Community Health Workers- change agents and mobilisers

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The American Public Health Association defines a community worker as: “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery”. Non-profits working towards improvement of vulnerable population rely on the work of these individuals, to achieve the organization’s mission.

Community health workers (CHW) are therefore fundamental for implementing field-level programming by engaging the community and the beneficiaries through participatory efforts. Carrying out initial work in the community through surveys, house-listing, community mapping, corner meetings, micro-planning etc. are crucial tasks in establishing first contact with the community. Initial community engagement activities carried by CHW(s) include identification of eligible beneficiaries, enrolling them for the sessions, services and trainings. They also mobilize community to participate in group education events and campaigns. Carrying out interventions in the community through group formation, group/community meetings, counselling, information sharing, capacity building, paying home visits, conducting growth monitoring health camps and vociferously following up with individual cases are significant activities carried by them. An important skill that they have mastered over their engagement with the community is customizing the information delivery based on the requirements of the beneficiary. Case management and referrals are other vital tasks carried by them to reach out to the beneficiaries.

A critical area of SNEHA’s research involved analyzing the motivations of these frontline workers, to both take up as well as sustain in this challenging role. As such, a study was created in order to gain insight into the perception of roles and responsibilities by CHWs as well as motivations and challenges they faced. The study comprised of in-depth interviews of the health workers from four NGOs namely: SNEHA, Apnalaya, Foundation for Mother and Child and Shelter Associates, to tap into areas, from background information and training, to personal and organizational factors.

Many themes emerged as to why CHWs decided to join the non-profit sector to begin with. Narratives expressed a desire to contribute to purposeful work, as well as to increase one’s knowledge base from a personal growth perspective. Others expressed support from supervisors as contributing factors to making the decision to join the organization. Another narrative offered willingness to try out work in a new field, and an opportunity to return to the workforce following marriage and motherhood as motivation behind initial association.

Community Health Workers also reported having a positive impact on beneficiaries who engage with trained staff during a critical phase in their growth and development. This, CHWs stated, gave rise to a capacity for self-reflection, increase in knowledge and discernible behavior modification, promotion of healthy relationships through candid conversations between beneficiaries and their parents, and added value through incentivized vocational courses, such as computer literacy and English speaking for beneficiaries. Most importantly, confidence and a personal connection and rapport is built in beneficiaries, and changes seen in youth that push forward that they will go on to produce an equitable society free from gender based or domestic violence.

As for their perceived role, many CHWs believe they served as teachers as well as resource personnel. However, they also believed their responsibilities and scope of influence transcended programming and campaign initiatives. They served as confidants and guides to youth and adolescents by providing them with a safe space, to share their experiences and voice their opinions.

Self-reported characteristics of an ideal CHW included: a strong work ethic, exceptional communication skills, and the ability to generate goodwill through intensive rapport-building efforts in communities. Many front line workers left feeling their own exposure to topics during training left them having not only gained knowledge but also triggering introspection and empowerment within them themselves.

Most CHWs reported having a positive and supportive environment at work and were well satisfied with provisions offered by the organization, including training, timely salaries, flexibility with schedules, as well as staff support and real time feedback.

As for challenges that arose within their work, CHWs expressed the need to juggle multiple responsibilities, thus risking being overstretched. Financial situations also posed a challenge, as did organizational factors.

Perhaps one of the most moving aspects of the study was the participants’ personal account on the changes they had witnessed within themselves, having been part of the organization. While their role was believed to be multifaceted to include serving as a teacher, confidant and guide to the beneficiaries, a significant element that emerged from their personal journey with the NGO was their own process of self-reflection. This manifested in an internalization of knowledge within participants such that through their evolving understanding of themes, empowerment emerged. Affection and respect for working with interacting with children arose as well, contributing to a positive learning environment. Participants also expressed an increase in topical knowledge; skill based competencies, as well as improvements in communication skills and self-confidence. Most importantly, participants saw themselves community resources persons, with one expressing the view of being a change agents, with the ability to empower people in the community.

 

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These angels live on the ground – A Women’s Day Special

Ten years ago, Archana Ramesh Mahapade, 50, was out on a fund collection drive when she saw a large group of women.

