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1<br />
UTTAR PRADESH COMMUNITY<br />
MOBILISATION PROJECT<br />
The Proof is in the <strong>Process</strong><br />
Innovating the Self-Help Group Model to Impact Large-Scale Health Behavior<br />
Change and Service Delivery
2<br />
CREDITS<br />
Author:<br />
Michaela Partridge<br />
Graphic design & layout: RDD Design<br />
Publisher:<br />
RGMVP<br />
Publication Date: 2016<br />
Thank you to the <strong>UPCMP</strong> team and partners for sharing helpful insights,<br />
documentation and data. Also, this would not have been possible without the<br />
help of committed RGMVP staff, who organized events and key moments in<br />
the field for reflection and learning. And lastly, to the rural women of Uttar<br />
Pradesh, for whom this document seeks to recognize and benefit – may you<br />
continue to mobilize action with the same unwavering spirit that has inspired<br />
this great movement for change.
3<br />
ABOUT RGMVP<br />
Rajiv Gandhi Mahila Vikas Pariyojana (RGMVP) is a community-based flagship<br />
program that aims to reduce poverty and address social issues by activating<br />
the innate potential of women living in rural and marginalized sections of<br />
Uttar Pradesh, India.<br />
RGMVP has been operating in Uttar Pradesh since 2002, organizing women<br />
into Self-Help Groups (SHGs) to enhance their economic and social<br />
inclusion and also encourage them to demand their rights and<br />
entitlements from the government.<br />
RGMVP BELIEVES IN INNOVATION AND<br />
SCALE BY DOING THINGS DIFFERENTLY.<br />
WE ARE TRYING TO INSPIRE PEOPLE TO<br />
CHANGE THEIR MINDSET BY CHANGING<br />
THE TIME HORIZON AND THE DIRECTION<br />
OF THEIR INNATE ENERGY IN ORDER TO<br />
HELP THEM OVERCOME POVERTY AND<br />
EXCLUSION.<br />
Sampath Kumar, CEO<br />
ABOUT THIS DOCUMENT<br />
Going beyond mere micro-finance schemes, RGMVP has innovated the<br />
conventional SHG Model to emerge as a vibrant and inclusive system of<br />
leadership and holistic empowerment.<br />
The following document aims to capture the unique designs and<br />
processes built behind the RGMVP model, as they are made evident<br />
through implementation of the Uttar Pradesh Community Mobilization<br />
Project (<strong>UPCMP</strong>).<br />
<strong>UPCMP</strong> is a project funded by the Bill and Melinda Gates Foundation,<br />
in partnership with the Public Health Foundation of India, Population<br />
Council, Community Empowerment Lab and Boston University, Center<br />
for Global Health and Development.<br />
Through the activation of RGMVP’s SHG platforms, <strong>UPCMP</strong> has<br />
developed and successfully scaled-up a package of interventions to<br />
change health behaviors, improve delivery systems to reduce infant and<br />
maternal mortality rates.<br />
Since 2011, tremendous impacts have been felt across the state, in which<br />
hundreds of women have been able to turn life-saving knowledge into<br />
practice. The insights and data from this document seek to highlight<br />
these impacts, while also serving as a repository of information for<br />
development practitioners, researchers and academics who are<br />
interested in new approaches to large-scale health behavior<br />
change and improved service delivery.
CONTENTS<br />
Introduction......................................................................................................................6<br />
RGMVP Background .......................................................................................................7<br />
UPCM – The Project.......................................................................................................8<br />
Delivering Innovations ...................................................................................................7<br />
Critical Results & Milestones .........................................................................................7<br />
Lessons for the Future ....................................................................................................8<br />
Partner Organizations ....................................................................................................7<br />
Acronyms ..........................................................................................................................8
5<br />
INTRODUCTION<br />
Maternal health is closely linked to newborn survival. In India, where it is estimated that one woman dies of childbirth related complications every five <strong>min</strong>utes,<br />
we are hard-pressed to deter<strong>min</strong>e what strategies can actually ensure healthier behaviors and safer deliveries. Although facility births are increasing, the quality<br />
of care at birth, as well as the health information and networks available in rural areas, remains a major challenge. Many women still give birth at home, often in<br />
unsafe and unsanitary conditions, and rarely consult skilled health workers before or after delivery. As a result, many women and newborns needlessly die due<br />
to causes, which are largely preventable and treatable.<br />
EVERY FIVE MINUTES, AT LEAST<br />
ONE INDIAN WOMAN DIES DURING<br />
PREGNANCY AND CHILD BIRTH.<br />
World Health Organization, 2016<br />
Infant Mortality Rate<br />
Maternal Mortality Rate<br />
UP<br />
UP<br />
359<br />
292<br />
India<br />
India<br />
212<br />
178<br />
2010 2012 2007 - 20019 2010 -2012<br />
*Per 1,000 live births; Source: PIB<br />
*Per 100,000 live births; Source: PIB<br />
Health Indicators in Uttar Pradesh<br />
Uttar Pradesh (UP), India’s most populous state, persistently performs<br />
poorly on maternal mortality, reporting the maximum number of maternal<br />
deaths and Kerala the least 1 . A woman in UP has one in 42 lifetime risks of<br />
maternal death, where the probability is just one in 500 in Kerala 2 . Similarly,<br />
in the case of neonatal mortality, UP is among the top five high focus states,<br />
reporting 48 neonatal deaths per 1,000 live births 3 . UP also reports 95<br />
under-five deaths per 1,000 live births 4 , equivalent to one death for every<br />
13 school buses. Even more devastating is the fact that the majority of<br />
causes of death, like tetanus or diarrhoea, are largely preventable through<br />
vaccination or good hygiene.<br />
Limited Innovations Available<br />
Many private sector organizations are experimenting and innovating to<br />
address these challenges. Despite the existence of many proven life-saving<br />
interventions, there is still a dearth of community-based programs, which<br />
can take these interventions to scale rapidly and sustainably. Even where<br />
information is available, health seeking behaviors and barriers can often<br />
prevent women from adopting best practices, forcing many women to<br />
resort to high-risk behaviors 5 . Population Council heavily supported this<br />
reality in a landscape study in 2011 6 , stressing the need for Behavior Change<br />
Communication (BCC) strategies to address rural health barriers and shape<br />
demand for the adoption of preventative practices.
6<br />
COMMUNITY MOBILIZATION IS<br />
A CAPACITY BUILDING PROCESS<br />
THROUGH WHICH COMMUNITY<br />
MEMBERS, GROUPS AND<br />
ORGANIZATIONS PLAN, CARRY<br />
OUT AND EVALUATE ACTIVITIES<br />
IN A PARTICIPATORY, SUSTAINED<br />
WAY TO IMPROVE THEIR HEALTH<br />
AND OTHER CONDITIONS, EITHER<br />
THROUGH THEIR OWN INITIATIVE<br />
OR STIMULATED BY OTHERS 7 .<br />
Scope for Community Mobilization<br />
Most efforts to improve maternal and newborn health have focused on<br />
strengthening service delivery. And while improving access to, and quality<br />
of, important health services are essential, reducing maternal and newborn<br />
deaths also requires action at the community level. For this reason,<br />
Community Mobilization is recognized as a key intervention in the Global<br />
consensus on Reproductive, Maternal, Newborn and Child Health (RMNCH).<br />
Community Mobilization differs from, and can be more effective than, health<br />
education, as it aims to empower communities to change their situation. This<br />
involves an investment in people’s innate potential to become leaders, make<br />
decisions and take coordinated action to resolve health issues.<br />
Importance of Self-Help Groups<br />
In many rural communities in India, women have very few opportunities<br />
to improve their health or that of their families. Even where local health<br />
committees exist, they are often do<strong>min</strong>ated by community leaders or men,<br />
which can mean critical health issues affecting women and children falling<br />
to the wayside. Self-Help Groups (SHGs) provide the needed informal space<br />
to build on women’s interest in improving the health of their families and also<br />
have the capability of reaching the poorest and most marginalized women.<br />
Besides income benefits from small savings, SHGs encourage an exchange<br />
of ideas and information to identify problems and innovate as a collective to<br />
find solutions for overco<strong>min</strong>g economic, social and cultural barriers.
