INTERNATIONAL INSTITUTE OF HEALTH MANAGEMENT RESEARCH DELHI
Appraisal of Save A
Mother –Effective Social
Persuasion Platform
(ESP) in Amethi, UP,
India
IIHMR
2012
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International Institute of Health Management Research (IIHMR), Delhi- India
IIHMR, Delhi is an institution dedicated to the improvement in standards of health through
better management of health care and related programmes. It seeks to accomplish this
through management research, training, consultation and institutional networking in a
national and global perspective.
IIHMR Delhi
Study Team
Sector 18A Plot no3
Anupama Sharma
Dwarka
Dr. L P Singh
Delhi-110075
Shikha Bassi
Iihmrdelhi.org
This report may be freely reviewed, quoted, or translated, in full or in part, provided the
source is acknowledged.
The information and views expressed in this document may not necessarily reflect the
views of the IIHMR Delhi
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Contents
Page No
Acknowledgements .............................................................................................................................................. 3
Abbreviations ......................................................................................................................................................... 4
List of Figures…………………………………………………………………………………………………………………5
Executive Summary.............................................................................................................................................. 6
1 Introduction ........................................................................................................................................................ 8
1.1 Background……………………………………………………………………………………………………8
1.2 Objectives………………………………………………………………………………………………………9
2 Methodology..................................................................................................................................................... 10
2.1 Sampling Methodology………………………………………………………………………………….10
2.2 Sample Size………………………………………………………………………………………………..…10
3 Findings .............................................................................................................................................................. 11
3.1 In-Depth Interviews……………………………………………………………………………………...11
3.2 Focus Group Discussions…………………………………………………………………………...….20
3.3 Key Information Interviews…………………………………………………………………………..22
Chapter 4 Summary .......................................................................................................................................... 27
Chapter 5 Recommendations ........................................................................................................................ 28
Annexure……………………………………………………………………………………………………………...………29
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Acknowledgements
Appraisal of Save A Mother –Effective Persuasion Platform, Maternal Health Interventions
under Rajiv Gandhi Mahila Vikas Pariyojna (RGMVP) in Amethi, UP, India was successfully
completed due to the efforts and involvement of numerous organisations and individuals at
different stages of the study and we wish to acknowledge their contribution.
First of all I wish to thank Dr. Shiban Ganju , founder, Save A Mother Foundation and
Chairman of Atrimed Pharma, Bangalore for granting a opportunity to conduct this study.
We are also extremely grateful to the Save A Mother staff for their co-operation and
facilitation at village levels. We are particularly grateful to Shri Anoop Pant, Project
Manager of SAM-ESP and Shri Brijraj Yadav , field facilitator for all their assistance in
carrying out the field work at Amethi district.
Appreciation is also expressed to Ms. Shikha Bassi who provided administrative support
during the development of study tool. The study would not have been conducted without
support of Mr. Vikas Goel, finance in charge at IIHMR and Mr. Sujaram administrator at
IIHMR.
Extensive discussions were held during the study with district health officers, block health
officers, Swasthya Sakhi’s, ANM, and Pradhans of Amethi at various stages of the study. We
acknowledge the efforts of those officials and express our deep appreciation for their
enthusiasm and active participation.
This acknowledgement cannot be concluded without expressing appreciation to the
respondents, including the families of household and community members for their
tremendous patience and support without any expectation from the study.
