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Reaching Out to The Most Deprived And Vulnerable - The Urban Homeless

Introduction

The Homeless are the unfortunate segment of the urban poor. They have no fixed shelter but congregate at certain localities only to sleep during nighttime. They mostly live under the open sky. The total population in each area ranges from 1000 to 4000. Homeless people are marked as “high- risk” groups from health point of view bearing the risk of causing public health concerns in the society.  There is no targeted approach to ensure their health service needs. Public hospitals remain the only option for them to receive health services, but hidden cost in public hospitals and service delivery timing exclude them from receiving health services. Thus the health especially the SRH needs of the homeless has always been left un- attended.   To improving access to quality SRH and ESP by creating enabling environment, Marie Stopes, have developed a unique and innovative service delivery mechanism to address the SRH needs of this vulnerable group.

Objective

The overall objective of the homeless programme is to contribute towards improving the health status, especially SRH status of homeless women , men and adolescents in selected urban areas of Dhaka, Khulna and Chittagong.
The specific objective is to enable the homeless population of the selected urban areas to gain accesses to quality SRH and ESP services by : improving access of the targeted population to quality services; increasing demand for quality health services among the targeted population; creating enabling environment for the targeted population to access services; and demonstrating a replicable and sustainable model of pro poor service delivery.

Mode Of Service Delivery

Marie Stopes, under a special initiative to address the SRH needs of this vulnerable group, designed and introduced the homeless service. Before starting implementation of the services Marie Stopes conducted an intensive survey to assess their health status and , the health care they need and the health care behavior. Based on the survey findings, Marie Stopes identified the target groups as well as the service delivery locations, and developed a basic health care service package ( including maternal care) that is delivered from a mobile van. The van has been designed into a small clinic that is adequately equipped to cater  reproductive health and other services to the homeless. Services for the homeless people are rendered from 12 Service Delivery Points ( SDPs ) of Dhaka , Khulna and Chittagong cities. The satellites clinics are held in the in the late evening i.e. from 7:00 pm to 9:00pm, the time when these people return to their places of stay after work. The services team consists of doctors, a paramedic, field coordinator and three volunteers. Clinical services are provided to homeless female clients  from the Mobile Van Clinic while male sessions are conducted adjacent to the mobile van in a makeshift tent. The volunteers motivate the people to receive healthcares. They are selected from within the same(homeless) group, imparted training, and amply motivated to do activates. In each of the identified spot, Marie Stopes’s satellite team conducts clinical sessions once in a week. All providers who provide services to female clients are female and male providers serve male clients. The range of services is Family Planning (Oral Pills, Condoms, Indictable, IUD & emergency Contraceptives ), ANC,PNC, Syndromic Management of Reproductive Tract and  Sexually Transmitted Infections,  General health service, Child health service . The services are rendered free of cost with provision of drugs except for receiving Tk. 5 for the registration, which is for one time.

Voucher scheme for homeless population is also introduce by Marie Stope , under which vouchers are distributed to these homeless people to access services that are not available from the mobile clinics e.g. safe delivery ( Normal Delivery, Caesarean Section ),  STI Lab Diagnosis, MR, D&C and other services like , Dots, sever dehydration, and sever malnutrition MR etc. Referral services under the voucher are free.

For BCC and awareness development Marie Stopes selected Volunteers from the homeless community to work as peer educators and to motivate them to access service as required. Attractive BCC initiatives are used in the homeless spots to ensure that they are able to retain massages e.g. film shows, slide shows, folksongs rendered in simple and colloquial languages, group meetings are set up as well as one to one contact, all of which gives districts messages to create awareness about health issues.

Service Uptake By Homeless

Service Uptake By Homeless
Year
Total Client
RH GH CH ANC/PNC FP TT Others
2005 7751 1008 3178 2170 310 698 310 77
2006 13314 1731 5459 3728 533 1198 533 132
2007 12940 1682 5305 3623 518 1165 518 129
2008 13760 1789 5642 3853 550 1238 550 138
2009 16991 2209 6966 4757 680 1529 680 170
2010 19128 2487 7842 5356 765 1722 765 191
2011 21431 2786 8787 6001 857 1929 857 214

Provision of subsidized health services and free medicine has effectively ensured access to health services to the homeless people. Marie Stopes homeless program’s success is based on three distinct yet intertwined elements i.e. place, time and cost. Marie Stopes  has combined the three elements in a very innovative way that ensures health services to a section of the urban homeless people but not all. Currently Marie Stopes health service could reach around 10 – 15% of homeless population of the three cities. The majority of homeless people, however, remain outside of health service provision. Marie Stopes’ initiatives are bold yet inadequate in the context of total. So there is a need for Marie Stopes to replicate its model to expand services  in other places and  to be replicated by other NGOs.

In order to access services Marie Stopes aware the target group of the benefits of accessing SRH services. There fore Marie Stopes conducts extensive awareness building and BCC field based campaigns for homeless people to improve their knowledge and awareness on SRH and create demand for services. The specific BCC activities conducted are one to one and group discussions, slide shows, mobile film shows, street theater, street songs and pictorial massages on SRH and other health related issues. The volunteers  also undertake BCC activities among the home less and  create  a significant demand for the health services. The volunteers clearly know what they have to motivate the people, and accompany them to the satellite and the fixed centers when needed. Satisfied clients and the volunteers play a magnificent motivational role.

The main purpose of introducing Voucher Scheme for healthcare by Marie Stopes is to create incentives for the consumers to use care in the situations where supply side services are not available or where the consumers do not have the required access to the supply side services. Distance of the public facilities from the houses of consumers, lack of transport facilities, misbehavior of providers there, observation of too many formalities, long waiting time and unofficial fees etc seriously reduce access to the supply side facilities. In such situation vouchers enable the consumers to choose providers from among the accredited providers ( public or private ), empower the poor in the eyes of the providers and enhance providers’ accountability to them. Thus although both the supply side interventions and the voucher scheme provide free care, voucher yields some additional benefits to the consumers.

Challenges

  • Mobile nature of homeless population restricts service continuation and follow – up.
  • Makeshift arrangement for service delivery is a hassle and cost bearing.
  • As the services provided to the homeless free of cost , so donor support is a must.
  • Short timing.
  • Staff safety and security.

Author: Mohammad Hussain Choudhury, MBBS, DPH
Marie Stops Bangladesh


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