October 2017

Birth, Life, Dignity
Improving Maternal Health In India's Villages

Despite the 65 per cent decline in the maternal mortality ratio (MMR) in India between 1990 and 2013, the country still records the highest number of deaths of women during pregnancy and childbirth. Unlike the global targets, India is on the way to missing the MDG target of reducing the MMR to 109 per 100,000 live births by a wide margin.

Striving towards its overarching vision of 'Right To Life With Dignity For All', Oxfam India, with support from DFID's Global Poverty Action Fund (GPAF), started its project 'Improving Maternal Health in Six States of India' in 2012. The project is being implemented through nine partners in 420 villages of 18 districts in six states - Bihar, Jharkhand, Odisha, Chhattisgarh, Maharashtra and Rajasthan. It seeks to improve the maternal health status by strengthening the community's capacity to demand access to and monitor health services, while simultaneously engaging with the health system at multiple levels (local, district, state, and national) to address the gaps in the public delivery system. This series of features and opinion pieces will capture the interventions, the best practices, and social transformations on the ground and highlight the urgent need for integrating maternal health in all government programmes and policies.

Oxfam India works on enabling community and responsive policies to reduce inequality and poverty. Access to health entitlements and universal access to health are some of the key policy areas that can allow millions, especially the poorest, step-out of poverty. Oxfam India works with partners, civil society networks towards these.



India
Fulfilling The Promise Of Safe Motherhood  
Ajitha Menon

Whereas on the one hand it is true that India still registers the highest number of maternal deaths in the world and has not been able to meet its Millennium Development Goal target of bringing down the Maternal Mortality Ratio (MMR) to 109 per 100,000 live births, on the other hand, there is no denying that there has been a steady decline in the MMR - from 178 in 2011-2012 to 167 at present. What is needed now is that added push in the ongoing efforts to make better health services available to adolescent girls, pregnant women, new mothers and infants. The Oxfam India-led intervention, 'Improving Maternal Health in Six States of India', which took off in October 2012 with support from the Department For International Development (DFID), has reached out to 1,86,686 project participants in the six project states - Rajasthan, Maharashtra, Chhattisgarh, Odisha, Bihar and Jharkhand. The project also shows just how this seemingly illusive goal can be converted into a lived reality. From regularising the functioning of the Village Health Sanitation and Nutrition Committees in each of the 420 project villages to creating an army of community sensitisation workers, who empower people with information on healthcare, to devising innovative ideas for monitoring the progress of expectant mothers as well as tackling administrative hurdles, a slew of measures have truly inspired vigorous collective action and instilled a sense of responsibility and ownership among the people - the only sure-shot way to save vulnerable mothers and children.

* 'Boosting Community Based Monitoring through the revival of the Village Health, Sanitation and Nutrition Committees, in addition to concerted capacity building of community leaders and health workers, has been a conscious strategy as it leads to changed attitudes.'

WFS REF: INDO924O


India
Showing Women Easy Ways To Track Maternal Health  
Ajitha Menon

Everyone hopes to have a house. It is, after all, a symbol of security and stability. For the women of Jharkhand's Bada Ulatu village, too, a house signifies the same. But it also means something more - it is indicative of the well-being of a mother and her child. How, one may ask? Well, in Ranchi and Hazaribagh districts, expectant women in 70 villages are using a maternal services tracking tool, which entails drawing a house for every milestone they complete in their journey towards safe motherhood. From the foundation to the windows, door, and roof, and finally to the finished home with a happy family and a smiling infant, each phase is "constructed" once the new mother successfully completes the ante-natal check-ups, vaccinations, institutional delivery as well as the post-natal stage. Likewise, in Kandhamal, Odisha, people have created a village health atlas and use the 'bindi' (coloured circle) to keep an eye on how their pregnant women are faring. And in Kishanganj, Bihar, adolescent girls are working with village elders to monitor the delivery of not just health services but other government welfare schemes as well. Such simple, efficient community monitoring tools are enabling villagers to track the availability, quality and delivery of health services in 420 villages across six states, where Oxfam India, with financial support from UK Aid, has implemented a three year project (2012-15), along with grassroots partners, on improving maternal health.