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Abbreviations
ANM
Auxiliary Nurse Midwife
ASHA
Accredited Social Health Activist
AWW
Anganwadi Worker
CHC
Community Health Centre
CLA
Cluster Level Association
FGD
Focus Group Discussion
KII
Key Informant Interview
MIS
Management Information System
PHC
Primary Health Centre
RGMVP
Rajiv Gandhi Mahila Vikas Pariyojna
SAM
Save A Mother
SC/ST
Scheduled Caste/Scheduled Tribes
SHG
Self Help Group
SS
Swasthya Sakhi
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List of Tables & Figures
No
Title
Page No
Table 1
Sample Size at the Study site
10
Figure 1
Unmet Need for Family Planning
12
Figure 2
Birth Spacing
12
Figure 3
Women in Reproductive Age Group
13
Figure 4
Source of Drinking Water
14
Figure 5
Safe Drinking Water Practices
14
Figure 6
Access to Transport at the Time of Delivery
16
Figure 7
Burden of Transport Cost during Delivery
16
Figure 8
Reasons for Facility Based Delivery
17
Figure 9
Positive Factors Associated with Facility Based
Delivery
18
Figure 10
Reasons for Availing ANC
19
Figure 11
Women Delivered in 2011
19
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Executive Summary
This study Appraisal of Save A Mother –Effective Persuasion Platform, Maternal Health
Interventions under Rajiv Gandhi Mahila Vikas Pariyojna (RGMVP) in Amethi, UP, was
carried out after extensive preliminary fieldwork prior to submission of the proposal. In
conjunction with specialists, the final proposal was developed and Amethi was selected as
it was the first place of intervention. The study focused to process related outcomes on
awareness and behavior change.
The key parameters considered were resource
mobilization by community for maternal health, improved health seeking behaviour,
improved hygiene practices within households, improved coordination among different
health workers at village level.
The study consisted of a combination of quantitative and qualitative methods. The
quantitative methods included survey of women in reproductive age group and qualitative
methods involved focus group discussions, key informant interviews with medical officers,
SAM staff, ground level health workers and project manager. The selected blocks were
Shahgarh, Sangrampur, Gauriganj and MusafirKhana. Sample of 27 women in reproductive
age group was chosen for indepth interviews, 50 for FGD’s and 31 men for FGD’s. 4 ANM’ s,
5 ASHA’s, 5 Swasthya Sakhi’s, 4 Gram Pradhan’s, 1 Office manager, 1 Project manager and 3
Medical Officers were chosen for Key Informant Interviews.
The key findings of the study emerge from several components of the study. Swasthya
Sakhis are seen as a major source for dissemination of information on health issues such as
womens’ health in general, health and hygiene, maternal health, and have thus led to
improved health and hygiene practices. FGD’s and interviews findings shows the impact of
Swasthya Sakhi initiatives with improved institutional deliveries, immunizations and
utilization of health facilities. The greater shift is seen in universalization of facility based
delivery with improved access to transport and finances through community support and
SHG. The interviews with health workers highlighted the existing close knit working
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relationship between AWW, ANM, ASHA and Swasthya Sakhi for improving women and
child health. The study also brought the correlation of womens’ health with social
development to the limelight. The Swasthya Sakhi program being a component of SHG in
RGMVP demonstrated that women with improved financial security, improved power
relationships within household and society, enhanced awareness on health, increased
contribution in household decision making along with men and acceptance by men and
recognition to women, has brought remarkable change in health status and as well as in
overall development of villages.

It is imperative to carry out several such studies in other districts where the
programme has been running successfully for the past 3 years.

There is a strong need to recognize Swasthya Sakhis in the health system for their
crucial role in tracking women’s health status at a household level. Credit to their
work through MIS at PHC and CHC level in addition to ASHA and ANM is vital for the
continued success of the project.

The data management system at SAM needs to be strengthened along with adoption
of scientific methods for analysis such as conducting base line studies to monitor the
progress.

Emphasis on bringing awareness on family planning is equally important to bring
the maternal mortality to lowest levels apart from other factors.

In order to bring change at policy and programme level with improved resource
allocation, it is utmost required that the voices of Swasthya Sakhis and women are
heard by bureaucrats, far beyond their community,
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1.
Introduction
1.1
Background
Save A Mother Foundation (SAM) under Rajiv Gandhi Mahila Vikas Pariyojna (RGMVP)
started working in Amethi, Raebareli area in March 2008 with a mission to reduce
maternal mortality by 92% and neonatal mortality by 66% in about 900 villages around
Sultanpur in UP. The foundation created a Effective Social Persuasion Platform (ESP),
leveraging village health volunteers called Swasthya Sakhis to spread health literacy
awareness in their villages, to keep track of each pregnant woman in their villages and
connect them to public health facilities. The foundation introduced two Swasthya Sakhi
(female health volunteers) per village.
