Improving Health Systems Response Through Women's Self-Help Groups in India: Repeated Cross-Sectional, Quasi-Experimental Study

Abstract

Background: Maternal, newborn and child health (MNCH) interventions with women's self-help groups (SHGs) can improve its outcomes in rural communities through addressing health system barriers, and empowering women. We assessed the effect of large-scale implementation of health interventions integrated within SHGs compared with standard group settings, on group advocacy, women's self-determination, and norms around health care service delivery. Methods: Using a pre-post quasi-experimental design, 33 geographic blocks were divided into two groups: intervention and comparison. SHG women in comparison blocks received the usual microcredit program, and SHG members in intervention blocks received additional participatory training around MNCH issues through a community mobilizer who led at least one health meeting a month. Two cross-sectional surveys in 2013 (N= 2407) and 2016 (N=2974) were conducted among eligible women (i.e., 18-49 years, married, SHG member and had a live birth within 12 months). The outcomes in the study were: collective agency to negotiate with health center/workers, women's self-advocacy with health workers, self-confidence in accessing health services, and services from health workers including respectful care. Outcome effects were assessed using difference-in-differences (DID) methods. Findings: Of the 5089 women interviewed across the two-time points, the mean age was 26 (±4·7) years. The intervention improved women's collective agency to demand for services and improved key healthcare system related factors: self-advocacy with local health facility (DID: 16 percentage points[pp], p<0·001); improved health workers' response in providing: respectful care (DID: 3pp, p=0·035), getting appropriate referrals from frontline health workers (DID: 6pp, p=0·009), receiving help during emergencies (DID: 10pp, p=0·005); and postnatal care (DID:14pp, p<0·001). Interpretation: Self-help groups are important community institutions enabling poor women and their households to access finance and social services. Health interventions layered within these institutions enable women's participatory learning, collectivization, and ability to connect with health care providers in meaningful ways. Funding: This evaluation study was funded to Population Council by the Bill and Melinda Gates Foundation (#OPP1141832) and Project Concern International (061C-XX1ZZ-140700). The Population Council had designed and conducted the study on their own. The funders had no role in study design, data collection, data analysis or interpretation and decision to publish. Further, the paper was developed in support of The Lancet Series on Gender Equality, Norms and Health. We thank The Lancet Series leadership, and the Bill and Melinda Gates Foundation and the UAE government for their support to the publication of this paper as a supplemental paper to the Series. Declaration of Interest: None declared. Ethical Approval: All study procedures were reviewed and approved by the Institutional Review Board of the Population Council.