7<br />
Addressing The Problem<br />
In this context, RGMVP launched the Uttar Pradesh Community Mobilization<br />
Project (<strong>UPCMP</strong>) alongside a consortium of development practitioners,<br />
action-oriented researchers and behavior change experts to pilot and evaluate<br />
a unique model through social platforms. Partners include the Public Health<br />
Foundation of India (PHFI), Community Empowerment Lab (CEL), Population<br />
Council (PC) and the Centre for Global Health and Development (CGHD)<br />
at Boston University. With the generous support from the Bill and Melinda<br />
Gates Foundation, the project has revealed a promising, institutionalized and<br />
scalable social platform through which maternal, neonatal and child health<br />
interventions may be built upon.<br />
<strong>Process</strong> <strong>Document</strong> Objectives<br />
The present document seeks to capture the design and processes under<br />
<strong>UPCMP</strong> and articulate the deeper insights and explanations as to why and<br />
how positive results were achieved. It reflects on the various kinds of capacity<br />
building and health mobilization activities carried out, the process underlying<br />
these activities and the roles and responsibilities of individuals and groups to<br />
sustain the process. We hope to educate others about RGMVP and explain<br />
how it has innovated the conventional SHG model to expand and leverage<br />
its scope from mere micro-finance linked groups to vibrant and inclusive<br />
leadership building platforms with strong potential to impact family health<br />
outcomes at scale.<br />
1 UNICEF (2009). The State of the World’s Children:<br />
Maternal and Newborn Health.<br />
2 Ibid<br />
3 Registrar General of India (2016). SRS Survey 2014.<br />
4 Save the Children (2010). A Fair Chance at Life: Why<br />
Equity Matters for Child Mortality.<br />
5 Jenny Ruducha et al (2016). Who’s Advice Should I<br />
take? A Qualitative Study of Community Strengthening<br />
and Health Message Delivery in Rural UP. BU Centre<br />
for Global Health and Development.<br />
6 Population Council. Shaping Demand and Practices<br />
to Improve Family Health Outcomes: Designing a<br />
Behavior Change Communication Strategy in India.<br />
Uttar Pradesh ed. Vol. 1: Sage, 2012. Print.<br />
6 Population Council. Shaping Demand and Practices<br />
to Improve Family Health Outcomes: Designing a<br />
Behavior Change Communication Strategy in India.<br />
Uttar Pradesh ed. Vol. 1: Sage, 2012. Print.<br />
7 Howard-Grabman, Lisa et al. (2007). Demystifying<br />
Community Mobilization: An Effective Strategy to<br />
Improve Maternal and Newborn Health.
8<br />
RGMVP BACKGROUND<br />
THE HOLISTIC APPROACH<br />
Rajiv Gandhi Mahila Vikas Pariyojana (RGMVP) is the flagship program of<br />
the Rajiv Gandhi Charitable Trust (RGCT) based in UP. It was established in<br />
2002 to commemorate and take forward the vision of India’s former Prime<br />
Minister for the country’s development. Since its inception, RGMVP has<br />
helped to mobilize 1.4 million women and their families into SHGs. The<br />
edifice of RGMVP rests on the innate collective strength of these SHGs<br />
(consisting of 10-20 rural women) and their federations at village and blocks<br />
levels to act as social platforms to go beyond achieving financial well-being<br />
to address more urgent needs of health security and social awareness.<br />
UP ACCOUNTS FOR AN<br />
ESTIMATED 20% OF THE<br />
NATIONAL POVERTY AND 9%<br />
OF THE POVERTY WORLDWIDE.<br />
Three-Tier Institutional Model<br />
SHG<br />
SHG<br />
SHG<br />
SHG<br />
SHG<br />
VO<br />
VO<br />
VO<br />
BO<br />
SHG<br />
VO<br />
BO<br />
61<br />
53<br />
Self-Help Group<br />
Village Organization<br />
Block Organization<br />
359<br />
292<br />
47 A SHG consists of 10-20212<br />
women living in a neighbourhood who voluntarily<br />
42<br />
choose to form a group.<br />
178<br />
SHGs are federated into VOs, representing 150 to<br />
250 women, and then further federated into BOs, representing 5,000 to<br />
7,000 women.
9<br />
Service Delivery System<br />
These community-based institutions provide all marginalized women with a platform to unite<br />
based on gender and mutual concern, cutting across rigid lines of caste and religion, to mobilize<br />
their communities and its resources to better their lives. Serving as systematic platforms to help<br />
bridge the gap between government delivery systems and poor recipients, SHGs, VOs and BOs<br />
enable direct delivery of various services, including: access to health and nutrition entitlements;<br />
linkages with frontline health workers and departments; bank linkages; and various schemes to<br />
improve livelihoods, agriculture and education.<br />
Internal Social Capital<br />
RGMVP believes that the creation of well-being alone is not sufficient. While technical and<br />
sensitive support is provided to ensure SHG functioning for achieving financial inclusion, the<br />
process itself also identifies and nurtures a cadre of community level leaders, trainers and<br />
resource persons. This ever-expanding network of Internal Social Capital (ISC) is the key to<br />
sustaining RGMVP’s unique development model, as it is fully owned and managed by the<br />
community. This ensures a bottom-up and scalable approach, prioritizing local context and<br />
collective ownership as a means to address larger personal and social transformation.<br />
Institution & Capacity Building<br />
Ongoing training, counselling and support allow the community institutions to evolve alongside<br />
the women who manage them. As a continuous process, RGMVP and its partners invest in<br />
community leaders through various capacity building trainings on SHG concepts, as well as<br />
norms and management, which outline their roles and responsibilities. The more training an<br />
individual receives, the more capable she becomes in contributing to mobilization efforts.<br />
Sensitive support for women’s institutions at Village and Block levels help strengthen efforts to<br />
layer and direct the delivery of various services. This enables women’s institutions to strategically<br />
engage with the demand side while also working to make supply systems more accountable.<br />
CORE VALUES<br />
Unite<br />
Unite women in SHGs to collectively break<br />
barriers and plan for their futures<br />
Strengthen<br />
Strengthen SHG members through handholding<br />
support and capacity building<br />
Link<br />
Link SHGs and their families to existing<br />
structures of service delivery and resources<br />
Build<br />
Build social capital harnessing new<br />
information and creating support networks<br />
Grow<br />
Grow the SHG network by encouraging<br />
innovation and embracing volunteerism
10<br />
Layering Health Interventions<br />
The layering of health interventions and services in UP is especially critical considering the disproportionate number of neonatal and maternal deaths and<br />
malnutrition. This is compounded by poverty and constant financial burdens, leaving families helpless in the face of health emergencies. Regressive health<br />
practices and insufficient public health infrastructure further exacerbate the situation. In this regard, RGMVP operates as a strategic mechanism to connect<br />
the demand-supply bridge. Communities are seen not merely as recipients of care, but as powerful and informed health seekers, capable of demanding quality<br />
health services and improved access.<br />
RGMVP Expansion Map<br />
RGMVP has consistently expanded its outreach<br />
since its inception. As of December 2016, the<br />
project spans across 49 districts, including<br />
complete coverage of Bundelkund, the most<br />
underdeveloped region in the state.<br />
2006<br />
2011 2016<br />
3 33 49<br />
DISTRICTS DISTRICTS DISTRICTS<br />
Cumulative SHG Formation Progress<br />
Social Coverage<br />
1 5 000 0<br />
120 000<br />
900 0 0<br />
66,790<br />
88,806<br />
110,824<br />
130,167+<br />
1.3%<br />
OTHER 41.8%<br />
8.3%<br />
OTHER BACKWARD CASTE<br />
GENERAL<br />
6.2%<br />
MINORITY<br />
600 0 0<br />
37,217<br />
3 0 000<br />
0<br />
*As of Dec 2016; Source: RGMVP MIS<br />
2012 2013 2014 2015 2016<br />
40.8%<br />
SCHEDULED CASTE<br />
1.7%<br />
SCHEDULED TRIBE
11<br />
UPCM – THE PROJECT<br />
Project Goal: To improve Reproductive, Maternal, Neonatal and Child health by strengthening the management of behavior change through women’s social<br />
platforms<br />
Project Objectives:<br />
1. To increase adoption of evidence-based, high impact family health behaviors through SHGs to reach the poor<br />
2. To scale up evidence-based, high impact health behaviors and effective strategies to improve access to health services<br />
The Uttar Pradesh Community Mobilization Project (<strong>UPCMP</strong>) was launched<br />
as a four-year initiative (2012-2016) to further RGMVP’s commitment to<br />
improve health conditions among the poor. What has emerged is a unique<br />
Health Behavior Change model with strong potential to reduce maternal and<br />
newborn deaths at scale, which could indeed be replicated in some of the<br />
poorest communities in India. The following section, based on the experience<br />
of <strong>UPCMP</strong>, aims to describe this model at length – taking the reader through<br />
its participatory learning and action cycle, owned and operated by local<br />
women leaders.<br />
The principle objective of <strong>UPCMP</strong> is to reduce neonatal mortality by<br />
developing and scaling up a package of family health interventions, while<br />
also working to strengthen community management of Behavior Change<br />
Communications (BCC). Utilizing the SHG platform to identify target women<br />
and impart information on Reproductive, Maternal, Neonatal and Child Health<br />
(RMNCH), the project seeks to inculcate knowledge, strengthen skills and<br />
invite families to adopt better behavioral practices for safer pregnancies,<br />
newborn care and child health. Work with SHGs is complemented by efforts<br />
to strengthen health services and improve linkages with health systems.<br />
In line with RGMVP’s main operating strategy, <strong>UPCMP</strong> embraces a<br />
participatory learning and action cycle to identify and prioritize problems<br />
facing target women, and then mobilize action to address them. The<br />
process depends on SHG functioning, committed mobilisers and local<br />
health workers, active communication between SHGs and VOs and<br />
continuous capacity building and community support for measuring<br />
progress and impact. This section will reveal that the proof is in the process.<br />
When all cogs work together to activate SHGs, the results can indicate<br />
tremendous improvement in family health behaviors and increased access<br />
to life-saving health services.<br />
<strong>UPCMP</strong> EMBRACES A PARTICIPATORY LEARNING AND ACTION CYCLE TO IDENTIFY AND<br />
PRIORITIZE PROBLEMS...AND THEN MOBILIZE ACTION TO ADDRESS THEM.
