MIGRANT HEALTH PROMOTION PROGRAM
PRESENTED BY XINTU CENTER FOR COMMUNITY HEALTH PROMOTION, SHANGHAI OCTOBER 2007
Contact person: Ms. Xiaomu Guo Title: Executive Director Address: 4F Xi’ai Bd, 2795 Md. Yanggao Rd, Shanghai, 200135 Email: firstname.lastname@example.org Tel: 021-51879851 Fax: 021-50336510
This is a full program proposal developed by Xintu Center for Community Health Promotion, Shanghai (Xintu), to apply for a grant provided by GlaxoSmithKline (GSK), named Positive Action, Global Community Partnerships.
The proposal is developed on base of initial communication between Xintu and GSK. The full proposal is generated from a package of project concept papers presented by Xintu, which have been reviewed by GSK. In order to achieve maximum impact, a holistic program is developed which incorporates all the components in the concept papers. Sanlin Town of Pudong New district is identified as the program site, given its close link to the 2010 World Expo. The program distinguishes itself by comprehensive community-based initiatives and innovative strategies on self-sustainability.
The full proposal contains overall program design, annual work plan, program management issues and a detailed budget.
TABLE OF CONTENT
Themes and Work Plans………………………………………………………….22
Attachment: 1. Organizational Profile…………………………………………………………33 2. Program Detailed Budget (Excel)
Program Title: Promoting Reproductive Health for Migrant Population
Program location: Sanlin Town, Pudong New District, Shanghai
Program duration: 3 years (2008-2010)
Funding organization: GlaxoSmithKline
Total budget: 3,599,300 RMB (493,055 USD)
Program Implementer: Xintu Center for Community Health Promotion, Shanghai
Primary partners: Pudong New District Bureau of Social Development, Shanghai GlaxoSmithKline Xintu Center for Community Health Promotion, Shanghai
Non-Profit Organization Incubator, Pudong (NPI) Health Education Research Center, Fudan University (HERC, Fudan) Marie Stopes International China Program (MSIC) CSR & Company
Program content: Reproductive Health for migrant population -prevention of STDs and HIV/AIDS for migrant workers -safe motherhood (maternal health) for women and children -sexual health & contraception for migrant adolescents
Program goals and Objectives: The program aims to improve migrantsâ€™ reproductive health in target community, through 4
taking community actions on stimulating demand and delivering outreach services. Multi-sector collaboration is emphasized to maximize impact. It is expected that the innovative approach created by the program would become a replicable model nationwide, even internationally, after it’s proved to be successful. The objectives are: at the end of the program, 1. Migrants in target community have increased their awareness on protecting their reproductive health and preventing themselves and from reproductive diseases. 2. Community-based outreach services are made available for migrant workers and their families by an outreach team, to meet their reproductive health needs. 3. Public awareness on migrants’ health rights and needs is increased, and government policy for migrant health service is improved. 4. Mechanism of sustainable development is established, and the program model is proved to be replicable.
Key indicators: z
1.7 million people informed of migrants’ reproductive health rights and needs
100,000 migrants’ awareness on their reproductive health increased
50,000 people received reproductive counseling services
10,000 people screened on reproductive health diseases, and patients referred to affordable treatment 1000 migrant women received maternal health check, and patients with medical attention referred to affordable treatment At least 1000 professionals and officials from government, corporate and civil society are educated on migrant health promotion strategies The program model is introduced to at least 10 major cities in China
Program strategies: 1. Partnership The program is a collaborative initiative between three sectors, corporation, government and civil society. Resource from each sector is mobilized to address the health problem.
2. Advocacy The aim of advocacy is to create supportive environment through raising awareness on migrants’ health rights and needs, as well as to improve existing policy which effect 5
migrantsâ€™ health situation. Advocacy is targeted on both government and public, with different strategies. In order to maximize the program impact, promotion/advocacy strategy follows three steps, from the program to the model, from local to national.
3. Health education Health education is the key component of the program. Health information is carefully designed to fit in migrantsâ€™ information needs, and is delivered through channels that can effectively reach them. Besides public education, group communication and individual counseling are carried out to facilitate behavior change.
4. Outreach Service A team of field workers will be recruited and will receive intensive training on basic health knowledge, and more importantly, counseling skills. Their tasks are gathering information, delivering health knowledge, providing non-medical services, and assisting individuals and families to seek suitable services. The team members are equipped with service kits. They approach to migrants in their own communities or groups, deliver health information on group or individual base, provide counseling services concerning their reproductive health needs, and refer those who need advanced treatment to medical facilities. The operation of this outreach team is the key to make basic reproductive health service available to migrants.
5. Organizational capacity building By the end of three years, the program will become a registered community-based non-profit organization, in order to achieve sustainability. The organization will be owned by the community (guaranteed by governance structure), and will serve the target group in this community. During the program organizational capacity building strategies will be applied to insure this systematic change.
RATIONALE In China, large industrial cities attract a large number of internal temporary migrant workers from mostly rural areas. With the rapid economic growth, migrant population has increased massively over the last few years, 53 million in 1995, 79 million in 2000, and close to 150 million in 2006 (Zheng & Lian, 2005). Migration in China currently has the following characteristics: Firstly, the majority of migrants are young to middle age people, with an increasing percentage of family migration. Secondly, most migrants have a relatively low educational and literacy level. In cities where they work, migrants take 3-D (dirty, dangerous and difficult) jobs which local people are not willing to take. Finally, they move frequently, and therefore are referred to as “floating population”. Large migrant populations have caused many social issues, including education, health and social interactions. China has a strict household registration system that identifies people as either urban or rural residents, and all public services are planned and financed according to household registration. This dual system puts migrants in a much more disadvantaged position in urban society. Although working and living in the same city, they are not integrated and have very limited access to most public services. Meanwhile, as temporary workers, most of them don’t have any type of social insurance. They become a marginalized group in cities, challenged by unequal treatment and discrimination. Migrants’ special social-economic status means that they pay higher health costs and face greater health risks while contributing to the cities. The problems of poor working and living conditions, lack of health insurance and benefits and the inaccessibility of public health services have made migrants the most vulnerable group in cities. Reproductive health diseases, infectious diseases, as well as occupational diseases are the most common conditions in this group. Shanghai is one of the cities with the highest migrant population in China. One third (6 million) of its population are migrants. Under the national development strategy of building “harmonious society”, Shanghai government recognizes that integrating the migrant population into the social system is fundamental and unavoidable. While the city prepares for the 2010 World Expo with the theme of Better city, Better Life, the pressure to build harmonious communities has never been greater. For communities with a large number of migrants, the priority is to build inclusive public service system. However, without an effective administration measures, migrant population is a “hard to reach” group. Previous practices have approved that neither government administration instruments nor commercial market approaches can reach this population and deliver services effectively. Innovative strategies need to be adopted. This program addresses migrant population’s reproductive health problems, which are the most common health problems for this group, through a community-oriented approach. Both demand side and supplier side are addressed to fill the gap that currently exists. Multi-sector collaboration is developed to ensure the program’s impact on policy improvement, community development, and target group behavior change.
