Subramanyam, M, Ebert, C, Bommer, C, Bogler, L, Kumar, A, Varghese, S, Atre, S and Vollmer, S 2017. Impact of the Gram Varta programme on health, nutrition and women's empowerment in India, 3ie Grantee Final Report. New Delhi: International Initiative for Impact Evaluation (3ie)
Link to Source
Improving health, nutrition, water and sanitation (HNWASH) practices is not limited by just the lack of access to resources and services, but by limited public knowledge and attitude towards HNWASH, and utilisation of services. The Gram Varta intervention aims to involve community members to improve their knowledge on HNWASH, demand and utilise government services, and improve HNWASH outcomes. This evaluation assesses if Gram Varta has any effect on HNWASH knowledge and practices, women’s agency and empowerment, utilisation of government health services and ultimately child and maternal health outcomes in the Indian state of Bihar.
Reducing infant and neonatal mortality, maternal morbidities, and child mortality have remained a major priority in India, particularly in poorer states like Bihar. Bihar suffers high infant and neonatal mortality rates. In Madhepura district, where the evaluation was conducted, the infant mortality rate is at 64 deaths per 1,000 live births according to census figures from 201-13. An understanding of prevention and treatment of diseases and child care practices are poor in this region. Failure of many top down service delivery programmes highlights the importance of participation of communities in knowing the problem, changing their attitude and behaviours related to HNWASH, and demand for HNWASH services.
This evaluation investigated the following hypotheses:
- Participation in, acceptance and awareness of women’s self-help groups (SHG) as well as utilisation of government health services through SHGs.
- Women’s agency and empowerment in terms of economic independence, bargaining power, recognition and confidence in the community, domestic violence, family planning and nutrition decisions of the women and adolescent girls.
- HNWASH knowledge and practices in terms of own and child nutrition, awareness and prevention of diseases, risky consumption behaviour, domestic hygiene and sanitation as well as adolescent girls’ and women’s knowledge on sexuality and contraception.
- Behaviour during pregnancy in terms of health, nutrition, antenatal care visits, optimistic outlook and knowledge of abortions.
- Anganwadi centers in terms of utilisation, malnutrition treatment and prevention, quality of health services, facilitation of routine check-ups, and Anganwadi worker related outcomes.
- Health outcomes of women, husbands and children.
- Social cohesion in the community and neighbourhood.
The Gram Varta programme aims to improve health, nutrition, water, sanitation, and hygiene (HNWASH) indicators by changing attitudes and behaviour of communities. It is a community-based, participatory programme implemented by the Bihar Rural Livelihoods Promotion Society locally known as JEEViKA. It uses the participatory learning and action (PLA) approach and works through women’s self-help groups (SHGs) as agents of change. The implementing agency trained local women as facilitators to conduct 20 structured meetings with the SHGs and guide participants through a cycle of participatory action. The cycle consists of the identification and prioritisation of problems related to HNWASH, strategies to address these problems, demand and utilisation of health services from local service providers for better health outcomes.
Theory of change
Community mobilization through PLA approach empowers and creates a feeling of ownership of activities and processes, and lead to individual and community level sustainable change in attitude and behaviour towards HNWASH practices. Improved HNWASH practices, demand for service and the availability of services at the village level will lead to better health outcomes for women and children.
Gram Varta implementation was randomly assigned to 68 gram panchayats (village councils) of Madhepura district in Bihar. This randomisation resulted in 90 treatment villages and 90 control villages. Baseline and endline data was collected from 3,953 household heads and women in the reproductive age and 2,000 pregnant women (at the time of pre-implementation). About 316 community mobilisers and 265 Anganwadi workers were surveyed as well. The quantitative analysis is substantiated by qualitative appraisal of the participants’ experience and the social conditions influencing empowerment, health, hygiene, nutrition and sanitation using key informant interviews and focus group discussions (FGDs) to better understand the possible channels of change.
The results show mixed impact of the programme on key outcome indicators. Though the Gram Varta intervention, using PLA approach, led to better knowledge of health and nutrition among the participants, it is not translated into better uptake of government health services. Neither was there consistent evidence on actual health and nutritional improvements immediately after the intervention. This could be partly attributed to implementation challenges and the timing of the evaluation. However, there is some evidence on social cohesion, and women agency and empowerment. The study finds consistent and significant positive effect on women’s social capital and self-confidence, reduction in frequency and intensity of domestic violence and controlling behaviour by husbands.
All of these positive changes are likely to be very beneficial in low-resource settings with historically high levels of patriarchy. However, whether such changes lead to improved health and nutrition knowledge, practices or outcomes can only be known by investigating the long-term impact of Gram Varta participation.
Implications for policy and practice
One of the key recommendation to the implementing agency is to strengthen the coordination between the implementing agency and all the relevant government departments. This will ensure that service providers will be aware of Gram Varta programme and its progress, and continue to support the programme. A related recommendation is to achieve convergence of services that are targeting same communities and working towards complementary goals.