Oxfam in Action: Community based monitoring to improve maternal health in Odisha | Millennium Development Goals

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‘Improving Maternal Health in India’, an Oxfam-DFID programme since 2012, was implemented in 420 villages across 6 States. It sought to improve maternal health status by building capacity in communities to demand, access and monitor public health services. This document reports how the CSO CYSD in Odisha is innovating with films to spread the message on nutrition and maternal health. 
  OXFAM IN ACTION Community-Based Monitoring to Improve Maternal Health in Odisha E ight Millennium Development Goals (MDGs) were agreed by member countries following adoption of the Millennium Declaration by the United Nations Millennium Summit in 2000 — ranging from halving extreme poverty rates to providing universal primary education to all— to be realised by the target year 2015. One of the goals, MDG 5 was about improving maternal health by bringing down the Maternal Mortality Ratio (MMR) — a target was set for each country to bring down their ratio by three quarters between 1990 and 2015; which for India meant 109 per 100,000 live births by 2015. In 2007-09 the MMR was 212; it declined in 2011-13 but continues to be high at 167 1  with huge inter-state and intra-state disparities. Striving towards Oxfam’s vision of ‘right to life with dignity for all’, a project ‘ Improving Maternal Health in Six States of India’ was conceptualised under the Global Poverty Action Fund (GPAF) with support from Department for International Development (DFID). GPAF focussed on poverty reduction and pursuit of MDGs through improved service delivery, empowerment and accountability, work on conflict, security and justice 2 . The MMR and prevalence of malnutrition in project areas was much higher than the national average. Evidence related to coverage of services indicated gaps in government programmes and schemes reaching the poor and marginalised communities. The project sought to improve maternal health status by strengthening community capacity to demand, access and monitor health services — the public health system is still the only option for the poorest and most marginalised— simultaneously engaging with the health system at multiple levels (local, district, state, and national) to address the gaps in the public delivery system.Odisha, the most backward state 3 , performs poorly in most of the health-related indicators. According to the Annual Health Survey (AHS) 2011-12, Odisha’s MMR was at 237; the Infant Mortality Rate (IMR) at 59 per 1000 live births lagged behind the national figure (AHS 2011-12). This has improved to some extent. According to AHS 2012-13 data, Odisha’s MMR is 230 and IMR is 56. Odisha comprises about 20 per cent dalits and 23 per cent adivasis. And it is these women, especially, who are discriminated in their access to health care facilities, reproductive rights, proper diagnosis of diseases, and nutritious food intake. The prevalence of maternal and child undernutrition remains high in the state.The underlying cause of maternal mortality in Odisha is the low social status of women due to deep-set patriarchal mindset. Through their lives, women face intra household food injustice resulting in continued hunger and malnutrition, overall poor hygiene and sanitation, early marriages leading to teenage pregnancy, shorter birth intervals and each pregnancy being an additional risk due to an insufficient and inefficient antenatal care (ANC) system. According to National Family Health Survey-3 (NFHS-3), about 40 per cent women between 15-49 years suffer from nutritional deficiency and are therefore more likely to give birth to low birth weight children, thus perpetuating intergenerational cycle of undernutrition 4 . About 44 per cent children up to three years are underweight, 19 per cent are wasted and 38 per cent are stunted 5 . The prevalence of anemia among children and women in the reproductive age group is also high. About 74 per cent children aged 6-35 months and 68 per cent of pregnant women aged 15-49 years are anemic. Since 2013, Oxfam has partnered with Centre for Youth and Social Development (CYSD), in Odisha, in two districts of Kandhamal and Sundargarh. Here factors like poverty, illiteracy and inadequate access to health and other basic services increase vulnerability of the adivasis and dalits. CYSD established in 1982 has been working on improving the lives of tribals, rural and urban poor in the state with a focus on eradicating extreme poverty and hunger, ensuring social justice, good governance and citizen’s rights 6 . no. 3 | march, 2015 GPAF* project was implemented in 420 villages , 21 blocks  and 17 districts  spread over 6 states  of Odisha, Bihar, Jharkhand, Chhattisgarh, Maharashtra and  Rajasthan   420 VHSNC s  activated  & now monitoring community level health services11000 women  attended maternal health trainings 32000 people  participated in 56 health & nutrition melas Increased demand  for nutritional supplements and temporary contraceptives 19  out of 24 PHC s  now have referral transport compared to 5 PHC s  earlier * Global Poverty Action Fund  2   O xfam works with CYSD in 70 villages, 10 Gram Panchayats and six blocks in the two districts. Oxfam’s strategy for the project has been Community Based Monitoring (CBM) — building capacities, strengthening and empowering the community to ensure accountable and quality health services. So on one hand, CYSD focussed on reviving and regularising the Village Health, Sanitation