COMMUNITY PROFILE Community overview The program will take place in Sanlin Town of Pudong New District. Sanlin Town is located at the conjunction of three districts with large migrant populations, Pudong, Minhang and Nanhui.
Sanlin Town is located in south-west Pudong, and 70% of its residents are migrants. The official total population of Sanlin Town is 224,000 in an area of 31 square kilometers, among which there are 94,000 urban residents, 10,000 rural residents and over 120,000 officially registered migrants. This figure doesn’t include unregistered migrants, which counts for at least 50% of those who are registered, so the total population of migrants is likely to be around 180,000 out of a total actual local population of 284,000. Sanlin Town used to be an agricultural area. Along with the process of urbanization, industry has rapidly developed. In 2006, the town ranked 38 on the list of 100 richest towns in the country. In 2006, average annual per capita income for urban residents reached 24,000 yuan, and 10,600 yuan for rural residents. Migrants in the area earn on average 6,000 yuan per annum. In recent years, being the town closest to the 2010 World Expo site, Sanlin has received increasing attention from the government, the media as well as the public. 75% of the World Expo park area is in Sanlin Town. Sanlin is a key priority in the Pudong government’s strategic development plan, and is expected to be given the designation of “model town”. There has been much infrastructure construction and many public facilities have been established or remodeled. As a result, Sanlin has become one of the hottest
spots for investment in Shanghai. As an example, in response to the invitation for investment bids in the Sanlin World Expo Functional Area, 10 development projects will be located in Sanlin, with total investment of 6.5 billion RMB. Sanlin Expo Homeland was built in 2005 as one of the bases for resettling residents affected by the construction of the World Expo Park. The Homeland is located in a downtown area of Sanlin within Shanghai’s middle ring road. Within a few years, some 300,000 residents will be moved to this area. Sanlin Town is thereby becoming densely populated, with urban residents clustered in the central area, and migrants distributed in surrounding sub-urban areas.
Migrant population The following figures give an overview of the migrants in Sanlin. ¾
55% male, slightly more than female
77% from east China (neighboring provinces)
25% are children and adolescents (aged 0-19), 55% are young people (aged 20-30)
Over 70% of adults (over age of 15) are married
Over 82% of female migrants are procreative (aged15-49 )
Over 80% have not completed their middle school education
The figures paint a picture of a huge group of people with strong reproductivity, and at the same time, massive demand on health, especially reproductive health. For example, the percentage of procreative females in the migrant group is 22.6% higher than in the local female group. Among the procreative female population, 76.7% are at the peak age range of reproductivity (aged 20-34). The high level of reproductively generates huge demand for reproductive health services such as maternal and child health care, family planning and disease prevention and treatment. About 80% of migrants are manual labourers. Their average income is about 500 yuan per month (about 25% of local urban residents and 50% of rural residents). Migrant workers mainly work on construction sites and in restaurants, factories, etc. Some work as repairmen, dustmen and peddlers. Most migrants work long hours in labor–intensive industries under poor work conditions. Many are exposed to a variety of health and safety risks. There is a high incidence of workplace injuries and career-related diseases in this population. Migrant workers usually live in poor conditions, with crowded space and poor sanitation. There are three types of accommodation: work sheds (70%), rented houses in rural areas and small flats. Most migrant workers live in clusters in communities known as “villages in city” (slums). These communities usually are less developed and have fewer public resources. Poor living conditions also contribute to migrants’ health problems, especially their exposure to infectious diseases. 9
There is a community health center in Sanlin Town, which provides basic medical services to the community. Other hospitals in Pudong which provide reproductive health services are Pudong Maternal and Children Health Center, the First Maternal Health Care Center in Pudong, Pudong Oriental Hospital, Gongli Hospital, and some other private hospitals. These hospitals are either tertiary or district level facilities, with high standard of pricing. Instead of going to hospitals, most of the migrants visit private clinics for their treatment needs. These private clinics are poorly equipped and have very limited treatment skills. Cases of malpractice have been reported in recent years, which have caused serious damage, even death, to some patients.
Due to low social and economic rank, the migrant population has become the biggest vulnerable group in urban areas in China. Migrant population has high mortality and high incidence of common diseases, and has become high risk group for infectious diseases, sexual transmitted diseases (STDs) and HIV/AIDS. Risk factors relating to migrants’ health are analyzed from different perspectives, from social to individual. z
Social environment Urban society tends to discriminate against or ignore migrants and fails to respect their values or recognize their rights Health policy The overall health policy environment, subject to a dualistic social structure, keeps migrants from receiving equal health care services. As with many other social resources, health resources are allocated according to the residential registration management system. As a result, migrants (who are rarely registered as urban residents) are officially excluded from the urban health management system. Migrants’ health needs put an extra burden on the urban health service system. Service providers The health service providers, mainly the hospitals, are not motivated to provide health service to migrants. Public health and primary health service, planned by government, are found to be lacking of effective measures to reach migrant communities. Most public service providers are lack of effective channels and measures to extend their service to migrants. On the other hand, private health services, basically commercially oriented, don’t target on migrant group, given their limited ability to pay. Community action At the community level, communities are not ready to take action to fight the health problems the migrants face. Communities don’t have self-initiated organizations which represent the interests of migrants, or lobby for their interests. Migrants are usually not integrated in the communities they live. Health information Migrants lack access to the health information they need. In an urban setting, health information is delivered mainly via modern media, within the sphere of the integrated urban community. Migrants, usually left out of the community, lack access to this information. Deficiency of information leads to high-risk behavior and low service utilization. Individual practice Poor living conditions, high work load, high risk behavior and deficient nutrition all contribute to the risk. In addition, a high level of mobility allows migrants to carry infectious diseases and spread them to rural areas.
