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OXFAM IN ACTION

Creating Awareness to
Improve Maternal Health in Jharkhand
no. 4 | march, 2015

E ight Millennium Development Goals (MDGs) were


agreed by member countries following adoption of the
Millennium Declaration by the United Nations Millennium
Only two-thirds of the population has access to improved
sources of drinking water11 and it is one of the worst
performing states in terms of access to toilet facilities12.
Summit in 2000 ranging from halving extreme poverty
rates to providing universal primary education to all to be
realised by the target year 2015. GPAF* project was implemented in
420 villages, 21 blocks and
One of the goals, MDG 5 was about improving maternal 17 districts spread over 6 states
health by bringing down the Maternal Mortality Ratio (MMR)
of Jharkhand, Odisha, Bihar,
a target was set for each country to bring down their
ratio by three quarters between 1990 and 2015; which for Chhattisgarh, Maharashtra and
India meant 109 per 100,000 live births by 2015. In 2007-09 Rajasthan
the MMR was 212; it declined in 2011-13 but remains high
at 1671 with huge inter-state and intra-state disparities. 420 VHSNCs activated & now
monitoring community
Striving towards Oxfams vision of right to life with dignity
for all, a project Improving Maternal Health in Six States
level health services
of India was conceptualised under the Global Poverty
11000 women
Action Fund (GPAF) with support from Department for
attended maternal health trainings
International Development (DFID). GPAF focussed on
poverty reduction and pursuit of MDGs through improved
service delivery, empowerment and accountability, work
32000 people
on conflict, security and justice2. participated in 56 health & nutrition melas

Jharkhand, formed in 2000 after separating from the Increased demand for nutritional
state of Bihar, is the fifth least-developed state3, with supplements and temporary contraceptives
historically alarming levels of poverty, hunger and ill
health. The poverty ratio of Jharkhand is 45.3 per cent 19 out of 24 PHCs now have referral
(national average of 37.2 per cent), but a broader definition transport compared to 5
PHCs earlier
of poverty suggests that 74.8 per cent of the state is poor. * Global Poverty Action Fund
The health indicators too show a dismal picture: 43 per
cent women in Jharkhand have a Body Mass Index (BMI)
Oxfam has partnered with Child In Need Institute (CINI) in
below normal4.
two districts of Jharkhand Ranchi and Hazaribagh. CINI,
According to the Annual Health Survey (AHS) 2011-12, established in Kolkata in 1974, has since worked on health
Jharkhands MMR at 267 lagged behind the national figure and nutrition in West Bengal, Jharkhand and Chhattisgarh13.
of 1785. The Infant Mortality Rate (IMR) was only marginally In health, it has been working for long in the regions
better, at 38 deaths per 1000 live births, as against the lending technical support to the National Rural Health
national figure of 446. The 2012-13 AHS data showed Mission (NRHM)14 by providing training modules for the state
some improvement for Jharkhand - MMR was at 2457 and Accredited Social Health Activist (ASHA or Sahiyya).
IMR at 368. Infant and child mortality rates, however, are
In 2013, Oxfam partnered with CINI in Jharkhand in 70
disproportionately higher within the state among the
villages covering 15 Gram Panchayats in two blocks of
adivasis and poor households; adivasis consisted 28 per
Churchu (Hazaribagh) and Ormanjhi (Ranchi). These villages
cent of the states population9.
are a mix of Adivasi, Dalit and Muslim families. An integrated
Jharkhand lags behind in other health-related parameters approach is necessary to have an impact on issues related
as well only Bihar and Rajasthan rank lower than to nutrition and maternal health, said Faiz Ahmad, project
Jharkhand in terms of proportion of child marriages10. coordinator, CINI.
Integrated Approach to Nutrition and
Maternal Health
J panchayat polls were never held and Panchayati Raj
harkhand, till 2010, was the only Indian state where the village level. It acts as a sub-committee of the Gram
Panchayat with a minimum of 15 members led by an elected
Institutions (PRIs) continue to be in their infancy. Ranjan panchayat member. Potentially, all those working in the
Panda of CINI feels that since PRIs are still in the process of village around health related services would participate
being built, the health monitoring systems do not always in its meetings16. Till recently, VHSNCs have been more
work the way people normally expect them to. While on paper and not been very active in the project areas.
strengthening the PRIs has been a challenge for activists However, things have changed in recent years. The VHSNCs
forming the Village Health, Sanitation and Nutrition are now a pressure group within the Gram Sabha and the
Committee (VHSNC) under the ambit of PRI compound it block. At the district level, VHNSC federations are being put
further. in place.

