Mittal Shah, Kent Ranson & Palak Joshi Reaching the poorest: SEWA’s experience with reproductive health camps

SEWA SEWA is a trade union of women workers in the informal economy Started in 1972 by Ela R. Bhatt Provides services in Ahmedabad City and 11 rural districts of Gujarat state Main goals: economic security and self- reliance Major activities: organizing, banking and micro-finance, insurance, capacity-building, health care 2003 membership in Gujarat: 4,69,306

SEWA Health Delivering services since 1980 Aims to serve the poorest Current services delivered: –Preventive: health education and training, ante-natal care, immunization, occupational and mental health activities –Curative: low-cost medicines, TB treatment, mobile RCH care, traditional medicines

SEWA’s RH camps Since 1999 Partnership with UNFPA Targets women of reproductive age in Ahmedabad City and select villages in 5 rural districts 2003: 7,041 women received treatment 6 part-time physicians and 50 barefoot doctors and managers Fees: Rs. 5 consultation fee, medicines sold at wholesale price

Research Methodology Phase I Qualitative Phase II Quantitative Phase III Qualitative

Research Methodology Objectives: Explore barriers to RH camp utilization Identify indicators of socio- economic status (SES) Activities: FGDs with RH camp users & non- users, including wealth-ranking In-depth interviews with service providers & managers Phase I Qualitative

Research Methodology Objectives: Assess SES among RH camp users versus non-users Activities: Exit-survey Questions about households assets, utilities, dwelling and land ownership Randomly selected 1 camp (of max. 3) per day, and interviewed all users 535 interviewed Compared to: Gujarat population, DHS urban N = 1,709, rural N = 2,223 Used wealth index, principal factors analysis Phase II Quantitative

Research Methodology Objectives: Validate findings of previous phases, with a focus on “Why did the service reach (or fail to reach) the poor?” Activities: In-depth interviews with service providers Phase III Qualitative

Findings: barriers to utilization Demand High perceived cost Low perceived quality Fear of doctors/procedures Weddings, funerals Not empowered to make own decision Supply Timing of camps Cost Exemption policy unclear Limited continuity of care Door-to-door promotion misses some

Respondent 1: …If someone doesn’t have a good financial situation, they would not come at all! Respondent 2: They would think that, “What if they ask for more money in the camp? What would I do?” FGD with RH camp users and non-users Findings: perceived cost as a barrier to utilization

The poorest women would go out and do work for daily wages. They would say that “I will have to lose my wages to be able to attend the camp”. FGD with SEWA Health rural grassroots worker Findings: camp timing as a barrier

Findings: Top 5 indicators of SES (DHS, urban Gujarat, ) Frequency RankVariable DHS (N = 1,709) RH Camps (N = 377) 1If electricity lighting94.1%91.2% 2If biogas cooking fuel0.1%0.0% 3If gas cooking fuel57.0%34.7% 4If kaccha house5.3%18.9% 5If no toilet facility23.1%16.4%

Findings: Top 5 indicators of SES (DHS, rural Gujarat, ) Frequency RankVariable DHS (N = 2,223) RH Camps (N = 157) 1If private pit toilet12.9%1.9% 2If wood cooking fuel78.0%89.8% 3If private flush toilet6.6%3.2% 4If pucca house23.6%4.5% 5If electrical lighting77.0%92.4%

Findings: Percentage distribution of SEWA Health urban service users by SES quintile

Findings: Concentration curve, SEWA Health urban services RH Camps

Women’s training TB DOTS Findings: Concentration curve, SEWA Health urban services

Findings: Percentage distribution of SEWA Health rural service users by SES quintile

Findings: Concentration curve, SEWA Health rural services RH Camps

Findings: Concentration curve, SEWA Health rural services RH Camps Women’s training

SEWA Health’s RH camps services more effective in reaching the urban (vs. rural) poor –71% urban users from lowest 2 quintiles –43% rural users from lowest 2 quintiles RH camps slightly more successful in reaching the poor, among 3 services studied Policy implications: summary of findings

Why are SEWA Health’s RH camps successful in reaching the poor? Mobile approach: delivered to the “doorstep” in high-density urban and remote rural areas Service delivery by poor, local women Combined with efforts to educate and mobilize (create demand in) the community Trust in SEWA Costs are low

How can SEWA Health’s RH camps better reach the poor? Change timings to better suit poor, working women (e.g. evening camps) Modify fee-policy to reach poorest –Develop an objective system for granting, for example, all holders of “below-poverty line” cards Collaborate with government facilities, so as to access free medicines and physicians Address barriers faced by women –Involve men and senior Hh members in education –Encourage experience-sharing by women who have been cured