and Nutrition Committee (VHSNC), a key component of the National Rural Health Mission (NRHM) 7 , which in Odisha is known as the Gaon Kalyan Samiti (GKS) and, on the other, it created support structures for the GKS like Food Security Committee, Kishori Kalyan Samiti (KKS) and Barefoot Auditors.NRHM, launched in 2005, aimed at providing affordable and quality health care to rural population, especially the vulnerable communities. NRHM promotes CBM of health schemes, through VHSNC or GKS, by empowering community to monitor and take collective actions on issues of health and other social determinants of the village 8 . The GKS comprises elected members of panchayat including those working for health and health services — Auxiliary Nurse Midwives (ANM), Accredited Social Health Activists (ASHA) and Anganwadi Workers (AWW). They are mandated to meet regularly, supervise anganwadi centres, keep a tab on nutritional status of women and children and monitor the Village Health and Nutrition Day (VHND) or  Mamta Diwas . “Many in the village didn’t know about GKS. Even the GKS members didn’t know what their role was or that they were supposed to meet regularly. What happened earlier was that the ASHA used to go about collecting signatures of all the GKS members but there were no meetings,” said Anil Rout, field officer, CYSD. CYSD first made a list of all the GKS members in every village, called them for a meeting and explained their role. They were trained to monitor health services, raise questions and take action. With the revival and regularisation of the GKS meetings — last Thursday of every month— women started regularly visiting the ANM on Mamta Diwas , the anganwadis were closely monitored and mid day meals checked. Apart from the GKS members, Food Security Committee and KKS members also began attending these meetings. The Food Security Committee dealt with a range of issues from availability of foodgrains (both quantity and quality), issue of BPL cards, leakages at the public distribution centre, nutrition awareness to maternal health. The committee members, selected by the villagers, belong to the poor and marginalised communities and are beneficiaries of different food security schemes. The committee, formed a year ago, meets once a month. Under the project, CYSD formed a committee of adolescent girls (10-18 years) called KKS that gives a platform to young girls to discuss issues related to hygiene, sanitation and marriage. CYSD, through their peer educators’, talk to girls about the legal age of marriage (18 for girls and 21 for boys) and health complications for the mother and child in case of an early pregnancy. Barefoot Auditors are volunteers from the community who support different committees by spreading the word on meetings and trainings, reminding women about Mamta Diwas and even taking up issues with the GKS, Food Security Committee and KKS. Some members from KKS are trained as Barefoot Auditors.“The volunteers provide a support system to the ASHA and ANM. Even the Child Development Protection Officer (CDPO) sees merit in the work that the barefoot auditors do and assigns tasks,” said Rout. Instituting Change through Community Based Monitoring (CBM) 0501001502002503002012-13 2011-12 2012-13 2011-12 2012-13 2011-12 Odisha 23723021259754958234471422458213986572975679 Sundargarh Kandhamal MMR IMRUnder-5 Mortality Rate Annual Health Survey Data Source: http://www.censusindia.gov.in/vital_statistics/AHSBulletins  3   With awareness more women now attend Mamta Diwas or the Village Health and Nutrition DayMamta Digal, ASHA, Rajika Khol village has acted in a couple of films on maternal health produced by CYSD T he challenge for CYSD was to spread their message effectively. People came up with the idea of folk dance and song to address issues related to maternal health. CYSD took it a step further. “We thought why not films. And then we thought why not local actors,” reflected Rout. The five short Odiya films, shot and produced by a Bhubaneswar-based production house, deals with five themes — institutional delivery, contraceptives, birth spacing, nutrition and ANC. Besides these, there are three Still Audio Visuals (AVs) as well. The process of making the films and AVs began in 2013 and the first screening was held in August 2014. Until December 2014, CYSD had screened the films in 69 villages (33 in Kandhamal and 36 in Sundargarh). The unique feature of the film is that they have cast villagers and local health workers in leading roles; some have acted as themselves and become quite popular.Martha Digal is one such actor; she has been the ASHA of Rajika Khol village (Kandhamal district) for the last eight years. Martha has been working closely with CYSD, since 2012, on reviving the GKS, increasing the footfall on Mamta Diwas and holding trainings to promote institutional delivery and proper nutrition to improve maternal and child health in the village. Since 2012, her village has reported 100 per cent institutional delivery and no cases of infant mortality, maternal mortality or malnourishment. In 2014, she was awarded the best ASHA (at the district level). She played herself in two films — one was a film on institutional delivery ( Shabash Amit — Well Done Amit  ) and the other on antenatal care (Tini Parjaya — Three Chapters)  .