
Medical Officers) on developing proposals and plans for implement urban health 
programs;
· capacity building and training for NGO partners on health promotion, behavior 
change, etc.;
· facilitation and development of public-private partnerships; 
· coordination of study tours and visits to learning sites in model city programs; 
· conduct research and collect evidence on programming approaches and best 
practices; and 
· documentation and development of templates, guidelines, and models that can be 
replicated and used in other cities.
Indicators for developing indicators to measure progress on Result 2 need to be further 
developed. Illustrative process indicators include:
· Number of city programs targeting the urban poor implemented
· Number of public private partnerships facilitated 
Ultimately, these results should result in real, measurable improvements in health and 
behavioral outcomes amongst target populations. These would be captured at the 
objective level.
Sub-result: Generation of evidence on best practices and innovative program 
approaches from city-level demonstration and learning activities.
EHP-UHRC has implemented a demonstration city program in Indore and is in the 
process of developing another demonstration project in Agra. Per the guiding principles 
listed above, city-level demonstration and learning activities are intended to support 
Result 1 and Result 2 as a means to those ends, not ends in and of themselves. This is a 
key difference from the approach taken to date. It is not intended to undervalue the role 
of city-based activities, which have been critical to USAID and UHRC learning as well 
as to the consequent delivery of effective technical assistance which has already been 
discussed. Rather, it puts city-level activities in a context appropriate to the magnitude of 
the resources to be applied by USAID to the urban health program, that is, support of the 
development of improved approaches and for advocacy, particularly in the way that 
effective demonstrations can effect increased resource allocation for urban health. 
20
The evaluation team feels that the city-level models should be developed and used only to 
the extent they influence policies and programs at a state and national level. They can be 
used as demonstration sites, sites for development of “how to” manuals, or learning sites 
for training purposes.
This sub-result is also designed to capture technical assistance provision, capturing of 
lessons learned, and documentation of best practices that UHRC could provide for 
activities focused on the health of the urban poor implemented by others – municipalities, 
NGOs, other USAID activities, or other development partners.
4.2 Relative Roles of Technical Assistance, Technical Leadership Activities, and City￾based Demonstration and Learning Activities
It is recommended that USAID/India continue to support all three legs of current activity 
– including technical assistance at city, state, and national levels; technical 
leadership activities (e.g. conferences and publications); and city demonstration and 
learning activities. However, the emphasis in terms of level-of-effort and funding 
should strategically be first on TA, second on technical leadership, and third on city-level 
demonstration and learning, although it is important to maintain flexibility to adjust this 
balance to adapt to any changing circumstances at the policy level which may arise.
UHRC technical assistance should be focused at the State level, which is well￾positioned to link resources available from the GOI to the needs of the municipalities. 
However, UHRC TA needs to be coupled to sufficient capacity at the recipient end (i.e. 
State level) to be effective, and USAID should consider how best to support increasing 
this capacity (probably by placing long-term UHRC advisors at the State level, although 
the sustainability of this approach was of concern to the team).
At all levels, the UHRC should diversify the partners to whom TA will be provided, 
moving beyond RCH-2 to include ICDS, the Urban Development Authorities (SUDA and 
DUDA), and NGO or parastatal platforms such as CARE or SIFPSA. While UHRC has 
undertaken limited efforts in such outreach to date, building such partnerships will in 
some cases require considerable advocacy for the urban health agenda. The focus should 
be on developing long-term mutual commitments to this agenda, with UHRC providing 
technical assistance.
City demonstration and learning activities should be focused on cities with distinct 
socioeconomic, environment, or health characteristics or that present a special 
policy, leveraging, or learning opportunity. All demonstration activities should be 
entered into with a clear exit strategy. Because USAID resources for such activities are 
very limited, opportunities to learn from others’ investments, with minimal additional 
USAID investment under UHP, should be actively sought out. The team’s initial 
recommendation to focus mainly on medium-sized cities with high growth rates was 
made less restrictive following discussions with the Mission staff, acknowledging that 
capacity was weak in such settings and that some attention should be focused on working 
with large cities. 
21
The ultimate effectiveness of UHRC technical assistance efforts will depend critically on 
enhancing linkages and coordination at all levels. At the GOI level, there are 
opportunities to improve coordination and synergy between the different ministries 
(MOHFW, MOUD and MOHRD) as well as between their individual departments, such 
as those that touch on health, water and sanitation, and nutrition departments. In addition, 
UHRC is uniquely positioned to foster linkages between programs within Ministries such 
as between RCH and NACO. An additional area of UHRC support to USAID should be 
focused on developing improved linkages with urban health activities funded by other 
international agencies (e.g. World Bank, UNICEF, DfID, WHO, etc.).
There are also a number of issues that demand technical leadership and that UHRC could 
address in partnership with the GOI, subject to its own capacity and staffing limitations. 
Examples include:
- Assisting the GOI to improve referral linkages mechanisms, which are currently 
ad hoc and relatively weak;
- Developing guidelines/ methodologies to assist in burden of disease mapping for 
underserved poor urban;
- Supporting training from the GOI to state governments on formulating proposals 
for urban health guidelines;
- Develop recommendations to improve infrastructure provision and service 
delivery structures and quality, as a complement to health interventions;
- Increasing the focus on documenting implementation effectiveness, the flip side 
of the documentation of problem assessment and program planning.
- Improving and enhancing accountability mechanisms to the GOI for programs 
implemented at the state level and below, with agreed frameworks for monitoring 
and evaluation.
4.3 Recommendations for city-based demonstration and learning activities
The supportive role envisioned for the city-based activities suggests several promising 
avenues for the future and recommendations for UHRC.
· The team felt that the ward coordination model is a viable approach for achieving 
greater scale, including dimensions of both population addressed and the range of 
service which can be effectively and cost-effectively delivered. The evaluation team 
feels that more M&E work is needed before the effectiveness and, more importantly, 
the cost-effectiveness of this approach can be fully determined. Nevertheless, it is 
important to remember that different “models” will likely be required in other 
settings, so the effort to be devoted to impact-level M&E and cost-benefit analysis of 
any one approach needs to be reasonable in the context of a city program.
· UHRC should place emphasis on mining existing program experience for best 
practices, tools and methods. Developing new models and approaches is important 
but if models already exist there is no need to create them again The UHRC has the 
opportunity to identify and work with organizations, projects and programs that 
already exist on the ground but lack technical focus, effective programmatic 
22
approaches, appropriate or proper evaluation. Effective models can probably be built 
from these “platforms” more quickly than creating new city-level activities. As a line 
of work, the UHRC should aggressively identify these platforms and work towards 
influencing their health content and approaches.
