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In a
tribal
village in West Singhbhum, Jharkhand, the
facilitator of a women’s group initiates an
interesting game. First she invites one woman to
ride piggyback on another. Then a second woman is
made to simulate a
ghoda
(horse) by going down on all fours and carrying a
woman some distance. A third pair is asked to walk
hand-in-hand. The game is illustrative of Ekjut’s
approach towards handling socio-economic factors of
development in this belt of tribal communities.
Dr
Nirmala Nair, intervention manager of Ekjut, a civil
society organisation working in Jharkhand and Orissa
explains: “We tell the villagers that the game
illustrates how we want to tackle issues of
development. One can take the concerned persons
piggyback for a while; or one can go half the
distance carrying the other, like the horse; or one
can walk hand-in-hand, actively partnering each
other, which is the method we want to adopt.”
When Nair and Ekjut secretary Dr Prasanta K Tripathy
set up the CSO in Chakradharpur, in 2003, they did
not come with a readymade blueprint for development.
The issue of health was, as it were, thrust on them
when they found extremely high rates of infant
mortality and maternal deaths among the Ho and
Santhal tribal populations in the district. “We did
not want to replace the government; we believe that
people must seek their entitlements from the state.
But at the same time we felt we must do something
about avoidable deaths. We did not want to create a
small oasis but some evidence-based work that has
the potential to be scaled up. It had to be
affordable, feasible and one that empowered the
community,” says Dr Tripathy.
Since functioning women’s groups were already in
place, thanks to the efforts of an organisation
called PRADAN, it was decided to try something new
with the existing groups. With the villagers’
consent, a project involving community-based
participatory intervention was piloted in
Narangabeda, Khuntpani block.
Over a 10-meeting cycle the community would try and
identify its own problems and how best to tackle
them. The approach was not that of teacher but local
facilitator who would employ innovative games like
using pebbles to vote and build up a consensus,
puppet shows, plays and pictures to promote problem
prioritisation, planning, strategy development and
implementation.
An
article in the
Lancet
reported the results of a MIRA-Makwanpur study in
Nepal conducted in collaboration with the Institute
of Child Health, London. Instead of only medical
intervention, women facilitators were used as key
elements in reducing infant mortality by raising
awareness about the underlying causes of illness and
death, and empowering communities to address them.
An exciting chance finding of the Makwanpur study
was that maternal mortality too reduced thanks to
these activities. Ekjut wondered if a similar
intervention would work to address the issue of
infant and maternal deaths among dispersed tribal
populations in small hamlets. Could one tap into the
power of existing women’s groups?
PRADAN agreed to provide access to groups already
set up, and, in September 2004, in collaboration
with the Centre for International Health (a wing of
the Institute of Child Health) a project to improve
maternal and newborn health in Jharkhand and Orissa,
through the empowerment of tribal communities, was
launched.
Baseline data-collection showed extraordinary
newborn mortality rates. The proposed intervention
would be piloted in three villages. There was enough
evidence in these villages to show that the women
would be supportive of the efforts. “Adivasis resent
being talked down to and indicated that they would
support a method of pooling ideas rather than
pushing policies,” says Dr Nair. A random controlled
trial, involving a population of 228,000 from 36
clusters or villages in three contiguous areas of
Jharkhand and bordering Orissa, was then set up.
While all 36 clusters of 10-12 villages each would
come under surveillance, intervention would be
introduced in 18 randomly chosen clusters with a
buffer zone between each cluster of villages to
ensure that there was no contamination. A total of
227 women’s groups are currently involved. For
surveillance purposes, monitors were elected by the
villagers themselves. Each monitor had the task of
interviewing every woman who had given birth since
November 2004. Key informants of a birth are
traditional birth attendants or relatives. In the
case of a newborn or maternal death, monitors
conduct a detailed interview or “verbal autopsy” to
ascertain the actual cause of death.
Some of the findings include delays in seeking care
because the gravity of the situation has not been
realised, or the village quack has been called in.
Another problem is that this is elephant territory,
therefore unsafe at night.
In
the clusters chosen for intervention, a local
facilitator, also elected by the villagers, has been
made responsible for 10-16 women’s groups. The
facilitator works as a catalyst for change and takes
the group through a series of 10 meetings in which
issues of pregnancy, childbirth and newborn health
are discussed. Through a structured framework, with
each meeting taking place once a month, the women’s
groups go through four phases: identifying and
prioritising problems, planning strategies,
implementation, and assessing the impact. The 10th
meeting culminates in a big gathering with
invitations being sent to health and other
government officials. The group narrates its
experiences through a play or storytelling in order
to sensitise the larger population and seek its
help. Pressure is also brought to bear on the
administration.
Using a manual as a guide, the facilitator in the
first phase tells a story culminating in illness or
death. With the help of picture cards or charts to
match the situation, the group attempts to identify
the cause of death. For example, a malaria case will
depict mosquitoes and stagnant water. The picture
cards also help identify the illness in the local
idiom. In the beginning, any cause cited out of
superstition -- like possession by spirits -–
remains unchallenged.
After around six stories, the group prioritises the
issues to be tackled. Important things are learnt
through this process. For example, it was found that
more tribal infants suffered from diarrhoea in the
Indkata village than non-tribals. This is because of
a cultural practice where tribals do not breastfeed
their infants for the first few days.
At
the 10th meeting, and to disseminate information
within the larger community, the tribals use
socio-dramas, street plays, puppet shows and
song-and-dance.
One
of the most endearing examples of an entire
community’s enthusiasm for such an approach came
from the Juang tribe in Orissa. The women had
scripted a play but they felt too shy to enact it.
So the men of the community came forward, donned
women’s costumes and staged the play!
Although the study is still underway, Ekjut is
hopeful that anecdotal evidence of its considerable
impact on maternal and newborn health will soon be
matched by hard data.
(Freny
Manecksha is a Mumbai-based freelance journalist)
InfoChange News & Features, March 2007 |