The following section describes migrants’ problems and needs in three main areas of reproductive health.
STDs and HIV/AIDS High incidence of risk behavior and high mobility has put the migrant population at high risk of HIV/AIDS infection and spread. According to national statistics, 70% of people who live with HIV/AIDS are migrants. In Shanghai, in 2004, 74% of HIV/AIDS infections were among migrants. The migrant population has become the first priority for HIV/AIDS prevention in China. The risk factors are: High risk sexual behavior 80%of migrants are in their sexually active period of life. Freedom of movement and removal of traditional constraints is impacting young people’s behavior, especially their sexual behavior. According to a survey in Pudong, sex is no longer a taboo, and most migrants accept premarital sex behavior and cohabitation. Most of them have multiple sexual partners, or use sexual workers. When having casual sex with temporary sex partners, only 14% of migrants use condoms. Poor health knowledge and skills Lack of knowledge of HIV/AIDS makes migrants 1 unaware of the risks. A survey report shows that the HIV/AIDS awareness rate 2 is only 17.7% for migrant adolescents (age 15-24). 46% of them do not know about HIV/AIDS prevention and self protection. The survey also shows that most of them obtain their HIV/AIDS knowledge through the public media. But only 60% of them regularly read newspaper or watch TV. Migrant women are even more vulnerable. Basic information on HIV/AIDS, though available to women, does not seem to assist them on making decisions to avoid risky sexual behavior. Gender issues affect this group. They have difficulty in making independent decisions and negotiating with their sex partners because of the power relations between women and men. Both male and female migrants are exposed to the risk of STDs due to poor self-protection practices. Some infectious diseases were found more prevalent among migrants, mainly due to poor hygiene and living conditions. The poor living condition and unhealthy practices chronically harm the health of migrants and increase the chance of infection of certain diseases. A survey conducted in Pudong district, Shanghai shows that about 20% of migrant women suffer from reproductive diseases. The survey concludes that migrant women’s awareness and reproductive health has not been improved in last 10 years. Actually, both migrant men and women are reluctant to seek for treatment when they have reproductive diseases. In summary, the biggest barriers of STD and HIV/AIDS prevention for migrants are knowledge deficiency and poor self-protection skills. Maternal Health Migrants’ maternal health situation is greatly affecting the health of migrant women and their children. The following figures show the significance of the problem:
Survey on Migrant Adolescents Reproductive Health Service Situation, 2006 According to WHO recommendation, HIV/AIDS awareness rate refers to the awareness rate to three HIV/AIDS transmit channels and non-transmit channels.
In Shanghai, around 70%-80% of maternal death cases are migrant women.
Only about 57% migrant women go to hospital for delivery.
Only 25% of pregnant women receive formal pre-natal examinations.
64.3% of them never receive any type of pre-natal care.
Only 66% of migrant children receive regular vaccination.
Factors that have caused the problems are: Poor living conditions Intensive work load and poor nutrition affects pregnant women’s health and cause risk to delivery. Time constraints Migrant women work for long hours. They don’t have time to take care of themselves or for examinations. Also after delivery, they usually don’t take enough time off for post-natal care. Many of them don’t have their babies checked and immunized in part because to time constraints. Poor knowledge of care Most migrant women are unaware of potential risks of pregnancy and delivery. They are not aware of the importance of pre-natal examinations, especially in the early months. Affordability of service Migrants have to pay for most of their examinations, hospitalized delivery and children’s vaccination. Those who are not covered by insurance are not likely to go to hospitals to seek for services. Also, they lack information about services and their possible benefits. Private practitioners operate in migrant communities, some illegally. Many migrants tend to go to these private clinics for medical treatment. Poor medical condition and skills put patients at great risk, especially for delivery. In summary, the biggest barriers to migrant maternal health are lack of knowledge and unavailability of convenient, quality and affordable services. Family Planning & Contraception Migrant women, especially adolescents, have a great need for contraceptive knowledge and services. According to the survey mentioned above, only a small percentage of them are aware of common contraceptive methods. Although over 80% of them know about condom as an effective method for contraception, over 50% don’t know where to get contraceptive counseling and tools. Only 50% of them claim that they are capable of choosing suitable contraceptive methods when having sex. Failure of contraception leads to unwanted pregnancy, and result in high rate of induced abortions. Induced abortion rate for migrant women is significantly higher than that for local residents. Many migrant women are presenting in hospitals with a history of multiple induced abortions, which causes physical damage and severe potential risks. In China, the government family planning system distributes condoms to married couples for free, for the purpose of population control. But this free public service is not accessed by migrants, especially unmarried ones. Some of them purchase condoms from drug retailers. In Pudong, over 60% of drug retailers’ customers are migrants. But the problem 13
is, most drug retailers are clustered in urban communities. Suburban areas where most of the migrants are have far fewer shops. Staff in drug stores mostly lack health knowledge, and the customers can not get much counseling services form them. On the other hand, many migrants donâ€™t want to spend money on condoms and other family planning products which are quite expensive to them. Coming from rural areas, migrant women have less social power than women in cities. This fact affects their power in sex-related decision making. They lack the courage and skills to negotiate with their boyfriends or husbands when they are asked to have unprotected sex. Obviously, lack of protective knowledge, along with low availability of counseling services and products are the main barriers for migrant women in terms of contraception and family planning. In conclusion, as a special vulnerable group, migrants have great needs in reproductive health. Behavioral change is the key to maintaining and improving oneâ€™s reproductive health and preventing reproductive health diseases. The following needs should be addressed to facilitate behavioral change. 1. Migrantsâ€™ health problems need to be addressed and their right to reproductive health realized and respected. Discrimination and bias result in isolation and keep them even further away from services. 2. Migrants need adequate information on reproductive health. Being marginalized in urban settings, they have fewer information sources than local residents. Regular information distribution channels may not accessible to them. They need information that can reach their communities. 3. Counseling services play a significant role in facilitating behavioral change. Migrants need personalized and consistent counseling services to help them learn self-protection skills and make decisions on treatment. Counseling services need to be available in their communities, and easy to access. 4. Affordable reproductive health products and services need to be introduced to migrants. They may not be able to receive such quality services as local residents due to policy constraints and economic issues. But basic products and services need to be guaranteed. This program is designed to meet these needs through innovative strategies which are expected to lead to sustainable change.
