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 Background 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 program.
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 scale. 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 levels. 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- demographic characteristics) 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 trainers/ connectors 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 contraception. members’ visit within 2 days after delivery and exclusive All associations were breastfeeding in the first six found to be statistically months. significant * All associations were found to be statistically significant
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