* "We have barefoot auditors in every village, usually from within the community, who we train to use the monitoring tool. They, in turn, teach the village women. These days, mothers eagerly look forward to getting the house with a smiling infant."

WFS REF: INDO831O


India
People Power Boosts Grassroots Healthcare In Jharkhand  
Ajitha Menon

The old adage, 'united we stand, divided we fall', is finding inspiring examples within the network of the Prakhand Stariya Swasthya Samiti Sangh, or the District Level Village Health, Sanitation and Nutrition Committee (VHSNC) Federation in Ranchi district of Jharkhand, which is charting a new course towards better access to health services as well as greater social justice. Created under the auspices of a Department of International Development (DFID) supported Global Poverty Action Fund (GPAF) initiative, launched by Oxfam India in October 2012, the federation has infused a much-needed sense of belonging and yen for activism among local people and frontline health workers across Ranchi district. Little wonder then that today Sunita Devi, 32, a VHSNC member from Paancha village, is ready to make all efforts to get the health sub-centre in her hamlet functioning on a regular basis, while Anjali Kumari, 27, a ward member from Kucchu village, is writing to the local medical officer demanding strict action on the issue of improper dispersal of entitlements under the government-funded Janani Suraksha Yojana (JSY). As members of the Ormanjhi Block Federation, which is affiliated to the Prakhand Stariya Swasthya Samiti Sangh, both women are confident that "government officials and panchayat representatives are bound to give us a fair hearing and act on our suggestions because we belong to the federation". Of course, now this widespread network is not only driving the implementation of a range of government policies and schemes beyond just health services but it is also "proactive in settling many social and economic issues in a just manner for women who would otherwise be denied all rights".

* "Our interventions are quite effective and we witness quick action once a formal complaint is sent to the relevant authorities."

WFS REF: INDO804O


India
Capitalising On Sisterhood, Teenage Girls Generate Wealth To Secure Health  
Ajitha Menon

When the thatched roof over Neetu Kumari's mud home blew away during a violent thunderstorm she saw her parents worry about raising enough money to build one again. That's when the 15-year-old stepped up and offered to buy an asbestos or aluminium sheet roof on their behalf. Her parents were left astounded. Manti Kumari, 18, has funded her own schooling and college admission and when recently her mother fell gravely ill she even managed to raise enough money to pay for her treatment. Across 70 villages of Ranchi and Hazaribagh districts in Jharkhand there are numerous teenage girls like Neetu and Manti, who are part of successful micro-credit ventures, which gives them access to money as and when they need it the most. They have come together in groups of 15 with the support of Child in Need Institute (CINI), a local non-profit, and Oxfam India under a special maternal health campaign underway in the region. Interestingly, greater financial control has not only given these girls a voice in the family - their thoughts and opinions are not ignored by their parents like before - it has also enabled them to improve their health and nutritional status as well as firmly reject early marriage.

"Some of us have convinced our parents to build toilets after offering to pay part of the costs through loans taken from the group."

WFS REF: INDO713O


India
Tribal Mothers Count On Their Promised Day Of Healthcare  
Annapurna Jha

Kailashi Bhil, 30, Kankun, 20, and others have come a long way from the days when they would completely panic if they needed to visit a doctor. After all, taking out precious money and time to travel 40 kilometres from their small hamlet of Chamanpura all the way to Chittorgarh was no easy task. Yet, whether they wanted to get basic medicines or diagnostic tests, access antenatal care or give birth, these poor tribal women had no alternative but to visit the "big" district hospital because there was no anganwadi worker, Auxiliary Nurse Midwife (ANM) or Accredited Social Health Activist (ASHA) appointed to provide essential healthcare in their village. In fact, in their Udpura Gram Panchayat, comprising 14 villages, there was only one ASHA and one GNM (General Nurse & Midwife) to service the entire area. Fortunately for them though, the introduction of a maternal health campaign, initiated by Prayas, a local non government organisation, and Oxfam India has changed the unfortunate status quo. By ensuring that the monthly Village Health and Nutrition Day, mandated under the National Rural Health Mission, is held regularly, local women are now enjoying free antenatal check ups, routine immunisation and nutrition counselling right at their doorstep, which has improved the maternal and child health indicators in the area.

