National Consultation on Community Action for Health, Gulmohar Hall, India Habitat Centre, New Delhi I October 28, 2014 OUR EXPERIENCES, LESSONS AND WAYFORWARD PERSPECTIVES OF DEVELOPMENT PARTNERS ON COMMUNITY ACTION FOR HEATH Usha Kiran Tarigopula, Deputy Director

OUR APPROACH FOR SCALED COMMUNITY MOBILIZATION IN HEALTH 1 Create/leverage existing self-help groups to integrate Health Focus on most marginalized women and RMNCHN and WSH Facilitate participatory learning and action to improve health Facilitate access and linkages to frontline workers and VHSCs Promote collective action Work with members of groups to mobilize non-members Support states to strengthen accountability through local self-governance structures Generate evidence and share our learnings with government and partners to inform scale-up

COMMUNITY ENGAGEMENT FOR NHM/RMNCH+A: UP AND BIHAR EXAMPLE 2 Uttar Pradesh Focus on the most marginalized groups from BPL Promoted 70,000 groups in 160 blocks in 41 districts Trained ~ 100,000 women leaders as health volunteers Established a proof of concept to strengthen VHSNCs for MNCH Demonstrated potential of leveraging self- help groups (SHGs) to increase uptake of health interventions Demonstrated potential of leveraging self- help groups (SHGs) to increase uptake of health interventions Bihar Focus on SCs/STs and Pusmanda Muslims in 60 blocks in 8 districts; 36,000 groups Trained and capacitated ~2,600 as health volunteers and promoted participatory learning and action Encouraging health outcomes data from external midline Work to strengthen VHSNCs underway in 100 Panchayats Plans are being developed together with other partners for scale up through NRLM Focus in promoting individual and collective action for shifting norms, uptake of key interventions, linkages with health workers/facilities and links with VHSNCs

Source: Parivartan Midline; Notes: */**/***=adjusted difference significant at the 10/5/1 percent level. ns – not significant Chi-sq test for association between outcome indicators and time. */**/***=significant at the 10/5/1 percent level *** * Most marginalized women in SHGs with Health layering showed better increase in selected critical outcomes BIHAR: EARLY FINDINGS FROM MIDLINE EVALUATION ARE ENCOURAGING (1/2)

BIHAR: EARLY FINDINGS FROM MIDLINE EVALUATION ARE ENCOURAGING (2/2) Maternal Health New Born and Child careFamily Planning Source: Parivartan Midline; Notes: */**/***=significant at the 10/5/1 percent level. Chi-sq. test (unadjusted associations) Strong Correlations between health volunteer advice and selected outcomes for most Marginalized women in SHGs

COMMUNITY ENGAGEMENT IN HEALTH: SUPPORT TO STRENGTHEN VHSNCS IN KARNATAKA 5 Strengthen capacities of 1150 VHSNCs in two districts in Karnataka with GOK and foundation’s support through training and handholding: Understand roles and responsibilities Plan and monitor village-level health activities Help community prepare a practical and actionable health plan Take ownership of health services and facilities within the community Work together with different departments to achieve common health goals Help the community raise voice for provision of services & identify local problems and generate solutions

EVALUATION FINDINGS: INCREASED PROPORTION OF HEALTH TOPICS DISCUSSED IN THE LAST VHSC MEETING IN KARNATAKA

KARNATAKA: EVALUATION FINDINGS SHOW INCREASED PROPORTION OF VILLAGE ANNUAL HEALTH PLANS

Our experiences and evidence to date excites us about the potential to leverage community structures to complement the supply side interventions in health The biggest challenge in front of us is reaching scale with quality to support the aspirational goals of NHM Apart from working with VHSNCs and PRIs to strengthen monitoring and accountability for health, we see the GOI’s NRLM offers an incredible platform of women’s groups and their federations at scale to leverage for health Women’s groups offer incredible opportunity to shift social norms, increase of uptake of life saving interventions through household and community action for health The synergistic actions between FLWs, women’s groups, panchayats and other local structures critical to achieve community action for health In addition to supporting NHM and ICDS, we plan to provide national and state level TA to NRLM to develop and institutionalize capacity to integrate health © 2014 Bill & Melinda Gates Foundation | 8 IN SUMMARY….

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COMMUNITY ENGAGEMENT IN HIV PREVENTION: AVAHAN EXAMPLE 10 Focused in 5 southern Indian states over the last decade in 83 districts with most at risk Reaches 300,000 FSWs, MSMs and TGs 10,000 groups and over 100 registered CBOs Strong focus on risk reduction by addressing key issues like violence Strong evidence on how community mobilization can help reduce riskl Focused in 5 southern Indian states over the last decade in 83 districts with most at risk Reaches 300,000 FSWs, MSMs and TGs 10,000 groups and over 100 registered CBOs Strong focus on risk reduction by addressing key issues like violence Strong evidence on how community mobilization can help reduce riskl

© 2014 Bill & Melinda Gates Foundation | 11 Increased Collective and Individual PowerIncreased Knowledge and Uptake of Services Increased CCU Reduced Gonorrhea and Chlamydia Prevalence Low Medium High ** * * * * * * * *AOR p<0.05 **AOR p<0.001 EVIDENCE FROM AVAHAN: KARNATAKA EXAMPLE High Exposure to Community Mobilization drives change behaviors Source: Biological and behavioral survey, 2011 with random samples of FSWs in 4 districts in Karnataka, India (Bellary, Bangalore, Shimoga, Belgaum) N=1934 FSW

METHODOLOGY USED FOR BIHAR MIDLINE (I/II) Baseline Midline Endline 1 year Data Source:  Structured survey interviews with eligible* women from community groups  Structured survey interviews with community group leaders  Semi-structured interviews with key informants  Focus group discussions with program personnel (Community Mobilizers)  Used sub-sample of sc/st/pm women from Ananya survey data as comparison group * years, currently married, have < 1 year child

Sample SizesBaselineBaseline (ex. Patna)Midline (ex. Patna) Number of districts877 Number of blocks35 29 (S+H: 23; S: 6) 41 (S+H: 23; S: 6) Number of groups (Cross-sectional data) Number of women (S+H: 1523; S: 601) 2237 (S+H: 1653; S: 584) Number of groups (Panel data) 545 Analytical sample: Number of women belonging to common groups 1539 (S+H: 1095; S: 444) 937 (S+H: 720; S: 217) Analytical sample: Number of non-SHG women (most marginalized) from Parivartan program blocks (Ananya midline sub-sample) 363 (non-SHG women) S+H: SHG with structured health layered intervention S: SHG without structured health intervention Non-SHG: Most marginalized women not from the groups but from program blocks (Ananya midline sub-sample) METHODOLOGY USED FOR BIHAR MIDLINE (II/II)