Swasthya Sakhi is one of the members in a Self Help Group (SHG). SHG is a group of
poor rural women working as a community at a village level. Each SHG consist of 10-20
women addressing issues of financial inclusion, healthcare, livelihoods, education and
the environment. The SHG comprise of a President, Treasurer, General Secretary,
Samuh Sakhi, Swasthya Sakhi, book keeper and members. SHG working as community
institutions help women access their basic rights and entitlements, linking them to
existing state and non-state structures and resources, like the Mahatama Gandhi
National Rural Employment Guarantee Scheme (MNREGA) and the National Rural
Health Mission (NRHM), amongst others. 10-20 SHG’s constitute Cluster Level
Association or Village Organizations (VOs) at village level representing 150-200 poor
families. CLA in turn forms Block Level Association (BLA) or Block Organizations (BOs)
representing 5,000 to 7,000 women.
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Block Level Association
(BLA)
CLA
SHG
1.2.
CLA
CLA
CLA
CLA
SHG
Objective: The purpose of this evaluation is to validate the processes and procedures
undertaken by Save A Mother and to assess their effectiveness in reducing maternal
mortality in Amethi district
1.2.1. Specific Objectives:
1. To find out the awareness level among women on maternal health
2. To understand the knowledge attitude and practices for maintaining hygiene at
household level
3. To evaluate the awareness level of beneficiaries on Save A Mother interventions
4. To evaluate the awareness level of health workers on Save A Mother interventions
at all tiers of health system
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5. To assess the community awareness on various health schemes
6. To evaluate the extent of community support for transportation during delivery
7. To assess the health seeking behavior change for maternal health services since
inception of project Swasthya Sakhi
8. To find out the impact of self help group on women status in the society
2.
Methodology
2.1
Sampling Methodology
A cross sectional study using qualitative survey was carried out with key
stakeholders.
The Core Study Committee (CSC) will use three qualitative
techniques:
2.1.1. Indepth Interviews: To understand health seeking behaviour change, interviews
with mothers with at least one surviving child under 5 years of age were conducted
2.1.2. Key Informant Interviews: such as Sakhi, ANM, ASHA, Medical officers from CHC,
Sarpanch, etc.
2.1.3. Focus Group Discussion: In order to understand the dynamics and issues pertaining
to health and utilization of health services, discussion were conducted among
married women (15-49 years)
2.2
Sample Size
Using purposive sampling technique and considering Percentage of women (aged
15-49) who received full antenatal care (ANC) check up as performance indicator,
Amethi is chosen for survey as ANC coverage in Sultanpur is 5.2%, compared to
highest value of 10 % in other districts (DLHS-3). Four blocks were chosen namely
Shahgarh, Sangrampur, Gauriganj and Musafir Khana for the survey; and 5 villages
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in corresponding sub centre were selected from all four blocks. The sample size is
summarized in Table 1
Table 1: Sample Size at the Study site
Method
At a village level
At Block Level
27
0
5 groups (50)
0
5 groups (31)
0
ANM
4
0
ASHA
5
0
Swasthya Sakhi
5
0
Gram Pradhan
0
4
Office Manager
0
1
Project Manager
0
1
Medical Officers
0
3
In-depth Interviews
Women
Focus Group Discussion among
Married Women (15-49 years)
Focus Group Discussion
Married men (15-49 years)
Key Informant Interviews
For conducting data analysis SPSS 16.0 and Microsoft excel was used.
3.
Findings
3.1
In-Depth Interview Key Findings:
3.1.1. Awareness on women health issues
The selected 27 women for in-depth interview have given birth to their youngest
child 2-4 years ago (82%). 89% of these women received information about ANC.
The average age of mothers at the birth of their first child varies from 18yrs (25th
percentile) to 22 years (75th percentile); however 7% reported age less than 15
years. Maternal health education has been received by 86% of the women, mainly
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from Sakhi (64 %), Asha (7%) and 10% from both. Almost 52% of women were
satisfied with current number of children having an average gap between children
2-3.5 years (74%) in contrast to 92% reported no adoption of permanent method of
family planning.
