Community Mobilization for improving RMNCH+A outcomes Bill & Melinda Gates Foundation's support to National Health Mission Background

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Community Mobilization for improving RMNCH+A outcomes
Bill & Melinda Gates Foundation’s support to National Health Mission


The Bill & Melinda Gates Foundation shares India’s ambitious health goals, especially in UP and Bihar.
The India Country Office strategy of the foundation involves working across at least three potential
platforms to achieve impact at scale: supporting Government of India and select state governments in
implementing its activities, leveraging private sector providers, and communities.

While our work in government programs and private sector largely focuses on improving delivery of
health services to women, newborns and children, we recognize the multiple challenges that exist in
delivering these services to certain populations with the highest burden of disease due to the negative
social norms and different forms of marginalization which exist among these populations. Some
illustrations of these challenges are given below:
 Despite providing trainings to community health workers (CHWs), they may refuse to reach families
     from the lower caste or they may not provide entitlements such as JSY or JSSK. Due to such
     instances, services provided by NHM and ICDS programs may not reach the most marginalized and
     vulnerable communities.
 Preference for son may affect care for girl children at household level
 Women from marginalized communities may not exercise their voice to avail services and
     entitlements from CHWs

Our hypothesis (that we are currently testing through our investments in Bihar and UP) is that
communities have the power to deal with such challenges as they play three critical roles:
 Mobilize themselves to become active and aware consumers of services and entitlements available
   through public and private channels
 Establish and sustain social norm and behavior change at a community level
 Hold public and private providers accountable to delivery of services, information and supplies
   (through local self-government structures).

Please refer to Appendix 1 for our theory of change for community mobilization.

Our work in community engagement to date

The Foundation’s experience in community mobilization emanates primarily from the following
programs that we supported till date:

1. Avahan, our flagship program being implemented over the last decade has worked with most
   marginalized groups of female sex workers and high risk men having sex with men in the states of
   Andhra Pradesh, Telangana, Tamilnadu, Karnataka and Maharashtra to addresses key issues that put
   them at risk to HIV, e.g. violence and stigma that prevent them from consistent condom use. Today
   the community based organizations of sex workers are an active part of the national HIV prevention
2. Our support to NHM in Karnataka for improving maternal and neonatal health outcomes in eight
   northern districts of Karnataka involves demonstrating effectiveness of community monitoring
   through building the capacity of Village Health and Sanitation Committee (VHSC) leaders, frontline
   workers and Public Health Facility (PHC) staff in addition to establishing suitable mechanisms and
   systems in place. Please refer to Appendix 2 for an overview of this program.
3. Our support to Governments of Bihar and UP includes demonstrating the potential of leveraging
   self- help groups (SHGs) and their federations especially to improve uptake of life saving RMNCHN
   interventions. This is mainly through building collective action and accountability through facilitating
   linkages with front line workers and improving uptake of health behaviors by shifting social norms
   and improved household level actions. Our work with VHSCs in these states is still evolving as the
   VHSCs and PRIs are yet to become fully functional.

Our Foundation strongly believes that involving communities is important to promote demand, uptake
of interventions and achieve sustainable improvement in health outcomes. Our experiences to date
highlight the significance of investing and strengthening community organizations including VHSCs not
only to increase uptake of interventions and promote local action but to build linkages with health
providers and systems. We realize that functional panchayat raj institutions (Village Panchayats and
VHSCs) are a prerequisite for promoting community monitoring and accountability mechanisms as
envisaged in NRHM guidelines. The growing self-groups across different states under the National Rural
Livelihoods Mission program in multiple states provide incredible potential to leverage SHGs and their
federations to promote health behavior change and facilitate collective action for improved monitoring
and accountability.

Outcomes and learnings from our community mobilization

Our support to Government of Bihar and UP includes community mobilization to complement its supply-
side and behavior change communication efforts to improve RMNCHN outcomes. Our support aims to
(a) form and develop SHGs (b) train these groups on RMNCHN behaviors and (c) work with the National
Rural Livelihood Mission – “Jeevika” in Bihar to scale up the approach and d) strengthen VHSCs to
strengthening community monitoring and accountability.

In Bihar, our work in community engagement began towards end of 2012. Our partner Project Concern
International engaged communities in 2,645 villages across 64 blocks in 8 eight out of 38 districts. Early
findings from our midline evaluation show that at its current stage, the program has resulted in
significant improvements in women’s individual efficacy and behavior/household-dependent outcomes.
However, supply/systems-dependent outcomes have shown smaller improvements, and collective
action on the part of the group is yet to show significant improvements. Using a difference-in-difference
design, our midline evaluation (an external survey conducted at the mid-point of a program) seeks to
understand the impacts of SHGs and of health integration on health outcomes by comparing women in
our groups (the Intervention arm that had received health messaging and support) with Jeevika groups
(the Control arm with group setting that had not received any health messaging), and with a sample of
women in the same geographies and socio-demographic attributes who are not members of SHGs (No
SHG or Control arm with no group setting). This third arm will include drawing a sample of SC/ST and
Pasmunda Muslim women from the Ananya evaluation sample. While the early findings are available
comparing the first two arms, the analysis of data comparing with third arm is yet to begin.