· Knowledge of all urban health-related activities in India is limited – there is no one 
single repository of experience and knowledge. The UHRC could play this role and 
should collect, assess, and strategically transfer experience across urban health 
programs and to those in the program development stage. 
· The UHRC should have technical capacity, if not fully-dedicated staff, to address 
demand, supply, and systems issues. Demand creation and improved household and 
caretaker behavior alone is inadequate to improve service coverage. From a systems 
perspective, the UHRC needs to be able to identify and analyze bottlenecks to the 
delivery of health services and understand options and methods of overcoming these 
constraints. 
· The UHRC should look beyond its own learning and experience with city-level 
implementation and determine whether there are other programmatic approaches that 
would have more visible, more rapid impacts on service coverage and use. Beyond 
the opportunities presented under RCH and the NRHM, UHRC should look for other 
partners with large-scale platforms in urban areas to which assistance could be 
provided to increase impact on the health of the urban poor. Fully exploiting existing 
platforms, such as with technical assistance focused on strengthening a limited set of 
interventions targeted at the urban poor, could allow more rapid start-up and impact. 
· UHRC should focus its initial efforts in any city activity on a limited package of 
services, i.e. more than the focus on a single intervention such as measles 
immunization but less than a full suite of MCH and nutrition activities. For example, 
such a limited package could focus on routine distribution of vitamin A, promotion of 
exclusive breast feeding, use of ORS/ORT during episodes of diarrhea, provision of 
zinc for each bout of diarrhea, and promoting the “four cleans” for hygiene (clean 
water, clean hands, clean food, and a feces-free environment) and could probably be 
implemented quickly if built upon existing platforms.
· Though the UHRC has done a commendable job of documenting its city-level work 
to date, the UHRC should make sure that documents communicate effectively, are 
targeted well, and are as short and concise as possible. Recognizing that 
documentation is expensive, in the future, more attention could be placed on “how to” 
manuals, on results of monitoring and evaluation activities, and on advocacy pieces, 
with less emphasis on documenting inputs and processes.
· More “how to” manuals and guidelines for city activities are critically needed. They 
should be clear, concise and self-explanatory. The UHRC should examine existing 
manuals to determine if they are adequately complete and self-explanatory and what 
other manuals, addressing other aspects of the program, are needed. Those manuals 
should be developed as a matter of priority. Manuals should address all aspects of 
23
urban health programming including demand creation, community case management 
of common illnesses, BCC/IEC, supervision, and M&E.
· Where it becomes involved in operational aspects of urban health programs (such as 
in the current model in Indore), the UHRC should enter into such arrangements with a 
clear exit strategy laying out its level of support, the timeline within which it will be 
involved, and how quickly and in what manner it will reduce its inputs.
4.4 Niche for urban health within PHN and USAID
There are a number of opportunities for linkages and leveraging within USAID that can 
be more fully exploited. Within PHN:
· Improve linkages to reproductive and maternal health by identifying linkages with 
IFPS and ITAP. Linkage could also be considered with the PACT-CRH program of 
PATH and Abt Associates.
· Urban health related questions or an enhanced urban health sampling frame should be 
included in NFHS 3 questionnaire. 
· Mission-supported urban health activities could be linked up with the urban AIDS 
activities. 
· IndiaCLEN could be used for Urban Health related OR issues. 
One opportunity for coordination within USAID outside of PHN is with the EG office. 
Three specific opportunities were presented: potential investments by JBIC that could 
relate to urban health, the development of the Agra City Development Strategy, and 
possible water and sanitation activities under FIRE/D in Agra and Madhya Pradesh. It is 
recommended that PHN and EG develop a mechanism for regular communication on the 
progress of their respective activities, particularly if the Agra City Development Strategy 
bears fruit (though this was not certain at the time of this evaluation).
4.5 Role of Public-Private Partnerships
Key recommendations on public-private partnerships include: 
Coordination with Larger Public-Private Partnership Initiatives
It is clear that public private partnerships are expected to be a significant component in 
urban health programs and there is a high demand for technical assistance in this area. 
There are numerous larger initiatives on PPPs that are currently underway within the 
RCH 2 implementation plan and the USAID/India PHN office. Therefore, the team 
recommends that the urban health program strategy and UHRC activities be coordinated 
with these efforts to the extent possible. 
24
There is also a joint donor working group on PPPs and plans to staff a PPP cell within the 
National Health Systems Resource Center (a parastatal organization that will assist the 
GOI to implement RCH 2). This working group has already developed a concept paper 
on PPP guidelines, identified PPPs that are currently underway, and analyzed PPPs that 
are being proposed under State PIPs (program implementation plans.) It is critical that 
the urban health cell and PPP cell coordinate technical assistance efforts.
The USAID/India-funded IFPS 2 (Innovations in Family Planning and Services) project 
which provides funding and technical assistance to SIFSPA is primarily focusing on the 
development, testing, and replication of PPP models to support family planning and other 
RCH 2 services in Uttar Pradesh. The IFPS 2 will have a bilateral component that 
supports SIFSPA (a parastal organization) and the ITAP technical assistance component 
that will support SIFSPA to implement PPP models. To the extent possible, the urban 
health program should leverage this technical assistance component in addition to 
keeping up to date on the activities of the PPP cell and donor working group. While 
ITAP will focus primarily on supporting IFPS 2 and SIFSPA, it can also be a resource for 
the urban health program for specific, discrete activities such as developing planning 
guidelines for implementing PPPs within the context of municipal urban health planning 
exercises. The team also recommends that UHRC collaborate with ITAP before UHRC 
implements PPPs within city level demonstration and learning sites to ensure that state of 
the art knowledge is being applied and the activity is not duplicative. 
UHRC has just begun discussions to explore partnership opportunities with 
Confederation of Indian Industry (CII). There are several potential areas where a 
partnership would make sense. For example, CII described a project involving mobile 
health clinic vans to slum areas in Delhi where construction workers tended to reside. In 
addition to strengthening the UHRC-CII relationship, the evaluation team recommends 
that USAID/India PHN office also formalize a relationship with CII to address other 
technical areas. While CII has an interested in supporting maternal and child health, their 
priority areas of interest and support is in HIV/AIDs, tuberculosis, and hepatitis. 
Using Public Private Partnership Models to Improve Service Delivery
There are a variety of public private partnership models that can be applied within the 
urban health context. To the extent possible, the evaluation team recommends that 
UHRC builds upon existing infrastructure and facilitates partnership between the 
municipal corporation/district health office and the private sector rather than directly 
engaging in service delivery PPP on its own e.g. contracting out models or franchises. 
