Promoting Accountability for Maternal Health
The latest figures show that around 60,000 women die from pregnancy and childbirth in India every year (RGI 2011). Despite the declining trend in maternal mortality ratio over the past few years, with a maternal mortality ratio of 212 per 100,000 in 2004-06, India fell short of achieving the MDG target of MMR below 200 by 2007. Those who survive childbirth but are left with disabling health problems are not even counted, or have suffered the loss of their offspring. Policies and programmes pay scant attention to maternal morbidity and perinatal mortality.
There are deep inequities in access to the interventions that would prevent many of these deaths: skilled attendance at birth, emergency obstetric care and safe abortion services. The National Rural Health Mission (NRHM) launched in 2005 is India’s response to meet the MDG challenges for health. The NRHM is committed to triple the government’s health expenditure from 0.9% to 2-3% of GDP, to decentralization and to convergence.
While much effort has gone into creating demand for institutional delivery, some of the major health system constraints to ensuring women’s access to pregnancy and delivery- related health care have not been addressed. These include poor availability of appropriately trained health professionals, equipment and supplies at different levels of care; lack of effective referral systems; poor technical quality of care and a lack of systems which ensure governance within the health system and accountability to the community. The rapid increase in institutional deliveries within this context has caused an enormous strain on the public health system, contributing to further compromises in quality of care. There are also concerns that early discharge of women following delivery (in order to cope with the large numbers) may increase the incidence of perinatal mortality and maternal morbidity.
Recent reports of health system failures resulting in avoidable deaths, especially among those from socially marginalized groups bring home the issue of absence of community demand for services within the health systems. We need to be mobilizing social opinion on the unacceptability of the high maternal mortality ratios in a country with one of the fastest economic growth rates in the world today; and to enable public action to make health systems and communities accountable for maternal health.
Historical experience shows that social mobilization plays a significant role in ensuring broad-based action at multiple levels – from the household to national - to prevent maternal mortality and morbidity. A window of opportunity has been opened in this regard by the National Rural Health Mission, which has created spaces for community involvement and significant civil society participation in health development at various levels. In addition, National Guidelines have recently been issued mandating Maternal Death Reviews at district level in order to bring about systemic changes to improve maternal health care.
It is within this context that SAHAJ and ANANDI have initiated a collaborative project ‘Enabling Community Action for increasing Accountability for Maternal Health’ since 2012 in four Primary Health Centers of two backward and inaccessible blocks of Devgarh Baria, in Dahod district and Gogambha block in Panchmahals district respectively, covering 25 villages each. New partnership with Kaira Social Social Service Society (KSSS), a local NGO working in Anand and Kheda (comparatively more developed districts) has begun from January 2014 in Anand block (Rasnol PHC) and Umreth block (Pansora PHC) in 20 villages.
The project has two objectives: To enable communities to monitor accessibility and quality of maternal healthcare through use of ‘safe delivery’ indicators; and to equip communities with skills of identifying and reporting maternal deaths. And based on these interventions hold dialogues with healthcare providers and district health officers to make the health system more responsive and accountable.
This project is also an action research because it uses research as a means for planning implementation strategies following a continuous cyclical process of review, feedback and action. As part of the social audit and community mobilization process specified under the NRHM and the RMNCH+A (2013) health service delivery, the project has focussed on increasing social accountability for maternal health and conducting maternal death reviews to built capacities and skills of the PRI members, women’s groups/sangathans and the local CBO’s in understanding the technical aspects of maternal health and mortality within the rights and gender framework; as also in increasing awareness about entitlements and service guarantees; utilization of health facility checklists and tracking the quality of maternal health service guarantees.
The project has been raising awareness about the schemes, demanding transparency and empowering communities to monitor the maternal service health guarantees. The tools and processes followed for accountability mechanisms were:
a) Situational analysis regarding the availability, accessibility, quality and affordability of maternal health services in the four blocks.
b) Maternal health Care tool based on the concept of ‘Safe Deliveries’ both from technical perspective as well as women’s perspective, monitoring quality of ANC and PNC based on the NRHM standards was developed. The Tool is being filled for every pregnant woman in 8th month and up to 20 days after delivery in the project villages.
c) Report Card- The situation from the findings has been formed into a report card. This report card is reviewed every 6 months for assessing changes in the quality of care and shared with the community and the health officials at the block, district and finally the state level.
d)Village Health and Nutrition Day Observation Check list Community leaders along with partner teams are involved in the systematic monitoring of the Mamta Divas through a simple monitoring tool. Issues such as irregular conduct of Mamta Divas, lack of instruments and irregularity in supply of nutritional supplements by Anganwadi are being identified.
The report cards and VHND check list are used as a base for dialogue with different stakeholders such as the Sangathan members, the health system representatives, local elected representatives and other leaders. The dialogues lead to formation of collective plans with specified responsibilities for improving maternal health services. The findings from the ground have also been used to support the larger cause of maternal mortality through various other networks such as Jan Swasthya Abhiyan, Common Health, COPASAH, and so on. Please see links for Annual Reports, COPASAH article and Poster presentation at Cape Town.