12<br />
ORIENTATION OF RESULTS & ACTIVITIES<br />
To attain <strong>UPCMP</strong> objectives, some good results have been identified. These results specifically relate to the activities carried out under the project and can<br />
be stated in the following manner:<br />
RESULT 1<br />
RESULT 2<br />
RESULT 3<br />
RESULT 4<br />
Strengthened capacities of women’s<br />
institutions and individuals to<br />
mobilize rural communities and<br />
its resources to adopt preventative<br />
health practices.<br />
Under this result, various capacity<br />
building trainings and knowledge<br />
transfer activities are carried out<br />
in addition to continued SHG<br />
formation and nurturing.<br />
Increased awareness and knowledge<br />
about RMNCH behaviors and<br />
increased capacity to demand quality<br />
health services and<br />
improved access.<br />
Under this result, various BCC,<br />
awareness-raising and mobilization<br />
activities were carried out in addition<br />
to important linkages with supply<br />
side interventions.<br />
Enhanced coordination,<br />
collaboration and information<br />
exchange for the sustainability of<br />
BCC activities through consultative<br />
and participatory processes and<br />
advice networks for support.<br />
Under this result, the coordination<br />
with community stakeholders,<br />
women’s institutions and local<br />
health care workers are carried out.<br />
Selected community volunteers<br />
assisted in collecting and measuring<br />
outcomes related to knowledge<br />
and practices among the target<br />
population.<br />
Under this result, two rounds of<br />
community-managed Lots Quality<br />
Assurance Sampling (LQAS) was<br />
implemented to track and improve<br />
the quality of the process.<br />
INNOVATIONS<br />
Result 1<br />
Result 2<br />
Result 3<br />
INSTITUTION & CAPACITY BUILDING<br />
BEHAVIOR CHANGE MANAGEMENT PACKAGE<br />
PEER-TO-PEER PROPAGATION CYCLE<br />
Key innovations and activators<br />
for achieving these results at<br />
scale are further explained<br />
on page 20, in the section<br />
‘Delivering Innovations’.<br />
Result 4<br />
COMMUNITY-BASED MONITORING & EVALUATION
13<br />
UPCM STRATEGIC FRAMEWORK<br />
VISION<br />
Project Area<br />
To enable transformative health behavior change for safer pregnancies, newborn care and child health<br />
MISSION<br />
why?<br />
how?<br />
for whom?<br />
33<br />
DISTRICTS<br />
UP is among the poorest states in India<br />
and significantly lags behind in maternal,<br />
neonatal and child health care indicators<br />
By utilising existing SHG platforms and<br />
network to identify target women and<br />
disse<strong>min</strong>ate RMNCH information<br />
Pregnant Women, Recently<br />
Delivered Women and Mothers<br />
of Children (age 0-2 years old)<br />
HEALTH PACKAGE<br />
Maternal Health<br />
• Identification of danger signs & referral<br />
• Complication Readiness Plan<br />
• Family planning methods i.e. birth spacing<br />
• Promotion & facilitation of ANC/PNC<br />
Neonatal Health<br />
• Thermal Care<br />
• Exclusive Breastfeeding<br />
• Prevention of infection<br />
• Identification of danger signs & referral<br />
Child Health<br />
• Routine Immunization<br />
• Pneumonia Management<br />
• Diarrhea Management<br />
• Complimentary feeding practices<br />
4,500<br />
VILLAGES<br />
FOCUS AREAS<br />
1<br />
2<br />
3<br />
4<br />
120<br />
BLOCKS<br />
SHG formation<br />
& strengthening<br />
Capacity building<br />
training on RMNCH<br />
Diffusion of<br />
RMNCH knowledge<br />
Linkages with<br />
local health system<br />
Target geographies<br />
STRATIGIES<br />
IDENTIFICATION<br />
OF TARGET<br />
WOMEN<br />
COMMUNITY<br />
MOBILIZATION<br />
& DEMAND<br />
CREATION<br />
INTERACTION<br />
WITH TARGET<br />
WOMEN DURING<br />
MEETINGS<br />
ATTACH A SHG<br />
MEMBER TO<br />
TARGET WOMAN<br />
HOME VISIT<br />
TO RECENTLY<br />
DELIVERED<br />
WOMEN<br />
• 6.8 Million Population<br />
• 1.1 Million Households<br />
• 75,000 SHGs<br />
• 5,100 Villages<br />
• 120 Blocks
14<br />
MOBILISING ACTION: KEY ACTORS<br />
Frontline Health Workers<br />
Frontline health workers in India are divided into the three primary groups. These include Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives<br />
(ANMs) and Anganwadi Workers (AWWs). Together, they are known as AAA. The scope of their work may vary across states, depending on community needs<br />
and priorities of the various state governments. However, their roles are deeply intertwined at the community level.<br />
Accredited Social Health Activists<br />
Auxiliary Nurse Midwives<br />
Anganwadi Workers<br />
There are approximately 890,000 ASHAs across<br />
India, primarily making home visits to pregnant<br />
women and women who recently delivered.<br />
These home visits are designed mainly for health<br />
promotion and preventive care on topics such<br />
as nutrition, basic sanitation, birth preparedness,<br />
safe delivery and breast-feeding and essential<br />
newborn care. ASHAs do not receive a salary,<br />
but are financially incentivized to ensure and<br />
maintain records indicating that pregnant women<br />
receive antenatal care, encouraging institutional<br />
deliveries and for supporting healthy behaviors.<br />
This cadre was established under the National<br />
Rural Health Mission (NRHM) of India’s Ministry<br />
of Health and Family Welfare.<br />
ANMs are full-time government employees who<br />
manage the operations and service delivery at<br />
primary health centers or sub-centers 8 . They<br />
also lead home visits of pregnant and recently<br />
delivered women when required. As of March<br />
2011, there were approximately 208,000 ANMs<br />
working in these centers across the country 9 . A<br />
main objective of NRHM is to reduce maternal<br />
and neonatal mortality rates by increasing<br />
the number of skilled providers supporting<br />
institutional deliveries. For this, many efforts<br />
are being made to continuously train ANMs to<br />
become “certified” Skilled Birth Attendants 10 . Like<br />
the ASHAs they supervise, ANMs are managed by<br />
the Ministry of Health and Family Welfare.<br />
The AWWs manage nutrition and early child<br />
development programs in their communities.<br />
They also manage centers as distribution points<br />
for rations for pregnant women, lactating<br />
mothers and families with adolescent girls and<br />
children below age 6 11 . As part of their role,<br />
AWWs weigh each child under the age of 5 at<br />
least once a month, record the results during<br />
either a home visit or at the center, conduct<br />
health check-ups and identify children that<br />
require a referral to a primary health center or<br />
sub-center for immediate medical attention. In<br />
2012, there were 1.3 million AWWs in position 12 .<br />
AWWs work closely with ASHAs and ANMs. The<br />
team of AWWs is managed by the Ministry of<br />
Women and Child Development.<br />
8 Population Council (2012). Providing maternal and newborn health services: Experiences of Auxiliary Nurse Midwives in Rajasthan.<br />
9 Government of India (2011). Manpower at Sub-Centres and Primary Centres. Data Portal India.<br />
10 USAID and New Delhi: Intrahealth International (2012). Improving Skilled Birth Attendance in Jharkhand. Washington.<br />