"Last month, along with Kailashi I had also received my tetanus shot and given a blood sample for testing my haemoglobin level. It's such a relief to be able to get all this done in the village itself."

WFS REF: INDO615O


India
Jharkhand's Task Force That Sings And Counsels Young Mothers On Health  
Ajitha Menon

A lilting tribal melody catches the attention of the gaggle of women gathered at the Integrated Child Development Services (ICDS) centre in Jidu Pandra village in Ormanjhi block of Jharkhand's Ranchi district. Almost at once, all eyes follow the sound that is coming from the farthest corner of the room. As they keenly listen to the beautiful voice of Suman Devi, 25, singer and composer, gradually the Nagpuri lyrics explaining the ill-effects of child marriage start to sink in. When the melody comes to an end, in the ensuing stillness she gets on to opening a discussion on healthcare for women and adolescents. Suman is the barefoot auditor, or Gram Arogya Sakha, of her village, and she writes, composes and sings songs on health, sanitation and regressive social practices such as child marriage to sensitise the community as well as empower it to access government schemes for the welfare of young girls, pregnant women and newborns. In 70 villages of Ranchi and Hazaribagh districts, many such barefoot auditors have been trained to become valued change-makers by Child in Need Institute (CINI), a local non-government organisation, under Oxfam India's DFID-supported Global Poverty Action Fund initiative. The last three years have been enlightening and eventful for the villagers as they have gradually turned the wheels towards positive social transformation with the much-needed counsel of this skilled force.

"Songs have greater appeal than lengthy speeches. I initiate every meeting with a melodious number and once I know everyone's listening I talk in detail about the need for immunisation, taking iron pills, nutrition for pregnant women, and so on."

WFS REF: INDO428O


India
Community Action Revives A Sick Primary Health Centre In Pratapgarh  
Annapurna Jha

For years, the Primary Health Centre (PHC) in Devgarh, in Rajasthan's Pratapgarh district, had been functioning poorly. While the building was badly maintained - the toilets used to be filthy, there was no water supply and the waiting area was used to store junk - more often than not the duty doctor used to be absent. Consequently, patients coming in from 36 villages in the area were simply turned away. Everyone was putting up with the situation as they didn't think there was a way out. Till one day when the desperate pleas of the relatives of a young pregnant woman in need of urgent attention were completely ignored and their patience ran out. The poor tribal people of Devgarh got together under the guidance of their Village Health Sanitation and Nutrition Committee (VHSNC) and chalked out a radical plan of action to turn their "sick PHC" around. Today, quite remarkably, the community has access to free diagnostic tests, medicines and treatment facility, all of which have been most beneficial to expectant women, who no longer have to bear unnecessary expense or exertion in going all the way to the district hospital. That collective effort can enable a community to secure their rightful entitlements is the most important lesson that residents of Devgarh learnt when Prayas, a local non-profit, and Oxfam India began working with them as part of a maternal health intervention underway in the region.

"Thankfully, the PHC at Devgarh became operational by the time she was ready to give birth. Our ASHA arranged for the ambulance to take her there and within a few hours we had a healthy baby in our hands."