Figure 1. Unmet Need for Family Planning
Figure 2: Birth Spacing
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Figure 3. Women in Reproductive Age Group
3.1.2. Hygiene: Knowledge, Attitude and Practices
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Almost 85 % of women have no sanitation facility at home and 65% defecate in
open field or behind bushes. Only 11% reported toilet being build under
government scheme within the household.
Majority of women have access to drinking water either to hand pump (71%) or to
piped water facility (21%). However 44% of women reported open well as source of
water. Some women (14.3%) reported shortage of water too. Many women either
cover the water (64%) or boil it (21%) to ensure water is safe for drinking. 96% of
women wash hand with soap before eating and after defecation and 82% of women
confirmed that they have received information on hand washing. Most of the women
received information from Sakhi (63%) and ASHA (7%), rest being neighbor
combined with Asha and Sakhi.
Figure 4. Source of Drinking Water
Figure 5. Safe Drinking Water Practices
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3.1.3. Awareness on Save a Mother interventions among the beneficiaries and health
providers
Maternal health education is received by 85.7% of the women, mainly from Sakhi
(64 %), Asha (7%) and 10% from both, including information received for hygiene.
This confirmed the high awareness level among women. About 95% of women
reported Asha or sakhi visit during their last pregnancy. Women also stated that
presence of samuh (SHG) in village has played significant role in generating health
awareness. Around 70% of women confirmed being part of SHG as a member and
attending monthly meetings. 75% of women were also able to restate the fact that
presence of SHG has enhanced status of women in society.
3.1.4. Community Involvement and Participation
1. Community Awareness about Health Schemes
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89% women were aware of JSY, including 78% who were JSY beneficiary and have
received the amount. Women mentioned Sakhi , CLA meeting and SHG meeting as a
source of information for government run schemes.
2. Community Mobilization for Transport and Finance during Delivery
A fraction of the women reported receiving help from Sakhi (4%) and Asha (21%)
during pregnancy for arranging transport. Women reported being self sufficient to
gather help from either neighbor or from family during labor pain. Majority of
women (67%) self financed the travel to nearby facility during labor.
Figure 6. Access to Transport at the Time of Delivery
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Figure 7. Burden of Transport Cost during Delivery
3.1.5. Perception about facility based delivery
Saving a mother’s life (43%) and good service (29%) at health facility were the
prime reasons cited by women for delivering their youngest child at the facility. The
facility being clean and saving mother’s life were most common factors over home
based delivery. 89% of women will prefer delivery at health facility for next
pregnancy. 55% of women stayed beyond 24hours post delivery, however 15%
stayed for less than 2 hours. 96% of women rated their experience as good. Women
in group discussion confirmed the similar reasons for preferring facility based
delivery.
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Figure 8. Reasons for Facility Based Delivery
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Figure 9. Positive Factors Associated with Facility Based Delivery
3.1.6. Health Seeking Behaviour Change since the Inception of Project
Since 68% of the women interviewed gave birth in 2011, more than 89% of them
were anganwadi beneficiary, 93% received ANC and out of all women respondents
60% of them cited knowing their health as well as fetus status were key reasons for
receiving ANC. 93% of women confirmed that hygiene awareness given by sakhi
were useful and is applicable in daily routine.
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Figure 10. Reasons for Availing ANC
Figure 11. Women Delivered in 2011
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3.2
Focus Group Discussions
3.2.1. Focus Group Discussions with women
The group discussions with 50 odd women interestingly highlighted that male
participation and awareness on womens issues has improved drastically in the past
few years. They narrated that nowadays men at household are extending support in
daily chores such as cleaning, taking care of children and especially during
pregnancy on diet and nutrition, including motivating for regular ANC and facility
based delivery. On asked about what are other significant cultural change has taken
place, almost all women coherently narrated the story on how the unhealthy
practices responsible for post delivery complications and poor health were
eliminated to large extent in many villages. The practices highlighted were Sauri
pratha where women were not allowed to leave room for 21 days post delivery and
child breastfed for the first time only three days after birth; practice of using veils to
cover face and other body parts; custom of dowry in marriage; child marriage;
discrimination for son and caste discrimination has reduced drastically. Women
also identified that powerful network with women across villages through SHG has
generated significant level of health related awareness and that is responsible for
behavioral change like seeking medical care during sickness such as cough, cold, and
fever.
