participation for local action - institute of public …...services and schemes under the...

ParticipationforlocalactionInterimreportdated31stJan2016

InterimreportforParticipationforLocalActionstudydated31Jan2016

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ThisreportwaspreparedasthefirstdeliverabletowardspartialfulfillmentofthetermsofreferencebetweentheWHOAllianceforHealthPolicyandSystemsResearch,GenevaandVivekanandaGirijanaKalyanaKendra,Karnataka,Indiainaccordancewiththetechnicalservicesagreement(2014/484989-1)inDecember2015.

Submittedtothe:

ImplementationResearchPlatform(IRP)Secretariat,WHOAHPSRWorldHealthOrganization20AvenueAppia–1211Geneva27-Switzerland

By:

TanyaSeshadri,PrincipalInvestigatorCommunityHealthConsultantVivekanandaGirijanaKalyanaKendra,BRhills,Yelandurtaluk,Chamarajanagar,Karnataka,IndiaContributionsby:

PrashanthNS(co-principalinvestigator,InstituteofPublicHealthBangalore),DeepakKumaraswamyandRoshniBabu(VivekanandaGirijanaKalyanaKendra),BhargavShandilya(consultant-photographer),theteamatZillaBudakattuGirijanaAbhivrudhhiSanghaandthemanyhealthworkerspostedatsub-centersandprimaryhealthcentersinChamarajanagarworkingwithindigenouscommunities.

Acknowledgements:

WewouldliketothankMadeviN,Kamala,Roja,Sannathayi,JadeswamyandSadanandaSwamyfortheirhelpwithfieldwork;EvaLowell,KateBaur,KelseyHolmesandGraceFierlefortheirassistancetowardssituationanalysis;andtheDistrictHealthOffice,Chamarajanagaralongwiththeco-investigatorsfortheirsupporttothisresearch.PhotographoncoverbyBhargavShandilya,Portraitofasoligamotherandchild,availableunderaCreativeCommonsAttribution-Non-commerciallicense.©2015,BhargavShandilya.

TableofContentsLISTOFABBREVIATIONS...................................................................................................................................4SECTIONI:PROJECTBACKGROUND...............................................................................................................5SECTIONII:SITUATIONANALYSIS..................................................................................................................6ComponentA:MaternalhealthservicesforindigenouscommunitiesinNHM............6ComponentB:Statusofserviceavailabilityandutilization................................................10ComponentC:Stakeholderanalysis...............................................................................................14ComponentD:Toolbox........................................................................................................................16ComponentE:Community’sreflection.........................................................................................17ComponentF:Healthservices’reflection....................................................................................23

SECTIONIII:PROJECTPROGRESSANDNEXTSTEPS...................................................................................28ANNEXURES......................................................................................................................................................32


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LISTOFCOMMONABBREVIATIONS

ASHA AccreditedSocialHealthActivist

ANM AuxiliaryNurseMidwife

co-PI Co-PrincipalInvestigator

FGD FocusGroupDiscussion

GPS GlobalPositioningSystem

IDI In-DepthInterview

NHM NationalHealthMission

PAR ParticipatoryActionResearch

PHC PrimaryHealthCentre

PI PrincipalInvestigator

RMNCH+A Reproductive,Maternal,Neonatal,ChildHealthandAdolescentHealth

ST ScheduledTribe

TDI Theory-DrivenInquiry/Enquiry

VGKK VivekanandaGirijanaKalyanaKendra

SECTIONI:PROJECTBACKGROUND

Title:Participationforlocalaction:ImplementationresearchwithindigenouscommunitiesinsouthernIndiaforlocalactiononimprovingmaternalhealthservices

Keyobjectives:

1. Tostudylocalsocio-politicalissuesthatinfluenceaccesstothesafemotherhoodcomponentofNationalHealthMission(NHM)forindigenouspeopleinChamarajanagardistrict.

2. Toengagerelevantstakeholdersinaparticipatoryapproachtocontextualizetheexistingprogramimplementationinprimaryhealthcenters(PHC)coveringindigenouspopulations.

3. TodevelopamodelofstakeholderengagementthatcanguidecontextualizationofthesafemotherhoodprogramofNHMindistrictswithindigenouscommunities.

Method:Theoverallstudydesignisparticipatoryactionresearch(PAR)tobringtogetherthedifferentstakeholderstodevelopcontextualizedsolutionstoimproveutilizationofsafemotherhoodservicesbytheindigenouscommunity.Simultaneouslyatheory-driveninquirytriestoexplainimplementationoutcomesofthestakeholderengagementstrategy,andproposedlocalsolutionsandeffortsatperipheralhealthcentres/areas.Whiletheformercomponentfocusesonaparticipatoryapproachtowardscriticalreflectionandlocalaction,thelatterfocusesonbuildingacontext-sensitiveanalyticalexplanationforthechangeseen.

Duration:Jan2015toAug2016(revised)

Expectedoutcomes:Thefinaloutcomewillbetwo-fold,(1)aplatformfordistrict-levelplanningwithinter-sectoralengagementacrossvariousgovernmentdepartmentswithcommunity-basedorganizations,civilsocietyandacademiaand,(2)atheoryexplainingpoorcoverageofreproductiveandchildhealthschemes’utilizationbyindigenouspeopleinChamarajanagardistrict.Bothofthesewillbeacrucialinputintodistrictandstatehealthanddevelopmentpolicy,andwillhelpinmakingthesemoreinclusive.TheadvocacyofourfindingscouldalsoleadtofurtheractivitiestoaddresssafemotherhoodproblemsinChamarajanagardistrictparticularlyfocusingonindigenouscommunities.

SECTIONII:SITUATIONANALYSIS

Theobjectiveofthesituationanalysiswastobringtogethertheperspectivesofthreekeyactorsrelevanttomaternalhealthofindigenouscommunitiesinthedistrict(theresearchers,thecommunityandthehealthserviceproviders,aslistedbelow).Intheparticipatoryactionresearch(PAR)process,weenvisionedaplatformthatbroughttogetherthesethreeanalysestoarriveatanegotiatedwayforward.Wedividedtheactivitiesintheprojectacrosssixcomponents,threereflectiveanalysesbystakeholders,andthreetechnicalcomponentsbytheresearchers,asshowninfigure1.FIGURE1.PROJECTCOMPONENTSANDSITUATIONANALYSIS

ComponentA:MaternalhealthservicesforindigenouscommunitiesinNHM

Underthiscomponent,weconductedadeskreviewoftheexistingmaternalhealthrelevantservicesandschemesundertheReproductive,Maternal,NeonatalandChildHealthplusAdolescentprogram(RMNCH+A)oftheNationalHealthMission(NHM).NHMistheflagshiphealthreformoftheIndiangovernment,beingimplementedsince2005.RMNCH+Aistherecenteditionofthereproductiveandchildhealthprogramsthatwaslaidoutin2013underNHMacrossIndia.RMNCH+Aadoptsthelifecycleapproachtotacklekeycausesofmaternalandchildmortalityasshowninfigure2.Inthisstudy,wefocusonlyonthematernalhealthservices’relatedcomponentsfromantenatalperiodthroughdeliverytopostnatalperiod.Abortionrelatedservicesarenotincludedinthescopeofthisresearch.


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FIGURE2.RMNCH+ASTRATEGY*

*RTI/STI–reproductivetractinfections/sexuallytransmittedinfections,IUCD–intrauterinecontraceptivedevices,OCP–oralcontraceptivepills,IFA–ironandfolicacid,JSY–jananisurakshayojana,JSSK–jananishishusuraskhakaryakrama,SNCU–sicknewborncareunit,NBSU–XXX,IMNCI–integratedmanagementofneonatalandchildhoodillnesses,NRC–nutritionalrehabilitationcenters,ORS–oralrehydrationsolution

ApartfromthecentrallyfinancedschemesandactivitiesunderRMNCH+A,Karnatakalikeotherstates,initiatedcertainschemestocomplementtheexistingmaternalhealthservicesasshowninfigure3.Detailsofallschemeswerepreparedinahandoutbasedoninformationprovidedbythedistricthealthofficeandgovernmentprogramdocumentsavailableonline(AnnexureI)


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JSSK–jananishishusurakshakaryakram,108–ambulanceservicesforreferralandemergencytransport.#Visualrepresentationofschemesbyauthors

RMNCH+Amadeanexplicitfocuson‘reachingtheunreached’intribalareasalongwithothervulnerablepopulations.Thiswasarticulatedthroughvariousstrategieslikedifferentialplanningandneed-basedfinancingtohighprioritydistricts;strengtheninghealthinfrastructuremainlyinhighfocusdistrictslikestaffingprioritytoremotesthealthcenters;incentivesforpersonnelinhardtoreachareas;publicprivatepartnershipstoreachunderserved/un-servedareastosupplementpublichealthcare;mobilemedicalunitstillinfrastructureisstrengthenedinunderserved/un-servedareas,andmaternitywaitinghomesinhardtoreachortribalareas.Fortribalhealthinspecific,thestatesaredirectedtomapouttribalareasandhardtoreachpocketsandcloselymonitorprogressintheseareas;createspecificplanandbudgetintribalareas;allowflexibilityofnormsforstaffrecruitment,infrastructuredevelopment,additionalmobile-medicalunityindistrict,andperformancebasedincentivestostaffinselectedareas.

Nextwelookedatavailabledatatoidentifyareaswithindigenouscommunitiesinthedistrictandidentifygovernmenthealthcenterscateringtothesecommunities.Basedoninformationcollectedfromthedistricthealthteam,theexistinghealthmanagementinformationsystem(HMIS)andavailablegovernmentevaluationreports,weidentifiedthehealthcenterscateringtothesecommunitiesasseeninTable1.Atotalof26oftheexisting61PHCswerecategorizedastribalPHCbasedoninclusionineitherthedistricthealthofficereportorthegovernment

FIGURE3.GOVERNMENTSCHEMESRELATEDTOMATERNALHEALTHINKARNATAKASTATE#


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evaluationreport.UnfortunatelythecriteriausedtocategorizeaPHCasatribalPHCbyeithersourceisnotavailable.

TABLE1.TRIBALPHCSIDENTIFIEDINCHAMARAJANAGARDISTRICTIN2015(26TOTAL)

Taluk PHCname TypeofPHC* SourceChamarajanagar(4)

Bedaguli Regular Districthealthoffice#Chandakavadi Regular Statereport##Honganooru 24x7 StatereportKagalavadi 24x7 Districthealthoffice

Gundlupet(5)

Baragi 24x7 StatereportBommanahalli Regular Districthealthoffice,StatereportHangala 24x7 StatereportKaggaladahundi 24x7 Districthealthoffice,StatereportMangala Regular Districthealthoffice,Statereport

Kollegal(15)

Bandalli 24x7 DistricthealthofficeCowdallli 24x7 DistricthealthofficeDodinduvadi 24x7 DistricthealthofficeKamagere 24x7 DistricthealthofficeKudluru 24x7 DistricthealthofficeLokkanahalli 24x7 Districthealthoffice,StatereportMadhuvanahalli Regular DistricthealthofficeMaartalli 24x7 DistricthealthofficeMeenya Regular DistricthealthofficeMMHills 24x7 DistricthealthofficePalya 24x7 StatereportPGPalya 24x7 DistricthealthofficePonnachi 24x7 DistricthealthofficeRamapura 24x7 DistricthealthofficeThellanur Regular Districthealthoffice

Yelandur(2)

Agaramamballi Regular StatereportGumballi 24x7 Districthealthoffice,Statereport

*24x7indicatesserviceavailabilityfor24hrs7daysaweekfordeliveriesandisprovidedadditionalsupportintermsofinfrastructureandstaffunderNHM;regularindicatesaPHCthatisnotcategorizedas24x7#BasedondataprovidedbyDistrictMonitoring&EvaluationOfficer,Chamarajanagar##LabeledasTribalPHCbyPHCperformanceassessmentreportApr-Sep2014-15publishedbyDepartmentofHealthFamilyandWelfare,GovernmentofKarnatakausingHMISwebportalFurther,theproportionofindigenouspopulationinaPHC’scatchmentpopulation,thenumberofsub-centresunderaPHCthatcateredtoindigenouscommunitiesortheproportionofindigenouspopulationinaSC’scatchmentpopulationisnotavailable.DataanalysisatthePHCorevenSClevelthereforeonlyindicatestheaverageperformanceorutilizationofservicesatthefacilitylevelandgivesnoreflectionofutilizationorcoverageofservicesamongtheindigenouscommunitiesinagivenareaoratagivenhealthcenter.TheHMISdatacurrentlyavailableatthefacilitylevelprovidesacomprehensiveoverviewofavailabilityandutilizationofmaternalhealthservicesamongothersateachfacility.Howeverthisdatacannotbedisaggregatedforindigenouscommunitieswithnoothersourceforsuchdata.Independentstudypublicationsand


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governmentreportswerescannedtohelpconstructaprofileforthehealthcenterstoallowit’sfunctioningtobelinkedtothevariousissuesidentifiedinfluencingaccesstomaternalhealthservices.Forinstance,intherecentevaluationofhealthcentersacrossthecountryintermsoftheiraccess,conductedbytheNationalHealthSystemsResourceCentre,sevenofninePHCsidentifiedasdifficult-to-accessinChamarajanagardistrictareamongthetribalPHCsidentified.Duringthestakeholdermeetings,itwillbeimportanttostartbyfirstdefiningwhatatribalPHCwillbeandnarrowdownthelistaccordingly.Fornow,allanalysisincludesthetwenty-sixPHCsidentified.

ComponentB:Statusofserviceavailabilityandutilization

Mappingservicesavailable:Onetaskundertakenwastomapthegovernment(PHCandhigherreferralcenters)andrelevantprivatehealthservicesthatprovidematernalhealthservicesacrossthedistrict.Giventhatgeographicalterrain,forestcoverandphysicalaccessarekeyfactorsinfluencingaccesstohealthservices;mappingofhealthcentersandtribalvillageswillhelpshowcasetheseissues.

Globalpositioningsystem(GPS)recordingswerenotedusingMotionXGPSsoftware1,anduploadedwithbasicfacilityleveldetailstoCartoDBsoftware2,therebyprovidinglayeredmapsforeachtaluk.ThiswasoverlaidonexistingGPSmapsforvillagesofindigenouscommunitiesacrossthedistrictinaprevioussurvey,anduploadedonGoogleearthsatellitemaps,tohelpvisuallyhighlightthechallengeswithterrainandaccesstohealthservicesbythecommunity,andtotribalvillagesforthefrontlinehealthworkers.ThetalukmapforYelandurisshowninfigure4wherebothhealthcentersandtribalvillagesareseen.TheformatforGPSandfacilityleveldatacollectionisprovidedinAnnexureII.Atotalof32(outof47)healthcentersweremappedtodateseenintable2.ThisexercisewillbecompletedinFeb2016andmapsprepared.Additionalinformationontypeofservicesprovided,infrastructure/humanresourceavailabilityandserviceutilizationwillbesequentiallyaddedaslayerstothesemaps,toallowforrichervisualizationandpresentation.

1MotionXisahandheld/mobilebasedGPSapplicationforobtainingpositioncoordinatesintheformoflatitude-longitude

2CartoDBisaanonlinecloudcomputingplatformthatprovidesgeographicalinformationsystemenabledwebmappingtoolsfordisplayinawebbrowser.2CartoDBisaanonlinecloudcomputingplatformthatprovidesgeographicalinformationsystemenabledwebmappingtoolsfordisplayinawebbrowser.


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FIGURE4.GPSMAPPINGOFHEALTHCENTERSANDTRIBALVILLAGESINYELANDURTALUK

TABLE2.MATERNALHEALTHSERVICEPROVIDERSINTHEDISTRICTMAPPEDUSINGGPS

Taluk Governmenthealthcenters Privatehospitals

PHCs Higherhospitals(CHC,TH,DH)

Chamarajanagar 4+1*(4+1) 2(2) 4(4)Gundlupet 2(5) 1(1) 2(2)Kollegal 8(15) 1(1) 3(7)Yelandur 1(2) 1(1) 2(2)Total 16(27) 5(5) 11(15)*TribalMobileHealthUnit

Serviceutilization:Intermsofutilizationofservices,thisanalysiswasrestrictedtoPHClevelandbasedonrecentgovernmentreports.Itisimportanttonotethatduetonon-availabilityofdisaggregateddatafortribalcommunities,theserviceutilizationpresentedisforthefacilityforallcommunities.Whilethislimitsitsusefulnesstocarveouttribalcommunity-specificfindings,thisdataindicatesthegeneralperformanceofthetribalPHCsinthedistrictintermsofserviceavailabilityandutilization.PerformanceofthetribalPHCsisshownintable3for24PHCsbasedonthePHCperformanceassessmentforApr-Sep2014-15usingtheHMISdata.ThisassessmentwasbasedonafacilityscorecardsystemdevelopedbyNHMtohelpsensitizedistrictstostreamlinedataentryandvalidation,tostrivetowardsimprovingfacilitylevelperformanceandasaguidetohelpfocustheireffortsviareview,monitoringandresourceallocations(figure5).TwoPHCs(MeenyaandThellanur)werenewlyestablishedandhencedataisnotavailableforthesebefore2015.