“When I saw the line and the women waiting patiently, I became curious. I joined them and found out that interviews were being conducted for the position of a community worker at SNEHA. I was selected and that is how my journey began.”

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Archana Ramesh Mahapade, Community Organizer, SNEHA

It is community workers like Archana that help drive the impact of SNEHA, Society for Education, Nutrition and Health Action, an organization that for many decades now, has been working towards improving the health of women and children in slum communities.

SNEHA’s community centres in the vulnerable areas are key to driving the program. The community organizers are drawn from the community itself, and their ease and familiarity with the local population makes them an invaluable asset.

However, as Anupama points out, the familiarity does not guarantee that their presence or advice is always accepted.

“When we first tell people about SNEHA and the work we do, many look tense and turn away. Some women even shout at us and we do feel bad. But we always come back the next day. Eventually their attitudes change when they realize that we are there for good, and not just for a day.”

Once the ice is broken, it takes a few more sessions before they start talking about their lives. “Initially, when we ask them about family planning methods, they are not honest. They say everything is good but as we probe further, we get to know about the situation at home, the pressures they face.”

Building this intimacy is critical given the many levels of SNEHA’s intervention. It goes beyond maternal and newborn health to child nutrition, and sexual and reproductive health, issues that girls and women have never been encouraged to think about. SNEHA offers crisis intervention, counseling, medical and legal help to survivors of violence. It also works on prevention in communities and enables government systems to respond in an effective and sensitive manner.

Access into the homes and lives of women here is vital,  and the community organizers enable that.

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Saira Shaikh, CO, Govandi

“The women in my area come to the city after marriage and they are lonely and unaware”, says Saira Shaikh, 38, a community organizer at Shivaji Nagar in Govandi. Govandi, one of Mumbai’s largest urban settlements, is home to a large population of migrants, who depend on odd jobs to make a living.

“They face violence at home and have no one to turn to,” adds Shaikh. “The violence is made worse by the low unemployment levels. The husbands spend the daily wages on other women or on drinking. We give these women strength by telling them to come forward and seek help so they can start providing for themselves and their kids. We also encourage them to stand up to their husband. Over a period of time, they start to listen and assert themselves. “

Often it can take as long as two years for behaviour change to set in.

Saira brings up the case of a woman in Shivaji Nagar who was pregnant with her fifth child. Her hemoglobin count was just 7.6 and she was always complaining of feeling dizzy and weak.

“The husband would shout at her for being lazy and as we started visiting her we realized that she hadn’t even registered her name at the local hospital”, says Saira. “This was because her husband would not give her money even to go to the hospital. She was a victim of domestic violence. Her husband would even shout at us when we paid a visit. ”

Saira finally took the help of a senior SNEHA staff member to convince the husband. “We were very patient and calm but it still took three months to get him to agree to a hospital delivery. In the meantime, we took the help of the local municipal health staff and started giving her injections and monitored her diet closely. Because she had little money, we encouraged her to eat dates, which are cheap but high in nutrition. She was able to have a healthy baby. “

The episode offers a glimpse into the level of focus and dedication that the community organizers bring to the job.

“In my experience, women and children’s health is an issue everywhere, “ says Archana. “The kids are weak but the mothers don’t think anything is wrong because they compare them with other kids in the neighborhood. They don’t realize that their child has not met important growth indicators. “

Given the sensitivity of such matters, I ask Archana how she speaks to the mothers without making them feel inadequate.

“When we talk to the women, we ask them what the kids eat and the answer almost always is – “I cook but he doesn’t eat what I make”. Then we ask if the kids have been given pocket money that day. The mother realizes that the child has spent the money on buying snacks, and does not want to eat what is cooked at home. We get the mothers to stop doing that. We also show them ways to cook such that the food is to the child’s taste. Like to partially fry an egg and add the roti so the child gets protein and carbohydrates. We have been able to encourage all the women to breastfeed, which was not the practice earlier.”

Ask Archana what difference being a community organizer has made, and her face lights up.