11 Ibid.<br />
12 Ibid.
15<br />
RGMVP Health Mobilizers<br />
RGMVP has deployed a cadre of dedicated community volunteers to mobilize action across UP. The volunteers are regularly trained and educated on existing,<br />
new and upco<strong>min</strong>g government interventions as well as life-saving RMNCH information and practices. The collective strength of health mobilizers and SHGs<br />
creates an advocacy channel to strengthen supply side interventions and also generate demand for women’s rights and entitlements.<br />
Internal Social Capital<br />
Meeting Sakhis<br />
Community Resource Development Institutions<br />
RGMVP ISC are the key to ensuring RGMVP’s<br />
bottom-up mobilization approach. ISC are<br />
identified and trained to lead health discussions<br />
during SHG meetings, identify target women<br />
at the Village Level and use the ISC tool-kit for<br />
effective implementation at the SHG level. As<br />
part of their tool-kit, ISC fill health registrars to<br />
record and track the progress of target women.<br />
During meetings, ISC show health videos and<br />
also facilitate the use of various communication<br />
materials. Lastly, ISC engage with Panchayati Raj<br />
Institutions and Panchayat health committees<br />
to ensure support in identifying and<br />
disse<strong>min</strong>ating health messages through village<br />
level meetings. To date, 1,200 MS’s have been<br />
trained and mobilized.<br />
In 2014, RGMVP developed the MS strategy<br />
to fill the last mile gap. It was found that<br />
health outcomes were closely linked to group<br />
functioning. Thus, the MS strategy aimed to<br />
deepen the process of vertical expansion by<br />
not only leading health mobilization activities,<br />
but also ensuring active participation in, and<br />
proper functioning of, SHG meetings. The MS<br />
is responsible for attending SHG meetings,<br />
ensuring member contribution and helping<br />
SHGs uphold core principles. In addition,<br />
they impart RMNCH information, co-facilitate<br />
SHGs in identifying target women and ensure<br />
representation of SHG members in VO<br />
meetings. As of December 2016, 5,081 MS’s<br />
have been mobilized.<br />
CRDIs are made up of unique teams of rural<br />
women with first hand SHG experiences and<br />
success stories. Perfor<strong>min</strong>g the role of leaders,<br />
mentors and co-facilitators, CRDI members are<br />
extremely instrumental in scaling up RGMVP<br />
processes and interventions. Eight Community<br />
Resource Development Centers (CRDCs)<br />
serve as constructive incubation units for CRDI<br />
women to receive training and assimilate key<br />
concepts, ideas and techniques. With necessary<br />
training ranging from MNCH health practices<br />
and identification of issues to data collection<br />
and reporting, CRDI members are equipped with<br />
the relevant skills to internalize, practice and<br />
diffuse critical health messages and empower<br />
their communities.
16<br />
OPERATIONAL STRATEGIES<br />
Identification of<br />
Target Women<br />
The most fundamental<br />
activity for <strong>UPCMP</strong> is to<br />
continuously work to identify<br />
target women (pregnant,<br />
recently delivered or mothers<br />
of children aged 0-2 years).<br />
The introduction of Dayara<br />
Mapping has been especially<br />
helpful in accelerating this<br />
process. The unique method<br />
encourages SHG members to<br />
visit at least five households<br />
in their neighbourhood to<br />
identify target women and<br />
accordingly report back to the<br />
SHG with a list. After compiling<br />
the collective lists of target<br />
women within the SHG, the<br />
concerned MS then shares it<br />
with AAA at the VO level. With<br />
an average of 10-20 members<br />
per group, the method has<br />
the potential to cover over 50<br />
households.<br />
Community Mobilization<br />
& Demand Creation<br />
1 2 3<br />
In a large-scale project, it is<br />
especially difficult to sustain<br />
outreach to communities<br />
with messages that are<br />
standardized, accurate and<br />
effective. <strong>UPCMP</strong> has therefore<br />
carried out a range of strategic<br />
mobilization activities, relevant<br />
to every stage of the process.<br />
From initial invitations to<br />
attend general body meetings<br />
and events with local<br />
health workers to periodic<br />
health video screenings<br />
and awareness campaigns,<br />
activities are designed to<br />
provide as many opportunities<br />
to engage target women<br />
as possible. With increased<br />
exposure to interventions, the<br />
aim is inspire collective action<br />
for women to demand quality<br />
health services and improved<br />
access.<br />
Interaction with Target<br />
Women During Meetings<br />
Iterative interactions<br />
with target women take<br />
place during SHG and<br />
VO meetings to increase<br />
awareness and identify<br />
danger signs among the<br />
pregnant women and<br />
newborns. Meetings focus<br />
on sharing messages,<br />
which promote safe health<br />
practices, such as Kangaroo<br />
Mother Care (KMC) or<br />
Skin-to-Skin thermal care,<br />
exclusive breastfeeding and<br />
clean cord care. In addition,<br />
meetings provide immediate<br />
assistance to target women<br />
for preparing a complication<br />
readiness plan. Backed<br />
by SHG and VO support,<br />
women are able to seek<br />
out services and additional<br />
information with confidence<br />
and authority.<br />
Dayara Mapping enables<br />
early identification of target<br />
women within communities<br />
and allows for opportunities<br />
to build relationships with<br />
target women and their<br />
household influencers to<br />
promote healthy behaviors<br />
and improve family health<br />
outcomes. Results indicate<br />
a major consolidation of<br />
efforts, in which the initiation<br />
of Dayara Mapping along<br />
with the MS strategy has<br />
greatly accelerated the<br />
mobilization process.
17<br />
Attach a SHG Member<br />
to Target Women<br />
4 5<br />
When a target woman is<br />
identified (either through<br />
Dayara Mapping or<br />
otherwise), designated MS or<br />
ISC simultaneously work to<br />
link her with a SHG member<br />
for continuous support.<br />
This connection aims to<br />
reinforce health messages<br />
as well as provide emotional<br />
and social support to the<br />
women before, during and<br />
after pregnancy. The SHG<br />
member is responsible for<br />
facilitating increased uptake<br />
of antenatal care (ANC) and<br />
postnatal care (PNC) services;<br />
providing basic health and<br />
nutrition advice; and ensuring<br />
that the mother, newborn<br />
and family influencers are<br />
connected to the health<br />
information pipeline.<br />
Home Visit to Recently<br />
Delivered Women<br />
Postnatal home visits to<br />
SHG and non-SHG women<br />
are critical to <strong>UPCMP</strong> in<br />
reinforcing the use of best<br />
practices in RMNCH. As<br />
a mandate of the project,<br />
home visitations with an<br />
ASHA are conducted on<br />
the first, third and seventh<br />
day after delivery. This<br />
is to order to ensure the<br />
initiation of breastfeeding,<br />
Skin-to-Skin thermal care<br />
and to also offer additional<br />
counselling and sensitive<br />
support. Recorded on a<br />
monthly basis at the VO<br />
level, home visits not only<br />
indicate the efficacy of<br />
health layering, but also<br />
attest to the successful<br />
diffusion of information<br />
beyond the SHG fold.<br />
TRAINING RESOURCES<br />
Posters<br />
Posters on issues help participants to easily understand and<br />
identify issues, such as danger signs during pregnancy<br />
Flash Cards<br />
Flash Cards are extremely useful during group exercises to<br />
help participants clearly identify and collectively discuss<br />
Pocket Chart<br />
Pocket charts offer participants a chance to learn about issues<br />
by sorting ‘good’ and ‘bad’ behaviors displayed on cards<br />
Fact Sheets<br />
Region-specific fact sheets provide detailed information on<br />
SHG membership, maturity and geographic coverage<br />
Mapping Checklist<br />
Check-lists at the VO level encourage members to<br />
collectively identify health facilities in each village<br />
KMC Video<br />
The short narrative of a recently delivered woman highlights<br />
the benefits of Kangaroo Mother Care to enhance knowledge<br />
Visual Mapping<br />
Encourages the use of pictures and embraces an individual’s<br />
memory power to replicate models for imparting knowledge
18<br />
HEALTH MOBILIZATION ACTIVITIES<br />
INVITE<br />
WATCH<br />
MEET<br />
Welcome/Congratulations Letters<br />
As part of the mobilization strategy, official<br />
“Welcome” or “Congratulations” letters (‘Badhai/<br />
Subhkmana Sandesh’) from the VO are handdelivered<br />
to the identified pregnant or recently<br />
delivered women. These letters helps to break the<br />
ice with the women and provides an opportunity to<br />
cordially invite them to attend a SHG meeting for<br />
discussions on health. The gesture not only allows<br />
for an emotional connection, but also encourages<br />
women to ask immediate questions and testifies to<br />
the support from the VO. The letters also contain<br />
valuable heath tips, which benefit the entire family.<br />
Health Video Screenings<br />
Also as part of the strategy, health video screenings<br />
are organized to educate women and their families<br />
about maternal, neonatal and child health. These<br />
screenings have proven to be a powerful medium<br />
for diffusing health messages at scale. Audiovisual<br />
instantly engages one’s curiosity, overcomes<br />
obstacles of illiteracy and most importantly, merges<br />
key messages with a relatable cultural narrative. In<br />
rural areas where oral traditions do<strong>min</strong>ate, health<br />
video screenings show every sign of being able<br />
to enhance community health knowledge and<br />
encourage positive decision-making.<br />
Community Meetings<br />
‘Aam Sabha’, ‘Purva’ (hamlet) and Night meetings<br />
are critical for community mobilization and the<br />
widespread diffusion of health messages. Meetings<br />
are held in every local governing body or Gram<br />
Panchayat (GP), and are organized and facilitated<br />
by RGMVP ISC to ensure and maximize attendance.<br />
Participants include SHG members, non-SHG<br />
members and AAA as well as the village head or<br />
Pradhan. Discussion topics cover core beliefs and<br />
strategies, rights-based entitlements, and various<br />
health messages and information about linkages<br />
with government services and facilities.<br />
Additional leaflets and IEC material, including<br />
the monthly newsletter ‘Samara Sangathan’<br />
is distributed as a way to connect with target<br />
women and bring them under the fold.<br />
Small, easy-to-use and PICO projectors have<br />
enabled smooth operating for ISC, creating a<br />
sustainable method for information sharing<br />
across the project area.<br />
‘Aam Sabha’ (general body SHG meetings) have an<br />
especially high impact, as they offer a collective<br />
learning experience where a maximum number<br />
of people can attend.
