Small groups of women, adequately supported, will come up with scalable and sustainable solutions
Women are best-placed to solve grassroots health problems. Men need to get out of the way.
India has abysmal health indicators. For every 1,000 live births, 28 children die in their first 28 days and 34 in their first year (Sample Registration System bulletin, 2013 and 2016). According to the census, the sex ratio for children below six decreased from 927 females per 1,000 males in 2001, to 919 in 2011. The World Health Organization says nearly 45,000 women die with childbirth every year in India.
These are issues of women and their children. They are closest to the problem, and they would have the best solutions. They are often left out because they face barriers such as household compulsions, social and cultural norms and ways of working designed and supervised by men. My experience in grassroots public health is that small groups of women, adequately supported, will come up with scalable and sustainable solutions. Three examples, two from my own experience, come to mind.
In India’s villages, health and nutrition are driven by three women frontline workers—Accredited Social Health Activist (ASHA), Anganwadi Worker (AWW) and Auxiliary Nurse Midwife (ANM), or AAA. They often do not know beneficiaries most at risk in their dominion. Why blame them? Most north Indian villages don’t have maps.
In Rajasthan, AAA in 2,700 villages came together to map their villages. They finished this massive task in six months with minimal support from the supervisory system. Village mapping has empowered these women, improved their effectiveness and ultimately led to healthier villages. The state has adopted this system and over 100,000 frontline workers across the state are now being trained on village mapping.
I had a similar experience when leading the Gates Foundation’s HIV prevention program, Avahan. Male-dominated organizations, all well-intentioned, viewed sex workers as helpless beneficiaries who would pick up condoms thrown at them. Nobody was asking two important questions—how many condoms are needed and what prevents their uptake? When I visited sex workers groups across India, I learnt that they had answers to both questions. They said, “We know all about condoms. The violence that we face daily is the real issue. It is why condoms are not being used." The community came together to design and implement a solution; the response time to abuse improved and HIV infection rates dropped.
Uttar Pradesh has the worst infant mortality and under-five mortality numbers in the country. It ranked last among 21 states in NITI Aayog’s “Healthy States, Progressive India" report published in February. In this context, the Rajiv Gandhi Mahila Vikas Pariyojana is improving maternal and child health in villages through women-led self help groups. Local women trained as Swasthya Sakhis (health volunteers) visit homes, discourage child marriage, promote institutional deliveries and connect beneficiaries with ASHA workers. In a state where pre-natal sex determination is the norm, women are uniquely equipped to sensitise each other on “their" issues.
The issue of male domination continues as we consider program funding and governance up to the highest levels. Quite a few Delhi-headquartered international non-profit organizations are at the forefront of women and child health solution delivery. With a couple of notable exceptions, they are all led by men. The Indian Medical Association has had only one female national president since 1928.
Apart from Kerala’s K.K. Shailaja (and West Bengal chief minister Mamata Banerjee), all state health ministers in India today are men. Since 1967, only two of 15 Union health ministers have been women.
The situation could be better at all levels, but the answer is at the grassroots. Leave it to small groups of women working together and provide help that they ask for. Women will come up with solutions that are scalable and sustainable. Since I went into public health delivery, I have had the opportunity to sit with hundreds of remarkable women’s community groups. I’ll stick my neck out and say that few of these groups would have worked with men in charge.
The government has launched some exciting, all-important health related programs such as Swachh Bharat, Ayushman Bharat and ending tuberculosis. Are we asking where and how women can lead? That is the route to success at the grassroots.
Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok
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