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FIGURE5.INDICATORSUSEDFORASSESSINGPHCPERFORMANCE

TABLE3.PHCPERFORMANCEASSESSMENTFORAPR-SEP2014

Taluk NameTypeofPHC

GradesforindicatorsAgood,Baboveaverage,Caverage,Dpoor

Hum

anresource

Infrastructure

Drugandsupplies

ServiceAvailability

Clientorientation

Serviceutilization

Overallgrade

Chamarajanagar

Bedaguli Regular D C B B D D CChandakavadi Regular B A A B A D AHonganooru 24x7 C A A A A B AKagalavadi 24x7 C B A A B C B

Gundlupet

Baragi 24x7 B B A A C C BBommanahalli Regular C B A B B C BHangala 24x7 A A A A A B AKaggaladahundi Regular B A A A D D BMangala Regular C C A B D D C

Kollegal Bandalli 24x7 B A A A A B A


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Cowdallli 24x7 C C A B D D CDoddinduvadi 24x7 A B A A C B AKamagere 24x7 A A A A A B AKudluru 24x7 B A A B A B ALokkanahalli 24x7 B A D B B B BMadhuvanahalli Regular A A A A A B AMaartalli 24x7 A A A A A B AMMHills 24x7 B A A A C C BPalya 24x7 C A A B B B APGPalya 24x7 B B A A D B BPonnachi 24x7 B B A B B C BRamapura 24x7 B A A A A A A

Yelandur

Agaramamballi Regular A A A B A C AGumballi 24x7 A A A B A B A

Intermsofinfrastructure,drugsandsuppliesmostPHCsperformedwell.Howeverwhenitcametoclientorientationandserviceutilization,manyPHCsperformedaverageorbelow.InChamarajanagartribalPHCs,humanresourceshortageisevidentevenin24x7PHCsandreportpoorutilization.Thisisdespitebeinginthedistrictheadquarterregion.InGundlupet,clientorientationandutilizationagainarethemainissuesdespiteadequateserviceavailability.InKollegal,thepictureappearsmixedwithapparentwellperformingPHCsavailablewhilesome24x7PHCsreportingstaffshortageandpoorutilization.3PHCsacrossthefirst3taluksareclearlyidentifiedtohavemultiplechallengesneedingfocusedinterventionsfromthedistrictteam.

Nextasimilardetailedanalysiswillbeconductedforthe2015-16dataatthePHClevelandthenforthesub-centerlevelingeneralandusingtheRMNCH+Ascorecardfocusingonmaternalhealthserviceprovisionandutilization.

Healthseekingbehavioramongindigenouscommunitiesformaternalhealthservices:Tohelpunderstandtheperspectivesofwomenfromthelocalindigenouscommunity,twonestedstudieswereconductedinonetribalPHCarea.

a)Thefirststudyaimedtoidentifyfactorsinfluencingmaternalhealthcareseekingbehavior,andreflectsonthewomen’sperspectivesofthequalityofmaternalservicesreceivedtoallowbettercustomizationofrecommendations.Hereweconducted14interviewswithmotherswhodeliveredinthelasttwoyears,followedbypreliminaryanalysisanddevelopmentof3casestudies.TheseinterviewswereconductedinKannada,andthentranslatedandtranscribed.Analysisisongoingbutweshareafewinsightsthathaveemerged.Amongwomeninthecommunitythereisalsoasocialpressuretobestrongduringpregnancyanddeliveryesp.whenthepainbegins.Womenfeelthatitisexpectedofthemtointernalizesuchpainanddiscomfortevenfromtheirhusbands.Mostofthewomenfeelthathealthcentersarerelativelysaferthan


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homebutfeeluncomfortablewithgoingtherefordeliverymainlyduetoconductofinternalexaminationsand/ormaledoctors.Asenseofhelplessnesswasnotedbythewomen’snarrationsaboutselectingwheretodeliver–adecisionoftenmadeorinfluencedlargelybyeldersandmother.Acceptancetoseekantenatalcarewasmuchhighergiventheflexibilitytoplanandprepareforitwithnotimerestraints.Howeverincaseofdeliverytheseconditionsdonotexist.

b)Thesecondstudyaimedtoexplorehowmaternalhealthadviceinfluenceactionstakenduringpregnancytopostnatalperiodamongsoligawomen.Firstthreefocusgroupdiscussionswereconductedwithwomenofdifferentagegroupstohelpidentifycommonthemesthatwereconsideredimportantduringpregnancybythewomen.Nextsixin-depthinterviewswereconductedwithwomenwhohaddeliveredinthelasttwoyearsexploringtheirperceptionsonhelpfuladvice,apparentpositiveandadversebehaviorduringpregnancythatinfluencedtheirhealth,androleofself,husbandandfamily,communityandhealthservicesinensuringtheirhealthduringpregnancytillpostnatalperiod.Similartotheearlierstudy,theseinterviewsweretranslatedandtranscribed,andanalysisisongoing.Preliminaryfindingsrevealthatadviceisamajorpartofthelocalcultureandinfluencesmaternalhealthoutcomes.Adviceinthisperiodmainlypertainstodiet(bothgoodandbad),physicalactivityandspirituality.Whilethewomensoughtmedicaladvicefromhealthworkersandhospitals,theysoughtandreceivedmostotheradvicefromfriendsandwomenintheirfamily.Thehusband’srolewaslargelylimitedtodecision-makingasintotraveltohealthcentersortests,andtheyseldomparticipatedinroutinediscussionsorplansduringpregnancy.

ComponentC:Stakeholderanalysis

Thestepsfollowedinthiscomponentarelisted:

1. Identifykeystakeholders2. Characteristicsofstakeholders3. Stakeholdersmapping

Step1:Identificationofkeystakeholders:ThepolicyunderconsiderationisRMNCH+AunderNationalHealthMission.Basedonprogramdocumentsandaninitialbrainstormsessionwithdistrictco-investigators,allstakeholderswithanylevelofinvolvementwiththeeithermaternalhealthservicesorthetribalcommunitieswerelistedwithfewdetailsabouttheirlevelofaction,sector,andrelationtothegivencontext.ThedetailedtableisattachedinAnnexureIIIandshowninfigure6.


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FIGURE6.STAKEHOLDERSIDENTIFIEDBYLISTINGEXERCISE

Step2:Characteristicsofstakeholders:Thelistofstakeholdersnextwasanalyzedtodetermine“clusters”ofstakeholderswithdifferentlevelsofinterestandlevelsofinfluenceovertheissue.Constructingstakeholder’scharacteristicsincludedassessingtheirknowledgeonthepolicy,theirposition,interest,availableresources,powerandleadershipinrelationshipwithpolicyunderanalysis.Thisassessmentisbeingundertakenviabrainstormsessionswithco-investigatorsandaseriesofstakeholderinterviewsconductedbytheresearchteam.Withthedelayinreceivingethicsapproval,workunderthiscomponentwasdelayed.Todate,atotalofseveninterviewswereconducted–threeamongdistricthealthteam,twowithcommunityleaders,onewithPHCstaffandonetaluklevelofficer.Transcriptioniscompletedandanalysisisongoing.Meanwhiletheremainingstakeholderinterviewswillbeundertakeninthecomingmonths.Step3:Stakeholders’mapping:Inthenextstep,wewillplotthestakeholdersbytheirinterestandpowerina2x2table.Actorswithhighpowerandinterestsalignedwiththepurposearecriticaltoachievingthepurpose.Theywillbetheprimaryaudienceandshouldincludeboththeimmediatedecisionmakersandopinionleaders-i.e.thepeoplewhoseopinionmatters.Stakeholderswithhighinterestbutlowpower,orhighpowerbutlowinterest,shouldbekeptinformedandsatisfied.Ideallytheyshouldbesupportersfortheproposedprogramorpolicychange.Theseareoursecondaryaudience.Throughouttheprocess,weshallstrivetomainstreamgenderequalityintheprocessesandproceduresofstakeholderanalysis.Weshalltakeintoaccountthedifferentsituationsandinterestsofwomenandmenthroughouttheproceduresandprocessesofstakeholderanalysis.


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ComponentD:Toolbox

Atoolboxconceptwasconceivedtocompileliteraturefromdifferentsourcesonprojectrelevantthemesandtomakethemavailableduringtheupcomingstakeholderdiscussions,developmentofprojectoutputsandrelatedwriting.Themainthemesthatwillbecapturedbythetoolboxare(figure8):

a) HealthoftribalcommunitiesinIndia,asthereisaneedforanonlinerepositorywhererelevantliteraturefromscientificpublicationstoreportsisavailable;

b) Maternalhealthrelatedinnovations/interventions,sincethecommunityandhealthdepartmentwillneedtoimplementlocalactions/solutionsinthecomingmonths;and

c) Participatoryactionresearch,forinputsonresearchmethods,ethicalissuesandwriting.Stepsinvolvedindevelopingthetoolboxarelistedbelow:• Aconceptnoteexplainingthepurposeofthetoolboxsimilartothissectiondeveloped.• Articles,programdocumentsandreportsrelatedtotherelevantthemesareidentified.This

isdonethroughdifferentstrategiesincludingaliteraturereview,visitingrelevantgovernmentwebsites,andbysharingtheconceptnotethroughrelevantsocialnetworkstoresearchandcivilsocietyorganizationsacrossthecountry.

• Eacharticle/documentischeckedtomatchwithinclusioncriteria3foreachtheme,andonlyifso,uploadedtoMendeley.InMendeley,eachdocumentissystematicallycataloguedbasedontherelevanttheme,typeofdocument(publication,report,etc.),andappropriatekeywords(tags)areassignedtofacilitatesearchinthefuture.

• Formaternalhealthinnovations,asimpleformattocollectinformationwasprepared(AnnexureIV).Thiswassharedacrossnetworksandeachinnovationorrelevantinterventionsharedwillbereviewedandpooledtogether.EventuallytheseinnovationsorinterventionswillbetranslatedintoKannada(thelocallanguage)andmadeavailableforconsiderationduringfuturediscussionsbetweencommunityrepresentativesandimplementersi.e.districthealthteam.

3Fortribalhealthandmaternalhealth–year2000onwardsandwithinIndia;forPAR–noyearorcountrylimittoliterature


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Todate,194contributionstothetribalhealthrepositorywerereceived.Thesedocumentsarebeingscreenedbytheinclusioncriteria,andthenwillbecataloguedandtaggedappropriatelyintheMendeley4.

TheinitialeffortstomapmaternalhealthinnovationsinIndiawithresultedinidentificationoftwenty-sevencasestudies.Whilethisisanongoingprocessandwillbefurtherreviewedanddevelopedbasedontheformatearlierprovided,thelistofinnovations/interventionswithbriefsummariesareprovidedinAnnexureV.

Twenty-twodocumentsincludingarticlesandmanualsarecompiledunderthePARtheme.Aproposedexpansionofthemethodreviewtoincludeimplementationresearchmethodrelatedisbeingconsideredtofacilitateinsightsintothelargerresearchproject.

ComponentE:Community’sreflection

Thiscomponentcomprisesofanextensivecommunityledeffortinmappingoutthestatusofaccessingmaternalhealthservicesamongallindigenouspeopleinthedistrictfollowedbyareflectiononissuesandpriorities,anddevelopmentofphoto-storiesvisuallycapturingthecontextandsomeofthethemesthatemergedfromthecommunityanalysis.

Actorsinvolvedandtheirroles:TheZillaBudakattuGirijanaAbhivrudhhiSangha(DistrictIndigenousPeoples’DevelopmentAssociation)partneredwiththeresearchteamtoundertakethemappingandanalysisofaccesstomaternalhealthservicesbywomenintheircommunities.Theassociationcreatedasub-committeetopartnerwiththeresearchteamandoverseethe 4Adesktop&web-basedsoftwarefororganizingandmanagingreferences/documents.

FIGURE7.TOOLBOXCONCEPTUALIZED


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process.Theyrecruitedtenfieldinvestigators(fivemenandfivewomen)andafieldsupervisorfromthecommunitytovisitthetribalvillagesandcollectrelevantdata.TheresearchteamledbythePIandresearchassistantalongwithtwofieldassistantssupportedtheorientation,capacitybuildingandmentoringoffieldinvestigatorsintermsofrelevantinformation,datacollectionandanalysismethods.

Method:Theoverallmethodforthiscomponentisdiagrammaticallyrepresentedinfigure8.

FIGURE8.COMMUNITYLEDREFLECTIONONTHEIRACCESSTOMATERNALHEALTHSERVICES

1.Planning:Twomeetingswereconductedbetweentheresearchteamandcommunityassociation–firstonorientationtotheproject,itsoverallmethodandoutputs,andsecondonthecommunityledreflection–aimandpossiblemethodsbrainstorm.Theassociationdecidedtocreateasub-committeetoplanandoverseeallworkinthefield.Theyalsodecidedtorecruittenfieldinvestigatorstovisiteachtribalvillageandcollectrelevantinformation.Thefieldinvestigatorswererecruitedinteamsoftwowithonemaleandonefemaleinvestigatorineachteam.ThreetalukswereassignedoneteameachandtheremainingtwoteamswereassignedtoKollegaltalukduetothelargernumberofvillagesinthetaluk(table5).Onefieldsupervisorwasalsorecruitedtohelpwiththelocallevelplanning,coordinationandfieldsupervision.

TABLE4.COMMUNITYFIELDINVESTIGATORSANDVILLAGESCOVERED

Taluk No.oftribalvillagesestimated*

No.offieldinvestigators

Finalno.oftribalvillages

Chamarajanagar 25 2 24Gundlupet 33 2 32Kollegal 80 4 70Yelandur 10 2 9


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Total 148 10 135

Theresearchteamconductedatwo-dayworkshopforthefieldinvestigatorstohelpbuildtheircapacityonmaternalhealth,availablegovernmentservicesandschemes,andondifferentmethodsofdatacollection.Indiscussionwiththeassociation,itwasdecidedtodevelopachecklisttoenablerelevantdatacollection.TheformatisenclosedinAnnexureVI.

2.Villagevisits:Eachteamoffieldinvestigatorsplannedtheirvisitwiththefieldsupervisor.Theyvisitedeachtribalvillageintheirarea,andinteractedwithdifferentgroupsofpeopleincludingvillageelders,pregnantwomenand/orrecentlydeliveredwomen,schoolteacher,anganwadiworkerandASHAasavailable.Theycollectedinformationbroadlycategorizedinthreesections:ageneralprofileofthetribalvillagevisited,ahand-drawnmapofthevillagewithsomeindicationofaccesstothenearesthealthcentersandtransportforthesame,andadetailednoteonhowwomenandeldersinavillagefeltabouttheiraccesstomaternalhealthservicesthroughpregnancy,deliveryandafterinthepostpartumperiod.Theresearchteamconductedafollow-upmeetingamonthlatertodiscusstheexperienceofthefieldinvestigators,refreshknowledgeaboutthevariousservicesandschemes,anddiscusschallengesfacedbytheminthefield.ThesevisitswereinitiatedinJuly2015andcompletedwithinsixmonths.

3.Reflection:Thereonwardsthefieldinvestigatorsmetonceamonthwiththeirfieldsupervisor,andresearchassistanthandingovertheinformationwithfeedbackondifficultiesfaced,andqualityofdatacollected.Thiscontinuedoverthemonths.Twocopiesofnotesweremaderegularly,onesharedwiththesub-committeefortheirreflection,andanotherwassharedwiththeresearchteam.

Afterthreemonthsofdatacollection,atwo-dayworkshopwasheldtostartsomereflectiononthecontentofthefieldnotes,andtocompileandprepareataluk-levelanalysis.Thisworkshopfocusedonthemesemergingfromthevariousfieldnotestakingintoconsiderationbothpositivestatementsandissueshighlighted.Thethemesthatemergedwereusedasaframeworktoanalyzeeachvillagefieldnotetoprepareasummarytablehighlightinganysignificantcasesidentified.ThetrainingandalldocumentationwereconductedinKannadathelocallanguage.ThesesummarytablesweretranslatedintoEnglishandthentheresearchteampreparedtaluksummaries.Thepreliminaryfindingsofthisreflectionaredetailedbelow.

4.Analysis:Thesub-committeeiscurrentlyreviewingthefieldnotesforeachvillageandpreparingtalukreportsinKannadafocusingontheirprioritiesindiscussionwiththeresearchteam.Thesesummarieswillnextbediscussedandtakenforwardasadistrictlevelreportbythesub-committeesupportedbytheresearchteam.Thisreportwillbesharedforadvocacybytheassociation,andusedfortheupcomingstakeholdermeetingsintheresearch.