19<br />
FOCUS AREAS<br />
CELEBRATE<br />
Village Baby Showers<br />
‘Goadh Bharai’ (Baby Shower) events, traditionally<br />
held among family and friends to celebrate a<br />
woman’s pregnancy, have been transformed under<br />
<strong>UPCMP</strong> to impact entire communities. MS’s and<br />
other trained community leaders have utilized<br />
these occasions as opportunities to engage directly<br />
with pregnant women and their families to spread<br />
critical health messages and provide access to<br />
vaccination and nutritional information, care and<br />
services. AAA as well as the village Pradhan can<br />
attend the events and collectively work together to<br />
establish linkages and encourage behavior change.<br />
A plate of essential food groups along with iron<br />
tablets is a typical gift for expecting mothers,<br />
setting in motion a chain of healthy habits for<br />
themselves and their baby.<br />
CONNECT<br />
Village Health & Nutrition Day<br />
Village Health and Nutrition Day (VHND) is an<br />
important point of convergence for <strong>UPCMP</strong>,<br />
interfacing between target women and the health<br />
system. ISC, MS and the VO work in tandem with<br />
AAA and PRIs to organize subsequent events.<br />
This helps to optimize results and ensure the<br />
attendance of target women. On the VHND,<br />
women can interact freely with the AAA and<br />
obtain basic services, like vaccinations and iron<br />
tablets, and important health information. VHNDs<br />
also provide on-site counselling and support for<br />
creating demands for better health services.<br />
The coordination between MS, ISC, AAA and<br />
PRI representatives in arranging VHNDs can<br />
bring about dramatic changes in the way people<br />
perceive health and health care practices.<br />
Maternal Health<br />
• Antenatal Care Practices<br />
• Women’s Contact with AAA & SHG<br />
During Pregnancy<br />
• Complication of Delivery Preparedness<br />
• Institutional Delivery<br />
• Postnatal Stay at Facility<br />
• Knowledge of Pregnancy Danger Signs<br />
• Uptake of IFA Tablets<br />
• Complications During or After Delivery<br />
• Postnatal Care for Mothers<br />
• Family Planning i.e. Birth Spacing<br />
Newborn & Child Health<br />
• Initiation of Breastfeeding<br />
• Kangaroo Mother Care & Delayed Bathing<br />
• Clean Cord Care<br />
• Newborn Danger Signs & Complications<br />
• Exclusive Breastfeeding<br />
• Complimentary Feeding of Children<br />
• Age Appropriate Immunization<br />
• Identification of Pneumonia Symptoms<br />
• Management of Diarrhoea through<br />
ORS/Zinc
20<br />
1.<br />
INSTITUTION<br />
& CAPACITY<br />
BUILDING<br />
DELIVERING<br />
INNOVATIONS<br />
RESULT 1<br />
Strengthened capacities of women’s<br />
institutions and individuals to<br />
mobilize rural communities and<br />
its resources to adopt preventative<br />
health practices.<br />
Under this result, various capacity<br />
building trainings and knowledge<br />
transfer activities are carried out<br />
in addition to continued SHG<br />
formation and nurturing.<br />
-<br />
Achieving better health outcomes<br />
require a boost of resources as<br />
well as adequate local capacity to<br />
use those resources effectively.<br />
Capacity building is critical to<br />
sustaining health outcomes and<br />
encouraging self-reliance/reducing<br />
reliance on external assistance.<br />
Thus, <strong>UPCMP</strong> seeks to strengthen<br />
individual capacity as well as the<br />
social platforms used to implement<br />
RMNCH initiatives. It is in this dual<br />
focus that the project has been able<br />
to continuously improve processes,<br />
devise new solutions and sustain<br />
outreach among target populations.<br />
KEY ACTIVATORS<br />
SHG Formation & Nurturing<br />
No problem exists in isolation.<br />
While maternal mortality may be<br />
attributed to lack of awareness and<br />
advice networks, lack of economic<br />
resources and sustainable livelihoods<br />
are also major factors. For this<br />
reason, RGMVP is relentless in<br />
its efforts to continuously form<br />
and nurture SHGs to eventually<br />
become institutionalized and selfreliant.<br />
Once emboldened with the<br />
necessary support, SHGs can begin<br />
their own journeys of transformation<br />
through livelihood enhancement,<br />
income generating activities, credit<br />
utilization, and preparation of Family<br />
Investment Plans.<br />
Inclusive Learning: V-Maps<br />
Women’s low educational status<br />
limits their access to health<br />
information. Women also have<br />
fewer opportunities to interact<br />
with sources or providers of<br />
information. In addition, the<br />
gendered socialization of women<br />
and girls discourages learning<br />
about sexuality and reproduction.<br />
Together, these barriers place<br />
women at an extreme disadvantage<br />
in recognizing symptoms of health<br />
problems, and therefore, delaying<br />
health-care seeking. Visual Mapping<br />
or hand-drawn ‘V-Maps’ help to<br />
counter information leakages, ensure<br />
social inclusion and speed up the<br />
mobilization process.<br />
V-Maps include:<br />
• Best maternal, neonatal<br />
and child health practices<br />
• Visions for family’s prosperity<br />
• Rights and entitlements<br />
• Ways to take action and<br />
mobilize others
21<br />
Training Of Trainers<br />
As a continuous effort to roll out new activities and<br />
keep pace with existing activities, various capacity<br />
building training programs are conducted in a<br />
cascading manner. The source of information<br />
or training first passes through the Program<br />
Management Office (PMO). This initiates<br />
the Training of Trainers (TOT) process<br />
enabling messages to flow downward<br />
with the ultimate goal of reaching<br />
target women. While sometimes<br />
specific to the individual’s roles<br />
and responsibilities, training is<br />
designed to equip all mobilizers<br />
with the relevant and<br />
necessary skills to be able<br />
to internalize, practice and<br />
diffuse critical messages<br />
to other members<br />
of the community,<br />
especially non-<br />
SHG members.<br />
INFORMATION SOURCE<br />
PMO<br />
CRDC<br />
BO<br />
VO<br />
SHG<br />
TARGET WOMEN<br />
RPO<br />
CRDI<br />
MS<br />
ISC<br />
SHG<br />
MEMBER<br />
The TOT structure<br />
is a major crux of<br />
information flow for<br />
<strong>UPCMP</strong>, ensuring<br />
that critical health<br />
messages reach<br />
target women.
22<br />
2.<br />
BEHAVIOR<br />
CHANGE<br />
MANAGEMENT<br />
MODEL<br />
DELIVERING<br />
INNOVATIONS<br />
RESULT 2<br />
Increased awareness and knowledge<br />
about RMNCH behaviors and<br />
increased capacity to demand<br />
quality health services and<br />
improved access.<br />
Under this result, various BCC<br />
awareness-raising and mobilization<br />
activities were carried out in<br />
addition to important linkages<br />
with supply side interventions.<br />
-<br />
<strong>UPCMP</strong> has emerged as a<br />
unique Health Behavior Change<br />
Management Model. As a fluid<br />
process, health messages are<br />
received through ToT from<br />
CRDI members and then<br />
further disse<strong>min</strong>ated to target<br />
populations through SHGs. Roles<br />
and responsibilities of ISC are<br />
allocated at different levels, while<br />
continuous institution and capacity<br />
building takes place. As a result,<br />
an information pipeline is secured,<br />
important government linkages are<br />
made and a sustained structure for<br />
quality interaction is established.<br />
KEY ACTIVATORS<br />
Pipeline Strategy for Information Flow<br />
As previously described, a number of periodic outreach activities – leaflets on<br />
RMNCH issues, VO letters, etc. – have been conducted to motivate and inform<br />
target women and their family members. As a starting point for diffusion, all<br />
information passes through BO level meetings, where VO representatives and<br />
critical mobilisers first learn of their importance. Information is then shared<br />
during VO meetings, attended by SHG representatives who then impart the<br />
information to their individual SHGs. Thereby, ensuring that the information<br />
reaches target women and households.<br />
INFORMATION<br />
BO<br />
VO<br />
SHG<br />
TARGET WOMEN
23<br />
Demand-Supply Linkages & Interaction<br />
1. BMGF Technical Support Unit<br />
While SHGs are responsible for continuous health layering through regular<br />
awareness and orientation programs, synergy with the BMGF Technical<br />
Support Unit (TSU) provides an added advantage for securing linkages.<br />
TSU is supporting the UP government to improve the quality of services<br />
and supplies at government facilities. Its work overlaps 26 blocks of the<br />
<strong>UPCMP</strong> area. BO level interface meetings between TSU and <strong>UPCMP</strong> staff<br />
have helped to provide better access to services and supplies from frontline<br />
workers and also usher support from government officials at Block and<br />
District levels.<br />
2. Overlapping Health Initiatives<br />
Government-sanctioned and pre-existing projects have created much<br />
added value and indirect impacts to <strong>UPCMP</strong>. For example, the<br />
Thrive Network, formerly known as Embrace, is mandated by the<br />
government to provide baby warmers to rural communities. In<br />
2015, the involvement of GAIN across 50 Blocks was another<br />
major contribution, as it focused on spreading information<br />
about child health practices and nutrition. Another key factor<br />
was the involvement of the IDEAS team from the LSH, who<br />
conducted a study to identify key innovations for scaling up.<br />
3. Village Health Sanitation & Nutrition Committee<br />
One of the key elements of the National Rural Health Mission is the<br />
Village Health, Sanitation and Nutrition Committee (VHSNC). As the name<br />
suggests, this committee is expected to take collective action on issues<br />
related to health and its social deter<strong>min</strong>ants at the village level. Since<br />
2005, VHSNCs have been set up at the village level (within the Panchayat)<br />
across states. This has meant considerable convergence between VOs<br />
and supply side interventions, providing the required support for women’s<br />
institutions to emerge as vibrant platforms to improve the health status of<br />
their communities.<br />
3. Village Organization Health & Gender Committees<br />
The Health and Gender Committee (HGC) is one of five important<br />
committees organized within the VO. HGCs works in tandem with<br />
the VHSNC (above) in cross-cutting health issues and strengthening<br />
interventions. Members are co-opted to become a part of the VHSNC within<br />
the Panchayat and are also encouraged to actively participate in Gram Sabha<br />
meetings to push the agenda on health issues raised within the VO, such<br />
as improved functioning of health providers, promotion of VHNDs, greater<br />
support to local health workers and ensuring access and use of quality<br />
equipment and supplies.<br />
INTERFACE MEETINGS HAVE HELPED TO PROVIDE BETTER ACCESS TO SERVICES AND<br />
SUPPLIES FROM FRONTLINE WORKERS AND GOVERNMENT OFFICIALS.
