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By Freny Manecksha An interesting experiment in getting tribals to identify and prioritise their problems, especially relating to infant and maternal mortality, is under way in Orissa and Jharkhand
In a tribal village in West Singhbhum, Jharkhand, the facilitator of a women’s group initiates an interesting game. First she invites one woman to ride piggyback on another. Then a second woman is made to simulate a ghoda (horse) by going down on all fours and carrying a woman some distance. A third pair is asked to walk hand-in-hand. The game is illustrative of Ekjut’s approach towards handling socio-economic factors of development in this belt of tribal communities. Dr Nirmala Nair, intervention manager of Ekjut, a civil society organisation working in Jharkhand and Orissa explains: “We tell the villagers that the game illustrates how we want to tackle issues of development. One can take the concerned persons piggyback for a while; or one can go half the distance carrying the other, like the horse; or one can walk hand-in-hand, actively partnering each other, which is the method we want to adopt.” When Nair and Ekjut secretary Dr Prasanta K Tripathy set up the CSO in Chakradharpur, in 2003, they did not come with a readymade blueprint for development. The issue of health was, as it were, thrust on them when they found extremely high rates of infant mortality and maternal deaths among the Ho and Santhal tribal populations in the district. “We did not want to replace the government; we believe that people must seek their entitlements from the state. But at the same time we felt we must do something about avoidable deaths. We did not want to create a small oasis but some evidence-based work that has the potential to be scaled up. It had to be affordable, feasible and one that empowered the community,” says Dr Tripathy. Since functioning women’s groups were already in place, thanks to the efforts of an organisation called PRADAN, it was decided to try something new with the existing groups. With the villagers’ consent, a project involving community-based participatory intervention was piloted in Narangabeda, Khuntpani block. Over a 10-meeting cycle the community would try and identify its own problems and how best to tackle them. The approach was not that of teacher but local facilitator who would employ innovative games like using pebbles to vote and build up a consensus, puppet shows, plays and pictures to promote problem prioritisation, planning, strategy development and implementation. An article in the Lancet reported the results of a MIRA-Makwanpur study in Nepal conducted in collaboration with the Institute of Child Health, London. Instead of only medical intervention, women facilitators were used as key elements in reducing infant mortality by raising awareness about the underlying causes of illness and death, and empowering communities to address them. An exciting chance finding of the Makwanpur study was that maternal mortality too reduced thanks to these activities. Ekjut wondered if a similar intervention would work to address the issue of infant and maternal deaths among dispersed tribal populations in small hamlets. Could one tap into the power of existing women’s groups? PRADAN agreed to provide access to groups already set up, and, in September 2004, in collaboration with the Centre for International Health (a wing of the Institute of Child Health) a project to improve maternal and newborn health in Jharkhand and Orissa, through the empowerment of tribal communities, was launched. Baseline data-collection showed extraordinary newborn mortality rates. The proposed intervention would be piloted in three villages. There was enough evidence in these villages to show that the women would be supportive of the efforts. “Adivasis resent being talked down to and indicated that they would support a method of pooling ideas rather than pushing policies,” says Dr Nair. A random controlled trial, involving a population of 228,000 from 36 clusters or villages in three contiguous areas of Jharkhand and bordering Orissa, was then set up. While all 36 clusters of 10-12 villages each would come under surveillance, intervention would be introduced in 18 randomly chosen clusters with a buffer zone between each cluster of villages to ensure that there was no contamination. A total of 227 women’s groups are currently involved. For surveillance purposes, monitors were elected by the villagers themselves. Each monitor had the task of interviewing every woman who had given birth since November 2004. Key informants of a birth are traditional birth attendants or relatives. In the case of a newborn or maternal death, monitors conduct a detailed interview or “verbal autopsy” to ascertain the actual cause of death. Some of the findings include delays in seeking care because the gravity of the situation has not been realised, or the village quack has been called in. Another problem is that this is elephant territory, therefore unsafe at night. In the clusters chosen for intervention, a local facilitator, also elected by the villagers, has been made responsible for 10-16 women’s groups. The facilitator works as a catalyst for change and takes the group through a series of 10 meetings in which issues of pregnancy, childbirth and newborn health are discussed. Through a structured framework, with each meeting taking place once a month, the women’s groups go through four phases: identifying and prioritising problems, planning strategies, implementation, and assessing the impact. The 10th meeting culminates in a big gathering with invitations being sent to health and other government officials. The group narrates its experiences through a play or storytelling in order to sensitise the larger population and seek its help. Pressure is also brought to bear on the administration. Using a manual as a guide, the facilitator in the first phase tells a story culminating in illness or death. With the help of picture cards or charts to match the situation, the group attempts to identify the cause of death. For example, a malaria case will depict mosquitoes and stagnant water. The picture cards also help identify the illness in the local idiom. In the beginning, any cause cited out of superstition -- like possession by spirits -– remains unchallenged. After around six stories, the group prioritises the issues to be tackled. Important things are learnt through this process. For example, it was found that more tribal infants suffered from diarrhoea in the Inkatha valley than non-tribals. This is because of a cultural practice where tribals do not breastfeed their infants for the first few days. At the 10th meeting, and to disseminate information within the larger community, the tribals use socio-dramas, street plays, puppet shows and song-and-dance. One of the most endearing examples of an entire community’s enthusiasm for such an approach came from the Juang tribe in Orissa. The women had scripted a play but they felt too shy to enact it. So the men of the community came forward, donned women’s costumes and staged the play! Although the study is still underway, Ekjut is hopeful that anecdotal evidence of its considerable impact on maternal and newborn health will soon be matched by hard data. (Freny Manecksha is a Mumbai-based freelance journalist) InfoChange News & Features, March 2007
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