Oxfam focused on leveraging and activating existing In the villages, VHSNCs comprise of 15-25 members. Women
village-level institutions like the VHSNC and strengthening participation in general has remained low in the past, for
capacities of the community to ensure better delivery of instance, in Gram Sabha meetings. Powerful and influential
health and nutritional services. This was complimented by men would often hold Gram Sabha meetings at night and
formation of Village Health Resource Centres (VHRC) that circulate the register the following day at the womens
provided the village a library with Information, Education SHG meetings for them to sign, essentially leaving the
and Communication (IEC) materials, posters and calendars poorest and weakest out of the decision making process.
to build community awareness on health and nutritional However, VHSNC guidelines mandating 50 per cent women
aspects. Mass awareness campaigns were organised to membership improved their participation both in the Gram
underline the importance of nutrition to maternal and Sabha and VHSNC in the last three years. For instance, out
child health. of the 25 VHSNC members at Palu village in Ranchi district,
only four are men.
The VHRC also acts as a repository of information on
existing government schemes. The centre offers useful Now, the VHSNC and Gram Sabha meetings are well
information to the community, particularly pregnant / coordinated. In Ormanjhi block, for instance, Gram Sabhas
lactating mothers and adolescent girls. It hosts regular are held on the 19th of every month and, in all the 35
meetings of adolescent girls, VHSNC, and womens SHGs of villages, VHSNC meetings precede them. This is to ensure
the village and displays the outcomes of these processes that decisions taken at the VHSNC are shared with the
prominently at the Centre. VHRCs are run out of community Gram Sabha for implementation. Decisions are taken
centres or attached to the Anganwadi or Sub Centre. In democratically and CINI played a key role in facilitating this.
some cases, the house of the Barefoot Auditor15 becomes Most of the villages were unaware of the provision of untied
the VHRC. funds, of Rs 10,000 provided to the VHSNC

VHSNCs were formed as part of NRHM to take collective Training by CINI ensured better planning and spending
actions around health and its social determinants at of the untied funds on sanitation, drainage, hand-pump

Annual Health Survey Data


300
267 270
245 244
250

197
200 182

150

100
55 51 50 44
38 36 40
50 32 30 31 29 35

0
2011-12 2012-13 2011-12 2012-13 2011-12 2012-13

Jharkhand Ranchi Hazaribagh

MMR IMR Under-5 Mortality Rate


Source: http://www.censusindia.gov.in/vital_statistics/AHSBulletins
2
repairs, payment for unaffordable treatment and holding A committee, with members from the VHSNC and the Gram
Village Health and Nutrition Day (VHND). For instance, in Sabha, monitors local institutions like Anganwadis and Sub
Olattu village in Ranchi, the VHSNC decided to buy a bed Centres. To equip them better, CINI trains the VHSNC and
in the local Sub Centre as abdominal examinations of joint committee members on Community Based Monitoring
pregnant women were being conducted without one. (CBM). As a part of this monitoring system, in some places,
VHNDs are held on the same day as VHSNC meetings.
The planning exercise has become so popular that This apart, hemoglobin and blood pressure checks are
Olattu village refers to the VHSNC as Dus hazaar wala conducted and tests for expectant mothers, if incomplete
samiti (Rs 10,000 Committee). Despite delays in the on one day, are carried over to the next day.
disbursement of funds, villagers proceed with planning
and implementation. For instance, the Gram Sabha and In this regard, the Auxiliary Nurse Midwives (ANM) from
some SHGs in Olattu have committed finances to planned Olattu village informed that the Sahiyya and Anganwadi
activities. There is an increased sense of accountability worker supported by Barefoot Auditor (BFA) and field
as well. Everyone in the village keeps a tab on the animator ensure that all women attend. They also shared
expenses now, said Kanti Devi. that trainee nurses from nearby private hospitals volunteer
with the ANMs who are usually overworked.

Training Adolescent Girls on Maternal


Health and Nutrition
S
eventeen-year-old Suman sings a song at the VHND do they attend meetings but are spearheading activities
meeting at Jidu block in Ormanjhi. Chotta umare chotta around health melas. I got an opportunity and I came out
umare na debe biha, suna baba ho, chotta umare na debe of the house, says Suman. She recently made her debut on
biha. The song, loosely translated is a plea to her father to radio and now plans to train as a singer. A Sahiyya points
not marry her off, as she is very young. An active member out that girls were not allowed to sing earlier. Sumans
of the adolescents girls group, Suman is a local celebrity popularity has brought a positive change; many young girls
who composes and sings her own song in Nagpuri, the are now encouraged to participate in events during health
local dialect of the adivasi belt. She motivates villagers melas.
around entitlements, ills of child marriage and importance
of nutrition to the health of mother and child. Suman is part Health melas held in the last three years have helped spread
of the team of peer educators who are involved in Oxfams awareness about a balanced diet. Innovative concepts
GPAF project in Jharkhand. like Tiranga Bhojan or tri-color17 meal is promoted and
discussed in the adolescent girls meets. This focuses on
Adolescent girls in these project villages meet regularly nutritious food available locally and helps pregnant and
at VHRC to discuss issues related to nutrition, personal lactating mothers inculcate right food habits and follow
hygiene and marriage. Sahiyyas, Barefoot Auditors and a balanced diet at an affordable cost. Sahiyyas, Barefoot
project animators are also present at these meetings. Auditors and field animators from CINI conduct nutrition
They play a vital role in creating awareness on health and counselling around Tiranga Bhojan.
nutrition among the young and expectant mothers. VHRCs
are designed to become a knowledge hub around which Health melas have helped question objectionable cultural
peer educators, like Suman, train and motivate young practices around pregnancies and motherhood. For
girls from the village on health and
nutritional aspects.