“I am so proud to be a CO. I have helped women who have suffered multiple miscarriages, deliver healthy babies. I have also been able to help couples conceive by telling them about ovulation. The money may not be much but the satisfaction is huge. It has helped to build ties within the community. Now when I don’t go to the community even for a day or two, the women tell me you haven’t come for so many days,” laughs Archana.

SNEHA – A community-based health model that delivers

Public health in urban areas is one of the most persistent, yet neglected, issues facing the developing world. Cities present an especially challenging canvas given the many different factors – migration, inadequate housing, lack of infrastructure, crime, political corruption, pollution, and dysfunctional health systems – that are in play.

Over 50% of the world’s population lives in cities and this number will rise in the next few decades. Due to migration, India’s cities are growing more than three times as fast as the rural areas, and it is likely that more than half of the country’s population will live in urban areas by 2050.

The factors that affect human health are many, ranging from climate change and greenhouse gas emissions to reproductive health and rights. Meeting them is key to India’s success in achieving universal health coverage and improved national health indicators.  96-of-109

The National Urban Health Mission in India aims to enable rightful access to quality health care. This is by setting up an improved public health system, partnerships, and community-based mechanisms. This is to be done with the help of secondary and tertiary institutions, urban health centres, and community outreach. The positive outcomes of such a partnership in Mumbai’s urban settlements, demonstrated by SNEHA, is the subject of a paper recently published in the prestigious medical journal The Lancet.

The interventions of the Society for Nutrition, Education and Health Action, SNEHA, interventions are born out of 16 years of work with women and children in informal settlements. They range from maternal and neonatal health, sexual and reproductive health, childhood nutrition, and prevention of violence against women and children. What makes SNEHA’s model unique and effective is that it integrates these activities, and the model can be replicated in urban settlements across India, perhaps in many developing countries as well, with some tweaks for local, cultural specifics.

SNEHA’s adoption of an integrated approach came after a large neonatal trial conducted in Mumbai. It was felt that this would be an effective method given the multiple health issues faced by women and children, and the belief that communities would be more responsive to an intervention that had both, physical presence and service delivery.

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Every SNEHA centre is equipped with three full-time community organizers with backgrounds similar to the people they reach out to. They are trained to bring together the themes of reproductive, maternal, and neonatal health, child health and nutrition, and prevention of violence against women and children into the community services. They are responsible for home visits, group meetings, organizing day care for malnourished children, and community events, in close association with existing systems.

A survey was done before, and two years after SNEHA’s intervention on three main outcomes – family planning in women (15–49 years), immunization of children, and wasting among children less than five years. The survey looked at secondary outcomes as well, like violence against women or children, number of home births, pregnancies in women younger than 20 years, to name just a few.

There were significant improvements in the met need for family planning, and full immunization. Compared to the NFHS 2015-16 figures of 14% unmet need in Mumbai, the results in the areas of intervention was 22%. Again the NFHS-4 findings showed that 46% of children between 12–23 months in Mumbai were fully immunized. Contrast that with the intervention area rates of 69%. The findings were similar when it came to wasting in children, and diet among children.

There were other positive fallouts seen as well like the use of sturdier material to build homes, building of private toilets and use of safe, drinking water.

The challenges of meeting the health needs of settlements in an urban milieu are many. The shifting nature of the population and specific cultural beliefs can often slow down rates of progress. However, the overwhelmingly positive outcomes demonstrated by SNEHA’s model shows a way forward to city governments across developing countries who are grappling with ways to improve health in informal settlements.

Link to The Lancet paper – http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30363-1/abstract

Why Family Planning must be key priority in Budget 2017

Just this month, a woman died and five others were critical after a surgery at a family planning health camp in Maharashtra’s Yavatmal district went horribly wrong.

The woman who died was just 36 years old. The death, according to reports, occurred because the government doctor at the Primary Health Centre cut the intestine instead of the fallopian tube while operating on her.

The tragedy brings home the critical gaps in India’s family planning programs especially in large parts of rural India. Given this, it is important that the government prioritizes family planning in the upcoming Budget to ensure that young couples are offered information about, and given access to FP options.