There are several models that can be successfully incorporated into urban health 
programs at the municipal level. PPPs at the city level have the opportunity to address 
two key issues — (1) the shortage of ANMs, and (2) improved quality of private health 
care that is already being sought out by target slum residents. These models need to be 
assessed within each context for the following: cost; availability of qualified providers; 
price to beneficiaries; sustainability; administrative complexity; and health impact. The 
appropriateness of various models will differ according to each city. Therefore, the team 
recommends that UHRC work with ITAP to develop PPP assessment guidelines that can 
25
be incorporated as municipal planning tool. Potential PPP models (not an exhaustive list) 
for use in urban health settings are described below:
· Contracting Out: Contracting out refers to an agreement or contract for a private 
provider to manage a government health unit or provide health care services on behalf 
of the government. This model is best used in situations where the government health 
services are unavailable or nearly defunct. The feasibility of contracting out models 
should generally be assessed on quality and cost dimensions. In essence, does 
contracting out result in higher quality, greater coverage, and lower/equivalent cost 
than the government providing the services itself? Other issues for consideration in 
contracting out involve the government’s (municipal corp or district health office) to 
effectively manage, monitor, and ensure payment of the contract. UHRC is planning 
on implementing a contracting out model in Agra—soliciting NGOs to provide RCH 
2 services in underserved peri-urban slum. The team recommends that UHRC 
obtains assurances from the District Health Office on its plans to take over the 
contract within a reasonable time frame and provide TA to enhance its capacity to 
manage the contract.
· Franchise: A franchise is a model where a private provider is given the “right” or 
franchise to provide certain services in a prescribed manner under a branded network. 
The franchiser typically owns the “brand” and will often monitor quality, price, and 
set some guidelines for how the franchisee conducts business and uses its brand. The 
franchisee usually will benefit from marketing, brand recognition, access to training, 
etc. The franchiser is usually an NGO or private organization. Franchise models are 
being seriously considered within the RCH 2 implementation plans. Franchise 
models are highly applicable within the urban health context. However, setting up 
franchise models requires considerable effort and expense. Therefore, we 
recommend that UHRC not try to set up its 
own franchise network. Rather UHRC should 
try to partner with existing or new franchises 
that are being created under the RCH 2 PPP 
efforts. 
· Social Marketing: Social marketing is the 
use of commercial marketing strategies, 
distribution networks, and branding to 
achieve a social objective. There are several 
social marketing programs that are working in 
India including the PSI maternal child health 
program, Hindustan Latex program, and the 
USAID-funded PSP One project. The team 
recommends that UHRC partner with existing 
social marketing programs in cities that are 
the focus for technical assistance and 
demonstration and learning sites. For 
example, in Indore, a partnership with PSI 
could result in Basti CBO workers selling 
socially marketed products for a small profit. 
Corporate Social 
Responsibility
Corporate Social Responsibility 
is gaining considerable ground 
in India with the well publicized 
efforts of Tata and formation of 
groups such as Confederation of 
Indian Industry (CII) and 
Federation of Indian Chamber 
of Commerce and Industries 
(FICCI). In addition, social 
clubs such as Rotary 
International and Lions Club 
have played significant roles 
supporting various health issues. 
In Indore, the Lions Club is 
playing an active role in the 
Ward Coordination model. 
26
· Capacity Building/Local Partnerships with Private Providers: The shortage of 
ANMs and difficulty in providing sufficient coverage is well documented. The team 
discussed this issue with a variety of stakeholders in the field and discovered that at 
least one LHW (Lady Health Worker who is responsible for supervising ANMs) and 
the Chief Medical Officer in Agra have already begun to form an informal 
partnership with private providers to address this issue. 
The LHW in Indore has formed partnerships with three private providers in her 
catchment Ward to provide immunization services to slum residents since her ANMs 
were finding it difficult to cover the entire catchment area. She provided these 
providers with the vaccines and supplies and negotiated the price they would charge 
(Rs. 20) for the immunizations. Slum residents in the catchment ward were given the 
choice of either going to the immunization camp, waiting for the ANM worker to 
come on her monthly rounds, or going to a nearby private provider for Rs. 20. Since 
the Rs. 20 was often less than losing a day of work waiting at the immunization camp 
or waiting around for the ANM to arrive, many people availed of the private provider. 
The CMO in Agra also indicated that his office was in talks with private providers to 
form this type of partnership with an expanded basket of services—providing 
vaccines, family planning supplies, ORS, and cotrimoxizol to certified providers in 
exchange for lower fees. 
The team believes that this may be a cost effective model that addresses the ANM 
shortage issue while providing slum residents with the choice to avail themselves of 
services that make the most economic sense for their particular circumstance. We 
recommend that UHRC further explore formalizing this model perhaps with added 
incentives such as training, recognition program, etc. Partnerships with association 
such as the local or state chapters of the Indian Association of Pediatrics, Indian 
Medical Association may be helpful in facilitating this type of arrangement. 
4.6 UHRC Organizational Development
To date, the USAID urban health program has been implemented through the EHP IQC 
mechanism. As EHP comes to a close, USAID has made the decision to support the 
long-term institutionalization of UHRC. The Urban Health Resources Center is 
envisioned to become an institutionalized Indian NGO with unique capabilities to serve 
as the nodal technical leader in urban health issues, as already discussed.
 Key recommendations on UHRC’s organizational development are listed below:
1. Communications and Branding Strategy: The evaluation team recommends that 
UHRC develop a comprehensive communications, marketing and branding strategy 
to launch its new identity. In addition, the team noted that the project would benefit 
from greater clarity and clearer messages about its activities and purposes. The team 
recommends a period of co-branding to take advantage of the recognition and 
existing brand value of “EHP”, while allowing the “UHRC” to begin to be 
recognized. The team also noted that the USAID branding strategy may create 
obstacles for UHRC. The team recommends that in this scenario, USAID/India may 
27
wish to investigate whether a grant/cooperative agreement mechanism would provide 
greater flexibility. 
2. Management: The increasing managerial burden on the Director as the program 
scales up and UHRC becomes institutionalized is apparent to the team. We 
recommend that the recruitment of senior staff to UHRC be a top priority. In 
addition, UHRC senior staff should review which managerial duties can be delegated 
to other staff. Assuring quality of technical support to GOI stakeholders will be 
critical. UHRC can develop an orientation plan for new staff as well as ensuring that 
there are open lines of communication to the Delhi office. 