“I had never acted before but I was encouraged by my family. It’s a matter of pride that people are motivated and the ANM and doctors are watching these films. Personally, if these kinds of films were shown earlier, I would have taken precaution and not gotten pregnant a third time,” smiled Martha. Thirty–four year old Martha was married when she was 15 and has three children. She became an ASHA after her third child was born.The Oxfam project has shown two changes — one, more women are opting for institutional deliveries and second, the demand for contraceptives has increased. The films have ensured that issues like family planning, sterilisation, birth spacing and use of contraception like condoms and copper T are discussed in the open.Earlier, Mamta Diwas  was taken for granted. Due to the films and regular intervention by CYSD, pregnant women have now started going for regular checks and they are aware that they have to be checked for blood pressure, weight and haemoglobin. Apart from film screenings, the messages also spread through word of mouth, reaching out to many indirectly. The films are in demand even in villages not covered by Oxfam. Mamta Digal, cast in Mamta (a film on anaemia in pregnant women), feels encouraged by the fact that films are raising questions on social practices detrimental to the health of both mother and child. It is common for women to continue working through their pregnancy putting their health at risk. Manjula Kanhar continued with her Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) work during pregnancy, digging pits. It is after one of the films that she stopped going to work, took regular rest and took iron-folic tablets on the ANM’s advice. These tablets are usually avoided as people believe that it will cause complications in pregnancy. Innovating With Films  4   Oxfam India, 4th and 5th Floor, Shriram Bharatiya Kala Kendra, 1, Copernicus Marg, New Delhi 110001Tel: +91 (0) 11 4653 8000 www.oxfamindia.org Oxfam India is a member of a global confederation of 17 Oxfams and is registered as a company under section 25 of the Indian Company Law.    Author:  Savvy Soumya Misra  Acknowledgements: Nisha Agrawal, Pooja Parvati, Oommen C Kurian, Deepak L Xavier, Pallavi Gupta, Akshaya Kumar Biswal, Jitendra Kumar Rath, Nihar Ranjan Thakur and Anil Rout (CYSD)  Photo Courtesy:  Savvy Soumya Misra© Oxfam India March 2015.This publication is copyright but the text may be used free of charge for the purposes of advocacy, campaigning, education, and research, provided that the source is acknowledged in full. The copyright holder requests that all such use be registered with them for impact assessment purposes. For copying in any other circumstances, permission must be secured. E-mail: policy@oxfamindia.org.Oxfam India, a fully independent Indian organization, is a member of an international confederation of 17 organizations. The Oxfams are rights-based organizations, which fight poverty and injustice by linking grassroots interventions to local, national, and global policy developments. Though films talk about both male and female contraception, there is a greater demand for female contraception. Male sterilisation is almost nil at the moment 9 , it is a matter of concern that the films lack clarity on this topic. “The films should show how vasectomy is done. They should also talk about the difference and the impact of male and female sterilisation on the health of men and women respectively. This will help promote vasectomy,” said Mamta. There is a demand for regular screening of films. The screenings are restricted due to frequent power cuts or inaccessibility — one film screening that Oxfam was present for was interrupted due to power failure. Due to lack of connectivity, no screening had taken place in one of the villages. “We will have to find a way to either take the film there or bring them to a screening,” said Rout. A schedule for screening needs to be drawn in a manner that men do not miss out on the screenings; they are usually out during the day working. Though meetings and trainings ensure interaction and hands-on advice, audiovisual media like films make a deeper and long lasting impact. The fact that actors are from within the community is a huge motivation to watch these films and emulate as role models. And, as Mamta puts it, “I knew a few things about maternal health in the past but learnt much more while reading the scripts and playing my part. If there are more films on other issues, it will not just be interesting but easier to understand.” Notes 1 http://www.censusindia.gov.in/vital_statistics/mmr_bulletin_2011-13.pdf ; these are the latest figures, the earlier figure was at 1782 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/207456/GPAF-Gender-Guidelines-3 http://www.thehindu.com/news/national/rajan-panel-ranks-odisha-most-backward-state/article5170719.ece4 NFHS- III5 NFHS- III6 http://www.cysd.org7 National Rural Health Mission was merged with the National Urban Health Mission in 2014 to form the National Health Mission8 http://nrhm.gov.in/communitisation/village-health-sanitation-nutrition-committee.html9 http://orissa.gov.in/e-magazine/orissareview/2012/sep/engpdf/51-60.pdf; According to the AHS, 30.1 per cent women and only 0.3 per cent men underwent sterilisation. Women at a film screening at Duti Mendi village Films ã Shabash Amit - Institutional delivery ã Mamta- Nutritionã Tini Parjaya - Antenatal Careã Jagan Gaatha - Contraceptionã Duiti Prashna - Nutrition AV shows Institutional Delivery, Nutrition during pregnancy and Family Planning Outreach  In Kandhamal and Sundargarh, since August, the film screenings in 69 villages  have directly reached out to over 2500 adults  and nearly 1400 adolescents  and to nearly 2100 (adults and adolescents) indirectly.
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