Abt Associates Inc.In collaboration with:

Avenir Health | Broad Branch Associates | Development Alternatives Inc. (DAI) | Johns Hopkins Bloomberg School of Public Health (JHSPH) |Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)

Enabling communityaction for maternalhealth: A case studyfrom Gujarat, India

Strengthening People-CenteredServices through ImprovedAccountability

January 29, 2017

Asha George, Subhasri S, Rajani Ved,Jaya Gupta, Diwakar Mohan,Amnesty LeFevre, Renu Khanna

Stark inequities within a well performing stateDahod

47% mothers 3 ANC vs.13% full ANC

29% ANM residing atsubcenter

14% subcenter laborroom in use

17% PHC 24 hours

Anand69% mothers 3 ANC vs.

37% full ANC56% ANM residing at

subcenter47% subcenter labor

room in use75% PHC 24 hours

Panchmahal55% mothers 3 ANC vs.

24% full ANC0% ANM residing at

subcenter9% subcenter labor

room in use45% PHC 24 hours

Dahod andPanchmahaldistricts: remote,rural, tribal

Anand district:wealthier, moredeveloped 2

Community Action for Maternal Health

NGOs working at community level through women’sgroups, health committees and self help groups

Covering 45 villages in two different regions of Gujarat

Approximately 108,000 people

6 primary health centers (PHC) and 25 sub-centers

Key strategies

Framing and awareness of entitlements by pregnant women,community and providers

Community monitoring of receipt and delivery of services

Dialogue with providers and administrators about gaps identified

Awareness: Safe delivery discussions andranking

Awareness: Community meetings & toranbanner

Awareness: mahiti patrika/ entitlementsposter

Monitoring: Healthy mother tracking tool

Monitoring: VHND monitoring tool

Monitoring: Maternal death reporting

Complimentgovernmentreporting

Broadenresponsibility forreporting deaths

Broadenunderstanding ofmaternal deaths

Dialogue: Report cards

Dialogue with government health services

ANC utilization improved substantially in tribal districts,particularly for elements previously neglected

Social links Clinical exams Lab tests Commodities

Underlying SERVICE DELIVERY processes that explain theoutcomes, based on project reporting of dialogues

Restarting of services, previously only on paper

Increase in number of VHNDs in hard to reach areas

Deliveries being conducted at once defunct PHC

Repairs that improved quality of service environment

Leakages fixed at one PHC

Toilets provided for women in a sub centre

Underlying GOVERNANCE processes that explain the outcomes,based on project reporting of dialogues

Building of relationships between government & community

Training imparted by health providers to women’s groups

Invitation to do Joint Maternal Death Review by the THO

Inappropriate practicesaddressed

Chiranjivi scheme licensewithdrawn from a Privatehospital

Collusion between ASHAs andPrivate Practitioners revealed

Lessons for scale up: Community level

Participatory process of developing consensus aroundproblem, framing entitlements, developing tools

Iterative process that allows for local adaptations

Takes time but deep dividends for ownership

Process intensive intervention

Intensity of monitoring tools vs. community capacity

Should poor women be volunteering to monitor service delivery?

Who is the community: Fulcrum for the project? Whole community

Community platform: women’s groups, health committees, self help groups

NGO and community volunteers

Lessons for scale up: Role of NGOs

Orientation of NGO and nature of community platform

NGO reputation improved despite tensions

Capacity and relationship building required at all levels

Initial tensions with health personnel and administrators

So what?

HEALTH EFFECTS

Community accountability initiatives can directly improvehealth care utilization, with important equity effects

Requires time, resources, flexibility

GOVERNANCE EFFECTS

Even in a ‘well performing’ state, NGOs play a critical rolein addressing both demand and supply side barriers thatcan inhibit the functionality of governments in providingquality services

Requires facilitation, trust building at multiple levels

Abt Associates Inc.In collaboration with:

Avenir Health | Broad Branch Associates | Development Alternatives Inc. (DAI) | Johns Hopkins Bloomberg School of Public Health (JHSPH) |Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)

Thank youAll the respondents, including women and volunteers at community level, NGOvolunteers and staff, government health officials and health care providers in thedistricts and at the state levelDr.Dholakia, Ministry of Health and Family Welfare, Government of GujaratSunanda Ganju, Mahima Taparia, Pallavi Saha, Calvin Parmar, Sandhya (SAHAJ)Neeta Hardikar, Pradeepa Dube, Sheela Khant, Rita Parmar, Urmila Baria, Mena Rathva,Veena Baria, Devgadh Mahila Sangathan members and other field volunteers (ANANDI)Father Joseph Appavoo, Meena, Sunita Macwan, Bhanu, Usha, Hetal, Geeta and localvolunteers (Kaira Social Service Society)Dr. Pankaj Shah, Dr. Leela Visaria, Dr. Sridhar Srikantiah, Dr. Sundari RavindranCommonHealth: Coalition for Maternal-Neonatal and Safe AbortionMacArthur Foundation for their partnership and financial supportMarianne El-Khoury, Rachel Stepka, Carlos Avila, Nicole Barcikowski, Catherine Connor(Abt Associates)Jeremy Kanthor (DAI)Robert Franks, James Willett, Elliot Rosen (JHSPH Administrative Staff)IIHMR, Abt Associates and JHSPH IRB committees and support staffJodi Charles, Scott Stewart (USAID)

www.hfgproject.org