24<br />
3.<br />
PEER-TO-PEER<br />
PROPAGATION<br />
CYCLE<br />
DELIVERING<br />
INNOVATIONS<br />
RESULT 3<br />
Enhanced coordination,<br />
collaboration and information<br />
exchange for the sustainability of<br />
BCC activities through consultative<br />
and participatory processes and<br />
advice networks for support.<br />
Under this result, coordination with<br />
community stakeholders, women’s<br />
institutions and local health care<br />
workers are carried out.<br />
-<br />
The Peer-to-Peer Propagation<br />
Cycle of knowledge diffusion under<br />
<strong>UPCMP</strong> has developed from an<br />
organic and participatory process<br />
of communicating. Local health<br />
workers, RGMVP ISC, women’s<br />
institutions and various external<br />
stakeholders all act as important<br />
cogs in the wheel to impact family<br />
health outcomes. No role is more<br />
important than another. United by a<br />
common goal, individuals perform<br />
their duties, report conditions to<br />
required Village and Block levels,<br />
and consistently collaborate with<br />
one another to collectively share,<br />
organize and carry out activities.<br />
KEY ACTIVATORS<br />
Bottom-Up Approach<br />
A bottom-up approach help enables<br />
an immediate system of reporting,<br />
in which SHGs can raise issues up<br />
the chain of influence, or itself,<br />
provide the solution. This grassroots<br />
approach is crucial for building trust<br />
and encouraging individuals and<br />
family influencers to adopt healthier<br />
behaviors. Despite even the best of<br />
intentions, some health messages<br />
are rejected due to traditional health<br />
norms and practices. However, as<br />
one study indicated, target women<br />
in SHG areas are more likely to turn<br />
away from traditional beliefs and<br />
listen to local health workers than<br />
target women in non-SHG areas.<br />
Target women<br />
were asked to<br />
advise a woman<br />
in a hypothetical<br />
situation to evaluate<br />
their perceptions on<br />
traditional beliefs.<br />
“I WOULD LISTEN<br />
TO WHAT ASHA SAYS...<br />
MY FAMILY MEMBERS<br />
THOUGHTS ARE VERY<br />
OLD AND OUTDATED.”<br />
(<strong>UPCMP</strong>/SHG Area)<br />
Facilitating Linkages<br />
Communication between local<br />
health workers and SHGs and VOs<br />
is vital in the facilitation of health<br />
linkages, as well as the continued<br />
exchange of target women lists<br />
and sharing of demand for health<br />
services. A study conducted in<br />
2016 found AAAs to be a main<br />
trusted source of health advice and<br />
information for recently delivered<br />
and lactating women 12 . It also found<br />
that the more engagement AAA<br />
have with other health workers and<br />
the VO and SHG platform, the more<br />
likely target women are to utilize<br />
health facilities for deliveries and<br />
consult others for advice.<br />
“SHE WOULD FACE<br />
PROBLEMS IF SHE<br />
PRACTICED WHAT<br />
ASHA TOLD HER AND<br />
DID NOT LISTEN TO<br />
HER IN-LAWS.”<br />
(Non-<strong>UPCMP</strong>/SHG Area)<br />
12 Jenny Ruducha et al (2016). Who’s Advice Should I take?
25<br />
Advice Networks<br />
<strong>UPCMP</strong> has seen a tremendous<br />
increase in the collaboration of SHG<br />
members with AAA in disse<strong>min</strong>ating<br />
health information within the<br />
villages. As SHGs continue these<br />
efforts, AAA work to expand the<br />
horizon even further by engaging<br />
with other stakeholders to secure<br />
health supplies, provide care to<br />
women during emergencies, and<br />
offer guidance to other AAA when<br />
questions arise. Interaction with the<br />
Village Pradhan has also helped in<br />
connecting target women to SHGs<br />
and AAA, and providing assistance<br />
during emergencies.<br />
ANM<br />
TARGET<br />
WOMAN<br />
CRDI<br />
SHG<br />
WOMAN<br />
RGMVP<br />
MS<br />
RGMVP<br />
ISC<br />
ASHA<br />
TARGET<br />
WOMAN<br />
TARGET<br />
WOMAN<br />
ASHA<br />
SHG<br />
WOMAN<br />
AWW<br />
SHG<br />
WOMAN<br />
CRDI<br />
TARGET<br />
WOMAN<br />
Community<br />
Resource<br />
Development<br />
Institutions<br />
Government-<br />
Supported<br />
Local Health<br />
Workers<br />
Existing Self-<br />
Help Group<br />
Members<br />
RGMVP<br />
Internal Social<br />
Capital<br />
Pregnant,<br />
Recently<br />
Delivered<br />
Women or<br />
Mothers with<br />
Children (0-2)<br />
Connectivity Through mHealth<br />
The availability and use of cell phones have created an opportunity to incorporate mHealth platforms to enhance and track communication among<br />
ANM, AWW and ASHA; coordinate with RGMVP MS, ISC and CRDI; effectively report and resolve problems with health supplies; and develop a mobile<br />
social network to connect target women with health workers, other target women and SHG members.
26<br />
4.<br />
COMMUNITY<br />
MONITORING<br />
& EVALUATION<br />
DELIVERING<br />
INNOVATIONS<br />
RESULT 4<br />
Selected community volunteers<br />
assisted in collecting and measuring<br />
outcomes related to knowledge and<br />
practices in the target population.<br />
Under this result, two rounds of<br />
community-managed Lots Quality<br />
Assurance Sampling (LQAS) was<br />
implemented to track and improve<br />
the quality of the process.<br />
-<br />
Among various Monitoring, Learning<br />
and Evaluation (MLE) activities<br />
under <strong>UPCMP</strong>, two rounds of Lot<br />
Quality Assurance Sampling (LQAS)<br />
surveys were proposed to monitor<br />
project activities so that corrective<br />
measures could be taken, if<br />
necessary. Central to this initiative is<br />
the involvement of CRDI members<br />
to ad<strong>min</strong>ister the survey and record<br />
quality data. CRDIs are crucial to<br />
MLE and subsequently a direct<br />
reflection of project outcomes.<br />
Thus, many innovative learning<br />
techniques and methods were used<br />
to better equip the women for this<br />
important undertaking.<br />
KEY ACTIVATORS<br />
Ongoing Technical Support<br />
Population Council (PC) has been<br />
essential to <strong>UPCMP</strong> in providing<br />
technical assistance during<br />
implementation and continuously<br />
working to develop salient<br />
operations research projects. As<br />
a crucial point of departure, PC<br />
conducted the baseline survey<br />
for the learning phase Blocks,<br />
measuring key maternal and<br />
newborn health indicators for<br />
the project. PC<br />
has also played<br />
an especially<br />
important role in<br />
data collection<br />
for LQAS by<br />
working closely<br />
with different<br />
teams of CRDI<br />
women in<br />
the fields and<br />
internal MIS staff<br />
to ensure timely<br />
completion<br />
of work and<br />
data quality.<br />
Assessing Performance<br />
CRDI teams were given rigorous<br />
training through a number of<br />
innovative hands-on techniques<br />
to provide participants with<br />
experiential learning. These include<br />
classroom demonstration, role-play<br />
and mock practices, and simulation<br />
exercises for conducting surveys.<br />
Several strategies were adopted to<br />
ensure the quality of surveys to be<br />
conducted in the fields, including<br />
house listings to<br />
identify eligible<br />
respondents<br />
and trial surveys<br />
to identify<br />
and address<br />
problems in<br />
data collection.<br />
Data quality was<br />
further assured<br />
using on-spot<br />
observation<br />
checks and<br />
back-checks<br />
by PC.