In 2015, the Health Ministry announced some welcome measures in this regard, like expanding the basket of contraceptive choices and ensuring their availability in district hospitals. There are now three spacing methods of contraception in the government FP program – Centchroman, Progestin Only Pills, and injectable contraceptive – offering greater choice and independence to users.

But India is still way short of the commitments it has made under FP2020. At the 2012 London summit, the country had promised to provide FP services to an extra 48 million new users by 2020.

The progress report in 2015-16 shows just how far we are from that goal. Less than eight million extra users have been catered to until July 2016. To meet the targeted numbers, the government has to allocate more resources towards meeting the FP needs of the population.

Census 2011 showed that over 10 crore girls in India get married before they are 18 years old. Young couples, across communities, come under great pressure to have a baby within a year of marriage. Many of them want to delay babies but don’t have the information or access to do so.

Expanding contraceptive choices for men and women while important is not sufficient by itself. They have to be empowered about exercising these choices and this has to be done through sustained community awareness campaigns by the government, civil society and other stakeholders. This needs extra staff on the ground and therefore more funds. The budgetary allocations to health and FP need to be substantially hiked.

India spends just 1.3% of its GDP on healthcare, a figure far lower than countries like Bangladesh, Brazil, Russia and China. Even Afghanistan and Nepal allocate more. Budget 2017 needs to address this shortfall.

Unsafe abortion – A major risk in India

Just how grave a threat unsafe abortion is for women is brought home in the data that 10 women die everyday in India. The country sees over 65 lakh pregnancy terminations every year. Unsafe abortion ranks as the third leading cause of maternal deaths in India. Hence access to safe abortion methods is critical to prevent these deaths.

In this context, the US President Donald Trump’s decision to bring back the Mexico City Policy, popularly called the Global Gag Rule, has major implications for women around the world, including India.

The Mexico City Policy is a US government policy that requires foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” with non-US funds as a condition for receiving US global family planning assistance. As of January 23, 2017, this includes any other US global health assistance, including HIV and maternal and child health (MCH).

The rule is a dangerous move against reproductive rights, as organizations will now have to choose between receiving American foreign assistance funds and providing comprehensive care. It dictates to foreign NGOs not just how American aid is to be used but also lays down that they must not spend their own money on providing abortion, and abortion-related services.

Poor or no access to contraception and safe abortion is a major public health crisis for women in the poor countries. The Global Gag Rule puts them in more danger as it puts them at risk of unsafe abortions.  The policy change will lead to the withdrawal of aid set aside for contraceptive access as well as comprehensive abortion care worldwide.

Once again politics has prevailed, and with the stroke of a pen powerful men have decided the reproductive rights of millions of women across the gobe.This is a move that affect women’s health and endangers their rights and independence. And the impact is widespread and damaging as it is well documented that giving women control over their reproductive health, improves not just the health outcomes of mothers and children but is key to economic progress.

Innovative approaches to tackling malnutrition

The malnutrition-related deaths of nearly 600 children barely 100 kilometres from Mumbai in 2016 underlines the critical need for various stakeholders to come together to find ways to bring about behaviour change, and ensure that benefits charted out under various government schemes actually get to those who most need them.

The fact is that children do not die of malnutrition but of causes due to malnutrition. Stunting is a better indicator of malnutrition and according to studies 51% of children and adults among tribal populations in Maharashtra are undernourished and stunted. This is a significant figure and one that has not shown sufficient improvement in the last few years.

Across India, the occurrence of wasting among children is serious. Even within the limits of the financial capital Mumbai, NFHS-IV shows that one-fifth of children under the age of five years suffer from wasting. This is very serious indeed given the associated risks of disease, even death, among children who are very underweight.

Since 2011, a program introduced and managed by SNEHA and CRY has shown the way forward when it comes to tackling urban malnutrition, especially wasting. Over a period of two years, the percentage of wasting in children reduced sharply from 18% to 12% in the slums of Mankhurd, Govandi and Kurla situated in the suburbs of Mumbai. SNEHA’s intervention in child health and nutrition in Dharavi showed equally encouraging signs – a fall of wasting from 18% to 13%.