This program is designed under the conceptual framework of health promotion, demonstrated in the figure: Figure 1 Health promotion conceptual framework
Selfmanagement Health communication
Supportive environment Service provider reorientation
Utilization; Organization & individual
Healthy community, healthy people
According to the framework, the ultimate outcome of the program is a healthy migrant community and improved reproductive health for migrants in the community. Intermediary outcomes of the program are the establishment of a community-based reproductive health promotion organization owned by the community, which plays the role of providing basic services to the target group and link them to existing medical services. To achieve the outcomes, health education, advocacy and service availability will be addressed through various activities.
Goal, Objectives and Outcome Indicators The program aims to improve migrants’ reproductive health in the target community, through community actions to stimulate demand and delivering outreach services. Multi-sector collaboration is emphasized to maximize impact. It is expected that the innovative approach created by the program would become a replicable model nationwide, even internationally, after it’s proved to be successful. The 3-year program is a comprehensive package, composed of several intervention initiatives. The objectives are: by the end of the program, 1. Migrants in target communities have increased their awareness of protecting their reproductive health and preventing themselves and their families from reproductive diseases; Outcome indicators: 100,000 migrants have increased their awareness on their health rights and needs
Migrant adolescents’ awareness rates regarding STDs and HIV/AIDS prevention are increased from 17.7% to 80%
Migrant women’s awareness rates regarding contraception and disease prevention are increased from 50% to 80%
Migrant women awareness rates regarding safe motherhood and maternal health are increased from 40% to 80%
2. Community-based outreach services are made available for migrant workers and their families by an outreach team, to meet their reproductive health needs. Outcome indicators: 50,000 people received reproductive counseling services
10,000 people screened on reproductive health diseases, and patients referred to affordable treatment
1000 migrant women received maternal health check
3. Public awareness on migrants’ health rights and needs is increased, and government policy for migrant health service is improved. z
1.7 million people have received information regarding migrants’ reproductive health rights and needs At least 1000 professionals and officials from government, corporate and civil society are informed of migrant health promotion strategies Government work plans for migrant reproductive health updated (by Pudong New District FPC, CDC and BSD)
4. Mechanism of sustainable development is established, and the program model is proved to be replicable. Outcome indicators: z
A community-owned reproductive health promotion organization set up and registered as a local NGO, with a strategic plan for sustainable development Program outcomes nation-wide
The program model is introduced to at least 10 other cities
Partnership The program is a collaborative initiative between three sectors, corporation, government and civil society. As showed in the figure, the three parties work together to realize the program, which eventually becomes a community-based organization. Figure 2 Program partnership
Government (administrator) -policy support -multi-dept. participation
Corporation (donor) -financial support -PR and advocacy
Civil society (implementer) -program management -organizational development
At operation level, Xintu will develop partnership with some individual professional companies and organizations from all three sectors, by sub-contracting certain activities out to them. The reason for this out-sourcing approach is to mobilize more resources to achieve maximum impact of the program. The following organizations will be involved: z
Health Education Research Center of Fudan University (HERC, Fudan), a professional institution on public health, will be contracted to conduct a thorough community survey at the beginning of the program. The survey results will be documented and published, and guide the development of health education materials. The survey will be one of the most comprehensive research projects in the field for migrant reproductive health. CSR & Company, a new firm which provides consultation services to corporations on CSR, will be invited to organize a national forum on CSR, named Corporate Partnership with Community. CSR & Company has developed wide contact with both commercial and non-profit organizations. With their network, organizations will be brought in to share GSKâ€™s experience working in community with community-based organizations. Marie Stopes International China Program (MSIC) will be contracted to develop guidelines and manuals for field work. MSI China program has been working in the field of adolescent reproductive health for many years in China, and has established a few chain clinics with the brand â€œYou & Meâ€?, in five cities in China. 18
Non-Profit Organization Incubator (NPI) will be contracted to organize the seminar of cross-sector collaboration on public service scheduled in year 2. NPI is currently working with Shanghai government (Shanghai Bureau of Civil Affairs) on developing community-based public service social entrepreneurs.
Advocacy The program has a major focus on advocacy. The aim of advocacy is to create supportive environment through raising awareness of migrantsâ€™ health rights and needs, as well as to improve existing policies which affect migrantsâ€™ health situation. Advocacy targets on both government and public sectors, with different strategies. In order to maximize the program impact, promotion/advocacy strategy follows three steps, from the program to the model, from local to national. Each year has a different advocacy focus, which systematically approach to program impact. Figure 3 Program promotion/advocacy strategies
Year 3 Year 2
Year 1 Program promotion Professional seminar
Model promotion; National seminar
Health promotion; Regional seminar
In Year 1, advocacy focuses on promoting the program to both the government and the public. Local government will be familiarized with the overall approach of the program, and is convinced that the program is in alliance with government strategies on building harmonious society. General public will receive the message that a joint initiative will take place to address migrant health. A 1-day seminar for service providers (public and private) will be held to discuss migrant health service model. In year 2, with the health education campaigns and outreach services delivering to the community, the advocacy focus will be switched to promoting reproductive health. At the end of the year, a 2-day seminar on cross-sector collaboration on public service will be held in Shanghai, to promote civil society participation in public service. Also, in the same year, a national forum on corporate social responsibility will be held in Shanghai, to promote corporate-community partnership. In the last year, with program knowledge generated, advocacy focus will be moved on to introducing the program model nationwide. Professionals, government officials, NGO representatives and media reporters from Beijing, Guangzhou, Shenzhen, Chengdu, Chongqing, as will as major cities in Jiangsu and Zhejiang will be invited to participate in
sharing program knowledge and discussing possibility of replication. Health education Health education is a key component of the program. Health information will be carefully designed to fit migrantsâ€™ information needs, and will be delivered through channels that can effectively reach them. Besides, public education, group communication and individual counseling are carried out to facilitate behavior change. Health education materials and distribution methods will be developed for each sub-group to meet their diversified information needs. Table 1 education material development framework Target groups
Male migrant workers
Construction sites, Terminal markets, Logistics companies Recycling stations
STD and HIV/AIDS prevention, Self care and protection, Condom use,
Posters, Pamphlets, Specially designed Gift-sets
Manufactories, Restaurants, Hotels, Domestic service companies
Sexual health for women; Personal hygiene; Self protection; Contraception methods; Reproductive tract infection; Induced abortion and risks;
Pamphlets, Posters, specially designed Gift-sets
Middle schools; High schools; Vocational training facilities