3. Organizational Structure: UHRC will face challenges in rationalizing the 
organogram and staffing for the new organization. The evaluation team recommends 
that UHRC undertake a comprehensive technical skills and staffing review once the 
business planning is complete and programmatic goals are set. This review should 
include a review of existing technical skills and capacity to identify additional skills 
or training needs. In addition, the roles and responsibilities of the Delhi office vis a 
vis city and GOI technical support should be clearly articulated and defined to ensure 
quality of technical assistance and adequate support. For example, technical staff in 
Delhi can be measured during performance evaluation on support to city programs. 
4.7 Complementary mechanisms to support USAID urban health programs
The USAID/India urban health program, and the EHP-UHRC implementation of the 
major part of the program, is cutting edge in terms of its focus and progress. It can fairly 
be said that no other Mission in the ANE region has so comprehensively considered its 
role in the problems of urban health at the country level and taken concrete programmatic 
steps to address it. While implementation began under the USAID/W-based EHP, it 
would be fair to say that, at this point, in terms of the lessons learned specifically relevant 
to urban health programming, USAID/Washington has less to offer USAID/India than 
vice versa.
That said, there is much specialized expertise in both AID/W staff and in the projects 
supported by AID/W, expertise in topics such a immunization, health systems, hygiene 
improvement, that could fruitfully be tapped for technical assistance to the UHRC. 
Because resources for the urban health program are very limited and focused on country 
activities rather than purchasing expatriate TA, it is proposed that “leveraged TA” 
opportunities be sought from AID/W central projects such as BASICS and the Hygiene 
Improvement Project, i.e. that TA be sharply defined and piggybacked on related TA 
either in India or by stopping in India en route to other TA assignments in the region. 
Properly managed, such TA should be available at low cost and could, over time, have a 
large technical payoff for both UHRC and the cooperating agency.
USAID/W also needs to evolve to respond to the demands from Missions for technical 
and program partnerships in urban health. One key issue which will be addressed soon is 
staffing. Beginning in late 2005,and partly in response to effective USAID/India 
advocacy on urban health with USAID/W, GH/HIDN and the EGAT Bureau’s Urban 
Programs Team will jointly support a full-time position focused on urban health. The 
28
objective in establishing the position is to have one person dedicated to advocacy efforts 
for urban health, to identify and work with Missions that wish to address this issue, to 
share lessons learned from field activities (including both those supported by USAID and 
those supported by others), and to establish innovative mechanisms and partnerships to 
facilitate Mission investment in urban health.
4.8 USAID management
The team recommends that the flexibility of USAID management of the urban health 
program and, specifically, of the EHP-UHRC be continued. Clearly, an evolution of the 
policy environment away from enthusiastic support by the GOI for urban health activities 
would require a shift of priorities and resources. But even absent a dramatic shift, having 
flexibility allows the exploitation of new opportunities, a strategy that has proven very 
effective to date in building support for work in urban health.
The nature of such interactions strongly suggests that a cooperative agreement would be 
more appropriate than a contract for ongoing support to the UHRC. The team 
recommends looking at a GH leader-with-associates award implemented by World 
Learning as a possible mechanism; this was designed for support of in-country NGOs and 
would seem to be appropriate for the gradual weaning and increasing independence of 
UHRC.
4.9 Monitoring and evaluation 
Monitoring and evaluation (M&E) has played an important role in EHP-UHRC 
implementation to date but needs to be significantly strengthened to meet future needs. 
Monitoring of program inputs and processes will be important to determine the cost of 
doing business and the efficiency with which the program is operating. Outputs should 
be monitored to determine productivity while periodic monitoring of outcomes (e.g. 
coverage of interventions) is needed to measure program impact. The M&E framework 
for the UHRC should be well defined with clear input, process, output and outcome 
performance indicators followed by periodic reporting in a simple, easy to read format.
The revised results framework proposed by this evaluation team focuses on three results: 
1) improved programming, 2) improved policy environment and resource allocations, and 
3) support of and assistance to city-based demonstration and learning activities to help 
achieve the other two results. Demonstration and learning activities will show how to 
improve coverage of key interventions including a range of services that exceed those 
provided under the existing city programs. In supporting these activities, the UHRC will 
need to expand the breath and depth of its support to carefully demonstrate and 
document the expanded impact that that these approaches may have.
Specific recommendations for future monitoring and evaluation efforts:
· While monitoring of inputs and processes (e.g. training, facilitating, meetings, 
puppet shows) and outputs and outcomes (e.g. number of vaccinations given and 
vaccination coverage rates) are all necessary, future monitoring should focus 
more heavily on outputs and outcomes. Urban health activities, however diverse, 
29
need to clearly demonstrate their effectiveness. Such “proof of concept” is a key 
learning objective that the UHRC could be well positioned to exploit with 
strengthened M&E capacity. Proof needs to come in the form of evidence that 
processes lead to products which lead to improved coverage of key interventions 
in the most cost/effective manner possible.
· The UHRC’s M&E program should be based on a clear, simple M&E framework. 
This framework should have clear and concise input, process, output and outcome 
indicators, a well defined and explained method for collecting needed data, clear 
guidelines for recording and reporting out of results in a timely manner. 
Significantly more work is needed in this regard.
· Current UHRC reporting does not concisely communicate clear messages about 
what is being accomplished. Building this capacity within UHRC will not result 
from a few technical assistance visits by an external contractor. Rather, it is likely 
that some kind of strategic partnership over the long term with another 
organization with more experience in monitoring and evaluation will be required.
4.10 Additional activities to support urban health program development
The team also identified several key gaps which require further investigation and thinking 
but were beyond the scope, available time, or timeframe for this evaluation, including:
· A detailed evaluation from a public health perspective of the initial city proposals 
which were developed using the EHP-UHRC guidelines, with recommendations 
for revision of the guidelines, including their application, as necessary.
· Including consideration of the health systems issues for the urban poor being 
explored by PHR under an ANE Bureau and EGAT/Urban Programs comparative 
analysis in Indore and Manila.
· Exploring links to microfinance institutions, self-help groups, etc.
· Tightening linkages to address environmental sanitation, water supply, and 
hygiene issues as part of the urban health planning process, and developing viable 
solutions to these critical issues.
· Conducting a cost-effective analysis of the ward coordination model, using best 
estimates of public health impact.
· Identifying TA needs of UHRC and developing a plan to help meet these needs.
· Establishing criteria for city-level TA support and cataloging likely candidate 
cities.
Each of these is recommended for follow-up action by USAID/India.
5.0 General Lessons Learned in Urban Health Programming
30
The evaluation felt there were some general lessons to capture, drawing upon the 
experience of this evaluation but also similar evaluation work undertaken by others, such 
as the World Bank’s Urban Slum Project.
