Promoting Social Accountability Through the Use of Picture Materials for Non-literate Women in Uttar Pradesh, India

By: Jashodhara Dasgupta, Senior Adviser, SAHAYOG

Banda-VHND
Community meeting in Banda district where a woman leader explains the organisation of a Village Health and Nutrition Day (VHND) services that pregnant women should receive in every VHND

High rates of maternal mortality in many parts of northern India persist owing to an inadequately equipped public health system compounded by disrespectful and negligent treatment of poor women. The Government of India has instituted several measures to enable women to access maternal care without costs barriers, and many health messages reach communities about pregnancy care and hospital births. But there is far less public education on health entitlements and service guarantees; consequently, the frontline providers take advantage of this to trick women into paying for free services such as treatment, medicines and transport.

UttarPradesh-checklist
Capacity building in district Mirzapur, Uttar Pradesh, 2012: Women examine the picture-based checklist that tells them which maternal health services are completely free in all public health facilities

The organisation SAHAYOG along with several district-based partner community-based organizations (CBOs) have been raising awareness and information about entitlements among poor semi-literate women in the northern state of Uttar Pradesh, India, using simple picture materials. During capacity-building workshops, interactive picture materials depict the problems to start discussion and then explain entitlements. Women’s group leaders use these flashcards to inform other women during local village meetings. The illustrations are simplified as tools and checklists to enable the women’s groups to monitor those entitlements. Their findings are then collated by SAHAYOG and partner CBOs for presentation before public officials in the district and state.

  • In 2010, the women learned through a site visit and picture cards what a health
Gorakhpur
Neighbourhood survey in Gorakhpur district, 2013: a leader of the local women’s group is filling in the picture tool about post-partum services received

sub-centre should be equipped with, as promised by the Indian Public Health Standards (IPHS). This was followed by community monitoring of local health sub-centres in 71 villages across 11 districts using pictorial checklists.

  • In 2011, women learned which services should be provided in the supplementary nutrition centres(Anganwadis) of their villages through a set of picture cards. They used a ten-point checklist to monitor 62Anganwadi centres in seven districts.
  • In 2012, women were informed through picture materials about their entitlements to free maternal and child health services. They used pictorial checklists to conduct a neighbourhood survey with 410 recently-delivered women on costs of care, across 228 villages in 11 districts.
  • In 2013, women learned about essential postpartum care, and used pictorial checklists to conduct a neighbourhood survey with 992 recently-delivered women about the care actually received, across 173 villages of eight districts.
  • In 2014 women learned about essential antenatal care and nutrition services to be provided during Village Health and Nutrition Days (VHND). They used pictorial checklists to investigate the VHNDs being conducted across 100 villages of seven districts.
    • PictureTool
    A picture tool that informs women about the services they are entitled to get during the VHND at their village, including basic ante-natal examinations. It enabled them to monitor the extent to which pregnant women in their neighbourhood were actually receiving these services. The findings were collated and presented to district health officials, and then state health managers.

     

    It is easy to intimidate poor families from rural areas who lack information about maternal health entitlements and the corresponding accountability of service providers. But if non-literate women are equipped with knowledge of the health services they are entitled to receive, they are enabled to negotiate better quality and more respectful care. This occurs not only when they access health services, but also when women leaders confidently present their findings to public officials and the media. The authentic voice of actual service-users provides a ‘reality check’ for the administrators, who often provide their own cell- phone number to them, asking for more feedback. It has enhanced the credibility of the facilitating CBOs who have been included in many health committees in their district.

    Chitrakoot
    District health dialogue in Chitrakoot district, 2013: a leader of the local women’s organisation is presenting the feedback from the neighbourhood survey of postpartum care

    Conclusions

    1. Information asymmetry prevents poor non-literate groups from effectively accessing maternal health and nutrition services, even when they are entitled to these
    2. Capacity building for semi-literate women should include interactive picture material that encourages reflection and analysis of local problems, likely causes and possible courses of action
    3. Community awareness regarding entitlements can be enhanced with picture tools such as flashcards and posters that explain the concepts simply
    4. Community monitoring of entitlements through pictorial checklists can be done by semi-literate women to present feedback to public officials.
    5. Picture materials in the form of charts, flashcards and picture checklists empower socially excluded and marginalised women to engage as active users and concerned citizens in improving their health services.

    This post is part of our blog series, “Social accountability and community mobilization for maternal health,” hosted with COPASAH and the Centre for Health and Social Justice (CHSJ).