Sexual development; Self care and protection, Sexual behavior and risks, Contraception methods; HIV/AIDS prevention; relationship development
PPT presentation, Pamphlets, Webpage
Families, Community centers
Maternal health for women and children; Importance of pre-natal check; Pregnancy care and nutrition; Pregnancy syndrome and treatment; Preventing miscarriage; Post-natal care and nutrition; Breast feeding and infant health;
Pamphlets; Leaflets; Specially designed Calendars;
Reproductive health and life quality; HIV/AIDS prevention; Health for women and children
Posters, Leaflets; Stickers
Communities, Public locations
Totally there will be 27 workshops conducted for groups of migrants in various settings. The topics are listed below: Table 2 workshop topics Target groups
Construction sites, Terminal markets, Logistics companies Recycling stations
1. STD and HIV/AIDS prevention
Manufactories, Restaurants, Hotels, Domestic service companies
1. contraception and birth control 2. HIV/AIDS and women 3. gender and health
1. sexual development & self-care 2. sex and HIV/AIDS 3. relationship development
Outreach Service A team of field workers will be recruited, mainly from migrant groups. They will receive intensive training in basic health knowledge, and more importantly, counseling skills. Their tasks are gathering information, delivering health knowledge, providing non-medical services, and assisting individuals and families to seek suitable services. The team members are equipped with service kits containing educational materials, information collection worksheets, basic physical checking tools and small gifts (non-medical products). They approach to migrants in their own communities or groups, deliver health information on group or individual base, provide counseling services concerning their reproductive health needs, and refer those who need advanced treatment to medical facilities. The operation of this outreach team is the key to make basic reproductive health service available to migrants. The field team will be managed through developing field work protocols and setting up an effective information system. The team membersâ€™ service behavior will be monitored to make sure they follow the protocol. Organizational capacity building The key for sustainable development is for the program to become an independent community organization. The organization will be owned by the community (guaranteed by governance structure), and will serve the target group in this community. As a capacity building organization, Xintu will provide support on governance structure, leadership development, strategic planning, fund raising, etc. Another partner of the program, NPI, will also provide support to it.
THEMES AND WORK PLANS
To achieve program outcomes, each year has a theme. Activities are arranged according the themes. In year 1, partnership will be built, consensus will be reached, and the community will be sensitized and prepared for change. In year 2, education and services are delivered to our target groups. In year 3, knowledge is generated and the model is ready for replication. The theme of year 3, Better Community, Better Life, corresponds to the theme of 2010 World Expo, Better City, Better Life. Table 3 program themes Years
Year 1 (2008)
Year 2 (2009)
Partnership building; Community sensitizing;
z z z
Kick-off meeting (press conference) Community survey Develop education materials Introduce the program to public Recruit field team Train field workers Seminar for health professionals
Knowing, Caring Understanding
Year 3 (2010) &
Health education; Service delivery;
Education material distribution Field workshops Counseling/home visits Screening National CSR forum Regional promotion seminar
Better Community, Better Life organizational development; Program promotion z
Annual work plans are developed as following:
Same service activities as year 2 Register a new NGO Opening ceremony for the NGO Receive study tours Produce program dissemination materials National promotion seminar Final evaluation
Partnership for a future
Annual objectives: by the end of year 1, 1. partnership is established, with key stakeholders’ roles and responsibilities clarified, 2. the public is educated on migrants’ rights and needs in reproductive health, and 3. community work force is set up to prepare for large scale services. Output indicators: z MoU signed z # of people informed on program information z # of professionals/social workers/field workers trained on migrant health work Quarters
1. partnership building 1.1 preparation meeting I: at district level 1.2 preparation meeting II: at town level 1.3 design, print and distribute program introduction kits 1.4 conduct kick-off meeting & press conference 1.5 conduct coordination meeting with township government agencies 2. public education 2.1 conduct a thorough community reproductive health service market
2.2 develop a special report on migrants’ reproductive health needs and publish it in newspapers 2.3 develop a website for the program 2.4 design public education materials 2.5 recruit college students to distribute program introduction materials to general public 2.6 conduct assemblies at workplaces and community public sites to introduce the program to migrants (6 times) 3. building community taskforce 3.1 recruit a program manager and two program assistants 3.2 set up program office in Sanlin Civic Center 3.3 recruit 50 migrants from different sub-groups as contracted field workers and conduct orientation 3.4 conduct services skills training workshop to the field workers (one training workshops each year, with different topics) 3.5 recruit 48 volunteers (social workers) from sub-communities and conduct workshop to train them on skills working with migrants 3.6 conduct a service provider seminar to discuss migrant health service model 3.7 develop guidelines and manuals for field work 4. annual review (program committee meeting)
Knowing, Caring & Understanding
Annual objectives: by the end of year 2, 1. majority of migrants in the community are educated on reproductive health knowledge and skills, 2. individuals and families have received non-medical services, or referred to proper medical services as needed, 3. individuals are screened or tested on reproductive health diseases, and 4. pregnant/maternal migrant women received pre-natal and post-natal examinations. Output indicators: z # of people educated z # of people received non-medical services z # of people screened on reproductive tract infection and other STDs z # of women receiving pre-natal and post-natal examinations Quarters
1. public education 1.1 Distribute education materials to workplaces and families by field workers and volunteer social workers 1.2 conduct education workshops in workplaces (25 workshops, 50 people for each) 1.3 conduct workshops in schools for adolescents (12 schools) 2. counseling 2.1 equip the field workers with education materials, products and field work tools (records, worksheets, products as gifts) 2.2 field workers reach to individuals in their communities and conduct education and counseling 3. screening 3.1 work with Maternal and Children Health Care Center to conduct migrant women reproductive tract infection screening initiatives (6 missions in communities, 1000 people each time) 3.2 refer patients to medical treatment (negotiate with hospitals for discount charge) 4. maternal health 4.1 set up record system for migrant women in maternity 4.2 conduct periodical home visits to families with maternal health needs, provide basic check and counseling 5. Conduct national SCR seminar: Corporate Partnership with Community 6. conduct a seminar on cross-sector collaboration on public service 7. annual review 24
Year 3: Better Community,
Annual objectives: by the end of year 3, 1. education and services are continuously conducted, 2. knowledge and experience are generated and introduced nationwide, and 3. a community-owned organization established for sustainable development. Output indicators: z # of people educated z # of people received counseling services z # of people screened on reproductive tract infection and other STDs z # of women received pre-natal and post-natal examinations z # of people the program outcome is introduced to z Registration of a new NGO Quarters