· There are no simple solutions or universal model for addressing the health of the 
urban poor or the poor living in urban slums. There is a need for flexibility to 
apply the most effective available approaches depending on the local situation. 
Focus on a few critical services and monitor their delivery.
· There is tremendous opportunity in urban health to partner with community-based 
organizations as well as private sector
· Long term financial sustainability, institutional viability, and adequate human 
resources are, as always, critical to the long-term sustainability of urban health 
efforts. 
· From the beginning ensure management focus on outputs and outcomes rather 
than inputs. All other evidence is of little consequence. This will require a 
baseline, clear indicators of inputs, process and outputs, a method for collecting 
needed data, and the clear and concise recording and reporting out of results in a 
timely manner. Without this evidence the appropriateness and effectiveness of the 
approach will always be in question. 
· Be careful about creating and disseminating guidelines, methods and materials 
that are not thoroughly tested and grounded in evidence that they produce the 
intended results.
· Documentation should be minimized while still being complete. Strive for clarity,
simplicity, and smaller size. Documents that are repetitive, wordy and unclear 
document events, and maybe progress, but do not communicate impacts well.
31
Bibliography
Documents of Government of India (GoI) 
1. Tenth Five Year Plan (2002-2007) by the Planning Commission, GoI
2. Programme Document of Reproductive and Child Health II (RCH II) 
Documents of USAID-India 
1. Child Health Strategy, March 2001
2. Urban Health Strategy, June 2001
3. Scope of Work for CDM India: Task Order 807, dated June 19, 2004 
4. Urban Health Evaluation Scope of Work (SoW), March 2005
Reports of EHP-UHRC as of March 2005
Reports pertaining to Knowledge Inventory
1 Reproductive and Child Health Scenario in Urban Madhya Pradesh
2 Reproductive and Child Health Scenario in Urban Uttar Pradesh (Draft)
3 Reproductive and Child Health Scenario in Urban Delhi (Draft)
4 Prevention of Diarrhoea through Hygiene Promotion- Job Aids
Reports pertaining to Advocacy
1 Report of Urban Health Symposium at 49th All India Annual Conference of 
Indian Public Health Association, 2005
2 Report of Urban Health Symposium at 32nd Annual Conference of Indian 
Association of Preventive and Social Medicine, 2005
3 Report of Symposium on ‘Strategies for Prevention and Control of IDA 
among Children and Women in Urban Slums’, 2004
4 Report of Urban Health Advocacy Activities at 42nd National Conference of 
Indian Academy of Pediatricians, 2005
Reports pertaining to Demonstration City Programs
32
1 Activity Report-133: Indore Situational Analysis
2 Activity Report-127: Participatory Community Health Enquiry and Planning 
(PCHEP) in Selected Urban Slums of Indore
3 Hygiene Promotion Trial in Urban Slums of Indore, Madhya Pradesh (Draft)
4 Investigating Age Appropriate DPT-I and DPT-III Immunization Status of 2-6 
months old infants in selected slums of Indore (Draft)
5 Maternal and New Born Care among the Urban Poor of Indore
6 Situational Analysis Report of Agra City for Guiding Urban Health Program
7 Maternal and Child Health Survey in Slums of Indore (Draft)
8 Differential Health Conditions across Slums- Findings from Slum Assessment 
and Maternal Child Health Survey in Indore
9 Quarterly Progress Report of Indore Urban Child Health Program
Reports pertaining to Technical Assistance to Government of India
1 Activity Report-135: Technical Assistance to Government of India for Urban 
Health Planning and National Guidelines
2 Technical Assistance to Government of Uttaranchal- Process Documentation
3 Capacity Building Process for Evidence-based Consultative Urban Health 
Planning (Document based on Urban Health Planning Workshop, Kolkata, 
2003)
Collaborative Documents
1 Guidelines for Development of City-Level Urban Slum Health Projects
2 Improving the Health of the Urban Poor: Lessons Learned and the Way 
Forward (Report of the National Consultation, 2003)
3 Five Year Urban Health Proposal under RCH II for Agra
4 Five Year Urban Health Proposal under RCH II for Bally
5 Five Year Urban Health Proposal under RCH II for Dehradun
6 Five Year Urban Health Proposal under RCH II for Haldwani
7 Five Year Urban Health Proposal under RCH II for Haridwar
33
8 Report on Technical Capacity Enhancement Workshop for Madhya Pradesh, 
Uttar Pradesh & Uttaranchal, 2004
9 Report of State Level Urban Health Workshop for Uttar Pradesh, 2004
34
Annex 1: Contact List 
USAID/New Delhi
Mr. Robert Clay, Director, Office of Population, Health & Nutrition
Dr. Massee Bateman, Chief-MCH and Urban Health Division 
Dr. Rajiv Tandon, Sr. Advisor-Child Survival
Ms. Sheena Chhabra, Chief-Health Systems Division
Dr. Randy Kolstad, Chief-Reproductive Health Division
Ms. Rebecca Black, Director-Office of Economic Growth 
Mr. N. Bhattacharjee, Program Manager- Office of Economic Growth
Mr. Ashok Jha- Office of Economic Growth
Mr. David Foster, Sr. Urban Advisor- Office of Economic Growth
GOI
Dr. Kirti Parikh 
Member - Planning Commission
Yojna Bhawan
New Delhi
Mr. Prasana Hota
Secretary, Family Welfare
MOHFW
Room No. #149, Wing 'A'
Nirman Bhawan
New Delhi - 110 001
Tel.: 2301 8432
Board: 23022200 (X: 2643)
Fax: 2301 8887
Internet: http://www.nic.in/mohfw
Dr. Raj Bhan, Secretary
Secretary
Department of Biotechnology
Block-2, CGO Comples
Lodhi Estate
New Delhi – 110 002
Tel: 91-11- 24362950
Fax: 24360747
Dr. S. Y. Quraishi, Director General, NACO
National AIDS Control Organization
Ministry of Health and Family Welfare 
9
th Floor, Chandralok Building 
New Delhi
35
E
-mail: nacodel@vsnl.com; 
Dir.:23325331
Board No: 3325335/3325343/5340 (X: 11)
Fax: 2373 1746
Mr. Chaman Kumar
Joint Secretary
-DWCD, GOI
A
- 605, Shastri Bhawan
New Delhi
Mr. A.K.Mehra
Secretary, Tariff Commission
Ministry of Commerce & Industry
GOI
7th Floor, Lok Nayak Bhawan,
