Implementation Research With the Soliga Indigenous Community in Southern India for Local Action on Improving Maternal Health Services

Abstract

Since 2005, the National Health Mission (NHM, till recently the National Rural Health Mission) brought significant health reforms to improve the quality and reach of reproductive and child health services in India. It brought increased financial resources and decentralisation of health planning to the district level. However it is still largely implemented in its national form with little-to-no adaptation to a district’s context. On the other hand, indigenous people in India are socio-culturally distinct from the general population, and in Chamarajanagar district (where the study is set), these communities are in significant numbers and yet face varying degrees of social exclusion in accessing health and other services. For instance, these communities record lower antenatal care and immunisation coverage, with higher proportions of home deliveries when compared to others. The main goal of this study was to facilitate contextualisation of the safe motherhood programme of NHM in areas with indigenous population in Chamarajanagar district with the aim of improving access to services for them. The key objectives of the project were: 1. To study local socio-political issues that influenced access to the safe motherhood component of NHM for indigenous people in Chamarajanagar district, 2. To engage with relevant stakeholders in a participatory approach to contextualize the existing program implementation in primary health centers (PHC) covering indigenous populations, and 3. To develop a model of stakeholder engagement that could guide contextualization of the safe motherhood program of NHM in districts with indigenous communities. An inter-disciplinary team consisting of researchers, implementers and local non-governmental organisations (NGO) and community-based organisations was constituted. This team steered a participatory engagement of community groups on one hand, and engaged with health workers and other key actors on the other. They supported community members to analyse their own situation of access to maternal health services through field visits and regular discussions. They facilitated dialogues between various actors involved in planning, implementation and/or monitoring of maternal health services from the periphery to the district and finally at the state level. The overall study design was that of a participatory action research (PAR) to engage with the local indigenous communities through a community-based organization, and with other key actors including the district health services. A theory-driven inquiry approach was integrated to try and explain the implementation outcomes of the stakeholder engagement strategy, and proposed local solutions. While the former component focused on a participatory approach towards critical reflection and local action, the latter intended to focus on building a context-sensitive analytical explanation for any change seen. The study was conducted from December 2014 to September 2016. The outcomes identified at the beginning of the project were: (1) creation of a platform for district-level planning with inter-sectoral engagement across various government departments with community-based organizations, civil society and academia and, (2) a theory explaining poor coverage of reproductive and child health schemes’ utilization by indigenous people in Chamarajanagar district. With respect to the first outcome, inter-sectoral engagement was achieved to desirable levels, however key actors did not come together in a common platform at the district level as foreseen. Instead, different actors engaged via different platforms at different levels including the research team members, community, and district health services. The research team facilitated these engagements through existing opportunities or spaces for interaction through the course of the research. The second outcome on developing a theory explaining poor utilization was achieved to a lesser extent due to methodological and operational difficulties, and delay in implementation of the intervention. However, one of the most important outcomes that could sustain beyond project duration was the problematisation of health/healthcare among the indigenous community-based organizational leadership; till recently, their pre-occupation with forest rights and access to non-timber forest produce trumped over their health/healthcare demands.