1. public education 1.1 distribute education materials 1.2 conduct education workshops in workplaces (20 workshops) 1.3 conduct education workshops in schools (3 schools) 2. counseling 2.1 field workers provide information to people in their communities, and refer them to further counseling or treatment 3. screening 3.1 conduct migrant women reproductive tract infection screening initiatives (4 missions in communities, 1000 people each time) 3.2 refer patients to medical treatment 4. maternal health 4.1 conduct home visits to families with maternal health needs 5. organizational capacity building 5.1 conduct preparatory workshop and set up governance structure for a new community organization 5.2 register the organization as a community reproductive health promotion center 5.3 develop strategic plan for the center 5.4 hold opening ceremony for the center 6. advocacy and program promotion 6.1 receive study tours from other districts and cities (4 times) 6.2 produce a documentary of the program and distribute it 6.3 produce an album for the program and distribute the copies 6.3 conduct national seminar to promote program outcomes 7. program final evaluation
1. Xintu Center for Community Health Promotion (Xintu) Xintu, an officially registered local NGO, is the primary implementer of the program. Xintuâ€™s core competencies are community health promotion, program management and organizational capacity building. See attachment 1 for detailed information of Xintu. Xintu has added the following value to the program: Innovation Xintu has strong background working in the field of community health promotion. In the past, Xintu is experienced in creating innovative mechanisms to solve health problems. Successful cases include setting up community hospitals and clinics (vision centers) in Hainan, Sichuan, Guizhou and Yunnan. Xintu believes that the communities have potential ability to identify and solve health problems of their own, and community-based organizations are in the best position to serve the community. Innovative ideas that Xintu brings to the program are: integrating HIV/AIDS prevention into the broader concept of reproductive health, which affects more people and is less likely to cause discrimination,
creating a new type of service provider which focuses on disease prevention and health promotion, and introduce it into the existing service chain,
adopting comprehensive strategies to make service more available, accessible and affordable, and
initiating a holistic intervention which consists of environment building, group and individual behavior change, organizational and community development.
Quality As a professional health organization, Xintu has deep understanding of reproductive health diseases and how they affect peopleâ€™s lives, as well as what kinds of services are needed. Unlike many health programs that only conduct mass public education, Xintu carefully designs a continuum of services, from information to treatment, from public education to individual facilitation. Program quality will also be guaranteed by Xintuâ€™s project management capabilities, which has been built through rich project management experience. The following points demonstrate the quality of the program: z
Educational materials are carefully designed, using health communication strategies to make sure health messages are effectively delivered to different sub-groups. Participatory training courses and workshops are developed, using participatory learning strategies, Services are standardized by developing guidelines and service protocols for health education, counseling, home visiting, non-medical treatment, etc. 26
a monitoring system will be set up to collect and manage program information.
Networking Xintu has a good relationship with local government agencies. At national level, Xintu also has contact with national CDC, national Committee of Family Planning, Ministry of Health and Chinese Academy of Social Science. People from these agencies will be invited to promotion activities. International NGOs in the field who have partnership with Xintu will also be involved. Moreover, with its nationwide network of health institutions, Xintu could be helpful with the program scaling up process in the future, in other communities in China.
2. Pudong New District Bureau of Social Development (Pudong BSD) Representing the government, Pudong BSD will become a functioning partner by coordinating government resources to support the program. Department of Health, Family Planning Committee and CDC will all be involved in both promotion activities and community activities. Community initiatives (educational campaigns, screenings) will be jointly conducted by Xintu and individual government agencies, according to the theme of the initiatives. The local government has been carrying out outreach services to migrant communities, but not effectively, due to the high cost of human resources and lack of vehicles to reach target groups. The program, on the other hand, adopts a bottom-up approach as opposed to government led top-down approach. Thus joint initiatives will improve the effectiveness and efficiency. Working as a partner in the program, the government will explore a new approach of collaborating with the private sectors, both commercial and non-commercial, and develop policies for sustainable collaboration.
Management Structure Figure 4 demonstrates the management structure of the program. Figure 4
Program management structure
Program committee -GSK -Government -Xintu
Program assistant 1
Program assistant 2
Representatives from the three parties will from a program committee which directs the program strategies and oversees its progress. Its function is to make sure the program is meeting mutual benefits and contributing to strategic goals. A program manager will be recruited to be responsible for program implementation. The manager reports to the program committee and receive technique support from the consultant team. The program managerâ€™s job is to make sure the program activities are conducted as planned, and solve problems coming up during the course of the program. Two program assistants will be recruited to assist the program manager. Program assistant 1 is responsible for information collection and management, and making sure the communication channels to all stakeholders are unimpeded. Program assistant 2 is responsible for organizing community work, including training, workshops, screening, etc. The field team consists of 50 field workers who are recruited from migrant groups. They work in their communities to carry out education, counseling and referral. Their work is 28
monitored by a monitoring system operated by the program manager. A few senior consultants are invited to the program, participating in training, education and promotion activities. 4 senior consultants from different fields have been identified: Dr. Feng Li, Director of Health Education Research Center, Fudan University, health education expert Dr. Shaoping Wan, board director of Xintu, reproductive health expert Dr. Zhao Lv, Director of NPI, organizational development expert Dr. Minghua Li, East China Normal University, migrant social work expert
Donor Involvement The program is funded by GSK, a world-famous pharmaceutical giant who actively supports public health initiatives at the same time of providing high quality health products. In this program, GSK is recognized as not only the donor, but an active partner. Through the program, the three parties, GSK, Xintu and local government, forms an alliance to promote the health of a disadvantaged population. This establishes a model of multi-sector collaboration on solving health problems. As an active partner, GSK is involved at all stages of the program in various activities. Planning stage GSK global and GSK China work closely with Xintu, the designer of the program, at the planning stage. Through active communication, consensus is made on program key strategies and program site selection. On base of that, the program is designed to fit the vision and mission of both parties, and benefit the interests of both the community, the beneficiaries and the initiators. Beginning stage Preparation workshops and other communication activities will be carried out to facilitate consensus of three parties. Through the process, GSK will meet with government officials, learn about government strategies on migrant health and HIV/AIDS prevention, and develop a strategic collaboration. Implementation stage GSK will take part in all public promotion activities, including press conference, seminars/symposium, media report, etc. All printed materials will be reviewed by GSK PR division. GSK staff members will be invited to participate in community education activities. A Corporate Social Responsibility (CSR) forum will be conducted in year 2, to introduce the program to introduce the program to the CSR arena. Evaluation stage Annual review will be conducted by the program committee, the end of year 1 and 2. At the end of the program, external evaluation will be conducted by an evaluation team appointed by GSK.