Khan Market New Delhi- 110 003
Tel: 2469025 
akmehra@hub.nic.in
Dr. Gurpreet Singh
Senior Medical Officer
Incharge MIS Cell
4th Floor
Office of Project Director (IPP
-VIII)
Vigilence building
16, Rajpur Road
Delhi 
- 110054
Tel: 23978509 
M: 9868506582
Mr. Alok Kumar Jain, MD
National Horticulture Board, 
Minister of Agricultre
(Ex Secretary, HFW/DWCD Uttranchal)
85, Institutional Area
Sector
-18
Gurgaon
-120 015
Tel: 0124/95124 
– 2342992 / 2343414
Fax: 0124/95124 
- 2342991
Mr. T. V. Raman
Director (Area Projects)
MOHFW
36
Deptt. Of Family Welfare
A-520, Nirman Bhawan
New Delhi – 110 011
Telefax: 23794523
Dr. S. K. Satpahty,
Deputy Commissioner (ID)
Government of India
MOHFW
407 ‘D’ Nirman Bhawan
New Delhi – 110 011
Tel: 23017281
PARTNERS
Dr. G. V. Ramana
Sr. Public Health Specialist
The World Bank
70, Lodhi Estate
New Delhi – 110 003
Tel: 24617241/24619491
Fax: 24628073/24628074
Ms. Ranjana Kumar, Health Advisor, DFID
Mr. M. K. Padma Kumar, Sr. Dy. Program Manager, DFID
Department for International Development (DFID)
British High Commission, 
B-28, Qutub Institutional Area
New Delhi - 16
Tel.: 26529184 /26529123
Fax: 26529296
Ms. Darshana Vyas, Counterpart Interanational 
Mr. Ramesh K. Singh, Program Director, Counterpart International
Counterpart International-India
B Rajdhani Apartment
4
th Floor, B/h Manav Mandir
Memnagar 
Ahemdabad – 380 052
Tel: 079-30911593 / 27484567
Fax: 079-27474935
Email: ramesh@counterpart-india.org
Website: www.counterpart.org
Mr. Marzio Babille, Chief-Health Section, UNICEF
37
Ms. Lizette Burgers, Chief-Water Section, UNICEF
UNICEF
UN ICEF House
73 Lodi Estate, New Delhi 110 003
Tel: 24690401 
Fax: 24627521/24691410
EHP-UHRC
Dr. Siddharth Raj Agarwal, Country Representative 
Mr. Anuj Srivastava, Urban Health Planning Specialist 
Mr. Srinivas Varadan, Urban Health Planning Specialist
Mr. Pravin Jha, M&E Specialist
Mr. Mani Gupta, Capacity Building Consultant 
Ms. Karishma Srivastava, Program officer 
Mr. S. Kaushik, Research Specialist 
Mr. Sandeep Kumar, Indore Program Coordinator 
Mr. Prabhat Jha, Indore Program Support Officer 
Mr. Sainath Banerjee, Jamshedpur Program Coordinator 
Mr. Rajesh Dubey, Agra Program Development Specialist
Mr. Sanjeev Upadhyaya, Consultant
Mr. Biplove Choudhary, Consultant
Ms. Shivani Taneja, Consultant
Ms. Lehar Zaidi, Consultant
Mr. Sudhir Rao, Consultant
Environmental Health Project (EHP)
F-9/4, Vasant Vihar, N.Delhi – 110 057
Cell: 91 – 0 – 98114 32174
Tel: 2614 9781, 2614 9771
Fax: 51669281
LUCKNOW
Mr. Bhonwal, Secy. HFW, UP
Dr. K L Meena, Secy., DWCD, UP
Dr. L B Prasad, DG.FW, UP
Dr. Chittoriya, UH Cell UP
Mr. Diwesh Chaturvedi – ED, SIFPSA
State Innovations in Family Planning
Services Agency (SIFPSA)
Om Kailash Tower
19-A, Vidhan Sabha Marg
Lucknow – 226 001
Tel: 0522-2237497 / 2237496/498
Fax: 0522-2237574 / 2237388
38
Dr. R. C. Ahuja
Professor, Deptt. Of Medicine
KGMC Insitute of Clinical Epidemiology
King George Medical College
Lucknow - 226 003
Tel: 0522-2255199
Fax: 0522-2257674
Email: kgmcice@satyam.net.in
 kgmcice@sancharnet.in
Dr. Shally Awasthi
Professor
CSM Medical University
Deptt. Of Pediatrics &
Institute of Clinical Epidemiology
Lucknow -226 003 
Tel: 0522-2257329
Fax: 0522-218227/257674
Email: sawasthi@sancharnet.in
Mr. Prabhakar, State Coordinator-CARE, UP
CARE INDIA
B-718, Sector “C” 
Mahanagar
Lucknow 226 006
Tel: 0522-389 043 / 334 436 / 371 032
Fax: (0522) 383 570
Email: careup@lwl.vsnl.net.in
AGRA
Dr. Devkinandan, Principal & Dean, Agra Medical College
Dr. Roshan Lal, Agra C.M.O
INDORE
Dr. Uma Shashi Sharma, Mayor, Indore Municipal Corporation
Dr. A. K. Puranik, Chief Health Officer, Indore Municipal Corporation
Mr. K.K. Yadav Ward Councilor, Indore Municipal Corporation
Mr. Kishor Solanki, Acting Zonal Officer, Indore Municipal Corporation
Dr. Mukesh Bhachawat, District Immunization Officer, Deptt. Of Public 
Health, Indore
39
Dr. Shailja Wande, Medical Officer, Ward-5, Deptt. Of Public Health, 
Indore
Ms. Shobha Patil, LHV, Dept. Of Public Health, Indore
Ms. Anita Kamble, ANM Virndavan Dispensary, Deptt. Of Public Health, 
Indore
NGOs
Mr. Prashant Tiwari - Chief Program Coordinator, CECOEDECON
Dr. Ramesh Nagrath, Managing Trustee, Puspkunj Family Helper Project
Mr. Gokul Krishna Nair, Project Manager, Puspkunj Family Helper Project
Mr. Jeevan Kumar, Program Coordinator, Puspkunj Family Helper Project
Mr. Richard Peter, Director, Indore Diaocese Social Service 
society(IDSSS)
Ms. Anjali.B. Kumar, Program Manager, Indore Diaocese Social Service 
society(IDSSS)
Ms. Usha Agarwal, Director/Secretary, Bhartiya Grameen Mahila Sangh 
(BGMS)
Ms. Anjali.B. Kumar, Program Manager, BGMS
40
 Annex 2: Evaluation Team Scope of Work
1. Summary of main features and background
In three years the EHP-UHRC has become a nationally recognized technical assistance 
and information resource in urban health. Demand for technical assistance from the 
EHP-UHRC is high and increasing. City programs have been developed and have been 
successful in developing methods and producing tools. Some city programs have not 
developed as quickly as initially anticipated. Private sector activities are included in the 
city programs, but are not as prominent as the level of interest indicated elsewhere in the 
PHN office of USAID/India or that of the GOI. There is strong and apparently 
burgeoning interest and support at the highest bureaucratic and political levels for better 
addressing the health of the urban poor in India. The RCH program has evolved to be a 
very important vehicle for supporting urban health programs at scale and the EHP-UHRC 
has developed a strong position in support of that program. Newer initiatives focused on 
the health of the urban poor are being developed at the mission level (run out of the 
Prime Minister’s office – similar to a Presidential Initiative in the US). While the EHP￾UHRC initially focused on child health, its work has broadened into planning and 
systems issues in reproductive and child health or primary health care more generally. 