Preliminaryfindings:135tribalvillageswerecoveredacrossfourtaluksinChamarajanagardistrict.Thethreemainindigenouscommunitiesinthedistrictweresoliga,jenukuruba,and


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bettakuruba(thelattertwoareconfinedtoGundlupettaluk).Thesizeofthevillagesvariedgreatlywithsomevillageshavinglessthantenhouseholds,whilethelargeroneshaveover300households.Over5000householdsareestimatedacrossthedistrict.Morethanninetypercentreportedpresenceofananganwadi5withinorneartheirvillage.DistancefromamainroadanddistancefromthenearestPHCwasalsoassessed.Thesereflectedamixedpictureofaccessacrossthedifferentvillages.Forinstance,seventribalvillagesinYelandurareonthemainroadwhiletheremainingtwoarearound3kmawayanymainroads.HoweverthedistancetothenearestPHCis16to24kmawaytakingnearlyonehourtotravelbypublictransportation,notcountingthetimespentwaitingforthetransportsinceallthevillagesarewithinatigerreservewithinfrequentbuses.InKollegalalso,nearlyaquarterofthevillagesreporteddistancesof10kmormoretothenearestPHC.Fewvillagesreportedaslargeas30to50kmdistancefromthenearestPHC.Itisimportanttonoteherethatsincemostofthesevillagesarewithinforests,travellingthisdistanceisabiggerchallengegivenlimitedpublictransportation,nearlyabsentprivatetransport(barringfewtwowheelers),gameroads,wildlifeandrainfall.Free-handmapsdrawnforeachvillageprovideavisualrepresentationoftheenvironmentandgeographicalaccesstothevillageandnearbyhealthcenters(anexampleinfigure9).ThesedrawnmapsandGPSmapswillbetterhelpinhighlightingtheissueswithphysicalaccess.

FIGURE9.AFREEHANDMAPOFKONNANAKERE(ATRIBALVILLAGE)

ThepreliminaryanalysisofYelandurandGundlupettaluksummariesrevealedemergenceofcertainthemesorcategoriesintowhichmostissueswereorganized(figure10).

5Governmentdaycareforchildrenaged3-6yearswithobjectivestoprovidenon-formaleducationandonemid-daymeal.UndertheIntegratedChildDevelopmentServices,pregnantwomenalsoareprovidedwithonenutritiousmealeverydayatthecenter.


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FIGURE10.THEMESEMERGINGFROMCOMMUNITYREFLECTIONS

• Physicalaccess–Themostdiscussedaboutthemewaslargelyaboutgettingtoahealthcenterbothforantenatalcareanddelivery.Theinfrastructurefortransportavailabletomosttribalvillagesissimilar

o semi-weatherroadsthroughforests(distancetothemainroadcanbeashighas4-6km)

o withinforestreservessousuallytimerestrictiononmovementofvehiclesineveningandnight

o ifvillagedeepinforest,forestdepartmentchainacrossroadtopreventvehiclemovement

o limitedpublictransportation–frequencycanbeaslittleasonlytwiceadayinthedayonly

o minimalprivatetransportation–usuallysharetaxiserviceoflocalnon-tribalcommunities,autorickshawsnotavailable

o closest108generallystationedonetotwohoursawayo athirdofvillagesinGundlupet,andnearlyallinYelandurlocatedonmainroad

Walkingisthecommonestmodeoftravelforvisitingnearbyhealthcentersdirectlyortogettonearestmainroad.Pooravailabilityforvehiclesbarringfewtwo-wheelerswithinthecommunity,makestravellingforaregularcheckuporemergencyanexpensiveaffairbothintermsoftime,personstoaccompanyandmoney.Atnightandinrainyseasons,thisaccessisfurtherlimitedduetowildlifemovementinthearea.Theseissueswithaccessnotonlyrestrictmovementoutoftheareabutalsoareachallengeforhealthworkerstryingtobringservicesintothesevillages.Inalmostallvillages,issueswithaccessing108(emergency


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ambulanceserviceprovidedbygovernment)werereported.Evenif108ambulancesarecalled,theuncertaintyofarrivalandthedelayintransportationduringemergenciesandhelplessnesswithwaitingwerereported.Incidentsofdeliveriesoccurringathomeoronrouteinthe108ambulancewerealsoreported.Poormobilenetworksincertainforestareasmakeitalreadydifficulttocontacteveninanemergency.Since108vehiclesarelarge,theyareusuallynotabletotravelwithinforestsonsemi-weatherroadsandcompelthecommunitiestoorganizealternatetransportviajeepsonhire,localforestdepartmentorNGOjeepstotransportthepatienttillthemainroadandthenshiftintotheambulance.Oneconcernraisedbyfewwasalsothattheambulanceonlyprovidedtransportone-waytothenearesthealthcenter,andtravellingbackwasstillachallengethattheyhadtoovercome.

• Economicissues–Alargeproportionofhouseholdsearnedtheirincomeandisdependentondailywageworkthatisirregularandmakesitdifficulttoskipaday’sworkforanotherwiseregularcheckup.Theworkalsotakesthemfarfromhome(bothmenandwomen),insomeareasrequiringtemporarymigration.Somewomenalsoreportedthatevenduringpregnancy,sheisexpectedtoworktillthedayofdeliveryandsoonaftertoearnlivelihood.Repeatedlyindiscussionswiththecommunityandhealthworkers,anemphasisonexpenditureincurredduetotravelwasobserved.Manyacknowledgedthatwhilegovernmentserviceswerefree,thecosttotravelbothwayswithaccompanyingpersonstoanearbyhealthcenterforcheckuportestswasoftentoohigh.Fewreportsofexpenditureonmedicinesandtestsfromprivatesectorwerereceiveddespitevisitinggovernmenthealthservices.Mosthouseholdsalsodependedlargelyonthesubsidizedgrainsfromthegovernmentpublicdistributionsystem(mainlycarbohydrates),andsharedthataccesstonutritiousfood(withadequateproteins,andgreenleafyvegetables)waslargelyviaexternalmarketsandthisledtopoordietintakeduringpregnancyandhencepoorhealthoutcomes.

• Availabilityofservices–Inalmostallvillages,anganwadiswereavailablethoughirregular.Howevertheanganwadiworkerwasidentifiedasthemostimportantsourceofinformationonmaternalhealthcareandservices.InGundlupetinnearlyhalfofthevillages,betweentheASHA,ANMandanganwadiworkermaternalhealthserviceswereavailableonaweeklytomonthlybasisatthevillageitself.TheavailabilityofASHAandANMvariedgreatlyacrossthevillages–inYelandurnoneofthevillagesreportedpresenceofanASHA(atleast2to4expected)whileANMwaspostedbutinfrequentinvisitsandinconsistentinserviceprovision;inGundlupet–thisvarieddrasticallyacrossthevillages.Only3villagesreportedmonthlyvisitsbythemedicalofficer.PHCsareonanaverageanywherefrom16to24kmawayinYelandurmakingitseldomvisitedbutforemergenciesorcomplications;inGundlupetmostvillageswerewithin5kmfromthePHCbarringafew.

• Awarenessofservices/schemes–Thekeyinformantinalmostallvillageswasidentifiedastheanganwadiworkerbutoverallbetweenthethreefrontlineworkers,someinformationonantenatalcareanddeliverywasavailabletoall.Thequalityofinformationwasdifficulttoassess.Informationaboutrelevantgovernmentschemesandprocessestoacquirethemwas


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theleastknown.Localsocialnetworksandwomenwhowereeducatedorworkingoutsidewerealsoidentifiedasvitalsourcesofinformation.Thewomenwereoftengenerallyawareofcertainnutritionalsupplements,medicines,testsandregularcheckupsbeingneededduringpregnancy,andmostoftensoughtthemaswell.Foradviceondietandothers,theylookedtotheirfamilyandfriends.

• Acceptability-Forpregnancyrelatedcheckups,womenoftenvisitedthenearbyhealthcentersatleastonceintheirpregnancyatatimeandpaceoftheirchoosing,andreportedthatinstitutionaldeliveriesweresaferinthatcomplicationscouldbebetteridentifiedandappropriatereferraldone.Theactualchoicethoughwasmadeonlyatthetimeofdeliverydependingonvariousfactorsmentionedearlier.Howeverfewwomendidreportafearofhospitals–ratherafearofnotknowingwhatwouldbedoneinahospitalorfearofinjectionorprocedurediscouragingthemfromvisitinghealthcenters.Discomfortbytheideaofinternalexaminationsduringdeliveryandpresenceofamaledoctorwerealsoreported.Forpregnancycheckupsthough,acceptabilitywascomparativelyhigh.Inveryfewinstances,awomanactuallyreportedthatshechosetodeliverathomeduetobeliefintraditionalwaysoverchoiceofmodernhealthservices.Althoughhomedeliveriesdidoftenoccur,mostdeliverieswerereportedinPHCsreflectingalargeracceptanceofhospital-baseddeliveries.Immediateandexclusivebreast-feedingisalreadypracticedwithinthecommunity.

• Qualityofservices–Infrequentvisitsbyfrontlinehealthworkersandfocusonreportingandwriting–ratherthanprovidingusefulinformationandservicesweresomeofthecomplaints.Inafewvillages,ANMswerenotconsideredasreliablesourcesforserviceswhereasinonevillage,theywerehappywiththefrontlinehealthworkersandmentionedthattheworkersorganizedbi-monthlygatheringswherehelpfulhealtheducationwasprovidedtoallwomen.StaffnursesoftenconducteddeliveriesatPHCs,andpresenceofmaledoctorasabarrierwasmentionedbyafew.Informalpaymentsinthetuneof5to100rupeeswerereportedtothestaffatsomecentersaswell.

Ineachtaluk,onetotwovillageswereidentifiedwhichhadpoorestaccesstoservices.Thesevillageswereoftenrelativelyisolatedwithinforestwithtravelrestrictions,andseldomvisitedbyanyfrontlinehealthworker.Womeninthesevillagesreportedrelianceontraditionalhealthpracticesandhomedeliverieswithatraditionalbirthattendant.

Generallypoorsanitationfacilitiesandasocialproblemofalcoholismweretwokeythemesthatacrossthevillagescontributingtothepoorsocio-economicconditions,delayindecisionmakingandgeneralpoorhealthstatusaccordingtothecommunity.

ComponentF:Healthservices’reflection

FieldvisitstotribalPHCs:Asmentionedearlier,GPSmappingwasundertakenforgovernmenthealthcenterscateringtoindigenouscommunitiesacrossthedistrict.Duringthesevisits,PHC


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staffundertheleadershipoftheconcernedmedicalofficerwasorientedabouttheresearchandabriefinteractionwasundertakentogaininsightintotheirperspectivesonworkingwithindigenouscommunitiesfocusingonmaternalhealthservices.16(of26)tribalPHCs(andonetribalmobilehealthunit)werevisitedalongwith11sub-centersacrossthefourtaluks.Duringthevisits,theteamalsovisited11privatehospitalsinthedistrictprovidingmaternalhealthservices.

Interactionwithgovernmenthealthworkersincludingmedicalofficers:ApartfrombriefinteractionswiththePHCteams,theresearchteaminterviewedataluk-levelseniorladyhealthvisitor(seniorhealthassistantfemale)whoapartfromtheirownexperience,supervisethematernalhealthserviceprovisionandutilizationinallPHCsunderthem.Whiletheanalysisisongoing,thepreliminarythemesemergingaresharedbelow(figure11).Thesehelpprovideusefulinsightsintothechallengesfacedbythehealthworkersattheperiphery.

FIGURE11.ISSUESEMERGINGFROMINTERACTIONWITHHEALTHWORKERS

• Physicalaccessandgeneralinfrastructure–Similartothecommunity,transportationisidentifiedtobeakeybarrierthatappearstosignificantlyinfluencemotivationofhealthworker.ThiswasacommonconcernraisedbyallthehealthworkersweinteractedwithfromASHAtothePHCmedicalofficers.Theystatedthatnearlytwo-thirdofthetribalvillagesaresituatedinforestedareas,oftenwithinwildlifereserveswithsemi-weatherroadsonlyforaccess.Healthworkersarenotprovidedanyadditionaltransportationfortheirwork,oranyincentivestoensurethatwork.OnlytheASHAs(communityvolunteers)andoneANMbelongedtotheindigenouscommunitythemselves.Fortheothers,travelling


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tomanyofthesevillagesespeciallyduringthesecondhalfofthedayorduringemergencieswasasignificantchallenge.Limitedpublictransportationandloweconomicstatusoftenthehealthworkers’predictarebarriersbythemselvesforcommunitytotraveltopharmaciesorhealthcenterswhenreferredleavingalotoftheadvicetheygivetounresponsiveearsevenifriskisassociated.Almostallhealthworkersnarratedvariousincidentsduringemergencieswhenthisaccessbecamethesolereasonfortheundesirableoutcomes.Forallofthem,organizingemergencytransportisachallengethattheycommonlyface.Insometribalvillages,mobilenetworkisnotavailablemakingevensimplecommunicationtough.Calling108(designatedgovernmentambulance)stilldoesnotensurethattransportationarrivesontime.Inareasborderingotherstates,thecallwouldevenneedtobetransferredbetweenstatecenters.Evenif108wastorespond,theaveragedurationtakentoreachavillageisanywherebetweenonetooneandahalfhours.Inemergencysituations,theANMusuallytakesacallbasedontheurgencyofthesituation,andeconomicconditionsofthepatient.Insomecases,sheevengetsthecommunitytohireaprivatevehicletothenearestcenter.Inothertimestheyoftenreportthattheexpectingmotherwoulddeliverathomeoren-routetoahealthcenterduetothetimedelayinsecuringtransport.

• Follow-upachallenge–despitemostindigenouspeoplehavingamobilephone,poormobilenetworksintheforestoftenmakeitdifficultforhealthworkerstofollowupwithpatientsortheirrelatives.Giventhatphysicalaccessisdifficult,thefrequencyofinteractionbetweenhealthworkersandthecommunityincludingexpectingmothersismuchlower.Insuchscenarios,theyrelyheavilyoncommunicationviamobilephones.Somehealthworkersalsoreportedastemporarymigrationbytribalfamiliesinsearchofworkasareasonforpoorfollow-up,andlossincontinuityofcarecrucialforpregnancyanddeliveryrelatedcare.Acceptingthatadditionaleffortsareneededtofollow-upcertaincaseslikechildwhoseimmunizationisdueorexpectingmotherclosetoduedate,fewhealthworkersexpressedtheirhelplessnesstoensurethehealthofeveryregisteredexpectingmotherwhileothersevenreportedtakingtheirpersonalvehicleorhiringavehicletopursueaparticularcase.Thischallengealsoworsenedinvillagesthatwereremotelylocatedordeepintheforestawayfromthemainroad.Thelowsocio-economicstatusalsoledtopeoplenotbeingabletocontinuetreatmentormedicationormakeregulartripstonearbyhealthcentersorpharmacies,accordingtothehealthworkers.Eveniftheservicesormedicineswerefree,thecostfortraveltwowaysandthelossofwagesforthatlongtripisnotacostthatmostfamiliescanafford.Thesenon-medicaldirectandindirectcostshenceactasabarriertoregularfollow-upofmuchrequiredmedicalcare.

• Perceptionsaboutindigenouspeople–Almostallhealthworkersirrespectiveoftheircadredidnotbelongtothisoranyindigenouscommunity.Mosthealthworkersreportedno


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differenceintheirownattitudeorservicesprovidedtoindigenouscommunityintheirareawhencomparedtoothers.Themaindifferencestheyperceivedwereintermsofthebackgroundoftheindigenouscommunityandintheir(community’s)attitudetowardsgovernmenthealthworkersandhealthservices.Mosthealthworkersattributedtheirchallengesinworkingwithindigenouspeopletotheirloweconomicstatus,theirrelativepooreducationstatusandtheirculturalbackwardness.Thelatterwasexplainedinmanywayssuchasbeingsuperstitious,stickingtoapparentlytraditionalpractices,listeningtocommunityeldersovertheadviceofthehealthworkers,firmlybelievingingodforhealingandoftenchoosingthisoverhealthservicesprovided.Fewhypothesizedtheseasreasonsforthecommunitygenerallybeinglesscooperativewithhealthservicesandbeingpoorparticipantsinanyprogramorprocess.Someprovidedanecdoteslikewhentheyconductedhouse-to-housesurveys,thelocalpeoplequestionedaboutanydirectbenefitsandrefusedtoparticipate.Onementionedthatafterovercomingmanychallengeswhenshetriedtogivepoliodropstothechildreninthevillage,feweldersreprimandedherforheractions.Theyfeltthatthesewerepoorchoicesmadebythecommunity.Fewhealthworkersworkingintheseareasforlongwerecriticalofsuchsimplisticviews,andsharedtheneedforfocusedhealtheducationactivitiestoexplainorcounselthemtowardsunderstandingtheneedforservices.Oneevensuggesteduseofalternateaudio-visualmethodstocommunicatesuchmessagesforbetterretention.OneANMwhobelongedtothelocalindigenouscommunityexplainedthatwhilemosthealthworkersperceivedanelementofintentionalrejectionofservices,accordingtohermostpeopledidnotcomprehendtheneedorhowtopursuesomeoftheseissues,andthatadditionaleffortwaswarrantedtofacilitatetheservicestoreachthecommunity.