When asked about hygiene in their village, some of the women pointed out the
required need for adequate and functional sewage system in their villages, However
they agree that the situation is lot better than what it used to be five years ago.
Women cited many examples of cleanliness drives initiated by women themselves
from time to time in their villages; this has even motivated the village cleaners to
perform his duties. Each woman reaffirmed the strong association between
womens’ improved health statusformation of SHG. and the presence of Swasthya
Sakhi. In continuation, mothers stated that many changes in traditional practices
have occurred at village level after formation of SHG which was earlier hindering
their access to financial as well as non-financial resources.
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3.2.2. Focus Group Discussions with Men
The discussions with group of men gave the credit to presence of SHGs for improved
status of poor as SHG’s have acted as a social pressure group to ensure that the
benefits of government schemes, including JSY, are passed on to the actual
beneficiary in a transparent and expeditious manner. This has thereby resulted in
better acceptance of SHGs at the village level at least in the middle and lower
economic strata of households in the villages. Men also articulated that the
Swasthya Sakhi’s have been instrumental in connecting the community with health
workers and health facilities in the village level which has resulted in better
utilization of healthcare facilities. Men also added that there has been a steady
progress as far as health and hygiene related practices are concerned at the
community level. A landmark change has been seen in seeking and accepting
‘healthy’ health practices. On being prompted about recent changes in health care
vis-à-vis community and the beneficiary, the responses included a big increase in
opting for institutional deliveries, immunizations and utilization of health facilities
for general health problems. Other changes included a major shift in hygiene and
hygienic practices at the individual household and community level.
Another landmark change has been observed in the form of participation of women
in health and economically productive activities as per the participants in male
FGDs. As many as 80% men are comfortable in their female family member going
out and participating in health and economic related activities. They have accepted
the fact that women are equally responsible and powerful when it comes to issues
related to health education and general development of the family. Men have
become receptive to accompany women to health facilities and meeting venues as
and when required.
On being asked the reasons for this fundamental shift in the attitude of the men
toward their women in the participation in activities, the men responded in unison
that this has been made possible due to presence of programs and activities of Rajiv
Gandhi Mahila Vikas Prayajona (RGMVP). The RGMVP has provided women and
thereby to the families, an avenue for developing social networks and raising socio
capital at the local level. The micro finance activity has been able to identify and
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therefore help generate self-sustaining employment for the poorest of the poor in
each village. The impact of RGMVP was felt as inversely proportionate to well being
of the family.
Another area where a change has been noticed is regarding proactive approach of
the community towards immunization, vaccination and utilization of ICDS services.
As per the men participating in FDGs, the villagers now demand services rather
being approached by the health workers. However the change is still yet to come as
far as healthy living is concerned. At least half of the participants in focus groups
were of the opinion that the incentives meant for pregnant women, lactating women
as well as adolescent girls in the form of supplementary nutrition and money are
actually being utilized by the entire family. In reality, the supplementary nutrition
becomes complementary nutrition for the entire family. Though the money received
for institutional delivery is meant for the mother’s health, the ‘healthy’ food brought
for women is consumed by entire family thereby diluting the focus from woman
who has just delivered. Finally the community was very positive about the changes
in the hygiene practices at the village, family and individual level. As per the
community, people now wear clean clothes, keep household and surrounding clean
and take care of their menstrual hygiene in a much better way then they used to 10
years ago.
3.3
Key Information Interviews
3.3.1. Medical officer
During the appraisal visit, it was possible to meet 3 Medical Officers/Senior Medical
Officers in the project area. Each Medical Officer was incharge of a PHC, CHC and
district hospital. During general discussions, it was observed by the group that there
has been a general improvement in utilization of public health facilities in the last 5
to 10 years. In particular, changes have been observed in the form of an increase in
immunization, vaccinating women and adolescent girls, increase in institutional
delivery and general hygiene. However on the flipside, the motivation level of the
community towards institutional deliveries and family planning methods is still sub
optimal and there is scope of improvement in the same.