The program today is quite different from that planned for in 2002, when that national 
RCH program was not considered to be an opportunity, GOI interest appeared to be 
limited, as did political interest. The program has made a number of adjustments to 
respond to these opportunities as they arose. Responsiveness and flexibility have been 
hallmarks of the EHP-UHRC and these appear to be key features contributing to the 
strong relationships that have been built with the government. From the initial 
conception and throughout this program the definition of urban health and its 
determinants has been broad. On the ground activities have been largely confined to 
some aspects of child health (in city programs) and to RCH (technical assistance to the 
government in planning). Inclusion of non-child health elements, either USAID/India 
supported or otherwise, has been very limited. Likewise, inclusion of health-related 
factors outside of the health sector – especially water and sanitation for the urban poor –
has not been successfully addressed to date.
2. Purpose and Overview
This scope of work is for an evaluation of the overall USAID program of support in 
urban health. The objectives of this activity are to evaluate (1) the development of the 
urban health program – particularly in terms of positioning itself to substantially and 
measurably contribute to improved health among the urban poor in India; (2) assess the 
quality of program activities; (3) assess the institutional development of the urban health 
project; and (4) provide recommendations for the future direction, development and 
scope of USAID/India’s urban health program. The scope of work is comprised of main 
tasks, a series of questions to be addressed and related sections covering logistics and 
management, personnel and roles and responsibilities and deliverables.
3. Main Tasks
41
In order to accomplish the objectives of this evaluation, the team will be required to 
complete the following tasks.
1. Review background documents including the USAID India “Child Health 
Strategy” March 2001, the Urban Health Strategy June 2001, GOI plans and 
documents (Five year plans, RCH II), documents produced or supported by the 
EHP-UHRC in India and other relevant documents.
2. Participate in a team planning meeting at USAID/New Delhi to review and refine 
understanding of the SOW, agree on the table of contents of final product, 
establish roles and responsibilities and develop a detailed workplan for the 
evaluation.
3. Describe and assess the progress of the urban health program June 2001 –
February 2005 in major areas of work through
a. Interviews with major stakeholders
b. Presentations by EHP-UHRC staff
c. Field visits
d. Document review
4. Develop recommendations for program development and program priorities.
5. Develop and deliver a presentation of the evaluation process, findings and 
recommendations to USAID/India
6. Prepare a final report incorporating feedback from the oral presentation.
 
3. Evaluation Questions
These evaluation questions are meant to guide the team in information collection and 
analysis. The priority is to develop an analysis, supported by assembled information, that 
supports the recommendations. Analysis of the Recommendation Question Set will 
therefore provide the priority guidance for developing a detailed workplan and table of 
contents for the report.
Strategic Management Question Set
USAID/India Country strategic plan and strategic objective
1. How does the urban health program relate to priorities articulated in the 
USAID/India Country Strategic Plan?
2. Does this activity contribute to one or more of the cross-cutting themes covered 
by the country strategic plan (governance, gender, urban issues, partnerships, 
cutting-edge technologies)? If yes, how?
3. How successful has the activity been in addressing the problems and challenges 
identified in the country strategic plan?
USAID/India Strategic Objective 14
1. How appropriate is the urban health activity to the strategic framework and 
indicators of SO14?
42
2. Have opportunities to contribute to SO14 results been missed, and, if so, what 
opportunities and constraints can be identified?
Inter SO and interoffice collaboration
1. To what extent and in what manner has the PHN urban health activity benefited 
from work with other offices and SO’s?
2. To what extent and in what manner have PHN urban health activities contributed 
to urban activities in other offices or SO’s?
3. What are the practical possibilities for PHN to work more effectively with other 
USAID/India offices to improve the overall impact on maternal, child, and 
reproductive health of the urban poor?
USAID/W collaboration
1. Describe the nature and effectiveness of collaboration with ANE Bureau, BGH, 
and other bureaus in USAID/W. Describe opportunities and constraints for more 
effective collaboration.
2. What offices and activities provide the best opportunities for collaboration and 
support of USAID/India’s urban health program. Are there any technical projects 
in the BGH that are designed to provide assistance in urban health?
USAID Management and Implementation Question Set
1. How has USAID management contributed to problems encountered or activity 
accomplishments?
2. What aspects of USAID management have most contributed to program impact?
3. What aspects of USAID management have constrained program impact?
Partnership and Stakeholders Question Set
1. Describe the Indian government interest in the USAID/supported urban health 
program (includes all levels of government—central, state, city-level).
2. How does the USAID urban health program contribute to the national RCH 
program? Are there other central government missions, schemes or programs 
with which the USAID urban health program should be working?
3. How does the USAID urban health program complement other donors’ activities? 
Are there duplications? Is USAID support sufficient to meet the needs in the area 
identified for USAID support?
4. To what extent have stakeholders beyond the government been identified and 
working relationships established at the national, state, and city level. Describe 
opportunities and constraints to working more effectively with nongovernmental 
stakeholders.
Implementation Question Set
Activity design
1. To what extent has the USAID approach of providing flexible support for an 
evolving design been appropriate and successful? Would the program have 
benefited or been constrained were a more rigid design used at the outset?
43
2. To what extent has the program operated within the strategy established in the 
2001 Child Survival Strategy and the Urban Health Strategy? What have been the 
major areas of deviation from the original strategy, and what accounts for this?
3. Has the need for flexibility in the strategy and workplan changed over time? To 
what degree does the program benefit from flexibility currently?