• Struggletobridgebarriers

Whetheritisearlyageofmarriageormisconceptionsaboutinjectionsduringpregnancy,manyhealthworkersseemedawareofcommonnotionsandissuesamongthewomenesp.inrelationtopregnancyanddelivery.Someprovidedinstanceswhereevenroutinepaperworkrequiredtoparticipateinahealthschemeorprogramwasneededtobetakenupbythehealthworkersthemselvestoensurethateachbeneficiaryreceivedtheirdue.Howevertheselittleeffortsoftenwentunappreciatedbothbytheirsupervisorsandthecommunity.Caughtinbetweenreportingandavoidingbeingreprimanded,andprovidingservicestothecommunity,fewhealthworkerssharedsomecaseswheretheinteractionbetweentheservicesandthecommunitywaspoor,andhowthisonlyworsenedthecooperationtheyreceivedinthefield.Forinstance,inonevillagetheANMencouragedinstitutionaldeliveryandrecommendedtothewomentovisitthenearbyPHCforcare(around30kmaway).Whenapregnantwomanvisitedthehealthcenterwithhermotherfordelivery,therewasnomedicalofficerandonlyonenursewhoexaminedherinitiallyandthendidnotreturn.Thisledtothemotherconductingthedeliveryforthedaughter,andthemreturningwithagrudgeagainstnotonlythehealthcenterbutalsotheANMforsuggestingthis.


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Ontheotherside,onestaffsharedastoryofhowtheywerecalledinthemiddleofthenightforadeliverytoaremotevillageintheirarea.Theteamgottogetherandtravelledthroughtheforestinthedarknessforanhourormoretoreachthehouse.Butbythetimetheyreachedthewomanhadalreadydeliveredwithahealthybaby,andthefamilyhadgonebacktosleeplikeanyotherday,leavingnoonetobotherabouttheteam.Annoyed,theteambroughtthemotherandchildbacktothehealthcenterforadmission,andreporteditasaninstitutionaldeliveryfortheefforttheyputin.Manymoresuchstoriesreportedconveyaconstantstrugglebyhealthworkerstoperformtheirresponsibilitiesgiventhevariouslimitationsandcommunicationgapwiththecommunity.

• Shortageofstaffand‘band-aid’solutions-Theshortageforhumanresourcesisacrossallhealthcentersinthedistricts.Nearlyhalfthesanctionedpostsintribalhealthcentersarevacantwithnearlyone-sixthforfemalehealthworkers.Intribalhealthcentersgiventhedifficultgeographicalterrainandsurroundedbyforests,themotivationtoworkisrelativelyloweramongsomestaffleadingtovoluntarytransfersorirregularwork.Giventheshortage,differenttemporarysolutionsareappliedintribalhealthcenters.Forinstance,allpostsataninteriortribalPHCarevacant,sodifferentstafffromnearbyPHCsarepostedtherefortwotothreedaysaweek.Thisinevitablyleadstotwopartlyfunctioninghealthservicesintheseareas.WhilesomemedicalofficersofaPHCaregivenpostedtoanotherPHCastheacting-in-charge,oneANMmentionedthatshecoversfoursub-center’sresponsibilities.Despitetheselimitationsandbeingstretchedthin,weidentifiedmanyhealthworkerswhowereperformingalloftheirallocatedduties.Thecommunityintheirareasisawareoftheseshortcomingsandoftenorganizesprotestsandpetitionsdemandingforsanctionedpoststobefilled.Howeverthisshortageanditsimplicationsonexistingstaffandprovisionofexistingservicesissignificantinaterrainwherephysicalaccessisalreadyachallenge.

• Supportforwork-Whilemosthealthworkersspokevocallyaboutthelackofsupporttheyreceivefromtheindigenouscommunitieseventhebeneficiarythemselvesinorganizingservices,fewhealthworkersincludingmedicalofficersspokeaboutminimaltonilrecognitionorappreciationfromtheirpeersorsuperiorsregardingthehardshipstheyfaceonadailybasistoperformtheirresponsibilities.Fewmentionedcloselypartneringwithlocalnetworkslikeanganwadiworkers,schoolteachersandleaderstohelpsmoothentheirwork.Mosthealthworkersweredefensiveaboutanyquestioningoftheexpectedoutputsintheirarealikeantenatalcoverageorproportionofinstitutionaldeliveries.ImprovementIntheabsenceoffinancialandnon-financialincentives.

SECTIONIII:PROJECTPROGRESSANDNEXTSTEPS

Whiletheprojectwasplannedfortwelvemonths,delayinreceivingethicsapprovalnecessitatedano-costextensiontillAug2016,whichwasgrantedbyWHOinDec2015.TheprojectreceivedfullapprovalfromWHOEthicsReviewCommitteeinJan2016.

Allsixcomponentsasdescribedintheprevioussectionwereinitiated.FourcomponentsnamelyA(maternalhealthservicesdescription),B(serviceavailabilityandmapping),D(toolbox)andE(communityreflection)arenearcompleteandinthefinalstageofconsolidationandanalysis.ComponentsC(stakeholderanalysis)andF(healthserviceproviders’reflections)areongoingandareexpectedtobecompletedinthecomingmonthsasexplainedindetailbelow.

Toallowbettercommunicationandsomeinsightsintoresearchproject,theresearchteamadoptedanewsletterapproach.Onenewsletterwasgeneratedsixmonthsbacktobesharedamongthevariousco-investigatorsandthosesupportingtheresearch.ThisisenclosedasAnnexureVII.HoweverwithdelayinreceivingtheWHOEthicsReviewCommitteeapprovalanduncleartimelines,thiswasputonhold.Withthefullapprovalnowuponus,theteamwillagaincommencecreatingnewsletterssharingkeyresearchactivitiesandarticlesfromthetoolbox.

Nextsteps:

Inviewofthedelayinobtainingethicalclearanceforthestudy,manyoftheactivitiespertainingtotheparticipatoryactionresearchweredeferred.Astheactivitiesproposed,therearetwoaxesofenquiryinthisproject.ThefirstoneisthePARaxiswhiletheotheroneisthesimultaneouslyprogressingaxisrelatedtobuildingatheory(TDI).Whiletheformerhadthegoalofbuildingacommonplatformatthedistrictleveltobringtogetherseveralstakeholdersontribalmaternalhealth,thelatterfocusesonbuildinganexplanationforwhatworkedandwhy.Aspertheillustrationfromtheoriginalstudyproposal,variousoutputsrelatedtothesetwoaxesofinquirywereproposed.Intable6,weadaptedtheseactivitiesintotheremainingprojectperiod.Theremainingactivitiesareorganizedintothreemainheadings:participatoryactionresearch,theory-driveninquiry,anddissemination.

TABLE5.REVISEDTIMELINEFORREMAININGSTUDYDURATION

Researchactivities 2016

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

ParticipatoryActionResearch Situationanalysis

Reportwriting-community,interimreport Servicemappingandutilisationinformation

Healthseekingbehaviourfinalanalysisandwriteup Healthserviceproviderdiscussionsandreport

Maternalhealthinnovationmapping


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Stakeholderworkshops Communtyandimplementermeetingforreflection LocalsolutionsimplementedinPHC/communities Newsletterssharedwithco-investigatorsandotheractors Theory-DrivenInquiry Initialprogrammetheorydeveloped Refiningprogrammetheory Revisedprogrammetheoryfinalised Dissemination Howto-manualfordistricthealthmanagers Statelevelworkshop Engagewithmassmedia Photo-essays/casestudiesforteaching Projectfilm Participateinscientificconferences,writescientificpaper

PARactivitiesThedatacollectionactivitiesincludinginterviews,focusgroupdiscussionsandcasestudiesweretakenupbythefieldresearchersasdescribedearlier.Weproposetobringtogethertheanalysisandresultsofthetribalfieldinvestigatorswiththeanalysisandresultsofthehealthservicesstaffontoacommonplatform.Thiswillbedonein2workshops,oneinAprilandtheotheronelaterinJuly-August.Thepurposeoftheseworkshopsshallbetoarriveatashared/negotiatedunderstandingofwhythematernalhealthsituationamongtribalwomenispoor.

Forthefirstworkshop,weshallinvitethetribalfieldresearcherstosharetheiranalysiswiththedistrictteam.Otherstakeholdersinvitedtotheworkshopshallincludetheco-investigators,thedoctorsworkinginthetribalareaPHCs,andcommunityleaders.Wehopetosteerthediscussiontowardsproblem-solvingfocusingonwhatcanbedonelocallytoimprovethissituation.Wewillbreakoutintogroupsandeachgroupwillbrainstormpossibleshortandlong-termsolutionstobejointlydiscussed.Aplanofactionforfollow-upwillbedrawnupattheendoftheworkshop.

Weforeseethattheworkshopdiscussionswillresultinpossiblesolutionsthatmaybepiloted/implementedbetweenAprilandAugust.Inviewofthetimeconstraints,onlysmall-scaleandshort-termprojectsmaybeimplemented.Forthemorelong-termsuggestions,weshallproposetoincludethemunderthedistrict’sannualactionplaninthesubsequentyear.Indeed,suchaninclusionofanylocalsolutionsintothedistrict’sactionplanisanoutcomeoftheproposedstudy.

TDIrelatedactivities

Atpresent,theinitialtheoryisbeingformulated.Thebasisfortheinitialprogramtheoryistheprogramdocuments,fieldnotesandobservations.Theinitialprogramtheorywillfocuson


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implementerassumptionsastowhysuchacommonplatformoughttoformandhowitcouldleadtoimprovedmaternalhealthsituationfortribalwomen.Inthenextphase,aseriesofinterviewswithstakeholdersshallbeconductedtofurthercontestandrefinethetheorytodevelopabetterunderstandingofwhatisworkingandforwhom.Therefinedtheoryofwhatworked(andwhatdidnot),forwhomandwhyshallbefinalizedinJuly-August.Theoutputshallbeintheformofareport,portionsofwhichcanalsobeusedindisseminationatworkshopsandinpeer-reviewedarticles.

Disseminationactivities

ThepotentialfordisseminatingoutputsofaPARprojectaremuchmorethanconventionalresearchprojects.• Ajournalist-photographerontheteamisfinalizingaseriesofphoto-essaysonthetribal

healthsituation.Thesephoto-essaysshallbepublishedasaseriesinthecomingmonths(February–April).Wewillsharethemwidelyanddisseminateitstrategicallyamongpolicymakersatthestateleveltoimprovetheagendasettingontribalhealth.Wewillalsosharethemwidelyinsocialmediatogenerateawiderdiscussioninvariouscommunitiesofpracticeaswellasondiscussionforumsofpublichealthresearchercommunity.Thephoto-essaythemesareasfollows:

o Series1onintroductiontoindigenoustribalpeopleinsouthernIndia(figure12)o Series2onhowitistoliveinaforestandgrapplewithissuesofrights,accessto

servicesetc.o Series3onmaternalhealthinrelationtotheissuesraisedinseries1and2

FIGURE12.SCREENSHOTOFTHEFIRSTPHOTO-ESSAYTOBEPUBLISHEDINFEB2016

• Ashortfilmshallbemadetoenablethetribalfieldresearcherstosharetheirresults.Unlikeinconventionalresearchprojectswhereresultsmaybesharedinjournal/academiclanguageformat,oralnarrativesarethepreferredchoiceofsharingresultsinPAR.Thefilmshallcapturetheresultsinthevoiceofthetribalresearchersthemselves.Thefilmshallalsobea


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powerfuladvocacytooltoshowcaseatnationalandinternationalsymposiatotakethevoiceofthetribalresearchersdirectlytotheseaudiences.Thefilmshallbemadeinthreeiterationscapturingtheprogressatthreepointsoftime,beginningwiththetribalresearchers’’analysisandsuccessivelyaddingmoreandmorestakeholdervoicesandresponsestotheiranalysis.

• Thethirdeditionofthenationalconferenceonbringingevidenceintopublichealthpolicy(EPHP,seewww.ephp.in)isthepremierplatformforsharinghealthpolicyandsystemresearchdiscussionsandforengagementbetweenresearchersandpolicymakersinIndia.ItisconductedeverytwoyearsbyInstituteofPublicHealth,Bangalore(IPH).Wehavesubmittedaproposalforanorganizedsessionbyapanelconsistingofthetribalresearchersandotherco-investigators,endinginafishbowldiscussionontherelevanceofPARapproachessuchasthisonefordistrictmanagers.

• Apolicybriefshallbepreparedattheendoftheprojectfordisseminationtoalltribalareapolicymakersandimplementersacrossthecountry.

• Finally,adraftmanualfordistricthealthmanagersintribaldistricts,basedonlessonslearntfromthisprojectshallbepreparedinJuly-August.

• ThefourthsymposiumofhealthsystemsglobalisscheduledlaterthisyearatVancouver.Theresearchteamisapartoftwoapplicationsfororganizedsession,andwillalsoapplyforposterandmultimediasubmissions.(http://healthsystemsresearch.org/hsr2016)

LISTOFANNEXURES

AnnexureI GovernmentschemesformaternalhealthservicesinChamarajanagardistrictAnnexureII

FormatforGPSlocationandfacilityleveldatacollection

AnnexureIII Listofstakeholdersidentifiedinthedistrict AnnexureIV FormatforreportingmaternalhealthinnovationsinIndia AnnexureV Maternal,neonatalandchildhealthinnovationsv1 AnnexureVI Formatforcommunityfieldinvestigator’svillagevisit AnnexureVII PLAnewsletter

AnnexureI

GovernmentschemesformaternalhealthservicesinChamarajanagardistrict

Commonabbreviationsused:APL:AbovePovertyLineANC:AnteNatalCheckupsANM:AxillaryNurseMidwife.ASHA:AccreditedSocialhealthActivistAWW:AnganwadiworkersBPL:belowPovertyLine

MOU:MemorandumofUnderstandingIFA:IronandFolicAcidTablets/SyrupsPNC:PostNatalCheckupsST:ScheduledTribesSC:ScheduledCastes’TT:TetanusToxoid

Variousschemesand/orprogramsoftheGovernmentofKarnatakaaimtoreduceoverallmaternalandinfantmortalityrates.Differentschemesprovidedthroughoutthepregnancyperiodhelppregnantwomenbelongingtolowersocio-economicstatustoaccesshealthservicesandprovidefinancialincentivesforbetternutritionandcareofbothmotherandchild.

Theschemesinclude:

1. JananiShishuSurakshaKaryakaram(JSSK)2. PrasootiArike3. JananiSurakshaYojana(JSY)4. MadiluKit5. TayiBhagya6. TayiBhagyaPlus7. JananiSurakshaVahini8. NaguMagu9. 108ambulanceservices

JananiShishuSurakshaKaryakram(JSSK)1.Aim MaingoalofJSSKistoensurethatpregnantwomenandsickneonatesaccesspublic

healthfacilitiesunderJSSKatzeroexpenditure&reducetheirmortalityrates.JSSKsupplementsthecashassistancegiventoapregnantwomanunderJananiSurakshaYojanaandisaimedatmitigatingtheburdenofoutofpocketexpensesincurredbypregnantwomenandsicknewbornsingovernmenthealthfacilities.

2.Eligibility

ThisprogrammeincludesessentialservicesduringANC,delivery,andpostnatalcaretoallwomenandfreeservicestochildrenwithinoneyear.Coversallchildrenadmittedtogovernmenthospitalbelowoneyearageincludingthosefromoutsidethestate

3.Whatistheschemeabout

Thefollowingarethefreeentitlementsforpregnantwomen:• Freecashlessdelivery• Freecaesariansection• Freedrugsandconsumables• Freediagnostics• Freedietduringstayinthehealthinstitutions• Freeprovisionofblood• Exemptionfromusercharges• Freetransportfromhometohealthinstitutions• Freetransportbetweenfacilitiesincaseofreferral• FreedropbackfromInstitutionstohomeafter48hrsstayThefollowingarethefreeentitlementsforsicknewbornstill30daysafterbirth-nowexpandedtocoversickinfants:• Freetreatment• Freedrugsandconsumables• Freediagnostics• Freeprovisionofblood• Exemptionfromusercharges• FreetransportfromhometohealthInstitutions• Freetransportbetweenfacilitiesincaseofreferral• Freedropbackfrominstitutionstohome

4.Howtoobtainit ServicescanbeavailedbyallasbothBPLandAPLareEligible.PrasootiArike1.Aim ThisisagovernmentofKarnatakaschemeforthebenefitofpregnantwomenbelonging

toBPLfamilies2.Eligibility • BPLfamiliesonly

• Onlyfor2livebirths• Ingovernmenthospitalsonly


ThepregnantwomenhavetoregistertheirnameswiththeJuniorFemaleHealthAssistant(ANM)ofthearea.• TheentitlementsincludeRs1000duringthesecondANCcheckups,Rs300after

deliveryforruralwomen,Rs400afterdeliveryforurbanwomenpaidthroughbearercheques.