Key highlights of the early findings of our midline evaluation are mentioned below:
    i.  Since baseline, the strength of our groups1 has improved, particularly on record-keeping and a
        designated member responsible for addressing health needs while controlling for all factors
        including access to information from community health workers.
   ii.  There were also improvements in several community mobilization processes: compared with
        groups with no health, women in groups with health reported better self-confidence2 sense of
        collective efficacy3 and social cohesion4.
  iii.  In terms of health behaviors, compared to women in self-help groups (SHGs) without health
        layering, women in SHGs with health integration showed significant increases in uptake of 3 +
        ANC visits (31% to 42%), consumption of any IFA tablets (62% to 80%), birth preparedness
        (84% to 92%), institutional delivery (60% to 71%), skin-to-skin care (32% to 64%), clean cord
        care (15% to 73%), early initiation of breastfeeding (61% to 84%), immunization (DPT3) (43% to
        55%), and use of contraception(12% to 25%).
  iv.   These outcomes also reported highly significant correlations with reported receipt of advice
        from the saheli for ANC care, Birth preparedness, PNC, Newborn Care, Immunization as well as
        Family Planning.
   v.   While CHW visits to groups are still fairly low (
1. Create and leverage Self Help Groups model where health discussions are facilitated: Create and
   leverage SHGs that would primarily focus on most marginalized women and poor, include a trained
   community health facilitator to enable SHGs to discuss MNCH, FP and WSH issues in
   weekly/monthly meetings and promote collective actions. In addition, improve linkages to the
   supply side by getting ASHA and AWWs to attend these SHG and Village Organization (VO) meetings
   for improved access to services.
2. Work with SHGs to mobilize non-SHG members: Encourage SHGs to mobilize the target community,
   i.e. pregnant women and mothers with children of -9 to +2yrs of age) who are not members of SHGs
   to (i) access health and nutrition services such as vaccinations on Village Health and Nutrition Days
   (VHNDs) and (ii) meet regularly in small groups with AWWs and ASHAs, who would facilitate
   dialogues around health seeking behaviors. This would allow this model to reach scale as less than
   50% of the target population in any village is likely to be members of SHGs.
3. Share our learnings with government to scale-up the health mediated SHG model across the state:
   The National Rural Livelihood Mission (NRLM) is tasked with creating SHGs in each village to provide
   livelihood options to the rural poor through savings, loans for income generation and consumption,
   access to new tools and skills in different areas especially accessing livelihoods and various
   entitlements available through the government. While integrating health is part of the mandate
   under the NRLM program, they aspire to strengthen capacity for health. In Bihar, the state arm of
   NRLM - “Jeevika” currently reaches 200,000 SHGs (2 million households) and plans to expand to 1
   million groups (~ 12.5 million households) in the next 5-7 years, covering about 80-85% of the
   poorest of poor households in the state. We are supporting the Jeevika program together with
   other partners to strengthen capacity for health and help monitor health outcomes. In UP, the state
   unit of NRLM has been set up recently. Our goal is to provide technical assistance to the state units
   of NRLM in Bihar and UP to integrate health into the work of the SHGs and thus achieve impact at
4. Provide technical support to National Health Mission through our Technical Support Units (TSU) to
   drive accountability through local self-governance structures: The TSU will support the
   strengthening of local self-government structures such as Village Health and Sanitation Committees
   (VHSCs) which are part of the NRHM design to hold the health functionaries accountable for
   delivering services. In Karnataka, we support the ASHA workers and VHSC members by establishing a
   system of supportive community monitoring and building accountability mechanisms between the
   VHSC members, ASHAs and PHC staff. We plan to replicate this model in Bihar and UP.
Appendix 1

Appendix 2

Sukshema project in Karnataka: Strengthening supportive community monitoring

In 8 districts of northern Karnataka, as part of the Sukshema project, efforts to support the ASHA
workers and VHSNC members by establishing a system of supportive community monitoring and
building accountability mechanisms between the VHSNC members, ASHAs and PHC staff have been
successfully piloted and scaled up. This was done through development of the Supportive Community
Monitoring Tool (SCMT). This tool attempts to involve the community in planning and monitoring village
health service delivery to realize community participation and ownership of village health programmes
as envisaged in the goals of NRHM, strengthen community accountability towards village health in
general and improved outcomes in particular and provide opportunity for FLWs (front line workers) to
be supported by the community in their efforts. The tool also makes an effort to move the VHSCs from
playing a supervisory role to a supportive and collaborative role with the service delivery mechanisms on
the ground with VHSC members taking due responsibility for the situation and proposing joint solutions.
The VHSC members have been trained to use the tool which would in turn support them to understand,
assess and monitor health situations and evolve joint solutions.