27<br />
Field Learning Visits<br />
UTTAR<br />
PRADESH<br />
RGMVP<br />
Exposure visits were undertaken in<br />
West Bengal, Bihar and Jharkhand<br />
to gain insight into successful<br />
strategies, models and measures<br />
for strengthening the capacities of<br />
community health workers. The<br />
visit to Bandhan (West Bengal) in<br />
2012 stressed the importance of<br />
health forums and home visits, as<br />
well as health kits, linkages and<br />
referrals. Similarly, observing the<br />
Ananya Project (Bihar) in 2015<br />
helped consortium partners to<br />
better understand the project’s<br />
behavior change framework, in<br />
particular the elements, approach,<br />
tools and aids developed and used<br />
by the community. And lastly, the<br />
exposure visit to Ekjut (Jharkhand)<br />
in 2015 provided key insights into<br />
the process of another unique<br />
participatory learning and action<br />
cycle focusing on maternal and<br />
newborn health.<br />
JHARKHAND<br />
Ekjut<br />
BIHAR<br />
Ananya<br />
WEST<br />
BENGAL<br />
Bandhan<br />
THE VISIT TO WEST<br />
BENGAL STRESSED<br />
THE IMPORTANCE<br />
OF HEALTH FORUMS,<br />
HOME VISITS, HEALTH<br />
KITS, LINKAGES AND<br />
REFERRALS.
28<br />
RESULTS & CRITICAL MILESTONES<br />
Target vs. Achieved<br />
POPULATION<br />
71.9<br />
% ACHIEVED<br />
6.8M vs. 4.9M<br />
POOREST HOUSEHOLDS<br />
71.9<br />
% ACHIEVED<br />
1.1M vs. 816,012<br />
SHGS<br />
95<br />
% ACHIEVED<br />
75,000 vs. 71,000<br />
VILLAGES/GPS<br />
96<br />
% ACHIEVED<br />
5,1000 vs 4,900<br />
BLOCKS<br />
100<br />
% ACHIEVED<br />
120 vs. 120<br />
Target Women Identified (% of targets achieved)<br />
Diffusion Inside & Outside SHG Fold<br />
PREGNANT WOMEN<br />
RECENTLY DELIVERED WOMEN<br />
74%<br />
58%<br />
50<br />
40<br />
30<br />
2016<br />
OUTSIDE<br />
Pregnant Women<br />
Recently Delivered Women<br />
Mothers Of Childen (0-2 Years)<br />
INSIDE<br />
Pregnant Women<br />
Recently Delivered Women<br />
Mothers Of Childen (0-2 Years)<br />
MOTHERS OF CHIDREN (0-2)<br />
54%<br />
20<br />
10<br />
0<br />
JAN<br />
FEB<br />
MAR<br />
APR<br />
MAY<br />
JUN<br />
JUL<br />
AUG<br />
SEPT<br />
OCT<br />
NOV<br />
DEC<br />
*As of Dec 2016; Source: RGMVP MIS
29<br />
INTERNAL SURVEY: LQAS<br />
Accessed Maternal Health Services<br />
Maternal Danger Signs (Knowledge)<br />
Neonatal Danger Signs (Knowledge)<br />
34.5%<br />
3+ ANC<br />
check up<br />
100+ IFA<br />
Tablets<br />
Institutional<br />
Delivery<br />
PNC visit within<br />
a week of<br />
Delivery<br />
Bleeding Prolonged<br />
During Labour over<br />
Pregnancy 12 hours<br />
Bleeding<br />
after<br />
Delivery<br />
Swelling<br />
of hands &<br />
Feet<br />
Foul<br />
Smelling<br />
Discharge<br />
Convulsion<br />
- Fits<br />
Poor<br />
Suckling<br />
or feeding<br />
Redness<br />
& discharge<br />
around<br />
the cord<br />
Pneumonia Convulsion Fever Diarrhoea<br />
17.2%<br />
72.1%<br />
76.1%<br />
93.9%<br />
37.4%<br />
64.6%<br />
42.4%<br />
80.6%<br />
39.6%<br />
41.5%<br />
56%<br />
71.7%<br />
70.8%<br />
83.6%<br />
23.4%<br />
47.4%<br />
73.6%<br />
65%<br />
47.2%<br />
9.6%<br />
26.3%<br />
80.4%<br />
85.1%<br />
52.9%<br />
44.3%<br />
21.6%<br />
47.5%<br />
20.8%<br />
36.7%<br />
16%<br />
29.1%<br />
32.1%<br />
55.4%<br />
18.7%<br />
46.6%<br />
15.9%<br />
25%<br />
40.2%<br />
16.9%<br />
54.5%<br />
15.6%<br />
83.2%<br />
68.8%<br />
Early Newborn Care (Practise) Delivery Preparedness Plan (Practise) Pneumonia (Knowledge)<br />
44.6%<br />
Jun - 2014<br />
Jul - 2015<br />
KMC<br />
Delayed<br />
Dathing<br />
Clean Cord<br />
Care<br />
Exclusive<br />
breastfeeding<br />
(in last 24 hours<br />
of survey)<br />
Identified<br />
Institution<br />
Arranged for<br />
Transport<br />
Saved<br />
Money<br />
Identified<br />
People to<br />
Accompany<br />
Fast<br />
Breathing<br />
Chest<br />
Indrawing<br />
Grunting<br />
Sound<br />
*As of Dec 2016; Source: RGMVP MIS
30<br />
MATERNAL HEALTH BEHAVIORS<br />
Postnatal Stay at Facility for 24 Hours 100 or More IFA Consumption Institutional Delivery<br />
NEONATAL HEALTH BEHAVIORS<br />
Early Breastfeeding Delayed Bathing For 48 Hours Skin-to-Skin Care<br />
CHILD HEALTH BEHAVIORS<br />
Exclusive Breastfeeding Complimentary Food Initiation At 6 Months Age Appropriate Immunisation<br />
Significance test between Baseline and Endline estimates is based on Z test: p
31<br />
LESSONS FOR THE FUTURE<br />
Health Behavior Change Management is a cross-cutting and complex issue, requiring mobilization of knowledge, capacities and skills. Lessons learned have<br />
offered valuable insight, not only for RGMVP to enhance its work in UP, but also for other development practitioners, academics and researchers to consider<br />
such an approach for affecting other marginalized communities in India and around the globe.<br />
Allow Adequate<br />
Time for the <strong>Process</strong><br />
Ensure Community<br />
- Owned Approach<br />
Leverage Existing<br />
Networks & Structures<br />
1 2 3 4<br />
Diversify Meetings<br />
& Strategies<br />
Careful planning is essential.<br />
It is particularly important to allow<br />
enough time to identify communities<br />
where the approach can have<br />
the most impact i.e. among POP<br />
populations and SC/ST communities.<br />
The <strong>UPCMP</strong> Learning Phase was<br />
critical in achieving objectives, as it<br />
allowed the necessary time to learn<br />
about the local communities, identify<br />
strong and capable mobilizers and<br />
consult within the RGMVP streams<br />
of influences to deter<strong>min</strong>e how poor<br />
households could be most receptive<br />
to BCC strategies. The mobilization<br />
cycle is an intensive process that<br />
takes time, but using a systematic<br />
approach allows SHGs to develop<br />
cohesion and mutual support, work<br />
together to identify problems and<br />
solutions and take collective action.<br />
Significant value is attached with the<br />
process of community mobilization in<br />
order to attain <strong>UPCMP</strong> objectives. To<br />
sustain the efforts, it is very important<br />
that the women’s institutions,<br />
through which activities are carried<br />
out, become self-sufficient and<br />
take ownership in the mobilization<br />
process. SHG members need to be<br />
consulted, involved and integrated<br />
in the decision-making process and<br />
social changes should be driven<br />
from the community itself. In such<br />
cases, community mobilization can<br />
be seen as an approach and tool<br />
that enables people to organize for<br />
collective action by pooling resources<br />
and building the solidarity required<br />
to resolve local problems and work<br />
towards community advancement.<br />
Project implementation at the<br />
local level is especially challenging<br />
among rural populations, as it<br />
requires significant rapport building<br />
activities with community members.<br />
RGMVP was able to counter this on<br />
many fronts by utilizing its existing<br />
networks and structures, and by<br />
also galvanizing the influence it<br />
had already made among the poor.<br />
Recruiting local women with the right<br />
attitudes and skills as facilitators and<br />
mobilizers is also critical to success.<br />
Leveraging the existing network of<br />
ISC and others already familiar with<br />
SHG processes and local context<br />
proved to be especially efficient and<br />
effective. With continued nurturing<br />
and capacity building training, these<br />
local leaders are the life force to in<br />
the mobilization process.<br />
High levels of women’s<br />
participation can be achieved<br />
without financial or other<br />
incentives, especially if meetings<br />
address topics that are extremely<br />
relevant, such as newborn and child<br />
health. Covering a range of topics<br />
and using a range of methods and<br />
BCC communication materials<br />
helps to ensure good participation.<br />
Reach is further extended as<br />
mobilizers share knowledge<br />
with and provide support to<br />
other women in the community.<br />
Encouraging innovation among<br />
the women to adapt strategies and<br />
also develop new is another great<br />
way to expand and grow. Dayara<br />
Mapping, for example, may be a<br />
standardized method for targeting<br />
women, but there are many forms<br />
of implementation to ensure results.