• DuringeveryANCcheckup,theMedicalOfficeroftheHealthCentre/Hospitalputsthesignature,dateandsealontheANCcard.

• AninformationbookletonthedietaryrequirementsforthepregnantwomanhastobeprovidedbyIECwing,toeachofthem.

• Thisfacilityisextendedtoallpregnantwomenbelongingtobelowpovertyline

families• Thebenefitislimitedtothefirsttwodeliveries.TheJuniorFemaleHealthAssistant

hastorecordtheANCregistrationnumberalongwithnotingwhetheritisfirstorseconddelivery.

4.Howtoobtainit RegisterwithANMforantenatalcheckups,andprovidenecessarydocumentationsforBPLstatus

JananiSurakshaYojana(JSY)1.Aim JSYisbeingimplementedwiththeobjectiveofreducingmaternalandneonatalmortality

bypromotinginstitutionaldeliveryamongpoorpregnantwomen.2.Eligibility • MustbelongtoaBPLfamily

• Currentdeliverymustbefirstorsecondlivechild• Shouldbeabove19yearsofage• Musthavegot3ANCcheckups• MusthavetakenIFAandTTinjection• SC/STWomennotbelongingtoBPLarealsoeligible• IncaseifwomeniseligibleanddoesnotpossessaBPLcardsheisguidedthough

ASHAAWWtoobtaincertificatethroughconcernedrevenue• Atgovernmenthospitalsorempanelledprivatehospitals


Programmeprovidesfinancialassistancetopoorpregnantwomenundergoingdelivery.Forhomedelivery:Rs500;institutionaldelivery(rural):Rs700(urban):Rs600;Caesariansection:Rs1500.

4.Howtoobtainit RegisterwithANMforantenatalcheckups,andprovidenecessarydocumentationsforBPLstatus

MadiluKit1.Aim Toprovidepostnatalcareformotherandchildbyencouragingmotherstodeliverin

healthcenters/hospitalsinordertoreduceinfantmortalityandmaternalmortality2.Eligibility:

• Onlyfor2livebirths• Havetodeliveringovernmenthospitals

3.Whatisthisschemeabout

Kitcontainingessentialcareelementsforpostnatalmotherandnewbornbaby:19items• Mosquitocurtain• Mediumsizedcarpet• Mediumsizedbedsheet• Athickblanketformother• BathingSoap• Washingsoap• Clothtotieabdomenofmother• Sanitarypads• Combandcoconutoil• Towel• Toothpasteandbrush• bedspreadoverrubbersheetforthebaby• Bedsheetforbaby• Bathingsoapforbaby• Rubbersheetforbaby• Diaper• Babyvest• Sweater,capandsocksforbaby

• Oneplastickitbag.4.Howtoobtainit ObtainedafterdeliveryingovernmenthospitalsonlyTayiBhagya1.Aim ThisprogramaimstoprovidefreeservicetopregnantwomenbelongingtoBPLfamiliesin

registeredprivatehospitalsinitiallyin7districtsofKarnataka-nowextendedtoalldistrictsinKarnataka.Basedonpublicprivatepartnership.

2.Eligibility • MustbelongtoBPLfamily• Inregisteredprivatehospitalsonly

3.Whatisthisschemeabout

HospitalcansignanMOUwiththeDistrictHealthOfficeiffollowingcriterionismet.RecognizedPrivateHospitalsarereimbursedanamountofRs.3.00lakhandrecognizedGovernmentInstitutionswillgetanamountofRs.1.5lakhforevery100deliveriesconductedintheirinstitutionsincludingsurgeries.• Shouldhavemin10Inpatientsbeds• ShouldhavefunctionalOperationtheaterandDeliveryRoom• 24hoursavailabilityofgynecologists,pediatriciansandanesthetists• Shouldhavelinkswithbloodbank

4.Howtoobtainit Itcanbeobtainedatprivatehospitals,whichareregisteredunderTayiBhagyaScheme.TayiBhagyaPlus1.Aim Pregnantwomeninruralareastogetfinancialincentivesfordeliveringinregistered

privatehospitals2.Eligibility MustbelongtoBPLfamily3.Whatisthisschemeabout

Rs1000ondeliveryatregisteredprivatehospitals

4.Howtoobtainit Itcanbeobtainedatprivatehospitalswhichareregisteredunderthescheme(cannotavailJSYifthisschemeavailed)

NaguMagu1.Aim Aimistotransporthemotherandchildafterdeliveryfromthehospitaltotheirhomein

ordertopreventinfection2.Eligibility • MustbelongtoBPLfamily

• Mothershouldbeinhospitalfor48hoursafterdelivery3.Whatisthisschemeabout

Eachtalukwillhaveonevehicleforthispurposeexclusivelytodropoffmotherandchildwithin45kmsradiusatnochargestothebeneficiaries

4.Howtoobtainit Themothershouldhavedeliveredinaninstitution.InChamarajanagar,talukanddistricthospitalsonly

108ambulance1.Aim Emergencyresponsetotheneedy2.Eligibility Anybodyinthestateofemergency3.Whatisthisschemeabout

Freeambulanceservicefromthespotofemergencytotheinstituteforappropriatecare.

4.Howtoobtainit Call108fromyourphoneExplaintheemergencyoverphoneRespondtothequestions

AnnexureII

FormatforGPSlocationandfacilityleveldatacollectionUnique

IDServiceprovidername

Lat Long Taluk Typeofprovider*

Levelofservice*

Typeofmaternalhealthservicesprovided*

Visitedbytribal

women*

Legend:Typeofprovider1=Government2=Private3=Traditional4=NotqualifiedLevelofservice(forgovernmentheathcentersonly)0=NA1=Sub-center2=PHC3=Communityhealthcenter4=Talukhospital5=DistricthospitalTypeofmaternalhealthservicesprovided1=Antenataland/orpostnatalcheckup2=Normaldeliveries3=Operations(Caesariansections)4=SeriouscomplicationsVisitedbytribalwomen1=Yes2=No

AnnexureIII

ListofstakeholdersidentifiedinthedistrictSector Category Actorsincluded Reasonchosen/relationtopolicy

Governmenthealthdepartment

Districthealthteam

Districthealthofficer,reproductiveandchildhealthofficer,programofficers

• Technicalsupportforoperationalizationoftheprogram

• Programmanagementandstatistics• Responsibleforimplementationandsupervisionof

RMNCH+A• Financialmanagementofprogram

Community Districtadministrators

Districtcommissioner,panchayatpresidentandmembers,chiefexecutiveofficer

• Partofdistricthealthsociety-staff,financing,decisionmaking

• Monitordistricthealthsocietyfunctioning• Participateinmaternaldeathaudits• Workwithalldepartmentsbeyondhealth

Communitybasedorganizations

ZillaBudakattuGirijanaAbhivrudhhiSanghaSelf-helpgroups

• Advocateonbehalfofthecommunityfortheirentitlementsincludingschemes

• Communicatewithallvillagesabouttheirentitlements/schemes

• Experienceofworkwiththecommunityonforestrightsandotherwelfareschemes

• MandateisdevelopmentofindigenouscommunitiesOthergovernmentdepartments

Socialwelfaredepartment

TribalWelfareOfficer

• Responsibleformonitoringoveralltribalwelfareinthedistrict

• Havesomefinancialallocationforschemesincludinghealth

Forestdepartment

Conservatorforests

• Responsibleforimplementingrestrictionsinforest/tigerreserveswheremosttribalcommunitiesreside

• KeyactorwhendiscussingissueswithphysicalaccessGovernmenthealthdepartment

TalukhospitalsCommunityhealthcenters

Administrativemedicalofficers,OB.specialists

• Providespecialistservicesforcomplicationsandoperations

• Responsibleforsecondaryhospitalservicesinagiventaluk

Taluklevel TalukHealthOfficers

• Provideadministrativeandoperationalinformationaboutavailability,accessandutilizationofservicesbytribalwomenattaluklevel

• SuperviseandmonitorfunctioningoftribalPHCs,sub-centersandreporting

• Workwithtalukpanchayatandotheractorsattaluklevel

PrivateHealthProviders

Private-for-profithospitals

Detailedlistavailable

Providematernalhealthservicesfortribalwomen

Non

Governmental

Organizations

NGOhospitals

NGOsthatwork

forhealth

• Providehealthservicesfortribalwomen

• UndertakePublicPrivatepartnershipsforservice

delivery

• Alsorunprogramonsocialwelfareforcommunities

• Havegoodrapportandunderstandingoflocal

communities

Governmenthealthdepartment

PHC(Medical

Officers)

26PHCsand

tribalmobile

healthunit

• Responsibleforsafematernalhealthservicesfor

indigenouscommunitiesincatchmentarea

• Superviseandmonitoroutreachservices

• Superviseandinvestigateproblems,complications

anddeaths

ANMs(atSC) Detailedlist • Providecommunitylevelmaternalhealthservices

• Keyinformantforhealtheducationonsafepractices

andalsogovernmentprocessesandschemes

• Provideregularantenatalandpostnatalservicestoall

womeninareaandresponsibleforfollowupathome

• Incaseofhomedeliveries,expectedtoconductand

follow-upallcases

Community ASHA • Providevillagelevelmaternalhealtheducationand

informationonrelevantservicesandschemes

• LinkwithANMsoexpectedtoreportanyissues,

problemsandallrelevantdataregularlytothem

• Helpcounselwomenaboutsafehealthanddelivery

practices

• Helporganizetransportfordeliveriesand

emergenciesandaccompanywomentohealth

centers.

Othergovernmentdepartments

Womenand

Child

development

department

Child

Development

ProjectOfficer,

Anganwadiworkerineach

village

• Providenutritiontopregnantwomen

• Interactregularlywithpregnantandnewmothersin

thecommunityasasourceofhealtheducation

Researchersandacademiciansworkingwiththesecommunitiesoronaccesstomaternalhealthservices

AnnexureIV

Maternalhealthinnovation/interventioncasestudyformat1

1AdaptedfromHealthSystemsPolicyReformsOptionsDatabase(CentralBureauofHealthIntelligence,

GovernmentofIndia);Good,ReplicableAndInnovativePractices-NHSRCCoffeeTableBook,2015

(NationalHealthSystemsResourceCentre,GovernmentofIndia)andInnovationsinmaternalhealth:Case

studiesfromIndia(SAGEpublications).

Title Titleoftheinnovation

Category Maternal,neonatal,childhealthoracrossall

Typeofinnovation Informationsystems,technological,organisation,policy(sub-

category)-couldconsiderothersub-categorieslikedirectlyaddressingMCHissuesorindirectorgeneralhealthsystemreform,etc–definitionsandexamplesprovidedforeachsub-category

Backgroundofthe

innovation/programme

Givesbackgroundofwheretheinnovationwasdevelopedandimplemented,bywhom,where,whenandforwhatduration

Problemstatement Givesthebackgroundoftheproblem(maternal,neonatalorchildhealthrelated)addressedbytheinnovation/programusingkeydata&figuresavailable–explainstherationalebehindtheemergenceandrelevanceoftheinnovation

Describetheimplementationsettingandpolicy/localenvironmentwithinwhichthisinnovationis(tobe)implemented

Programmedescription Detaileddescriptionoftheinnovation–describingitsvariouscomponents,processofimplementation,involvedactors,levelofimplementationusingfiguresaspossible,expectedoutputsclearly

listedandexplained

Programmeoutcomes Pathwaystoimpact–possiblereasons/pathwaysthroughwhichthisprogrammeworks(orworked)toinfluencematernalorchildhealthoutcome

Impactofinnovationonmaternal,neonatalorchildhealthoutcomesbasedonevidencefromavailablestudiesandsecondarydatafromimplementers

Strengths Innovationtobeanalysedbasedon:

• scalability

• costing/financialinvestmentand

• potentialforintegrationwithexistinghealthservices/

programmesintermsoftechnology,protocols,etc

• relevancetogivencontext–strengthsorpointsinfavourlistedanddiscussedhere

Challenges Basedontheaboveanalysis–concerns,threats,limitationslistedanddiscussedhere

Additionalresources Usefulreferences(includingrelevantstudies,availableprogramorrelateddocuments,mediaifavailable)

WithinputsfromRoshniBabuandPrashanthNS,InstituteofPublicHealthBangalore.Thedocumentalsoincludesoriginaltextusedingoodfaithfromprimarysourcesmentioned/proponentsoftheseinnovations.Sourcesarehyperlinkedtointernetresources.

AnnexureV

Maternal,neonatalandchildhealthinnovationsinIndiaversion1dated14Dec2015

Listofinnovationsdividedintofourcategories:

1. Healthinformationsystems

IS1.MotherandChildTrackingsystemwithmobileintegration

IS2.Keyinformantsurveillancesystem

IS3.Maternalhealthreporter

IS4.Facilitybasednewborncaredatabase

2. Technologicalinnovations

TE1.Homebasedneonatalcare

TE2.Coldtrace–lowcostvaccinetemperaturesensorandinformationsystem

TE3.Logistimo–logisticsmanagementinformationsystem

TE4.ComprehensivePrimaryHealthManagementusinginformationcommunicationtechnology

TE5.Suyojana:Mobiledecisionsupportapplication

TE6.SickNewbornCareUnit

TE7.Embracewarmers

TE8.MobileVaani-maternalhealthcampaign

3. Organisationalinnovations

OR1.AccreditedSocialHealthActivist

OR2.Adolescentfriendlyhealthclinics

OR3.ComprehensiveEmergencyObstetricandNeonatalCarecenters

OR4.Secondauxiliarynursemidwifeatsub-centerinselectareas

OR5.ArogyaBandhuProgram

OR6.SkilllabsinBihar

OR7.MamtaGhar-birthwaitinghome

4. Policylevelinnovations

PO1.RMNCHAplusstrategy

POD.Maternaldeathaudit

PO3.Chiranjeevihealthscheme

PO4.Jananisurakshayojana-conditionalcashtransferforinstitutionaldelivery

PO5.MadiluKit(Babybox)

PO6.Transportationformotherandchildforusinghealthservices

PO7.Othercashbenefitschemesforexpectantmothers

PO8.Antenatalclinicintegratedwithyogaandnaturopathy

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InformationSystemsIdno. IS1Title MotherandChildTrackingSystem(MCTS)withmobileintegration

MNCH Maternal,neonatalandchildhealth(underfive)

Category InformationSystemsState(scaleofimplementation)

Karnatakafocusbutweb-basedMCTSinallofIndia(underNRHM)

Implementer GovernmentofKarnataka(underNationalRuralHealthMission)Year 2009onwardsDescriptionoftheinnovation

Awebenabledname-basedtrackingsystemwhichaimstotrackeverypregnantwomanonceregisteredforantenatalcarethroughdeliveryandpostnatalperiodtillthechildisatleastthreeyearsofage-therebyaimingtoassureservicedeliveryforantenatal,intranatal,postnatal,neonatalcare,growthmonitoringandimmunisationservicestothemotherandchild.InKarnataka,MCTSwascustomisedwithmobileintegration.Thissystemtriestotrackmotherandchildacrossvillageswithinthestateandreachesouttofamiliesofthebeneficiariesviamobilephonesandinteractivevoiceresponsesystem.Anexpectantmotherisissuedathayi(mother)cardwhichcarriesauniquebarcodewiththebasisofwhichalldatarelatedtothemotherandchildisintegratedtoonerecordleadingtocomprehensiveheathcarewithcontinutyofcareirrespectiveofplace.

Strengths *areawisereporting(unlikefacilitybasedforroutinesystems)*evenifwomanmovesfromoneareatoanother,thedataiscaptured*facilitatesworkoffrontlinehealthworkersinfollowingupbeneficiariesandreducesdataentrywork,andgivesthemaworkplanforeachbeneficiary*facilitateshealthmanagersatalllevelsfromdistricttonationalleveltobetterplan,implementandmonitorserviceseffecivelybasedonrealtimereporting.

Challenges *doesnotcaptureprivatesectordata,hence*lowercoveragewhencomparedtoroutinehealthmanagementinformationsystems*possibleunderestimationinurbanareas

Furtherinformation

AcomparisonbetweenHMISandMCTSdataonMCHindicatorsinselecttwodistrictsofKarnataka

MotherandChildTrackingSystem(MCTS)withmobileintegrationinKarnataka

StrengtheningandScale-UpofNationwideMother&ChildTrackingSystem(MCTS)-Examples.