WFS REF:INDO33OO


India
Family Planning Lessons From Trailblazing Muslim Teens  
Ajitha Menon

Ziratunnisa Khatun, 14, is an exceptional young woman. Apart from her studies, the one activity that she is really passionate about is going door-to-door in her Nooniya Basti, which falls under Mahingaon gram panchayat in Bihar’s Kishanganj district, talking to women about family planning, safe motherhood and the importance of eating nutritious meals. As part of her mission, she carries around with her samples of contraceptive pills, Copper T and condoms to show women how they can be used and tell them about the merits of keeping at least a five-year gap between children to ensure their health and well-being. Whereas, initially, the women used to be shocked at her “audacious” behaviour – how could an unmarried girl talk freely about sex and contraception – today, two years on, they have shed their hostility and share their concerns and questions without inhibition. Ziratunnisa is part of a group of committed girls, who belong to a conservative Shershabadi community, but have successfully managed to break the barriers of age and tradition to lead a campaign advocating for family planning. Constant encouragement from the Bihar Voluntary Health Association, a local non government organisation, which is running a special maternal health intervention in the district in collaboration with Oxfam India, has enabled them to transform the outlook of several women in the area.

* We spread the message that it was alright to use contraception to achieve spacing between children even if family planning per se was taboo.”

WFS REF:INDO3O9O


India
Gadchiroli Women Take Charge Of Their PDS Entitlement  
Dilnaz Boga

Bimlabai Adulwar, Radhika Hundra, Khembai Miri and 13 other tribal women from Pandarigota village in Gadchiroli district of eastern Maharashtra have worked out a practical solution to their food security problems. Since September 2014, their Self Help Group (SHG), the Sant Krupa Mahila Bachatghat, has been running the Public Distribution System (PDS) outlet in their quaint hamlet so that no family is denied their monthly share of basic food supplies like rice, flour and sugar. Till 2013, Bimlabai and others used to trudge four kilometres to Korchi town to get rations and most often they would come back empty handed - either the shop would be closed or the stocks were out. Things began to change when Ami Amchya Arogyasthi, a local non government organisation, and Oxfam India started an intensive intervention to ensure people's access to PDS ration as it is directly linked with improving maternal health and reducing maternal mortality and morbidity in the region. Not only did these enterprising women learn how to engage with officials to seek permission to open their own shops but they have also gained confidence to operate it successfully. There are six such all-women-run PDS outlets operational in Korchi today.

* "We don't have to depend on others for food. We won't be cheated, harassed or disappointed anymore. I'm glad we took charge."

WFS REF:INDO223O


India
In Southern Rajasthan, Villagers Have An Official Budget To Safeguard Mothers  
Annapurna Jha

An hour’s drive from the bustling town of Chittorgarh, the celebrated land of heroic warriors in Rajasthan, meet Suman Jain, a modern-day “soldier”, from Bheru Singhji ka Kheda village, who is striving to provide equitable healthcare to mothers and children in the area. Jain, an Accredited Social Health Activist (ASHA), is working closely with the Village Health Sanitation and Nutrition Committee (VHSNC) to enhance the quality of services provided at the nearby Health Sub-Centre (HSC), in addition to improving the state of sanitation and hygiene there. As one of the co-signatories to the bank account that receives untied funds for shoring up healthcare, among other facilities, in the village, under the National Health Mission, Jain is thrilled that she has been able to affect some real change. Since 2012-13, the VHSNC has been getting this valuable sum that they utilise the way they deem fit in consensus with the people. Today, like Bheru Singhji ka Kheda, there are 95 villages across Chittorgarh and Pratapgarh districts, where the VHSNC is actively using this money to buy basic medical supplies and refurbish infrastructure not just in the HSC but the village, too. This they are doing with the support of Prayas, a local non government organisation, and Oxfam India, that are implementing a maternal health project funded by UK Aid in the region.

* “We have purchased a weighing scale and a BP machine as we know this would facilitate the check up of pregnant women and young children. In addition, we have got a tank with tap installed at the HSC from the money allotted for the year 2013-14.”