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Although most Medical Officers have heard about Rajiv Gandhi Mahila Vikas
Pryojana (RGMVP), however they were not aware of their activities at the village
level. They did not know about self help group or community based workers like
Swasthya Sakhi. They attributed the change in utilization of health facilities to the
grass root level workers like ASHA, AWW and ANM. Only the MO of the PHC was
aware of his ANM going and attending the SHG meetings and advocating issues
related to health and hygiene.
3.3.2. ASHA
The Accredited Social Health Activist (ASHA) has been introduced under national
NRHM as a village level link worker with specific goal to make people understand
the importance of health practices and motivate them to utilize them. It was possible
to meet ASHAs during the visit. On an average, ASHAs are married women in their
30s and have 1 to 3 children. An ASHA will have oversight of a population anywhere
between 1000 and 1500 depending of her area of occupation. All of them were
aware of SAM-ESP and its initiatives. Depending on the village visited, the project
has been in operation for 1 to 3 years. According to ASHAs, the initiative includes
samuh (SHG) which has various sub committees to deal with issues pertinent to
people living in the village. ASHAs have been working in close contact with Swathya
Sakhi (SS) on health and hygiene related issues like ANC, NC, PNC, immunization and
promoting early breastfeeding for colostrum to the newborn among other activities.
According to them there has been a remarkable increase in number of institutional
deliveries in the last 2 years. According to them, this change has happened as a
result of both increased awareness, felt need for institutional deliveries a\nd
financial incentive being provided by the govt. to the women delivering at the health
facilities. All of them are aware of health related meetings conducted by SSs in their
respective areas. All the ASHAs reportedly attend these meetings on regular basis
and supplement skills of SSs in providing information to community on health and
health related issues.
All of them were unanimous in admitting SAM staff has strengthen linkages between
community and health facilities like sub centers and PHC by ensuring better
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coordination which leads to better use of healthcare facilities and services provided
there.
Besides health, they were also aware of other activities of SHG such as promoting
savings at household level, financial assistance to poor women thereby leading to
poverty alleviation.
On a general note, all ASHA noted that there have been fundamental changes in the
way rural people live in the last 5 to 10 years. A noticeable change has been seen in
cleanliness and thereby in reduction of disease prevalence. Another area a major
change has been noticed as a result of SHG is in attitude of men who are now more
open to their women leaving the house to participate in community meetings as well
as financially productive activities. Women, by bringing information on health and
healthy practices and financial inputs from SHG have been able to win confidence of
male members and therefore positioning themselves as an equal partner in
household and household related decisions.
3.3.3. Gram Pradhans
During the visit, it was possible to meet 4 out of 5 Gram Pradhans (or their spouses
in case of women gram pradhan being in place). It was interesting to note that
though there is a provision of women Gram Pradhans in some of the villages, with
exception of 1 village where woman Gram Pradhans was actually acting like one, in
other villages it was Pradhan Pati (The husband of Gram Pradhans) who actually
excerises also the power of Gram Pradhans and perform all the duties of Gram
Pradhans. All of them felt that womens place in the society has undergone a major
change in their area in last few years. Most of them gave credit to the presence of
SHG and CLA cadre in their village for ushering this change. Women place in the
society, as per Gram Pradhans, has been enhanced and recognized in the society.
Men initially felt threatened by this change but appreciation is fast evaporating.
Women have been able to bring new knowledge and financial security and stability
to the family and the society and have thereby strengthened their place in the
society as well. As per them the SSs have been instrumental in connecting people
with health services, health facilities and health workers. The coordination between
ASHA, SS and ANM has actually worked very well in these villages. All of them
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agreed that though there is progress in utilization of health care and hygienic
practices there is still scope for improvement of the services. Better sewerage
system, better health infrastructure in the villages are some of the issues’ that still
need attention.