AwardedtheTop11in2011InnovatorschallengeawardinstitutedbyRockefellerfoundationandm-HealthAlliance,USA

Idno. IS2

Title Keyinformantsurveillancesystem

MNCH Maternalhealthfromantenataltopostnatalperiod

Category InformationSystems

State(scaleofimplementation)

ThreedistrictsinstatesofOdisha(1)andJharkhand(2)

Implementer Ekjut,aNGOworkinginJharkhandandOdisha

Year 2006onwards

Descriptionoftheinnovation

Implementedindistrictswithpoorroutinebirthanddeathregistrationsystem.Firstidentificationstage-wherekeyinformanst(mainlytraditionalbirthattendants)identifiedtofurtheridentifyallbirthsanddeathsofwomeninresproductiveagegroupwithminimalfinancialincentives.Nextintheinterviewingstage,onefulltimeinterviewerforeachclusterwouldverifyinformationprovidedbykeyinformants,andinterviewallmothersaftertheirpostpartumperiod.Theythenattempttoverifyifadeathwasmetrnalornotbyinterviewingrelativesofthedeceased.Onemonitoringsupervisorperdistrictensuredsurviellance.Ifamaternaldeath,thenverbalautopsyconductedwithimmediaterelativesandalsowithhealthprovidersbasedoncooperation.Verbalautopsiesthenreviewedindependentlybytwolocalobstetricians.

Strengths *lowcostintervention(costsreportedindetailforallstagesinthewriteup)*couldbeusedtomonitortrendsinoutcomes-maternalandneonatal*canbeusedtomeasureimpactofvariousinterventionsinareaswithpoorroutinedata*helpfulforevidencebaseddecisionmaking*appropriatefortribalcommunitiesinIndia-whereroutinedataislacking

Challenges *similartoanymethodofmeasuringmaternalmortality-chancesoffalsepositiveshigh*limitationsofverbalautopsyapply

Furtherinformation

Innovationsinmaternalhealth:CasestudiesfromIndia-Bookavailableonline

Aprospectivekeyinformantsurveillancesystem-writeupinBMCPregnancyandChildbirth

Idno. IS3

Title Maternalhealthreporter

MNCH Maternalandneonatalchildhealth



Ahmednagardistrict,Maharashtra

3

Implementer Globalhealthbridge(GHB)withComprehensiveRuralHealthProject,Jamked

Year 2011


Amobile-basedhealthinformationsystemthatfacilitatesfrontlinehealthworkerstoprovidecontinuouscareandfollowupofbeneficiaries.Dataonmaternalhealthcollectedoncellphones,storeandgetdataviaSMS,andreceivetimelyremindersforeachbeneficiary.

Strengths *allowshealthworkerstofocusonseeingtheirbeneficiariesbymakingdatacollectionandfollowupstreamlined,*improvedqualityofdatacollection*enablessupervisionofhealthworkersandmonitoringofdata*nearuniversalavailabilityofmobilephonesinthecountrymakesitafavourabletechnologytohelpimproveinformationsystems

Challenges *integrationtoexistinghealthinformationsystemsnotclear*costinginformationandneededtechnologynotclearbasedondataavailable

Furtherinformation

Healthmarketinnovationswebsitewriteup

FinalistattheHarvardSocialEnterpriseConference"PitchforChange"Competition.

Co-winnersofthePrincetonEntrepreneurs'NetworkofBostonSocialEnterprisePitchCompetition.

Idno. IS4

Title Facilitybasednewborncaredatabase

MNCH Neonatalchildhealth



MadhyaPradeshinitially,nowacrosscountry

Implementer GovernmentofMadhyaPradeshwithUNICEF

Year pilotedin2011,scaledupinstatein2012,2013adoptedbyGovernmentofIndiaacrosscountry


Duetohighmortalityrateofinfantsaftertheyleavethesixknewborncareunit(SNCU)andwithinthefirstyear,aSMStrackingsystemutilizedinstateofMadhyaPradesh.OnlinedatamanagementandfollowuptrackingsystemusedinSNCUsfordataentryandanalysis.FollowupbyanautomatedSMSsystem,containsrepositoryofrelevantguidelinesandtrainingmaterial.Systemusedtotrackchildrenpostdischargeandensuretimleycheckupsirrespectiveofwheretheyareininfancy.

Strengths *healthofat-risknewbornscloselymonitoredtillchildisoneyearofage-therebyallowingbetterhealthoutcomes*favourablyadoptedbyGovernmentofIndiaandintegratedintoSNCUapproachacrosscountry*monitoringcellatstateandnationallevels

Challenges *needsimultaneousinvestmentsinalllevelsofcare-asitisareferralsystemsohealthoutcomesdependentonhowalltiers-fromcommunityhealthworkerstoPHCstoreferralhospitals

Furtherinformation

Bestpracticedocumentationinnationalhealthmission,MadhyaPradesh

BestuseofICTfore-GovernanceawardbyMadhyaPradeshITteam

TechnologicalinnovationsIdno. TE1

Title Homebasedneonatalcare(HBNC)

MNCH Neonatalhealth

Category Technological


PilotedinGadchiroli,Maharashtra.NowupscaledtoentirecountryunderNationalRuralHealthMission

Implementer SEARCH(NGOinGadchiroli,Maharashtra)andnowbyStatehealthdepartmentsunderNRHM

Year 2011onwards(country)


Significantproportionsofhomedeliveriesnotconductedbyskilledbirthattendants,andrealityofmothersreturninghomefewhoursafterdeliveryacrossdifferentstatesofIndia,broughtinthisstrategytocomplementtheongoingpushforinstitutionaldelivery.HBNCincludescarefornewbornbyASHAthroughaseriesoffrequentvisists,educationtomotherabouthealthypractices,newbornexaminationineachvisit,additionalvisitsforatriskneonates,earlyidentificationofillneess,followupofsickneonates,andcounsellingforpostnatalmotheronpostnatalcareandadoptionoffamilywelfaremethods

Strengths *additionalsupporttofamilytoensurehealthpractices*provisionofessentialnewborncareathomeitselfespecially*earlydetectionandreferralofillnesses*appropriateespeciallyforareasorcommunitieswithrelativelypooraccesstohealthservices*implementationatGadchirolifollowedbymultiplestudiesevaluatingstrategywithpositiveresults

Challenges *effectiveatsmallscaleintribalcommunities-effectivenessofstrategyafterupscalingnotknownyet*practiceofcommunityhealthvolunteersprovidinginjectablescriticisedbyasectionofmedicalprofessionals

4

Furtherinformation

HomebasedneonatalcareguidelinesNRHM

Homebasednewborncare:howeffectiveandfeasible?

Effectofhome-basedneonatalcareandmanagementofsepsisonneonatalmortality

Idno. TE2Title ColdTrace

MNCH ChildhealthCategory TechnologicalState(scaleofimplementation)

10sitesinIndia(alsoKenya(50),Mozambique(100),Indonesia,PhilipinesandLaos(12))

Implementer NexleafAnalyticsYear NADescriptionoftheinnovation

ColdTraceisalowcostwirelesssensorthatallowsremotetemperaturemonitoringsystemforvaccinesstorageandtransport.Itallowsthedatatomanageedataglobaldatabasetofacilitatedecisionmakingbygovernments,clinicsandotherglobalpartners.Onceinstalled,itgeneratesSMSmessagesandPDFreportsthatcanbecustomizedandtargetedtosupportdecisionsattheclinicandsupervisorylevels.Itincludesaweb-accessibledashboardthatprovidesaccesstonear-real-timeaswellashistoricviewsofdatasyncedfromthedevice.

Strengths *helpsstengthencoldchainespeciallyinareaswithlimitedresources*canbeintegratedwithexistingmanagementinformationsystems*helpsstreamlineclosemonitoringandtherebyhelpsensurequalityofvaccines*useslowcosttechnologybeingfurtherdevelopedindifferentlowandmiddleincomecountries*organisationpartnerswithmultipleinternationalhealthagenciesandTERIinIndia,andNGOsatgrassrootlevel

Challenges *noclearinformationonoverallcostsandtechnologyrequirementsFurtherinformation

WriteupontheNexleafwebsite

Idno. TE3Title Logistimo

MNCH Maternal,neonatalandchildhealthCategory TechnologicalState(scaleofimplementation)

across65KarunaTrustPHCsin5statesofIndia

Implementer Logistimo,KarunaTrust(NGO),Bill&MelindaGatesfoundation,GovernmentofKarnataka

Year 2012onwardsDescriptionoftheinnovation

Thismobileandweb-basedplatformallowsrealtimevisibilityofstocks,consumptionanddemandsatallhealthcentres,logisticalagilityviabettercoordinationbetweenthecentralhealthofficer,supervisors,pharmacistsandthefrontlinehealthworkers.Thisismainlypossiblebasedonsimpledataentryusingabasicmobilephonebyahealthworkerorpharmacistintheperiphery,withreal-timedataattheheadquartersallowingfortimelyavailabilityofessentialmedicinesandvaccinesatthepointofcare

Strengths *sincebeenimplementedingovernmentPHCssocanbeeasilyupscaledandintegratedinexistinggovernmenthealthservices*wasadaptedacross5statessoreflectsflexibilityandadapatabilityofprogramme*recognisedbyGovernmentofKarnataka

Challenges *evaluationstudiesnotavailableforcriticalreflectionFurtherinformation

LogistimoandKarunaTrustcollaboration

WinnerofbestpracticeawardbyGovernmentofArunachalPradesh

Idno. TE4

Title ComprehensivePrimaryHealthManagementusinginformationcommunicationtechnology

MNCH Maternal,neonatalandchildhealth



GumballiPHC,Karnataka,India

Implementer KarunaTrustinpartnershipwithEMC2

Year 2015onwards


TheComprehensivePrimaryHealthinformationcommunicationtechnologyprogramaimstoconnectcitizens,healthworkers,caregiversanddecision-makersinasingle,integratedplatform.Itenablesthedeliveryofpreventive,promotiveandcurativehealthatindividualandcommunitylevelby

5

comprehensivelyaddressingalldiseasesandconditionsincludingreproductive,maternal,andadolescentandchildhealth,schoolhealthandnutrition,communicableandnon-communicablediseases,publichealthandfacilitymanagement.Consistsofcomprehensivesoftwaremadeavailableusingabasicandroidtabletwiththecommunityhealthworkers.Dataentryisatthelevelofhouseholdtherebyallowingindividualleveldetailstobeentered.Itallowsforexistingreportscomprisingofcommunityleveldataonspecificdiseasesandservicecoveragetobegeneratedattheclickofabutton.Initialbaselinesurveyneededtoenterone-timebackgroundcharacteristics.Simpletouseandcomplianttoexistinggovernmentnationalhealthmissionguidelines.CurrentlybeingpilotedinaPHCinsouthIndia.Theplatformincludesinformationonbasicsocio-economicparameters,safewaterandsanitationstatus,individualmemberdetails,relevantclinicalhistoryincludingpregnancyandchildfocusedinformation,non-communicablediseasesandmentalhealthrelevantparameters.

Strengths *Helpsconvertexisting22manualregistersintoasingleintegratedplatform*allowscommunityhealthworkerstofocusonprovidingcareinsteadofspendingtimeonreporting*allowshealthcareproviderstogaincomprehensiveinformationforpatientsgiventhelackofsuchsystemsinIndiaespeciallyruralIndia*allowscomprehensiveanalysisofhealthstatusofthecommunityandtherebydatadrivendecisionmaking*beingpilotedandadaptedingovernmentPHCsosuitableforintegrationintoexistinghealthsystem-compliantwithnationalhealthmissionguidelines*allowsdatatoportedonlineratherthanpaperregisters

Challenges *Stillinpilotstage*Issuesofconfidentialityandsecurityofdatanotclear*needssmartphonetechnology

Furtherinformation

AvailableatKarunaTrust,Bangalore,India

Idno. TE5

Title Suyojana:Mobiledecisionsupportapplication

MNCH Maternalandneonatalhealth



GumballiPHC,Karnataka,India

Implementer Dtree(internationalNGO),SwasthiandKarunaTrust(IndianNGOs)

Year 2014


Amobile-basedm-Healthapplicationthatcreatedclinicalalgorithms(decisiontrees)thatrunsoncellphonesforhealthworkersinlow-incomecountries.Ithasbeenprimarilyimplementedwithpregnantwomenandhealthworkersatprimaryhealthcentersinordertointroduceamobile-basedsystemtoimproveprocessesandbuildaneco-systemtomotivatewomentodeliveratprimaryhealthcenter.ThiswasjointlydevelopedbyD-treeatechnologycompanyandSwasti,ahealthresourcecenter,andpilotedbyKarunaTrustinagovernmentPHC.Mobileapplicationdevelopedbasedonexistingnationalguidelines,providesANMswithquestion-by-questionguidetoassistexpectantmotherstohelpidentifyanyissueandproviderelevantrecommendations.Itallowstrackingofbeneficiariesprovidinginformationonnextappointments,referralsandbothhomeandhealthcentervisits.Applicationincludesregistration,antenatalhistoryandexamination,neonatalandmother'scareduringdelivery,dangersigns,pre-referralmanagementandhomebasednewborncarecounseling.Supervisorscanmonitorthecareattheperipheryviatheserver.Canalsogenerateneededmonthlyreportswithexistingdata

Strengths *Developedaroundexistingworkresponsibilitiesoffemalehealthworkersandusingexistingnationalprogramguidelines*focusesonmaternalhealthfrompregnancytopostdelivery*allowsfortransparencyindecisionmaking*potentialtoreducemorbidityandmortalityrelatedtopregnancyanddelivery*runsoffline

Challenges *IntegrationwithexistingHMISnotclear*potentialtoexpandbeyondmaternalhealthnotclear*resultsofpilotnotclear*needssmartphonetechnology*currentlyfocusesmoreonclinicalcareduringpregnancyanddelivery

Furtherinformation

Write-uponSwasthiwebsite

FinalistforawardbyVodafonegoodmobilehealthawards

Idno. TE6

Title SickNewbornCareUnit

MNCH Neonatalhealth



India

Implementer UNDP,NRHM(Stategovernmentshealthdepartmentsacrosscountry),NorwayIndiaPartnershipInitiative(NIPI)insomestates

Year


SNCUincludes-controlledenvironment,individualwarmingandclosemonitoringdevices,intravenousfluidandmedicationsbyinfusionpump,centraloxygen,oxygengenerators,bedsideproceduresandin-housesidelaboratoryservice,andfollowupclinics.TheNRHMhasconsentedtodevelopaSNCUineverydistrictofthenation.IndifferentstatestheSNCUmodelhasbeenfurtherbuiltuponwithadditional

6

innovationslikewithNIPIin4states-additionalemergencyandtriagearea,neonatalwardandstepdownunits;inKolkata-theconceptofnewbornaides(speciallytrainedfemalevolunteers)forhousekeepinginSNCU

Strengths *Basedonnationalguidelinesandintegratedintoexistinghealthsystem*initialevaluationsreportpositiveimpactonbringingdownneonatalmortality*potentialtobefurtherimprovedasseenfromvariousadaptations

Challenges *Whilepositivecasestudiesreported,challengesofupscalingthisreported(seedetailsinreference)

Furtherinformation

SNCUwrite-upbyNIPI

ImpactofadistrictlevelSNCUonneonatalmortalityrate:a2yearfollowup

Newbornaides:aninnovativeapproachinsicknewborncareatadistrictlevelspecialcareunit

ChallengesinscalingupofSNCU:lessonsfromIndia

Idno. TE7

Title Embracewarmers

MNCH Neonatalandchildhealth



SelectareasinKarnataka--alsoworkinHaiti,Ghana,Benin,Nepal,China,Myanmar,Zambia,Mozambique,EastTimor,Philippines

Implementer Embrace,Thrivenetworks-InIndiawithprivatehospitalinBangalore,KarunatrustinPHCs

Year 2009onwards


Embraceinfantwarmerisaninsulatedwrapproposedforlowresourcesettingsasanalternatetotheexpensivetraditionalfixedincubatoradoptingtheprincipleofkangaroomothercare.Trainedcaregiversinahospitalsettingcanuseembracenestinfantwarmerwhileanon-electricversioncanbeusedinhomesaswell.ThekeyfeaturesoftheEmbraceNestinfantwarmerinclude:SpecialphasechangematerialinWarmPakmaintainsatemperatureof~37°Cforatleast4hours;DoesnotrequireaconstantsupplyofelectricityPortableforin-clinicortransportusage;Reusableandeasytosanitizeandreuse;Enablesmother-to-childbonding.SofartheinfantwarmershavebeendonatedforfreethroughpartnershipswithlocalNGOs,provideholisticmaternalandchildhealthandevaluatethewarmer'simpact.Comprehensiveprogramassociatedwithproductwitheducation,training,monitoringandevaluation

Strengths *Appropriateforlowresourcesettings

Challenges *Independentcostingandevaluationstudiesnotyetfound*projectedcostsofabout200USDperwarmerishighfor

Furtherinformation

Embracewebsite

TheEconomistawardedEmbrace-2013EconomistinnovationawardinthecategoryofsocialandeconomicinnovationAwardedTheTechAwardsLaureateImpactAwardfor2015.