The percentage of children who received full immunization rose from 66% to 73% in the three areas mentioned earlier. There were also other positive changes, like rise in hospital deliveries (12 up to 15%), adoption of family planning methods (34% up to 59%) and a dramatic drop in pregnancies among women below the age of 20 years. (17% up to 4%).

The changes took place because of a sustained merging across different sectors at the community level to enhance child under-nutrition. This was backed up with enabling behaviour change through home visits, one on one counseling, awareness campaigns, and community meetings. This led to greater adoption of FP methods, immunization and better nutrition practices.

Urban malnutrition is a challenge not just peculiar to world cities like Mumbai. Tackling it requires innovative and creative approaches that take the community’s needs and pressures into account. The program by SNEHA and CRY offer a window into an approach that could show results in many parts of India to reduce malnutrition rates.

 

 

 

A compelling case for contraception

Recently Melinda Gates made a compelling, passionate statement about how giving millions of women access to contraception was necessary to end poverty and disease for both present and future generations.

The Bill and Melinda Gates Foundation, of which Melinda Gates is co-founder, has made it a mission to ensure that millions of women in developing societies have access to safe birth control measures. Since 2012, Ms Gates has been leading a worldwide campaign to get 120 million more women access to birth control by 2020. The BMGF has donated over one billion dollars towards family planning.

Never before has this fight for a woman’s right to decide if, when, and how many children she wants to have been more important. The recent India wide study on how ten million women in the country are forced to resort to unsafe abortions every year underlines the critical need to make contraceptive options available.

The study, done by the IndiaSpend team, highlights that myths and misinformation about contraceptive methods are still widely prevalent despite India having the longest government-backed family planning campaign in the world. Millions of women still lack access to contraceptive options. They are left with no option but to take over-the-counter pills or undergo dangerous, unhygienic surgeries to end pregnancies.

A 2016 Lancet report highlights how distant the prospect of safe abortions remains for rural Indian women. This is the case even nearly five decades after abortion was legalized in India. In the absence of safe methods, sales of popular abortion pills remain abnormally high.

Widening the basket of contraceptive choices, as the government did earlier this year, is a much welcome, long overdue step. But to be truly effective, these choices have to reach the millions of women in our smaller towns and villages. That needs better delivery systems, better training of doctors, and a mass awareness campaign. All of which remains a giant, gaping hole in our FP program.

Low contraceptives’ usage, a cause for concern

Despite the range of family planning options made available in India, data from the National Family and Health Survey, NFHS-4, is cause for concern.

The figures released for 14 states shows a fall in the use of contraceptives, compared to the previous NFHS survey done 10 years ago.

With options, awareness, healthcare access and incomes growing, the expectation was that women would exercise more say over their pregnancies, but the data doe not indicate that.

While West Bengal and Meghalaya show an increase in the use of modern contraceptive methods like OCPs and IUDs and a fall in sterilization, the figures for the rest of the state surveyed are not so positive. Over 50% of women prefer female sterilization and there is a decline in the use of contraceptives in some states.

What this means is that a large number of pregnancies continue to be unplanned or unwanted and access to contraceptive methods remains in the hands of a few. In rural areas, women still depend on government health facilities for supply and this is affected by lack of choices, irregular supplies and lack of skilled health providers at the district health centres.

The NFHS data for all the states is as yet not available and therefore a conclusion may be premature. However, the findings from these 14 states, many of which have seen some focused family planning campaigns, is a pointer towards how much more needs to be done.

Ensuring that contraceptive methods are available is a small part of the challenge. Getting women to use them, addressing the myths and empowering them with information about how and when to use these methods is a huge gap which remains unaddressed even in some of the relatively better off states. Tamil Nadu, for instance, shows no change in the use of oral pills. It was 0.20% in NFHS-3 and remains the same in NFHS-4.

Given India’s sizeable youth population and the high prevalence of early marriages, it is critical that resources be invested in making sure that information and access to modern contraceptive methods is made available in rural India.

“There is a need to focus on changing behaviour and the regular, smooth availability of contraceptives”, says Dr Ashok Dyalchand, Director, Institute of Health Management, Pachod. “At the moment, this is lacking”.