3.3.4. ANM
During the visit it was possible to meet 4 ANMs. All of them were aware of Save A
Mother Effective social Persuasion Platform (SAM-ESP). As per ANMs the SSs meet
children, women and other adolescent girls in the villages and educate them about
healthy living and healthy practices. They motivate people for better institutional
delivery, communicate the benefits of utilizing health services and facilitates
beneficiaries visit to health centre. Most of the ANMs have attended meetings of
Swasthya Samuh (Health committee of self health groups). Though the frequency of
attending the meeting by ANM varies from monthly to quarterly, the agenda of these
meeting, as recalled by ANMs, included the timing of the vaccination, TT, IFA tablets,
healthy nutrition and family planning. Some of them also recalled discussion of
hygiene and hygiene practices during the meeting that they attended. As per ANMs
they work in close coordination with SSs on connecting people to health facilities for
ANC institutional delivery, post natal care and immunization of children. As per the
ANMs the woman in the villages understands importance of healthy and hygienic
living. Though most of them actually lead a more healthy and hygienic life than 10
years ago. Some of them still continue with age-old practices like home delivery,
introduction of complementary feeding during exclusive breast feeding period and
immunization. As per ANMs the SAM staff has strengthens the linkage between
community and health facilities by motivating people and facilitating there travel to
health facilities. As per them both ASHA and SS, being from the community, are
more effective in motivating people for utilization of health facilities. Some of the
ANMS mentioned about increase in number of children turning up for immunization
on vaccination days, near universalization of institutional deliveries. Another
change noticed by ANMs was that people now actually asked for services rather
than being provided services by the providers. The credit for this, as per ANMs, goes
to ASHA and SS who have been instrumental in bringing about this change.
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3.3.5. Swasthya Sakhi:
The Swasthya Sakhi (the health friend, SS hereafter) is a village level or SHG level
worker who has played a pivotal role in the project. All the SSs have initially been
trained for a period of three days. She has been the change agent who has ushered in
a change at the commune or SHG level. She enjoys a great rapport with the women
in reproductive age group and is an informal friend and a confide date. She is
normally first stop for the pregnant women and their window to the services
available in public domain and otherwise. The uniqueness and success point of this
change agent is her umbilical relation with the local Self Help Group where she is a
key member. She not only brings in a window of opportunity for other avenues like
savings and agriculture but is also a connecting link with the other health workers at
the village level like ASHA, AWW and ANM. These grassroots level workers then
connect potential beneficiaries with available services.
All the SSs met were in their mid twenties to mid thirties, knowledgeable about their
work, had great communication skills and most importantly available to the village
women for help beyond their routine call of duty. As a result, they have actually
been able to act as a real sense change agent in incorporating healthy habits like
feeding of colostrums incase of
new born, exclusive a breast feeding and
consumption IFA tablets, etc. Besides this there has been a link between a potential
beneficiaries and health services. The areas where SSs have been able to make
difference include, improved utilization of ANC and near universalization of
Institutional deliveries. Though the monitory benefits of JSY have also made
significant contribution in improving the institutional deliveries, the preparedness
of community has also largely been phenomenon. They have also been able to act as
a ‘pressure group’ for local level service providers and in social reforms at the
community level. Some of the examples of the improvement in service delivery will
be full payment of JSY money to the beneficiary, availability of AWW, ASHA and
ANM at the village level and the socialist being member of the self health group and
CLA. SSs have been catalyst in leading the campaign against alcohol, tobacco and
women abuse at the local level. They have not only been able to sensitize
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community about services but also have been instrumental in insuring that services
are actually provided to intending beneficiaries. Another area of focus of SSs has
been hygienic practices. They have been able to inculcate healthy hygienic habits
like washing hands with soap after defecation, before and after meals each and
every times. Being asked to sum up their contribution in the project they echoed
that they have been able to bring women at the level of man in the society. There
approach is more holistic and the SHG network support have added to her
credibility.
4.
Summary
4.1
Health Awareness and Practices
Swasthya Sakhi has been major source for dissemination information on health
issues such as women health in general, health and hygiene, maternal health. More
than 64% of women credited Sakhi for providing the information in all the domains.