Idno. TE8

Title MobileVaani-maternalhealthcampaign




6Indianstates-Utarakhand,MadhyaPradesh,Odisha,UttarPradesh,Bihar,Jharkhand

Implementer Gramvaaniteam,India

Year 2009


MobileVaaniisproposedtobelikeasocialmediaplatformforruralusers.IthasabuiltinIVRSsystemthatallowspeopletocallintoanumberandleaveamessageabouttheircommunityorlistentomessagesleftbyothers.Issuesdiscussedrangefromlocalupdatesandannouncements,governmentschemes,andinformationsharing.Thisisaccompaniedbyavillageradionetworkingsystem(GRINS)anintegratedsoftwaresolutionforrunningacommunityradiostationthatallowsprogramschedulingandplay-out,fulltelephonyandSMSintegration,Internetstreaming,contentmanagementandstatisticalanalysisofplay-outhistory.Amaternalhealthcampaignwasconductedusingmobilevaaniandthreecommunityradiostations.Thiscampaignwasaimednotonlyatprovidinginformationtothelistenersaboutmaternalhealth,butalsotoinitiateadiscussionamongthemandseektheiropinionontheissue.Thecampaignwasspreadoveratimespanofeightweeksandasperthecontentplan,thefirstandthelastweekswerededicatedtoconductsurveystounderstandtheprevailingawarenessandperceptionsaboutissuesrelatedtomaternalhealthandassessanychangeinthebehavioroftherespondentsbytheendofthecampaign.Moredetailsaboutthecampaignavailablebelow.Thisforumaimstoprovideequitableaccesstocommunitymediaforumstoenablesocialchange.

Strengths *Helpsbridgecommunicationgap*useswidelyprevalentradioandmediatechnology*varietyofissues

7

canbetakenup*communityfocused

Challenges *Studiesevaluatingandcostinglacking

Furtherinformation

Maternalhealthcampaignusingmobilevaaniandcommunityradios

WinnersofmBillionthAwardSouthAsia2013

OrganizationalinnovationsIdno. OR1

Title AccreditedSocialHealthActivist


Category Organisational


India

Implementer NRHM

Year 2005


InspiredbytheMitaninprogramme,ASHAisaprogramofgrassrootsworkersunderNRHM(NationalRuralHealthMission),thelargesthealthcareprogramoftheGovernmentofIndiawhichstartedintheyear2005.ASHAarefemalehealthactivistsinthecommunitywhocreatesawarenessonhealthanditssocialdeterminantsandmobilizesthecommunitytowardslocalhealthplanningandincreasedaccountabilityoftheexistinghealthservices.The8factorsidentifiedbytheGovernmentofIndiacriticalforthesuccessofASHAare1.SelectionofASHAbyaprescribedprocessaspertheASHAguidelines.2.Linkagewithnearestfunctionalhealthfacilityforreferralservices.3.Identifiedtransportforreferralofcasesfromvillagetofacility.4.PriorityandrecognitionofcasesreferredbyASHAtoMO/ANM.5.SuccessfulorganizationofmonthlyVillageHealthSanitationandNutritionCommittee(VHSNC)andVillageHealthSanitationandNutritionDay(VHSND)ineveryvillagewiththeANM(AuxiliaryNurseMidwife)andAWW(Anganwadiworker).AnganwadiisthebasicunitofGovt.ofIndiaICDS(IntegratedChildDevelopmentScheme)6.MonthlymeetingofASHAatPHC.7.TimelypaymentofincentivestoASHA.8.TimelyreplenishmentofASHAKit.-whichcontains13Items

Strengths *linkbetweencommunityandhealthworkers*Studiesshowsignificantcontributiontoimprovingmaternalandhealthoutcomes

Challenges *roleassocialactivistlimited*worksmainlyasassistanttofemalehealthworker

Furtherinformation

IMPROVINGTHEPERFORMANCEOFACCREDITEDSOCIALHEALTHACTIVISTSININDIA

EvaluationofASHAprogrammeinKarnatakaunderNRHM

EvaluationofASHAintribalblocksofIndia

Idno. OR2

Title Adolescentfriendlyhealthclinics

MNCH Maternalhealth



India

Implementer NRHM

Year withNRHM


Named'Sneha','Maitri','Udaan'etc.invariousstatesisanotherinitiatveoftheNRHMtoprovidecounsellingandcurativeservicesprovidedtoadolescentsatprimary,secondaryandtertiarylevelsofcareonfixeddaysandfixedtimewithduereferrallinkages.CommoditiessuchasIron&FolicAcidtabletsandnon-clinicalcontraceptivesarealsomadeavailableintheclinicsfortheadolescents.Counsellingonnutrition,menstrualdisorders,personalhygiene,menstrualhygiene,useofsanitarynapkins,useofcontraceptives,sexualconcerns,depression,sexualabuse,genderviolence,substancemisuseandpromotinghealthybehaviortopreventnoncommunicablediseases.

Strengths *importancegivenunderRMNCHAplusprogramme*helppreparewomenforpregnancyanditscomplications*partoflifecycleapproach*integratedwithexistinggovernmenthealthsystem

Challenges *stillininfancyofimplementation*narrowfocusonreproductiveandsexualhealth*whileimportancerecognised,yettobetailoredtobeadolescentfriendly*notafeltneedinmostcommunities

Furtherinformation

ADFCwriteuponNRHMwebsite

EditorialonAdolescentsecualandreproductivehealth

8

Idno. OR3

Title ComprehensiveEmergencyObstetricandNeonatalCarecentres




StartedinTamilNadu,nowadoptedbyotherstatesaswell

Implementer GovernmentofTamilNadu

Year 2004


TheCEmONCCentreisequippedwithboththemanpowerandtheinfrastructurerequiredtocareforthemotherandthenewborn.Roundtheclock,thecentrehasObstetricians,Paediatricians,Doctors,StaffNurses,labtechnicians,andsupportstaffondutyandAnesthetistsoncall.Intensiveinputswereprovided,intermsoftrainingandphysicalinfrastructure,toensurequalitycare.Around508doctorsand562nursespositionshavebeensanctionedandpostedexclusivelyforCEmONCservicesinadditiontotheexistingdoctorsandnurses.Thecentreisequippedwithafullyfunctionalmaternityblock,includingalabourward,operationtheatre,bloodbank/storageunit,newbornward,newbornintensivecareunit(NICU)andisolationward.

Strengths *CEmONCaddressesissuesofemergenciesandreferral*adoptedbyotherstatesaswelltoday*comprehensiveinapproachbothwithequipment,guidelinesandcapacitybuilding

Challenges *additionalchallengesofHR,costs,infrastructure

Furtherinformation

WriteuponTamilNaduHealthSystemsProjectwebsite

Healthsectorpolicyreformoptionsdatabase

Idno. OR4

Title Secondauxilarynursemidwifeatsub-centreinselectareas




PilotedinKarnatakaCdistricts,ArunachalPradesh,

Implementer GovernmentofKarnatakainthestate,KarunaTrust,ArunachalPradesh;

Year 2012


2ANMsineveryvillageinnorth-easternstates:Duetoweatherconditions,lackofproperaccessibility,scatterednatureandremotenessofhabitablevillagesinnorth-easternstatesnadCategoryCdistricts,itisdifficulttohaveoneANMcateringtoavillage.So,asystemoftwoANMspervillagewasemployedwherebothprovidedthemuchneededsupportnotonlyinwork,butalsoinhousing,livingandcaringforthesickinvillageandeachother.Responsibilitiesclearlydemarcatedforeach.Focusonprovidingqualityservicestobeneficiariespossibleespeciallyinareaswithdifficultyinaccess

Strengths *suitedfordifficulttoaccessorvulnerableareas*solidarityandbetterretentionofstaff*givenshortageofdoctors,supplementsprovisionofqualitymaternalhealthservices

Challenges *availabilityofhumanresourceandbudget

Furtherinformation

Nofurtherinformationoncurrentimplementationorpilotavailable

CaseforinnovationmadeinreportsubmittedinKarnataka

Idno. OR5

Title ArogyaBandhuProgramme




Karnataka

Implementer GovernmentofKarnataka,medicalcolleges,NGOs

Year 2008


Karnatakaisapioneerofinnovativeschemesinmanyspheresincludinghealth.Onesuchinnovativeschemeis‘ArogyaBandhu’aPublic–Private–Partnership(PPP)launchedinJuly2008.ThePrivateMedicalColleges,NonGovernmentalOrganisations(NGOs),TrustsandothercharitableinstitutionsandPhilanthropicOrganisations,etc.,wereprovidedanopportunitytojoinhandswiththeGovernmentforprovidingbetterhealthcaretothecommunity.ThisisaKarnatakaHealthandFamilyWelfareSociety

9

fundedprojectundertheaegisofDirectorateofHealthandFamilyWelfare.PHCsselectedasunder:(a)

PHCslowinperformancei.e.,havinghighIMR&MMRandlowcoverageonimmunisationorlow

institutionaldelivery.(b)PHCswithmorenumberofvacanciesforlongduration.(c)C’categoryPHCswhich

aremorethan15kms.awayfromhighways.(d)TheproposalapprovedbytheDistrictHealthSocietyofthe

concernedDistrict.ThePHCswithabovesaidcriteriacanbegivenonPartnershipAgreement.Theinitial

contractforfiveyearswithclauseofrenewaleveryyearbasedonreviewofperformance.-thisschemenow

inexistencefornearlyadecade-hasshownmixedresultswithsomepositivecasestudiesandsomefailed

relationships.InterestinglymanystatesarenowtakingthisupwithNGOs.

Strengths *communitiesinareawithpoorhealthservicesgetaccesstoqualitymaternalhealthservices*beingtaken

upinselectdistrictsorareasbyotherstatesaswell*CasestudyofPPPinnortheaststatesshownsignificant

successintermsofprovisionofqualityservicesandimprovementinoverallindicators*temporarysolution

forlongtermproblemsofhumanresource

Challenges *Monitoringandgovernancebydistrictheathauthoritiescrucialgivenoutsourcingofpublicservicesto

privateentities*alignmentofagendasofprivateentitieswithgovernment'smandateiskey*notenough

studiesevaluatingthismodel*largerissuesofhumanresourceshortagesandinadequateresourcesremain

Further

information

ProposalforArogyaBandhu

OnecasestudyinKarnatakaonPPPatPHClevel

Idno. OR6

Title SkilllabsinBihar



State(scaleof

implementation)

Bihar

Implementer GovernmentofBiharwithUNICEF

Year 2011

Descriptionofthe

innovation

SkillslabsinBiharareestablishedinBiharattwolevels;DistrictandBlocklevel.TheSkillslabatDistrict

levelwassupportedbyUNICEFandtheonesatBlocklevelaresupportedbyCareIndia.Thenumberofskill

stationsalsovariedamongthese.

Theskillslabatdistrictlevelisestablishedin6districtsandBlock/InstitutionallevelSkillslabarelocated

in32institutionsin8districts.EachDistrictSkillLabconsistsof30skillstations-10pertainingto

obstetrics,15newborn&childhealthand5pertainingtoinfectioncontrolpractices,arrangedinaspaceof

1500sq.ft.Thetrainingprogramisconductedthroughathree-daymoduleforabatchof30.Onthefirstday,

afterintroductorysession,theexistingskills(andrelatedknowledge)ofeachtraineeisassessed,and

followingthis,supervisedpracticeafterdemonstrationatSkillstationsforeachtraineeisprovided.TheTOT

fortheSkillsLabtrainerswasheldinStateTrainingInstitute,TamilNadu.Thebatchoftrainers(24)

consistsofMedicaldoctorsandgraduatenurses.Thetrainer:traineeratiois5:1.Theposttraining

evaluationswereconductedinselectedskillstationsandlastsfor150minutes.

TheBlock/InstitutionalSkillslab,issetupina800sq.ftspace.TheSkillslabhasskillstations.Thetrainers

aregraduatenursestrainedatEVERONNInstitute,TamilNadu.Thistrainingisofferedatinstitutionallevel

andthetrainersaremobile.Trainingteamconsistsoftwotrainersandisallottedfourfacilitiesinadistrict.

TheyareprovidingtrainingtoallANMsandstaffnursesinahealthfacilityforaweek(oneoutofsix

modules)andthentrainersmovetonexthealthfacility.Afterthreeweekstrainersrevisitthefacilityand

assestheskillofANMsandGNMsandstartnextmodule.Presentably16mastertrainersareproviding

trainingin32Healthfacilities.In2012-13,sixtytwostaffnursesand127ANMsweretrainedatblock/

institutionallevelskillslab,andinthedistrictskillslab347doctorsand1555staffnurses/ANMswere

trained.Mobilementoringvisitshaveshown‘improvementinperformance’of80%inBhojpur,65%in

Rohtas,75%inKaimurand85%inNalanda(evaluationin4outof14districtsinwhichSkillslabislocated).

Strengths *focusonqualityofservices*improvementinskillsfordailyuse*relativelylowcost

Challenges *mentoringamustfollowingworkshop

Further

information

Nofurtherinformationoncurrentimplementationavailable

NationalHealthSystemsResourceCentreWebsite

Idno. OR7

Title MamtaGhar-birthwaitinghome



State(scaleof

implementation)

Gujarat

Implementer GovernmentofGujarat

Year 2011

10


AimtoIncreasetheutilizationofthehospitalbywomenfordeliveryandcare;Enablehigh-riskwomenorwomenfromremotetoaccessmedicalcareduringdeliveryperiod;Increasepercentageofwomendeliveredababywithtrainedprovidersathealthfacility.;Promoteearlyandexclusivebreastfeeding;Promoteminimum48hoursofPostPartumStayintheInstitutions.MamtaGharestablishedinareaswithhighriskbeneficiariesorremoteareas.MamtaGharoffers-antenatalservices,healthedcation,foodforbeneficiaryandattendant,childcareandambulanceservicesalongwithstayfor7-10daysnearendofpregnancy

Strengths *focusonqualityofservices*comprehensivecareprovided*maternitynolongerviewedasdisease*improvesrelationshipbetweenbeneficiaryandservices*focusonareaswithhighvulnerability

Challenges *additionalinfrastructureandhumanresources

Furtherinformation

Nofurtherinformationoncurrentimplementationavailable

NationalHealthSystemsResourceCentreWebsite

PolicyinnovationsIdno. PO1

Title RMNCHAplusstrategy


Category Policy


India

Implementer NRHM,UNICEF

Year 2013


ThenationalmissionmovedawayfromthefragmentedmaternalhealthapproachtoadoptingtheRMNCHAplusstrategyi.e.usingalifecycleapproachtosupportwomenandchildrenintermsoftheirhealth.Fivecategoriesofbeneficiariestargetedareneonates,children,adolescents,expectantmothersandwomenfortheirnutritionandreproductivechoices.

Strengths *intergenerationalimpact*comprehensiveandwholisticcare

Challenges *needtoshiftfromexistingfragmentedmedicalprogrammetocomprehensiveapproach*additionalresources

Furtherinformation RMNCHAplusstrategydocumentbyNRHM

Identificationno. PO2

Title Maternaldeathaudit

MNCH Maternalhealth

Category Policy


NRHMacrosscountry

Implementer NRHM

Year 2010


In2010,theMinistryofHealthandFamilyWelfare,GovernmentofIndia,introducedtheMaternalDeathReview(MDR)asastrategytoimprovethequalityofobstetriccareinthecountryandreducematernalmortalityandmorbidity.TheMDRprovidesdetailedinformationonvariousfactorsatthefacility,district,community,regional,andnationallevelsthatisneededtoreducematernaldeaths.Analysisofthesedeathscanhelpidentifythefactorsthatcontributetomaternalmortalityatvariouslevelsandprovideinformationthatcanbeusedtofillgapsinservice.Differentstateshaveadaptedthisprocesswithsomebuildupslikeinfantdeathaudits,communitybasedprocesses,etc.Variouspolicymakersfromthecommunityinvolvedinthisoutsideofhealth

Strengths *employssystemsapproachinidentifyingprevantableissuesthatledtodeath-allowstoidentifyissuesformtransporttoaffordabilitytoqualityofhealthservices*makesmaternalhealthatopictofocusforalldistrictlevelpolicymakers*allowsfocusonactionandprevention*Gujaratmodelofcommunitybasedreviewsreceivedpositivefeedback*lowcostandeffective

Challenges *underreportingforvariousreasonsnoted*manyinstancesmoreofafaultfindingenterprise*involvementoffamilylimited*investigationintoclinicalcauselimited

Furtherinformation http://www.who.int/woman_child_accountability/resources/Day2_Session4_India_MDR.pdf

RESULTSOFACOMMUNITY-BASEDMATERNALDEATHAUDIT,UNNAODISTRICT,UTTARPRADESH,INDIA.