WFS REF:INDO210O


India
Barefoot Auditors Ensure Healthcare For Tribal Mothers  
Dilnaz Boga

The barefoot auditors have been bringing in change in the predominantly tribal populated regions of Maharashtra that until recently did not have adequate access and knowledge about various health and nutrition schemes that they could avail for expecting and young mothers. Armed with training and information on reducing health risks and vulnerability, they have started turning the tide against maternal mortality, low level of awareness in the community and an unresponsive health system. Trained barefoot auditors, such as Manga Thackeray of Bhute village and Jagu Pahar of Vagharda, are committed to deliver on the promise of good health to their people. The duo is happy to have been handpicked to become change-makers under a maternal health intervention undertaken by Janarth Adivasi Vikas Sansthan (JAVS) and Oxfam India.

* “I make a note of the number of pregnant women in the village and talk to them about eating right and taking the necessary precautions. I even ensure that they get the diet and the monetary incentives they are entitled to under different government schemes.”

WFS REF:INDNC03O


India
Gadchiroli Women's Recipes for a Nutritious Fare  
Dilnaz Boga

Durga Bhisa, 29, a tribal woman from the small hamlet of Moegaon in Korchi block of Gadchiroli district in Maharashtra, enjoys cooking different dishes these days. This mother of two is a whiz at whipping up a batch of traditional favourites such as 'laddoos', 'karanji' (sweetmeats), and crisp savoury 'chaklis'. Her friend, Samrinbai Mantar, 26, too, is able to include 'upma' (semolina porridge), 'palak bhaji' (spinach dish) and 'sheera' (semolina sweet) regularly in her meals. Today, the two tribal women are eating tasty, nutritious fare - at no extra cost - because they finally know how to utilise the packets of semolina, jaggery, soya, wheat and other nutritious supplementary foods they get as Take Home Ration from their neighbourhood anganwadi centre every two months. While earlier, they were simply dumping the "tasteless powders" or feeding them to their cattle, now hundreds of local women like Durga and Samrinbai, across 35 villages in the region, have learnt to make 21 lip-smacking preparations from them, under a special maternal health intervention supported by Oxfam India.

* "Once a woman registers with the anganwadi, she starts getting ration from the following month. Each one gets three to four packets of upma, sheera or sattupeeth. Over the last one year, I've seen how their weight has increased."

WFS REF:INDNC16O


India
Binita, Martha and Others Make Maps To Ensure Better Health  
Sarada Lahangir

Binita Kanhara, 32, a tribal woman from Rajikakhol village, in Kandhamal district of Odisha, was happy the day she learnt she was expecting her first child. Nine months later, when the D-day came, her mother-in-law decided that the delivery would take place at home. Unfortunately, the newborn child did not survive as it was weak and anaemic and needed medical care. The incident left Binita traumatised for months on end. When she was expecting her second child she spent her entire pregnancy in misery, expecting the worst. This time around, too, the baby, born at home, was malnourished. But then, Martha Diggal, the local Accredited Social Health Activist (ASHA), miraculously came into her life and convinced the older woman to send Binita and the newborn to a hospital. By her third pregnancy, neither Martha nor Binita had to do anything other than call for an ambulance under the government’s Janani Suraksha Yoyana to take her to the health facility. Today, across 34 villages in Kandhamal, a district with one of the highest rates of maternal mortality in the state, an intervention helmed by the Centre for Youth and Social Development and Oxfam India, aimed at strengthening maternal health outcomes at the grassroots, is bringing about perceptible change. Here, it’s the creation of the village health atlas, a collaborative effort between the community, village health and sanitation committee and the government health workers that has made motherhood truly the wonderful experience it ought to be.

* “Being uneducated and ignorant I used to insist that my daughter-in-law follow what I did as a young woman. In my day, we were told not to eat nutrition rich food lest we became too heavy and had difficulty in child birth. Also, we had to be in isolation after delivery. I realise I was wrong.”