 

Not enough in this budget for Family Planning

Among the most widely reported statements at the International Conference on Family Planning held in Indonesia in January this year was that of the Indian Health Minister JP Nadda who said that the country was committed to meeting the FP2020 goal of providing 48 million additional women and girls with access to modern contraceptives by 2020.

A global partnership, Family Planning 2020, works with governments, civil society and the private sector to enable women and girls to make decisions regarding if, when, and how many children they want.

The Indian Health Ministry team also announced that women would have access to better quality family planning services. A promise that is being met with. Since April, injectable contraceptives and pills are being supplied to all district hospitals across the country.

However, the recent report by the Population Foundation of India points out just how distant that goal of recahing 48 million women and girls is.

While the provision for health in 2016 has grown by 22% over 2015, with FP seeing a substantial increase of 67% compared to previous years, health remains hugely underfunded in India. The rise this year, it points out, is insufficient to compensate for the whopping 54% decline in allocations to family welfare between 2013-14 and 2015-16.

Meeting the 48 million number needs more than simply expanding the basket of choices. It needs awareness campaigns and better rural health facilities to ensure that babies and mothers survive. Campaigns have to be tailored to meet the specific challenges that a country as varied as India throws up.

While the shift away from female sterilization is welcome, there seems to be widespread official myopia in acknowledging just how deep the links between family planning and broader development goals go, and this is disturbing.

Guttmacher Report underlines need to meet adolescents’ contraceptive needs

Twenty three million – that’s the number of adolescents at risk of unintended pregnancies in the developing countries.

The statistic, part of the Guttmacher Institute’s May report Adding It Up: Costs and Benefits of Meeting the Contraceptive Needs of Adolescents, again points out the huge gap in contraceptive services among adolescent women. The report says that many women who want to delay childbearing are not getting the services they need.

About 40 million of the over 250 million adolescent women between 15–19 years in developing regions are sexually active and want to avoid pregnancy, yet 23 million of them have an unmet need for modern contraception. Most adolescents with unmet need are using no contraceptive method while the rest depend on traditional methods, which have been proven to be not so effective.

All this underlines the need to make sure modern contraceptives is made available in developing countries. This, according to the report, will not only prevent unintended pregnancies but also prevent the 3,000 adolescent maternal deaths reported every year in developing countries.

At 21% India has among the highest unmet needs for contraception in the world. This is despite the fact that we were the first country in the world to launch a government-backed family planning program. However, today countries like Bangladesh and Indonesia, which started their programs much after India, are faring much better.

The government has recently launched a wider pool of contraceptive choices for women. Welcome steps, but there needs to be more focus on behaviour change communication. Young women and couples want to plan their families but do not know where to get the information.

Zika outbreak: Lessons for India

The fear and panic over the spread of the Zika virus disease has helped highlight the inadequacies many countries face in providing family planning and reproductive health services. The outbreak may be far from India’s shores, but those lessons hold true for us as well.

Zika has been declared a global public health emergency. There are fears, not entirely proven, that it is linked to birth defects in babies whose mothers contract the virus during pregnancy. Over 3000 cases of microcephaly—an oddly small head and an immature brain—have been reported in Brazil.

Given that the virus is spreading rapidly, with no proven vaccine in the horizon, women who are pregnant, or are likely to become pregnant, are in a spot.

In many of the countries affected, abortion is illegal. In some regions, contraceptives are in short supply. But going by the statements coming from political leaders, the onus seems to be entirely on women.

In El Salvador, women have been told to postpone getting pregnant for up to two years. How will they given that it’s not always accessible?

The public health system in many of these countries is in a poor state, much like in India. Rural areas, which are understaffed, are worse off. Again, much like in India. There is also great stigma attached to contraception.

Like India, the societies in many Latin American countries are deeply patriarchal. Cases of rape, including marital rape, are high. So where is the question of women exercising the choice to not get pregnant?

Zika is already out of the headlines, swept away by another crisis in another part of the world. But the outbreak has thrown up relevant questions. Like the need to build a strong public health infrastructure, make available a range of contraceptive choices, and most important, empower women to exercise those choices.