Program sustainability is a requirement of both the donor and the implementer of the program. For a program to become sustainable, it should not only focus on service. Instead, it should focus more on building a mechanism for the service to continue. In this program, sustainability strategies are developed at the design stage. The two key strategies are (1) stimulating the demand; (2) insuring the supply. Stimulating the Demand Even though it is clear that migrants need reproductive health, this need isn’t yet fully expressed as a demand. Lacking awareness (of their rights and needs) and resources (money, time, etc.) prevents the majority from seeking proper services. The following strategies are employed to stimulate demand: z
Health education Knowledge is the first step for behavior change. Adequate health information raises people’s awareness and willingness to protect themselves. Introducing suitable services Many people don’t access services simply because they are not aware of the existence of services. Others may think the services are too expensive or time-consuming. Making services more accessible and affordable is another strategy to raise demand. In this program, outreach services are delivered to this “hard to reach” group, and service packages are designed to reduce the cost. Empowerment Through group workshops and individual counseling, we approach to the most vulnerable groups (women, adolescents), teach them self-protection skills, and encourage them to make independent decisions about their health.
Ensuring Supply Establishing organizations is an effective way to sustain services. In this program, to sustain the services during and after program lifetime and embed them in the community, a community-based organization will be established. The new organization will be non-profit, governed by community stakeholder representatives, especially migrants. The key function of the organization is to bring appropriate services to the target people. It conducts health education and community initiatives, provides counseling services and reproductive health products, and refers patients to medical facilities. After the program, the organization’s financial support is expected to come from the following sources: z
Government outsourcing Public health services are regularly funded by government. Each year the organization will design public health projects and
apply for government funding. Public health projects include health education, community screening, etc. z
Government reimbursement When services are provided to the most disadvantaged groups, reimbursement will be provided by government (Bureau of Social Affairs). Each year a certain percentage of services will be reimbursed by the government. Service income Different from public health services which are paid by government, private health services are paid by the recipients out-of-pocket, or from insurance. During the program support, all services are free of charge, but the demand will be tested and feasibility for paid service model will be detected. When the program support is over, the organization will continue with providing free public health services, but will charge for individual services, including counseling, basic examination and treatment (non-medical). Patients with medical conditions will be referred to medical facilities. Price of the services will be set according to the target peopleâ€™s ability to pay, probably lower than existing services. With full operation, service income is intended to cover organizational operation cost. Social resources As an NGO, the organization is eligible to receive donations from corporations, foundations and individuals. Donations will be sought on a project basis.
The importance of ensuring supply is that this type of community-oriented service doesnâ€™t exist currently. Existing medical services are institution-based and have very limited ability to reach this group. Also in the reproductive health service area, there are many non-medical services which are not necessarily provided by hospitals. As stated above, the program has an integrated set of strategies for sustainable development, which benefit the process of donor exit.
Scaling Up Strategies With innovative intervention and sustainability strategies, the program has great potential to scale up. Once it is proved to have expected impact, the model can be replicated in other districts in Shanghai, as well as other cities with similar migrant settings. Along with the program, promotional activities will be carried out to introduce the model to people from outside. Given the outputs produced by the program, replicated programs will be much less costly. Public education materials, training courses for field workers and social workers, and materials for field workshops will be developed and tested, and can be repeatedly used.
The following table illustrates the categorized program budget, extracted from the program detailed budget in the excel form. Table 5 Program budget summary Amount Categories Year 1
Conference & meetings
Travel & accommodation
Service fee reimbursement
Office rental, equipment/ supplies
Material development Training
ATTACHMENT 1 ORGANIZATIONAL PROFILE Basic Information Name:
Xintu Center for Community Health Promotion (Shanghai)
Officially registered non-profit organization
Registered in Beurau of Social Affairs 3 , Pudong New District (Certification number 787888698)
Beurau of Social Development 4 , Pudong New District (Department of Health)
Business areas: Health education, training and capacity building, public health research, counseling and technique support, health program management
Financial status: Table 1 Total revenue for each year Financial years
Major Funding sources 5
Global Fund HIV/AIDS project (III, IV, V) Oxfam HongKong Amcham China (Beijing) Marie Stopes
According to Chinese legal system, organizations registered in Bureau of Social Affairs are legal NGOs. Due to strict government policies, only 20% civil society organizations are registered as legal NGOs.
Also according to the law, every legally registered NGO need to be supervised by a government agency. The NGO conduct annual report to government and goes through annual examination process.
5 Before its official registration, Xintu was a project in ORBIS International from 2002 to 2006, and was fully financed by ORBIS. See the part of History for clarifications.
XINTU’S VISION Xintu envisions to a world where everyone has his/her right on health and development.
XINTU’S MISSION Xintu promotes health and development for individuals, families and communities by enhancing service capacities of community-based health institutions, and to help them extending their health services to the communities they serve, especially to vulnerable groups and underserved population.
XINTU’S PRIORITIES Xintu’s Prioritized Diseases
Xintu’s Target Groups
--reproductive health and HIV/aids
--maternal health and safety
--people in rural communities
--other venerable groups to specific diseases
XINTU’S VALUES y
Participation Xintu facilitates active participation of donors, partners and beneficiaries, through information sharing, consensus making and collective decision making.
Transparency Through an effective financial management system, Xintu guarantees financial transparency.
Mutual interests Work with multiple sectors and various partners, Xintu considers each party’s interests, makes sure that all the parties are benefited as certain extent in the collaborations, and no harm made to any party.