Using the information in their benefit, majority of women (90%) were anganwadi
beneficiaries, has received ANC and also has availed JSY benefits. It has become
universal to have soap available for washing hands at every household level and
hygiene practices has improved at individual, household and at village level since
past 5 years. The paradigm shift is seen in behavior from health workers delivering
services to exercising demand for services at village level.
4.2
Utilization of Health Services
Institutional deliveries, immunizations, utilization of health facilities has improved
drastically as echoed by medical officers, ANM, ASHA, gram pradhan and SS in past 5
years. However the adoption of family planning methods is very poor as low as 93%
of women satisfied with current number of children hasn’t adopted any method,
hence has large scope for improvement. The amount received for institutional
delivery is still far from reaching to actual beneficiary as in most of the cases it is
being utilized to meet the household expenses. In almost all the cases transport is
arranged by women during delivery and this could be one challenge in accessing the
services. All women rated their experience as good during the stay at facility either
public or private, however some percentage of women stayed less than 2 hours post
delivery.
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4.3
Coordination among Health Workers
All the village level workers such as ASHA, ANM , AWW work closely with SS for
keeping updates on women status, for reaching to beneficiaries and providing
preventive services to women and children. The close connection invariably helps in
spreading awareness on various other health issues too. Most of the time the
platform used for IEC activities is SHG or CLA meetings.
4.4
Role of RGMVP in Improving Women Social Status
RGMVP has been active since past 10 years and has contributed immensely for
bringing upliftment of women in the society. Introduction of SS through SAM-ESP
model is a recent intervention in the SHG, in some villages SS is formed in past two
years where as in others she is working since 3 years. The health status of women
being directly linked to social status, has successfully worked hand in hand. The
improved financial security, improved power relationships within household and
society, enhanced awareness on health, women increased contribution in household
decision making along with men, men acceptance and recognition to women has
brought remarkable change in health status and well as in overall development of
villages.
5.
Recommendations
5.1
Recognition to Swasthya Sakhi in the health system
SS being active member of SHG play crucial role in tracking each women health
status at a household level. A village has two SS who maintains record of woman
activities related to health and this database comes handy to ASHA and ANM for
tracking pregnant women or vaccination dropout rates. This significant voluntary
contribution of SS for generating demand for services is not recorded at any level of
public health system. The medical staff at PHC level is aware of her initiatives and
hard work but the second and third tier is totally unaware of her presence. The MIS
at PHC and CHC level could include her name in addition to ASHA and ANM, such as
in case of women availing all 3 ANC’s, successful institutional deliveries, children
with full vaccination, etc.
This will boost her morale and it will be deemed
appropriate to credit her hard work and perseverance towards women heath.
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5.2
Surveillance and Data Monitoring
The manual data maintained by SAM on training records, maternal mortality, ANC
coverage, institutional deliveries is more so complete. However, the block level
situational analysis before inception of SAM-ESP is not available and thus difficult to
deduce the level of improvement in women health in past couple of years. The
scientific analysis and support to the results would be tricky in absence of a baseline
study, hence would recommend the same before initiating any new health
intervention at local level. At the same time due to convergence of many overlapping
government run programs on women health make the SAM-ESP success difficult to
quantify, henceforth establishing a robust MIS system in the form of electronic data
could be helpful in bringing out the analysis of work done so far at ground level.
5.3
Family Planning and Maternal Health
All the 4T’s of maternal mortality, Too many, Too early, Too close and Too late play
important role. May women have still two T’s that is Too many and Too early which
could be responsible for high maternal deaths. Many women expressed satisfaction
with current number of children but haven’t adopted any method. There is huge
unmet need and since not much significance is given on promoting family planning
methods at village level, SHG could be a good platform for promoting spacing and
permanent methods of family planning.
5.4
Advocacy
In order to bring change at policy and programme level with improved resource
allocation, it is required that the voices of SS and women are heard far beyond their
community. This can be initiated through meetings or round table discussion on a
monthly or quarterly basis or through campaign, hence should be integral
component of any health intervention.
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