WFS REF:INDNB17O


India
How To Transform A Defunct Rural Health Centre Into A Model Facility  
Ajitha Menon

One simply needs to walk into the Health Sub Centre (HSC) at Marwatoli village in Bihar', Kishanganj district to see what a well-run health facility should be like. It's spacious, neat and well-equipped with a separate labour room for conducting safe deliveries. Stationed on duty every day are two Auxillary Nurse Midwives (ANMs), who take turns to carry out immunisation as well as to monitor and counsel pregnant women and adolescents. Looking at this, it's hard to believe that till a year back, Marwatoli HSC was just another one of the numerous defunct small health centres that dot the region - its structure was completely dilapidated and the overgrown compound was being used by the locals to dry clothes and graze cattle. Then came the activists of the Bihar Voluntary Health Association, who, as part of a special health intervention launched by Oxfam India, motivated villagers like Anjari Begum, Shimoli Devi, Noorjabi Khatun, Mahendra Prasad Harijan, and others, to work together to ensure quality healthcare for everyone in the panchayat. That today Marwatoli has zero infant mortality and nearly 100 per cent institutional delivery is a proof of the strength of their collective action.

“We decided that our priority was to get the HSC functional and for this we mounted a strong campaign. We wrote letters to the panchayat and the District Magistrate urging them to utilise the untied funds given to each village to repaint and refurnish the HSC.”

WFS REF:INDNB03O


India
Channelising Girl Power To Fight Child Marriage  
Sarada Lahangir

Last year, Sujata Behera, 17, of Dankeni, a remote village in Kandhamal district of Odisha, did the unthinkable. Just two weeks before her upcoming marriage, this youngster, who hails from to a scheduled caste community, told her parents that she had decided not to go through with it. Sujata's father was livid while her mother tried to reason with her to change her mind. But the teenager was firm. Standing by her side was her special group of friends whose unwavering presence gave her the strength to defy her parents. The girls sat the elders down and explained why it was such a bad idea for Sujata to get married before her 18th birthday. Though it was not easy, they managed to convince them eventually. Who were these girls that came to support Sujata in her hour of need? Members of the Kishori Kalyan Samiti, an all-girl group set up in the village with the assistance of the Centre for Youth and Social Development, under the initiative, 'Improving Maternal Health Status in Six States in India', launched by Oxfam India. In 34 villages of Kandhamal, where 35.5 per cent girls are pushed into early marriage, these groups have given hundreds of teens the power to say 'No' to child marriage and save themselves from a lifetime of ill health and the misery of unfulfilled dreams.

"Despite being a victim of child marriage myself, due to social pressures I was ready to let my daughter give up her education and go through the same hardships that I am facing till date. Thankfully, I realised my mistake. I am proud that my daughter is part of a group that stands up for what's right."

WFS REF: INDNA07O


India
Fighting Graft, Jahangirpur's Muslim Women Secure Maternal Health Benefits  
Ajitha Menon

Corruption in the implementation of Janani SurakshaYojana (JSY), the government scheme that aims to decrease maternal mortality by promoting institutional delivery, was the first thing that came to light when the women of Mahesmara village, which falls in Jahangirpur Gram Panchayat in one of Bihar's most backward districts, Kishanganj, sat together to discuss the state of maternal health care in the area, under a special intervention launched by Oxfam India, under the Department of International Development (DFID)-supported Global Poverty Action Fund initiative. As Noorbano Begum, 46, encouraged the group to share their experiences related to accessing government benefits as well as the functioning of local health workers, someone mentioned how she had heard of a woman from a neighbouring village collecting the cash incentive given for having an institutional delivery under JSY twice within nine months. This led to the revelation that several women in Mahesmara had, in fact, never received any monetary benefit, although inquiry brought forth a startling reality - cash had been paid out against all the names registered for institutional delivery. What followed was a full-fledged movement against corruption that has not only resulted in a marked improvement in expectant women's access to healthcare but also increased institutional deliveries from 20 to 60 per cent in all the 22 intervention villages in Kishanganj district.

'We could manage to collect evidence and put it before the authorities who were compelled to suspend and later arrest the Medical Officer In Charge and others involved. At the same time, thanks to the movement, every woman in Mahesmara got to know their entitlements under JSY.'

WFS REF: INDN9290

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