11

BriefbyHNPnotes,WorldBank

Idno. PO3

Title Chiranjeevihealthscheme

MNCH Maternalhealth

Category Policy

State(scaleof

implementation)

Gujarat

Implementer Stategovernment

Year 2005

Descriptionofthe

innovation

Underthisscheme,thegovernmentwouldenterintoacontractwiththeprivateproviderto

catertoinstitutionalservicesforbothnormalandcomplicateddeliveryincludingC-Section

operationsandbloodtransfusionstotargetedpopulation.Thefieldworkersalsoexplainto

pregnantmothersbenefits/serviceswhichtheycanavailunderthescheme.Atthetimeof

delivery,thewomengoestopreviouslyidentifiedempanelleddoctors,getsthedeliverydone

freeofcharge.Shealsoreceivestransportationchargesfromthedoctor.

Strengths *bridgesaccesstocareissueandfocusesonsafedelivery*somestudiesshowreachtothe

mostvulnerableeconomically

Challenges *notuniversal-challengesoftargeting*outofpocketexpensesstillduetomedicinesandtests

*monitoringandgovernancestillanissue*somestudiesshownoimprovementinqualityof

servicesaccessedandcriticiselowreimbursementofprivatesector

Furtherinformation

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2761781/

http://www.nhp.gov.in/sites/default/files/pdf/chiranjeevi-yojana-details.pdf

Idno. PO4

Title Jananisurakshayojana-conditionalcashtransferforinstitutionaldelivery


Category Policy

State(scaleof

implementation)

India

Implementer underNRHM

Year 2005

Descriptionofthe

innovation

TheJananiSurakshaYojana(JSY)isoneoftheflagshipcomponentsoftheNationalRural

HealthMission,andthekeystrategytoenablewomentoaccessinstitutionaldeliveriesand

therebyeffectreductionsinmaternalmortality.Womenareprovidedwithcashincentivesfor

deliveringatgovernmentandrecognisedprivatehospitals.Increasedamountforcaesarian

sections,andinempoweredactiongroupstates.

Strengths *Inmanystudies,increaseininstitutionalattendancefordeliveriesshown.

Challenges *institutionalpreparednessquestionedinvulnerableareas*institutionaldeliveryequatedto

highqualityofservice-notresonantinmanyhealthcentres*inareaswithsignificanthome

deliveries-nofocusonsafedeliveries*shiftfrominstitutionalfocustosafedeliveriesneeded

Furtherinformation ProgrammeevaluationofJSY

Idno. PO5

Title MadiluKit(babybox)


Category Policy

State(scaleof

implementation)

Karnataka

Implementer GovernmentofKarnataka

Year 2007

Descriptionofthe

innovation

InspiredbytheFinnbabybox,KarnatakalaunchedaschemecalledMadiluwhereanywoman

belowthepovertylinewhodeliveredinagovernmenthospitalintheschemewouldgetakit

worthRs825.Thekitcontained18itemsofrelevancetocareformotherandnewbornchild

fromblanketstomosquitonets.AtotalNo.of12,99,767personsbenefittedby2013as

reported

12

Strengths *Helpsstrengthenrelationshipbetweenbeneficiaryandserviceprovider*providesallessentialitemsrequiredforhealthmotherandchild*improvesperceptionofserviceprovisionatgovernmenthealthservices*non-financialincentivetoencourageinstitutionaldelivery

Challenges *actualimpactofschemeonperceptionorqualityofservicesorhealthofmotherandchildlacking*Nostudiesfoundofyetonlyreportsofmisutilisationsinnewspapers*notuniversalunlikeinFinland

Furtherinformation WriteupontheGovernmentofKarnatakawebsite

Idno. PO6

Title Transportationformotherandchildforusinghealthservices


Category Policy


Karnatakafocushere,acrossIndiaadaptedbydifferentstates

Implementer StategovernmentinpartnershipwithEMRI

Year 2010


TitledArogyaKavacha,108ambulancestoprovidenecessaryemergencycareandtransportwhenneededasintimeofdeliveryorcomplications.PublicprivatepartnershipmodelwithGVKenterprises.Takepatientfromresidencetonearestappropriatehealthcentre.Numbersofutilisationsuggestthatnearlyhalfofthecallsarepregnancyrelated.In2013,Nagumagu(smilingchild)schemelaunchedbystategovernmentalone.Heretransportprovidedtomotherandchildfolliwngdeliverytoreachhomesafely.Establishedsofarinsecondaryandtertiarygovernmenthospitalsindistrictsonly.

Strengths *transportisabigprobleminreferralsandreachingappropriatehealthservicesinruralandurbanindia.

Challenges *minimumstudiesandutilisationanalysisavailablesoimpactdifficulttoassess

Furtherinformation Fromnewspaperarticles

Idno. PO7

Title Cashbenefitschemesforexpectantmothers


Category Policy


PrasuthiaraikeinKarnataka;MuthulakshmiReddyMaternityBenefitSchemeinTamilNadu

Implementer Respectivestatehealthdepartments

Year 2006


PrasuthiAraike-AnincentiveofRs.2,000/-isgiventopoorwomenforNutritionSupplementstobeprovidedduringprenatalandpost-natalperiods.14,53,999womenarebenefittedby2013.MRMBS-Cashassistanceof12000Rsinthreeinstallments(pregnancy,delivery,postnatal)towomenbelowpovertyline,above18yearsofageonconditionthattheyuseservicesatgovernmenthospitals,deliveratgovernmenthospital,completeimmunisationscheduleforchild

Strengths *targetBPLhouseholdswithcashincentives*highpoliticalsupportduetovisibility

Challenges *nostudiesevaluatingimpactyet*notuniversal*focusonlyongovernmenthospitalswhileutilisationofprivatesectorignored

Furtherinformation Respectivegovernmentwebsites

Idno. PO8

Title Antenatalclinicintegratedwithyogaandnaturopathy

MNCH Maternalhealth

Category Policy


TamilNadu

Implementer Stategovernment

Year 2010

13


WithSiddhabeingpopularinTamilNadu,thegovernmentofTamilNaduhasmadeeffortstoprovideoneAYUSHpractitionerineveryprimaryhealthcentreinaphasedmanner.Thesecentresareco-locatedwithadditionalPHCs.InadditiontotheDistrictHospitals,aSiddhawingwasoperationalizedinallblockPHCs.Therewere479suchunitspriortoNRHM.UnderNRHM,475additionalcentersstartedtoprovideAYUSHservice-300Siddha,including175collectivelyforAyurveda,Unani,Homoeopathy,YogaandNaturopathy.33YogaunitswereestablishedinPHCsin2010.TheantenatalclinicisonceaweekinthePHC.Integratedapproachfornormaldeliverywithoutepisiotomyfromearlystageofantenatalperiodisencouraged.Nearly50-80mothers-to-beattendtheclinicformedicalexaminationandinvestigationbytheallopathicdoctors.Whiletheywaitfortheexaminationorforthetestresults,groupsofexpectantmothersaresenttotheYogaandNaturopathyphysician.He/shecategorizetheantenatalCasesbytrimesterandprovideappropriatetreatment.DuringantenatalvisittoPHC,aNaturopathicDoctorworkswiththeexpectingmother,providingcounselingandeducatingheronlifestylechanges.Thisprocessbeginswithprenatalcare,continuingthroughbirthandafterthedelivery.Siddhadoctorsalsoprovidedrugsthatarerequiredduringpregnancy.Apartfromthis,theyogaphysicianteachesexercisesduringtheantenatalandpostnatalperiod,whenevermothersattendpostnatalcheck-upandduringinfantimmunization.Thewomenlearnexercisesunderdirectsupervisionandcontinuetopracticethemathome.Postural,breathingandpelvicfloorexercisesalongwithbackandspinaltwistexercisesaretaught.

Strengths *alignwithmandateofintegratingwithindiansystemsofmedicine*maternalhealthinfocusbeyondmedicalmanagement

Challenges *nostudiesevaluatingimpactyet*inselectareasonly

Furtherinformation NationalHealthSystemsResourceCentreWebsite

AnnexureVI

Formatforcommunityfieldinvestigator’svillagevisit

PartA:Villageprofile

• Nameofthevillage

• Population

• Totalnumberofhouseholds

• VillageHealthSanitationandNutritionCommitteeinthevillage(Yes/No)

• No.ofpregnantwomeninlastyear

• Noofdeliveriesinlastyear

• Generalinformationaboutthevillage

PartB:VillagemapKeypointstobecoveredwithinthemap

• Distributionofhouses

• Distancefromhealthcenters

• Schools

• Anganwadiifpresent• Distancetogovernmentoffices

• Problemareas

• Forestarea

• Distancetomainroad

• Waterbodysources

• Healthcentersifany,elsedistancetonearesthealthcenter.

• Importantlandmarks

PartC:AccesstomaternalhealthservicesDetailedinformationtobenotedonfollowingpoints–positiveandnegativepoints:

• Perceptionsaboutgovernmentmaternalhealthservices

• Utilizationoftheseservicesandschemes

• Issueswithaccessingservices(physical,financial,socio-cultural)andreasonfor

theseissues

• Anycasesidentifiedwhereapositiveornegativeexperiencewasnoted

This newsletter is an attempt to present a summary of the ongoing work in the implementation research project titled, “Participation for local action: Implementation research with indigenous communities in southern India for local action on improving maternal health services” (PLA), supported by the Alliance on Health Policy & Systems Research (World Health Organisation, WHO) and United Nations Childrens’ Fund (UNICEF) in Chamarajanagar district.

Our proposal received ethics approval from the Institutional Ethics Committee at Institute of Public Health, Bangalore in Dec 2015, and as fulfillment of our first deliverable as per our contract, the first installment of the project budget was released earlier this year. Our proposal, however, is still under review with the WHO Ethics Review Committee (ERC). In the last few months, they have gotten back to us with different queries that we have reviewed and responded to, and in some cases, even revised the proposal to incorporate their feedback. We are hopeful that the ethics approval process will soon conclude positively.

We currently have been pursuing the initial situation analysis phase of the project outlined in this newsletter. While we are concerned with the delay in ERC approval, we have communicated with the Alliance team, and they have responded favourably about the possibility of a no-cost extension. Meanwhile we continue to use the time provided to further strengthen our understanding of the situation in the district, and will provide bimonthly updates via this newsletter to all involved.

Project update

Participation for local action Bimonthly newsletter August 2015

Situation analysis

This section provides an overview of the situational analysis stage of research.

Page 2

Some insights Next steps

This section provides a glimpse of the upcoming steps in the coming months.

Page 5

This section provides a glimpse of the different outputs of initial work with insights gained.

Page 4

Supported by Alliance for Health Policy & Systems Research, & UNICEF

Annexure VII

Annexure VII

Annexure VII

Annexure VII

2

The situation analysis plan comprises of different components that come together with the aim of describing the context, the status of access to maternal health services for mothers of the district’s indigenous communities and explaining the reasons behind this picture. There are three different teams involved in this stage – the core team, the community representatives and the district health team. Through a series of interactions, the team divided the work into six components represented in the figure below. Largely they fall into three categories: a) understanding the maternal health services available and their coverage in the district with a special focus on areas with indigenous communities, b) reflecting on the issues with providing & accessing maternal health services for this community/area by the respective team, and c) collection of possible solutions/local actions. The methods across these components involve review of literature and secondary data available, interaction with different stakeholders involved, and self-reflection exercises by the community and district health team.

Situation Analysis

3

Ongoing activities: o Meeting with all co-investigators on research initiation at IIPH-Bangalore and one-on-one o Mapping of health centres across the four taluks in the district – public and private– with a

focus on maternal health services provided using GIS with a brief profile of each o Developing a booklet on maternal health services and schemes available in the district o Review of literature on participatory research, and issues with access to maternal health

services in tribal communities, tribal health status in India in general o Drivers of health seeking behaviour for maternal health services during pregnancy and

delivery – tools for interviews, group discussions and observation checklists o Stakeholder analysis – listing, tools finalised, preliminary mapping exercise o Community’s reflection:

• Repeated meetings with community’s representatives – zilla budakattu girijana abhivrudhhi sangha to understand the research, and plan for situation analysis

• Recruitment of field investigators taluk-wise to cover all tribal hamlets • Capacity building of field investigators on understanding maternal health, access to

health services, challenges associated, and methods of data collection • Field visits to tribal settlements by sangha representatives

Internships

Three students from USA undertook internships based at the BR hills office. Eva Lowell (undergraduate student from Colorado University) assisted the health service mapping across the district during her public health internship. Kate Baur and Kelsey Holmes (Masters of Global Health, Emory University) worked on studying drivers of health seeking behaviour for maternal health services among soliga women in Yelandur taluk.

National Tribal Human Development Report 2015

Tanya is working with Dr Sudarshan on writing a linear paper on health of tribal communities in India. This paper is one of seven background papers for the upcoming human development report in the nation – the first of its kind supported by UNDP and the Ministry of Tribal Affairs, Government of India.

o Health team’s refection:

• Informal interactions with few health workers, and medical officers working in tribal primary health centres

• HMIS data preliminary review • Situation analysis strategy drafted

o Photo-documentation strategy finalised o Revised proposal with final tools submitted to

ERC

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A glimpse of experience/learning so far

148 tribal settlements across 4 talukas – max 80 in Kollegal

Soliga main tribe – minority of jenukuruba, kadukuruba, yerawas – only in Gundlupet taluka

GIS mapping of health centres providing maternal health services in 3 taluks, mapping of tribal settlements in 1 taluk completed

Yelandur taluk health services and tribal settlement mapping using cartodb software

Stakeholders involved

When interacting with the community on maternal health and key factors influencing it, diet emerged as an important factor with various do’s and don’ts. Apart from diet, certain rules exist traditionally that pregnant women are expected to follow. They described different roles for household members (friends/family), community and health centres during their pregnancy. Few women shared their perceptions of government health workers, and local health centre staff based on their experience in the past with some discussion on privacy, safety and care provided. Some delivery experiences were explored in detail to understand factors that influenced their health outcomes, and overall experiences. (Based on exploratory discussions with tribal women in Yelandur taluk)

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- The project base is established at The Malki Initiative campus in BR hills. All project activities will be coordinated from this office.

- A plan for strengthening documentation processes and data storage was created and will be implemented. This involves use of project management software for different activities like evernote for field notes, and trello for project coordination and timelines. This will allow for better analysis and reporting.

- As mentioned earlier, we have received the first installment of the study budget. Budget realization stands at 12% direct costs in Jul 2015.

- Memorandum of understanding (MoU) finalized with sangha, and IPH. MoU/contracts with other partners pending, to be taken up on priority

- Bimonthly newsletters to be prepared and shared with all partners to keep them upraised on research progress, and to allow better participation for all.

- The community team will participate actively in the ongoing National Inquiry on Health Rights organized by the jana arogya andolana Karnataka.

- The implementation call for immunization could not be applied for due to various reasons. We are on the lookout for similar opportunities to take the work forward.

While ongoing activities will be completed, the key events in the coming months are listed below.

- ERC approval

- Completion of mapping exercises, and initial stakeholder analysis

- Community reflection – taluk wise, and then district level reflective analyses on issues identified in the field visits by the sangha

- Health team reflection – HMIS data analysis, disaggregated data analysis based on tribal status, reflective analyses on challenges in service provision

- Regular photo-documentation updates

- Joint workshop with community representatives and health team

- First stakeholder forum meeting for local action as outlined in the proposal

- Initial programme theory to be outlined following meeting

- Research protocol to be written up as paper

Next steps Project management

I would like to thank Dr Prashanth NS and Dr Deepak Kumaraswamy for their help with preparation of this newsletter. I would also like to acknowledge the support of Alliance of Health Policy and Systems Research and UNICEF for their support to the project and to the research team in coordinating with WHO ERC.

Dr Tanya Seshadri MBBS, MD community medicine Principal Investigator WHO implementation research project in Chamarjanagar district

IRP team: Dr Prashanth NS (co-PI), Institute of Public Health, Bangalore

Dr C Madegowda, Zilla Budakattu Girijana Abhivrudhi Sangha, Chamarajanagar

Dr Visweswaraiah KM, District Reproductive and Child Health Officer, Chamarjanagar

Dr Sadhana M, Karnataka State Health Systems Resource Centre, Bangalore

Dr Giridhara Babu, Indian Institute of Public Health-Hyderabad, Bangalore campus

Dr Arima Mishra, Azim Premji University, Bangalore

Dr Bruno Marchal, Institute of Tropical Medicine, Antwerp, Belgium

IRP field team at The Malki Initiative campus, BR hills

Bhargav Dwaraki Shandilya, consultant photographer, Bangalore

This document is for internal circulation purpose only

• Maternal health and nutrition in tribal areas: report of the fact-finding mission to Godda-Jharkhand

• Pregnancy-related Deaths in Rural Rajasthan, India: Exploring Causes, Context, and Care-seeking Through Verbal Autopsy

• Are marginalized women being left behind? A population-based study of institutional deliveries in Karnataka, India

• Economic Inequalities in Maternal Health Care: Prenatal Care and Skilled Birth Attendance in India, 1992–2006

• 'I can't take it anymore': Sights and awful sounds from the labour room of an Indian public hospital

• A Handbook: Why transformative storytelling approaches?

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