History & Achievement Before establishment, Xintu was a project in ORBIS International, an U.S. based NGO working on blindness prevention. The 5-year project, called China Training Network (CTN), started in 2002 and terminated in 2006. CTN was designed by ORBIS headquarters in 2001, at the critical turning point of ORBIS. According to its strategic development plan, the organization was under the pressure of switching from a technique oriented to community based organization, given that clinic technology had no linger been the biggest gap between western and developing countries. It was particularly the case in China. CTN was than designed to be an umbrella project to facilitate technology transfer from urban areas to rural areas where the most patients were. CTN’s goal was to develop a national network of organizations and individual trainers, to promote community based eye care services. ORBIS also had the vision that after CTN finished its mission in ORBIS, it would have the potential of becoming an independent NGO. CTN had been the largest project for ORBIS China program since its operation in China. 5 staff members are recruited for the project. Over the 5 years, CTN has conducted a wide range of activities to build capacity of health facilities, to extend their health services to communities. Table 2 Snapshots of CTN project Impact
An innovative approach is developed to promote community based, patient centered health service.
Over 1200 people trained (doctors, nurses, CHWs, administrators) 43,000 people screened on eye diseases 12,000 patients medically treated 5,800 surgeries performed Over 500,000 people educated on eye disease prevention Established partnership with 22 hospitals nation-wide 66 professionals developed as contracted trainers
CTN’s most successful case, apart from training events, was to establish three community-based eye hospitals in Hainan, Sichuan and Guizhou. CTN initiated the whole process of capacity building, from identifying social entrepreneurs, developing strategic plans, training of staff members, developing community networks, etc. Now these three hospitals are well functioning, with large number of surgical cases performed each year. The directors of the three hospitals are all on the board of Xintu. CTN project has helped ORBIS with its transfer from urban institution centered to rural community centered approach in China. At the main time, it has developed rich experience on community health work, as well as a nation-wide network with great potential. At the end of the project, people from the network were invited to a CTN sustainability workshop, in which Xintu’s blue print was drafted. Xintu Center of
Community Health Promotion was then set up and separated from ORBIS. After that, Xintu started its journey of self development and has expanded its focus to general health, with strategic focus on reproductive health, blindness prevention and chronic disease management. 2007 was the key year for Xintu, without ORBIS full financing. Xintu has raised over 100 thousand USD from multiple funding sources. Several projects were carried out, mostly in two areas: HIV/AIDS and maternal health. Key outputs are listed below: Table 3 Xintu project outputs in 2007 Project title
Beijing Migrant women maternal health promotion
Guizhou Miao minority group maternal health promotion
500 women and children screened
60 CHWs trained on community skills
150,000 residents educated
On-site intervention training of high risk groups
Global Fund III
CDC capacity building on HIV/AIDS prevention knowledge generation
Global Fund III,IV,V
Long-distance Technical Support Network Building
Global Fund III
Family Planning system capacity building in Jiangsu Province
10,000 migrant women educated on maternal and children health
2000 women received maternal health service 126 villages covered 140 on-site trained
1,400 CSWs received education on self-protection
240 CDC staff members trained
2,100 people trained
80 trainers trained
3000 family planning workers trained
Figure 1 Organograph
Dept of Program
Dept. of Research
Partner Community Organizations
Dept. of Finance/admin
Board of directors Xintu was established by a group of public health professionals and hospital administrators who shared the vision of adopting innovative approaches to promote community health. There are 11 board members, all actively involved in organizational governance and decision making. Brief introduction of three key persons are presented. Dr. Shaoping Wan is the chair of the board. He was a senior manager of Sino-British HIV/AIDS program, before he was assigned as the director of MSD HIV/AIDS prevention program financed by Merck & Co., Inc. Dr. Wan is a nation-wide famous professional and trainer in the area of HIV/AIDS prevention, and works as senior consultant for many national initiatives. He has trained over 6,000 field workers on AIV/AIDS intervention skills. A few books have been published and distributed on base of his work experience. With Dr. Wanâ€™s active support, Xintu has gained strong capacity on carrying out HIV/AIDS related programs. 37
Dr. Fei Long is the key founder of Xintu. Dr. Long has received his Doctorate at School of Population Health, The University of Queensland in Australia, MS and BS in School of Public Health, Sichuan University. Prior to his current position as the China Country Director of the Fred Hollows Foundation, Australia, he was the senior program manager of ORBIS China program. He was also the project manager of China Training Network (CTN), known as the predecessor of Xintu. He had led the CTN team to become an independent local NGO. Executive team Xintuâ€™s executive team is led by Ms. Xiaomu Guo, also a former team member of CTN ORBIS. Ms. Guo was a project manager, training specialist and M&E specialist in ORBIS, before she moved on to become the director of Xintu. Ms. Guo has been working in the field of NGO for over 10 years, in which she has developed her experience on program design and management, organizational development and training. Other team members are: Yi Zhong, MA, Program director, received her post-graduate degree in the University of Ohio, U.S.A., majored in women study and anti-violence. Dr. Alex LI, Research director, received his Doctorate at School of Population Health, The University of Melbun, Australia, majored in HIV/AIDS prevention. He is based in Australia. Lilian Ji, MA, Program officer, received her post-graduate degree in East Normal University, majored in psychology. Jerry Zhao, MD, Program officer, received her post-graduate degree in Fudan University, majored in epidemiology. Yan Zhang, MD, Program officer, received her post-graduate degree in Fudan University, majored in reproductive health and family planning. Consultant team A few consultants are recruited and actively involved in Xintu program work. They are: Dr. Feng Li, Director of Health Education Center, Fudan University Dr. Zhengyi Feng, Senior professor of Nursing School, Fudan University Dr. Simon Lv, Director of Pudong NGO development Center Partners: Xintu has developed partnership with 22 hospitals. They are from tertiary, district and community levels. They have all worked with Xintu and have committed to community health promotion. In the field of health and NGOs, Xintu has built strong reputation on capacity building. Several international organizations have worked with Xintu and have built partnership through collaboration. See the list below for details:
Table 4 Xintuâ€™s partnership with international organizations Organizations
Used to incubate Xintu; now Xintu offers consultation services to ORBIS and its partners
Xintu provided training (7 times) to Plan staff and partners
Marie Stopes International (MSI)
Xintu conducts a project supported by MSI (Family Planning system capacity building in Jiangsu Province)
Xintu conducts a project supported by Oxfam (Guizhou Miao minority group maternal health promotion)
Save the Children
Xintu provides training to its local partners on birth defect intervention
Xintu conducts a few projects supported by GF
The Fred Hollows Foundation (FHF)
Xintu provides training to its local partners on community health skills
Xintu supported Amity on building capacity
American Chamber of commerce, China
Xintu conducts a project supported by Amcham China (Beijing Migrant women maternal health promotion)
European Chamber of Commerce, Shanghai
Xintu organized volunteer program