City program implementation effectiveness and efficiency
1. Describe the city programs and characterize the accomplishments in Indore, 
Calcutta, Agra, Jamshedpur and Delhi. What have been the facilitating and 
constraining factors in these accomplishments? What are the main contributions 
of the city programs to the larger urban health activities of USAID, the 
government and other partners? What are the main contributions of the city 
programs to the long term improvement of health among the urban poor in these 
cities? What others lessons learnt can be identified?
2. Characterize the technical areas of intervention in city programs. To what extent 
has the program been assisted or hindered by a narrow focus on child health? Has 
the selection of technical components been appropriate to achieve impact in child 
health and nutrition? Characterize the quality of these interventions.
3. Characterize the methods and accomplishments of working with partners, 
governmental, not-for-profit and private sector for-profit, in city programs. To 
what extent has this methodology been successful in building a coalition of the 
most important stakeholders?
4. Specifically, characterize the efforts and achievements in working with the private 
sector – associations, networks of health care providers, independent health care 
providers, private hospitals and institutions, and the private corporate sector. To 
what extent has working with this sector been a success and what are the 
opportunities and constraints to work more effectively through the private sector 
to increase the scope, scale and impact of these activities?
5. Describe the approach to working with non-governmental, community-based 
organizations. To what extent has this approach been effective in identifying and 
recruiting effective partners, and developing and managing effective programs?
6. Describe the achievements in terms of improvement in health indicators among 
targeted populations; development, validation, and documentation of 
methodologies; and development of new knowledge through operations research. 
Assess the value of these achievements in terms of improving the health of the 
urban poor in India, at scale.
Technical Assistance to City, State, and GOI urban planning and implementation
1. Describe the nature and evolution of the technical assistance component of the 
urban health program. To what extent has the program been able to respond 
effectively (quality, extent of services offered) to demand from city, state, and 
national governments.
2. Describe the model of technical assistance management used – local vs. 
expatriate; full time staff vs. consultants; episodic support vs. long term 
placement and so on. To what extent has the model chosen facilitated or 
constrained the responsiveness and quality of technical assistance?
44
3. What is the significance of this technical assistance activity to the extent, quality, 
and ultimate effectiveness of programs aimed at improving the health of the urban 
poor in India?
Advocacy, Information Management and Research
1. Describe the products of the urban health program in terms of advocacy events, 
workshops, reports, and articles.
2. Describe the quality and effectiveness of these products.
3. Describe any tangible or probable benefits to the health of the urban poor in India 
of these products.
Development of Institutional Capacity in Urban Health in India
4. Describe capacity building activities of the urban health program that target 
government and non-governmental institutions. What have been the constraints 
to the effectiveness of these efforts? What are the opportunities identified and 
successes of these efforts? 
5. Describe and assess the organizational development activities under the EHP task 
order. Are the goals of institutionalization for long term leadership in urban 
health likely to be realized? Identify constraints, opportunities and critical areas 
for immediate action.
Problems and options
1. Are there any major problems or conflicts that require immediate attention?
2. What specific options are available for resolving any problems or conflicts or 
other implementation constraints? How would these options be implemented?
Recommendation Question Set
11. How should the main strategic elements of the urban health program be 
formulated? What are the primary results and indicators that should be tracked to 
measure performance?
12. What should be the technical breadth of the program within the PHN portfolio? 
What nature and process for collaboration with other offices within USAID/India 
are recommended? What linkages with USAID/W programs are recommended?
13. What are the recommended mechanisms to support these activities? Specifically, 
what activities can best be supported through the Urban Health Resource Center, 
and what activities may be supported through other mechanisms?
14. What level of effort and organizational arrangements should be employed to 
provide technical assistance at city, state, and national levels?
15. What is the strategic role of support to city activities within the overall program? 
What proportion of level of effort and in how many cities of what character 
should such programs be implemented?
16. What are the main aims of a program of operations research, publication of 
technical papers, consultations and conferences, and support to resource centers? 
What proportionate level of effort should be applied in each area?
17. What are the requirements for support for the organizational development of the 
Urban Health Resource Center – both from a strict OD point of view and from a 
technical capacity building point of view.
45
18. What balance of flexibility and rigid specificity should be sought in each aspect of 
the program in the future? What options are recommended to manage flexibility, 
if and where it is required?
19. What additional important activities can be recommended to inform the 
development of the urban health program – evaluations, analyses, research, 
tracking evolution of specific government programs and policies, and so on.
4. Evaluation Management
Roles and Responsibilities
Massee Bateman, CTO for Urban Health Project and MCHUH Division Chief, will 
provide overall guidance for the activity. Logistics support will be provided through the 
USAID/India PHN office and the EHP-UHRC office in New Delhi. 
The Evaluation Team:
John Borrazzo, CTO for the Hygiene Improvement Project, will be the team leader and is 
ultimately responsible for the evaluation team and its products. 
Dan Kraushaar, Director of BASICS III
Sonali Korde, Senior Technical Advisor for private sector/sustainable health in the ANE 
bureau of USAID/W
Rajiv Tandon, Senior Advisor Child Survival in USAID/India/PHN/MCHUH
Lehar Zaida, consultant, EHP-UHRC
Performance Period
March – April 2005: The team will work in India 7 – 18 March, which does not include 
travel, document review, and post-travel document revision time.
5. Deliverables
· Team Planning Meeting products: individual SOW”s for team members, table of 
contents for the final report, and workplan
· Oral briefing: The evaluation team will provide an oral briefing of its findings 
and recommendations to USAID/India staff. The team will also brief GOI 
counterparts and project managers of the Urban Health Resource Center on the 
main findings and recommendations.
· A draft report will be prepared prior to departure from country.
46
Annex 3: EHP-UHRC staffing pattern as of March 2005
The staffing pattern of the EHP-UHRC as of March 2005 consists of: 
1. Country Representative 
2. Documentation Officer 
3. Urban Health Planning Specialist (2)
4. M&E Specialist 
5. Capacity Building Officer 
6. Program Officer 
7. Administration Officer 
8. Contract Officer 
9. Accountant 
10. IT & Admin Support Assistant 
11. Intern – currently providing assistance in documentation activities. 
12. Research Specialist 
13. Librarian 
14. Jamshedpur Program Coordinator 
15. Indore Program Coordinator 
16. Indore Program Support Officer 
17. Agra Program Development Specialist 
In addition, EHP provides various consultants on an as-needed basis. 
The Country Representative supervises all Delhi staff and the city support staff is 
supervised by city Program Coordinators who in turn are supervised by the Country 
Representative.
47
Note that there are no expatriate full-time staff, though international consultants and EHP 
home office staff have been used to support EHP-UHRC efforts.
48
Annex 4: Presentation of initial findings to Mission staff, 18 March 2005
49
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51
52
53
54
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