Improving maternal and newborn health in deprived rural areas of Jharkhand and Orissa through empowerment of tribal communities

In collaboration with International Perinatal Care Unit IPU) of Institute of Child Health, Funded by Health Foundation, London, Our partnering Communities- ekjut’s work is with isolated communities, predominantly belonging to the Ho, Santhal, Oraon, Juang, Munda and Bhuyian tribal communities, as well as socially disadvantaged non-tribal people living amongst them. These tribal groups speak many different languages, but they share certain common characteristics. They survive on subsistence farming and forest produce, supplemented by wage labour. They live in villages and small hamlets as clans and families. Many have kept very old traditions and every facet of their life is intimately connected with religious belief, ritual practices, and a belief in supernatural place of worship is the sacred groves. It is these aspects of their culture that give meaning and depth to their lives, and solidarity to their social structure. Their health conditions are accentuated by widespread poverty, illiteracy, malaria and malnutrition. Development challenges are further exacerbated by the topography of the area in which ekjut works, so most sick mothers and newborns rarely reach a health facility. There are high levels of maternal and newborn mortality in rural tribal communities and many of these deaths may be prevented with a better understanding of ways to approach problems within the community.

The three track approach involves: Working with women’s groups to develop strategies for effective health promotion during pregnancy, delivery and the post-partum period Tracking Change to see the effectiveness of above Strengthening links between the community and primary health care providers to increase use of services and promoting good governance and policy change in order to improve health service delivery

Working with women’s groups Conscious of the fact that interventions that empower groups are more effective and scalable than individually targeted health education programmes and mobilization of women’s groups to improve health status of a population remains an essentially untapped resource, a health promotion intervention through women’s group was developed.

Piloting- This participatory process of intervention was piloted in three villages by a local woman chosen as a facilitator. The learnings from the piloting phase were incorporated into the manual that was used in the project. Training of facilitators: Eighteen facilitators chosen from local communities went through training in facilitation techniques and participatory modes of communication for conducting these meetings and also inputs to address issues of pregnancy, childbirth and newborn health. Facilitators at the 5 days training workshop Top The Intervention: Through a series of interactions at the monthly meetings the facilitator takes the women’s group through a ‘10 meeting action cycle’ Link. She encourages the women to discuss about the maternal and newborn problems using visual aids like picture cards and at the end of the ten meetings they are able to prioritize their problems and find appropriate strategies and solutions to be implemented for the same. At the culmination of the ten meetings a community meeting is held to inform the larger community about how the women have achieved the solution and to seek necessary support from the wider community. On-going intervention: This potentially sustainable health promotion intervention is now being tried with more than 220 women’s groups across three districts. Most of these groups are now implementing the strategies that they had developed. Street plays, puppetry, and story telling were just some of the innovative approaches used by the women’s group members during the community meetings to inform the larger community about their activities. Quotes on women’s group meetings: • “The women have benefited from savings groups, and believe that as a group they can solve many problems” (Women’s Group member) • “I like to attend ekjut meetings because in every meeting there is something new to know. What we know from the meeting will tell others so that they could know.” (Women’s Group member) • “We discussed that the play is the best way to communicate to the people about whatever we have learned. In a play the crowd gathers in large numbers. Those who have not been coming to the meetings earlier, will be motivated to come for the community meeting if we present to them a street play” (Women’s group member) • “I enjoy having meetings in this village. All the women are not literate but they understand whatever is discussed.” (Women’s Group Facilitator) • “We used to only discuss about economic activities, but it is good to see them learning so much about their health needs” (Sharbani) Tracking change :   The three districts chosen for the project include West Singhbhum and Saraikela -Kharswan of Jharkhand, and Keonjhar district of Orissa. Twelve cluters in each district.     Monitors at first Trainning Programme with theVisitors from Health Foundation and Institute of Child Health, London The project started with a prospective baseline survey to measure maternal and newborn health status for the first 9 months and to be continued for tracking the changes all throughout the duration of the project. 36 monitors from Saraikela- Kharswan and West Singhbhum districts of Jharkhand and Keonjhar district of Orissa have been trained to conduct the interviews with all the mothers in the 36cluster of villages we are working now..   A interview in progress A system of identifying every mother who have given birth and interviewing them after 42 days has been put in place. A detailed questionnaire is filled in by the monitors and inputted into a database for analysis at a later date. The monitoring started in November 2004. All the 36 cluster of villages will benefit from the health service strengthening interventions; however, the women’s group intervention will only take place in half of the clusters during the current phase of the work with the areas not covered by women’s groups. It will also include a cost-effectiveness analysis to establish whether the initiative is good value for money. In a randomized control trial it is important to measure the effective ness of the intervention in different clusters. This measurement should be collected concurrently to measure the effectiveness more accurately. In all the 36clusters all the births and deaths are being identified through key informants. These key informants are responsible for around 250 households and they assist the respective monitors. The monitor visit the mothers house and confirms the birth / and death before conducting the interview. Monitors collect information regarding the birth/ still birth/Neonatal death (0-28 days)/ maternal deaths/women death. The Baseline of our project started from 21 November, 2004 to 31 July, 2005 and we could cover a total birth of - 4672 , SB - 177, ND - 259, MD-25.   Health Services strengthening-   There is a well-established need (originally stated in the Alma-Ata Declaration, WHO, 1978) to consolidate the links between communities and primary health care services. Where services exist, the reasons for their under use are complex including physical barriers, quality of care and perceptions of service providers. Supply and demand are intimately linked and poor service quality may be at least partly the result of users having little voice in the design and management of services delivered in their name. The creation of a more demand driven environment for service delivery and a greater sense of “ownership” of health services at community level might therefore be expected to increase rates of use. Concerned and involved users with palpable influence are more likely to use services knowledgeably and appropriately and to pay greater attention to health messages. In the context of improving maternal and newborn health this may increase the likelihood of high risk pregnancies and at risk newborns being referred to health facilities more promptly. The project will work closely with the auxillary nurses and traditional birth attendants, who are the frontline government staff and community health providers. There is a definite need for health service strengthening within the project area and Ekjut will build on the good dialogue they already have with Government health officials. The project is aiming to improve service delivery at all levels and to improve referral links between them. Cluster level health committees have been formed in all clusters, and represent all villages and hamlets within that cluster. These committees are intended to help users have a voice in the design and management of services delivered in their name and contributes towards a more demand driven environment and rights based approach to service delivery. A greater sense of “ownership” of health services at the community level may improve the quality of care and increase rates of use. Members of the committees include people who show signs of leadership qualities and / or an interest in health, such as community leaders, village headmen, teachers, and married women and they become knowledgeable of the government health system and current health schemes. The committees follow a structured action cycle discussing maternal and newborn health related entitlement issues and the need for health services strengthening. As members of the ‘Hospital Management Societies’ Ekjut is able to influence the working environment of some of the hospitals. Ekjut is conducting appreciative inquiry workshops for government health providers at district and primary health centre levels in West Singhbhum, Saraikela Kharswan and Keonjhar. “Appreciative Inquiry” believes that in every functional system, despite all odds there are at least some positive things which make the system functional. The participants undergo a journey of “The Four D’s” namely Discovery, Dream, Design and Delivery and try to effectively fulfill the desired results.