This tool when adopted by the community has the scope to bring about collective responsibility among
community members in supporting FLWs and ensuring that socio-cultural practices that can directly and
indirectly affect the village health and more specifically MNCH are curbed and well managed.

Another key activity has been the establishment of Arogya Mantaps, a forum to promote collaborative
action at the sub centre level among all the FLWs such as the ASHAs, Anganwadi workers, JHAs as well
as community representatives from the VHSCs. This addresses the lack of community platforms for
planning and monitoring village health programmes. This forum is built on the basic premise of
generating and sustaining informal processes that organically unite the team of the FLWs (frontline
health workers) and community representatives. Arogya Mantap is envisioned to be a community driven
informal platform to achieve sustained collaboration between the different departments striving to
improve MNCH outcomes.

The above initiatives are in line with the new GOI guidelines that have listed the following activities and
outcomes for VHSCs- Monitoring and facilitating access to essential public services and correlating such
access with health outcomes, organizing local collective action for health promotion, Community
monitoring of health care facilities among others. These initiatives also support convergence at various
     Institutional Convergence: Gram panchayaths become the nodal points for different institutions
        working for improving public health, i.e., VHSNCs, Village Water and Sanitation Committee
        (VWSCs) and anganwadi level monitoring and support committee (ALMSCs), school monitoring
        committees (SMCs) as well as the RMNCH+A activities
     Human Resource Convergence: To reduce overlaps in the functioning of various functionaries of
        the public health system i.e., JHAs (F), JHAs (M), AWWs and ASHAs.
     Others: Ensure effective usage of the MNREGA for public health activities. MNREGA work force
        provides opportunities for this convergence. For example: The ASHA worker at the NREGA
        worksites could disseminate health information. ASHA disseminates health information on a
        particular day in a week at the worksites of MGNREGA.
Appendix 3

Midline Evaluation Findings on Health Outcomes of SHG+Health and SHG-Only Women in Bihar

      Domain                Indicators               SHG+Health                  SHG-Only Women                  DID (adjusted for
                                                       Women                                                          socio-
                                                  Baseline   Midline   p-value   Baseline   Midline   p-value   DID      p-value
                                                                       (Chi-                          (Chi-
                                                                       sq.)                           sq.)
  Antenatal care     Percentage who had 3         30.7       42.1
Snapshot of Existing Evidence along Expected Stages of Change in Bihar

The following table maps existing data from analysis of the MIS, baseline, and early midline findings against the expected
change process (forthcoming data is also shown).

 Groups           Groups         Training impact       Groups improve health              Groups +health              Diffusion to
 functioning      trained        on knowledge          outcomes                           inputs improve              communities
                                 and skills of                                            health outcomes
 16,369           All groups      Sahelis with good    Positive associations between:     In terms of health          To be
 groups           have           and very good                                            behaviours,                 examined as
 functional       received       facilitation skills   A.SHGs with strong collective      SHG+Health group            part of a special
 214,381          training on    went up from 78%      accountability and better          members have                study to be
 members          5 modules:     in December           results for health worker visits   reported                    designed, and
                  birth          2013 to 83% in        after delivery, practice of        improvements from           endline
 75% of the       preparedne     March 2014.           STSC, EBF, and complete            baseline to midline in:     surveys.
 groups meet      ss and         Sahelis delivered     age- appropriate immunization.
 4 times in a     antenatal      the complete          B. SHGs with leaders or            Antenatal care –
 month and        care,          content went from     members responsible for            including three or more
 ~85% of          postnatal      87% in December       hygiene & sanitation issues        antenatal care visits;
 groups have      care and       2013 to 93% in        and handwashing                    Consumption of 90+
 started          newborn        March 2014.                                              IFA tablets; Birth
 saving and       care, early    An exercise           C. Women’s participation in        preparedness,
 all groups are   and            matching the          weekly group meetings and          institutional delivery
 maintaining      exclusive      health outcomes       seeking treatment for              and postnatal care;
 the records      breastfeedi    of women in           pregnancy-related                  Institutional Delivery;
 and have         ng,            SHGs supported        complications, EBF on the first    Practice of skin-to-skin
 elected a         RI and FP.    by better             day and within one hour of         care; Practice of clean
 leader as                       performing            birth                              cord care; Early
 well (June                      sahelis is                                               initiation of
                                                       D. Membership in groups with
 2014 MIS                        currently                                                breastfeeding (within
                                                       high group strength and better
 data)                           underway.                                                one hour of birth);
                                                       results on obtaining ANC within
                                                                                          Immunization of the
                                                       the first three months of
                                                                                          child; and Use of
                                                       pregnancy, community
                                                       members’ visit within 2 days
                                                       after delivery and exclusive
                                                                                          All associations were
                                                       breastfeeding in the first six
                                                                                          found to be statistically
                                                       * All associations were found to
                                                       be statistically significant
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