The document discusses a case study from Gujarat, India, focusing on community action for maternal health in rural areas and the disparities in service utilization across different districts. It highlights key strategies used by NGOs to improve accountability and service delivery for maternal health, leading to increased antenatal care (ANC) utilization and improved health outcomes. The findings emphasize the critical role of community participation and NGO involvement in enhancing both demand and supply-side barriers in healthcare services.

1. Abt Associates Inc.
In collaboration with:
Avenir Health | Broad Branch Associates | Development Alternatives Inc. (DAI) | Johns Hopkins Bloomberg School of Public Health (JHSPH) |
Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)
Enabling community
action for maternal
health: A case study
from Gujarat, India
Strengthening People-Centered
Services through Improved
Accountability
January 29, 2017
Asha George, Subhasri S, Rajani Ved,
Jaya Gupta, Diwakar Mohan,
Amnesty LeFevre, Renu Khanna

2. Stark inequities within a well performing state
Dahod
47% mothers 3 ANC vs.
13% full ANC
29% ANM residing at
subcenter
14% subcenter labor
room in use
17% PHC 24 hours
Anand
69% mothers 3 ANC vs.
37% full ANC
56% ANM residing at
subcenter
47% subcenter labor
room in use
75% PHC 24 hours
Panchmahal
55% mothers 3 ANC vs.
24% full ANC
0% ANM residing at
subcenter
9% subcenter labor
room in use
45% PHC 24 hours
Dahod and
Panchmahal
districts: remote,
rural, tribal
Anand district:
wealthier, more
developed 2

3. Community Action for Maternal Health
NGOs working at community level through women’s
groups, health committees and self help groups
Covering 45 villages in two different regions of Gujarat
 Approximately 108,000 people
 6 primary health centers (PHC) and 25 sub-centers
Key strategies
 Framing and awareness of entitlements by pregnant women,
community and providers
 Community monitoring of receipt and delivery of services
 Dialogue with providers and administrators about gaps identified

4. Awareness: Safe delivery discussions and
ranking

5. Awareness: Community meetings & toran
banner

6. Awareness: mahiti patrika/ entitlements
poster

7. Monitoring: Healthy mother tracking tool

8. Monitoring: VHND monitoring tool

9. Monitoring: Maternal death reporting
Compliment
government
reporting
Broaden
responsibility for
reporting deaths
Broaden
understanding of
maternal deaths

10. Dialogue: Report cards

11. Dialogue with government health services

12. ANC utilization improved substantially in tribal districts,
particularly for elements previously neglected
Social links Clinical exams Lab tests Commodities

15. Underlying SERVICE DELIVERY processes that explain the
outcomes, based on project reporting of dialogues
Restarting of services, previously only on paper
 Increase in number of VHNDs in hard to reach areas
 Deliveries being conducted at once defunct PHC
Repairs that improved quality of service environment
 Leakages fixed at one PHC
 Toilets provided for women in a sub centre

16. Underlying GOVERNANCE processes that explain the outcomes,
based on project reporting of dialogues
Building of relationships between government & community
 Training imparted by health providers to women’s groups
 Invitation to do Joint Maternal Death Review by the THO
 Inappropriate practices
addressed
 Chiranjivi scheme license
withdrawn from a Private
hospital
 Collusion between ASHAs and
Private Practitioners revealed

17. Lessons for scale up: Community level
Participatory process of developing consensus around
problem, framing entitlements, developing tools
 Iterative process that allows for local adaptations
 Takes time but deep dividends for ownership
Process intensive intervention
 Intensity of monitoring tools vs. community capacity
 Should poor women be volunteering to monitor service delivery?
Who is the community: Fulcrum for the project?
 Whole community
 Community platform: women’s groups, health committees, self help groups
 NGO and community volunteers

18. Lessons for scale up: Role of NGOs
Orientation of NGO and nature of community platform
 NGO reputation improved despite tensions
 Capacity and relationship building required at all levels
 Initial tensions with health personnel and administrators

19. So what?
HEALTH EFFECTS
Community accountability initiatives can directly improve
health care utilization, with important equity effects
 Requires time, resources, flexibility
GOVERNANCE EFFECTS
Even in a ‘well performing’ state, NGOs play a critical role
in addressing both demand and supply side barriers that
can inhibit the functionality of governments in providing
quality services
 Requires facilitation, trust building at multiple levels

20. Abt Associates Inc.
In collaboration with:
Avenir Health | Broad Branch Associates | Development Alternatives Inc. (DAI) | Johns Hopkins Bloomberg School of Public Health (JHSPH) |
Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)
Thank you
All the respondents, including women and volunteers at community level, NGO
volunteers and staff, government health officials and health care providers in the
districts and at the state level
Dr.Dholakia, Ministry of Health and Family Welfare, Government of Gujarat
Sunanda Ganju, Mahima Taparia, Pallavi Saha, Calvin Parmar, Sandhya (SAHAJ)
Neeta Hardikar, Pradeepa Dube, Sheela Khant, Rita Parmar, Urmila Baria, Mena Rathva,
Veena Baria, Devgadh Mahila Sangathan members and other field volunteers (ANANDI)
Father Joseph Appavoo, Meena, Sunita Macwan, Bhanu, Usha, Hetal, Geeta and local
volunteers (Kaira Social Service Society)
Dr. Pankaj Shah, Dr. Leela Visaria, Dr. Sridhar Srikantiah, Dr. Sundari Ravindran
CommonHealth: Coalition for Maternal-Neonatal and Safe Abortion
MacArthur Foundation for their partnership and financial support
Marianne El-Khoury, Rachel Stepka, Carlos Avila, Nicole Barcikowski, Catherine Connor
(Abt Associates)
Jeremy Kanthor (DAI)
Robert Franks, James Willett, Elliot Rosen (JHSPH Administrative Staff)
IIHMR, Abt Associates and JHSPH IRB committees and support staff
Jodi Charles, Scott Stewart (USAID)
www.hfgproject.org