32<br />
WHAT THESE WOMEN LEADERS DO TODAY WILL UNDOUBTEDLY<br />
HAVE TRANSFORMATIVE IMPACTS ON THE NEXT GENERATION.<br />
Target SHG Areas to<br />
Expand Coverage<br />
Complement SHG Work by<br />
Improving Linkages<br />
Recognize Young<br />
Women’s Potential<br />
5 6 7 8<br />
Strategize in Countering<br />
Complex Barriers<br />
Continued formation of SHGs is<br />
essential for sustained mobilization.<br />
However, targeting and coverage<br />
of existing SHG membership can<br />
undoubtedly fast track the process,<br />
especially in terms of achieving<br />
positive health outcomes.<br />
Functioning SHGs provide the<br />
necessary platform to identify<br />
target women and also offer<br />
transformation beyond health.<br />
While many non-SHG women<br />
may initially turn to the processes<br />
for receiving health benefits,<br />
their relationship with mobilisers<br />
and association with women’s<br />
institutions can often lead to wider<br />
forms of empowerment. By virtue<br />
of simply co<strong>min</strong>g forward and<br />
seeking help, women can become<br />
financially independent and<br />
experience increased confidence<br />
in their abilities to take action.<br />
Efforts to mobilize action in order to<br />
address maternal and newborn health<br />
problems must be complemented<br />
by efforts to strengthen health<br />
systems and increase access to<br />
quality maternal, neonatal and child<br />
health care. Community leaders<br />
and local health workers are key<br />
actors in strengthening community<br />
links with health services and<br />
enabling communities to demand<br />
improvement in service provision.<br />
Communication between health<br />
committees situated within the<br />
local governing body and women’s<br />
institutions can also help to ensure<br />
the quality of services, as they have<br />
better knowledge of and access<br />
to government funds intended to<br />
improve health equipment, services<br />
and facilities.<br />
In 2013, RGMVP began organizing<br />
Young Women’s SHGs (YWSHGs) by<br />
leveraging the existing network of<br />
women’s SHGs. The overall aim is to<br />
provide adolescent girls with safe,<br />
social spaces to collectively learn,<br />
discuss and negotiate important<br />
issues that affect their health and<br />
well-being. As more YWSHGs were<br />
formed, it was found that the girls<br />
had a greater willingness to learn<br />
about and adopt healthier and<br />
safer practices. YWSHGs were also<br />
found to be excellent channels to<br />
disse<strong>min</strong>ate health messages, as<br />
the girls are predo<strong>min</strong>ately more<br />
educated with greater aptitude to<br />
assimilate ideas around health. To<br />
date, the initiative has formed over<br />
7,700 YWSHGs and has continued<br />
to complement SHGs in efforts<br />
to improve health outcomes and<br />
empower their communities.<br />
Socio-cultural, religious and practical<br />
factors can be a barrier to women’s<br />
participation in SHG meetings.<br />
Strategies needed to address<br />
these include concerted efforts to<br />
accommodate those for which the<br />
meetings are intended to benefit and<br />
secure the support of community and<br />
household influencers – be it taking<br />
advantage of village events, making<br />
regular home visits or communicating<br />
with village heads. Where other forms<br />
of resistance arise, women must<br />
be encouraged to depend on one<br />
another, learn from their experiences<br />
and grow as a unit to challenge<br />
destructive norms. Through a<br />
continuous exchange of information,<br />
ideas and support, what these women<br />
leaders do today will undoubtedly<br />
have transformative impacts on the<br />
next generation.
33<br />
PARTNER ORGANIZATIONS<br />
Bill & Melinda Gates Foundation<br />
BMGF is dedicated to improving the quality of live for individuals around the world. From poverty to health to education, BMGF areas of focus seek to build<br />
partnerships that bring together resources, expertise and vision. BMGF is working with a number of organizations across India to drive change. In Uttar Pradesh,<br />
specifically, the aim of BMGF is to understand options for scaling up community platforms to improve family health outcomes and converging supply and<br />
demand interventions. www.gatesfoundation.org<br />
Public Health Foundation of India<br />
PHFI is committed to working towards a healthier India. PHFI is helping to build public health institutional systems capacity in India for strengthening education,<br />
training, research and policy development in the area of Public Health. Established in 2006 as a public-private initiative, PHFI is an independent foundation<br />
head-quartered in New Delhi and its constituent Indian Institutes of Public Health (IIPH) (Andhra Pradesh), Delhi NCR, Gandhinagar (Gujarat) and Bhubaneswar<br />
(Odisha). www.phfi.org<br />
Population Council<br />
PC is an international NGO conducting promising research and delivering solutions to address critical health and development issues around the world.<br />
Working through a consortium, PC researchers have conducted numerous operations research projects to help develop evidence-based comprehensive<br />
behavior change communications strategies for improving reproductive, maternal, neonatal and child health outcomes in Uttar Pradesh, Bihar and other<br />
northern states. www.populationcouncil.org<br />
Boston University, Center for Global Health & Development<br />
CGHD at BU is a multidisciplinary research center that engages faculty from across the University to conduct and utilize high-quality applied research to impact<br />
the health of under-served populations around the world. Core functions at CGHD include conducting local needs assessments, generating policy and program<br />
relevant evidence through a range of methodologies, and assessing effective strategies, interventions and service delivery models. www.bu.edu/cghd<br />
Community Empowerment Lab<br />
CEL engages with local communities in Uttar Pradesh to help set up ecosystems to create a culture of innovation and address challenges. CEL has conducted<br />
a number of large community-based studies since 2003, including the Shivgarth study on newborn survival, as well as operations research and evaluation of the<br />
CARE INHP II program. The expertise of the CEL team in evidence-guided innovations and behavior change management has led to a significant reduction in<br />
neonatal mortality. www.community.org.in
34<br />
ACRONYMS<br />
AAA<br />
ASHA, ANM, AWW<br />
RMNCH<br />
Reproductive, Maternal, Neonatal and Child Health<br />
ANC<br />
Postnatal Care<br />
MS<br />
Meeting Sakhis<br />
ANM<br />
Auxiliary Nurse Midwife<br />
MLE<br />
Monitoring, Learning and Evaluation<br />
ASHA<br />
Accredited Social Health Activist<br />
ORS<br />
Oral Rehydration Solutions<br />
AWW<br />
Anganwadi Worker<br />
PC<br />
Population Council<br />
BCC<br />
Behavior Change Communication<br />
PHFI<br />
Public Health Foundation of India<br />
BMGF<br />
Bill and Melinda Gates Foundation<br />
PNC<br />
Antenatal Care<br />
BO<br />
Block Organization<br />
POP<br />
Poorest of the Poor<br />
BU<br />
Boston University<br />
PRI<br />
Panchayati Raj Institutions<br />
CEL<br />
Community Empowerment Lab<br />
RGCT<br />
Rajiv Gandhi Charitable Trust<br />
CRDC<br />
Community Resource Development Center<br />
RGMVP<br />
Rajiv Gandhi Mahila Vikas Pariyojana<br />
CRDI<br />
Community Resource Development Institutes<br />
SHG<br />
Self-Help Group<br />
GAIN<br />
Global Alliance for Improved Nutrition<br />
TOT<br />
Training of Trainers<br />
HGC<br />
Health and Gender Committee<br />
TSU<br />
Technical Support Unit<br />
IFA<br />
Iron/Folic Acid<br />
UP<br />
Uttar Pradesh<br />
ISC<br />
Internal Social Capital<br />
<strong>UPCMP</strong><br />
Uttar Pradesh Community Mobilization Project<br />
KMC<br />
Kangaroo Mother Care<br />
VHND<br />
Village Health and Nutrition Day<br />
LQAS<br />
Lots Quality Assurance Sampling<br />
VHSNC<br />
Village Health, Sanitation and Nutrition Committee<br />
LSH<br />
London School of Hygiene and Tropical Medicine<br />
VO<br />
Village Organization
“STRENGTH DOES NOT COME FROM<br />
PHYSICAL CAPACITY. IT COMES<br />
FROM AN INDOMITABLE WILL.”<br />
Mahatma Gandhi