Apart from trainings on health, the


adolescent girls group works to
ensure that every girl is educated.
In Hazaribaghs Mukru village, where
the group meets every Saturday at
VHRC, they have started an informal
small savings scheme. All the 19
girls deposit Rs 5 every week; these
are savings from their pocket money.
The saved money is then used to pay
for the board exam registration fee
for those who cannot afford to pay.

Earlier, girls were confined to their


homes and were not permitted
to attend meetings. Since CINIs
intervention, things have changed
for the better. Like Suman, not only
A street-play against child3marriage underway at an advocacy event in Ormanjhi
notes
1 http://www.censusindia.gov.in/vital_statistics/mmr_
bulletin_2011-13.pdf ; these are the latest figures, the earlier
figure was at 178.
2 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.ece
4 http://www.in.undp.org/content/india/en/home/operations/
about_undp/undp-in-Jharkhand/about-Jharkhand.html
5 http://www.livemint.com/Politics/3uK62sim31WSgbyB5Bw4AP/
Indias-maternal-mortality-rate-falls-but-still-a-long-way.html;
as viewed on Feb 27, 2015
6 http://www.livemint.com/Politics/3uK62sim31WSgbyB5Bw4AP/
Indias-maternal-mortality-rate-falls-but-still-a-long-way.html;
as viewed on Feb 27, 2015
7 The latest SRS data suggests that the MMR is at 208; http://www.
A stall at the local health mela in Kuchu village explaining
censusindia.gov.in/vital_statistics/mmr_bulletin_2011-13.pdf
Tiranga Bhojan and importance of leafy vegetables
8 http://www.censusindia.gov.in/vital_statistics/AHSBulletins/
AHS_Factsheets_2012-13/FACTSHEET-Jharkhand.pdf
instance, colostrum was avoided earlier but now, there is 9 http://www.in.undp.org/content/india/en/home/operations/
an increased awareness of its significance to the child. For about_undp/undp-in-Jharkhand/about-Jharkhand.html
home deliveries, the only known disinfectant was cowdung 10 http://www.unicef.org/india/The_Situation_of_Children_in_
and its application to the umbilical cord was standard India_-__A_profile_20110630_.pdf
procedure, often leading to infection and possible death. 11 http://www.in.undp.org/content/india/en/home/operations/
about_undp/undp-in-Jharkhand/about-Jharkhand.htm
Things are changing and deliveries by trained skilled health
12 http://www.unicef.org/india/The_Situation_of_Children_in_
workers are increasing; out of 1,196 deliveries in 2014 in India_-__A_profile_20110630_.pdf
all the 70 villages, skilled health personnel delivered 1,087. 13 http://www.cini-india.org/content/history
14 National Rural Health Mission and National Urban Health Mission
Once the project is complete, the immediate challenge were merged in 2014 to form the National Health Mission
for CINI will be to prevent a possible backlash driven by 15 http://www.thehindubusinessline.com/features/blink/
disappointment of the community whose expectations know/barefoot-auditors-call-local-officials-to-account/
from the health care delivery system have tremendously article6937338.ece
grown, given that the rate at which the system responds 16 http://nrhm.gov.in/communitisation/village-health-sanitation-
is far less than satisfactory. Though the awareness nutrition-committee.html
17 Tiranga Bhojan or Tri-Colour Meal is a concept used by CINI to help
amongst the community and the expectation from health
pregnant and lactating women and children inculcate right food
care delivery system has risen exponentially, health care habits and achieve a balanced diet with locally available food
system continues to be riddled with problems. The girls items. They are instructed to follow the colours of the national
are, however, confident of keeping the VHRC active thus flag, the white for milk, eggs and similar food items; the green
for fresh green vegetables and the saffron for ripe fruits, fish and
ensuring that the initiative outlives the project period.
meat, a combination of all three being necessary for a balanced
Jharkhand may be on its way- albeit at a slow pace- to diet that will help prevent anemia. Around Tiranga Bhiajan, there
realise some of the human development goals but a lot are group exercises, theatre, and also, nutrition counselling
remains to be done. There is hope that the achievements by Sahiyya, BFA and the field animator from CINI. Importance
of Tiranga Bhojan is often discussed in the adolescent girls
in these 70 villages create a ripple effect across other
meetings too and they take part in all these IEC activities as well.
districts of the state.

Authors: Oommen C Kurian, Pooja Parvati and Savvy Soumya Misra.


Acknowledgements: Nisha Agrawal, Deepak L Xavier, Pallavi Gupta, Pravind Kumar Praveen, Pratiush Prakash, Sanjay Suman, Faiz Ahmad (CINI), Sweta
Roy (CINI), Sanjay Sarangi (CINI) and Ranjan Panda (CINI)
Photo Courtesy: Sanjay Sarangi, CINI
Oxfam India March 2015.
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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.

Oxfam India, 4th and 5th Floor, Shriram Bharatiya Kala Kendra,
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Tel: +91 (0) 11 4653 8000 www.oxfamindia.org
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