Participatory women's groups: time for integration into programmes
Authors: Vinod K Paul
Journal: The Lancet Global Health (2016)

It is already reasonably well established that, with adequate coverage, the community-mobilisation approach of women's groups practising participatory learning and action is associated with a programmatically attractive reduction in neonatal mortality in low-resource high-burden settings.1Prost A Colbourn T Seward N et al.Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis.Lancet. 2013; 381: 1736-1746Summary Full Text Full Text PDF PubMed Scopus (374) Google Scholar In 2014, WHO recommended implementation of this intervention particularly in rural settings with low access to health services.2World Health OrganizationWHO recommendation on community mobilization through facilitated participatory learning and action cycles with women's groups for maternal and newborn health. World Health Organization, Geneva2014http://www.who.int/maternal_child_adolescent/documents/community-mobilization-maternal-newborn/en/Google Scholar The uncertainty, however, has been whether such an approach is actually scalable in public health programmes that are often driven by supply-side strategies. The study by Prasanta Tripathy and colleagues3Tripathy P Nair N Siha R et al.Effect of participatory women's groups facilitated by Accredited Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised controlled trial.Lancet Glob Health. 2016; 4: e119-e128Summary Full Text Full Text PDF Scopus (57) Google Scholar in this issue of The Lancet Global Health helps in filling this translational gap to a significant extent. In previous studies on this approach, the women's group meetings (the core of the intervention) were facilitated by local women specially recruited and trained for respective research projects.1Prost A Colbourn T Seward N et al.Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis.Lancet. 2013; 381: 1736-1746Summary Full Text Full Text PDF PubMed Scopus (374) Google Scholar In Tripathy and colleagues' cluster-randomised trial, conducted in five districts of the two eastern states of India, these meetings were instead facilitated by government-appointed village-level female health workers, namely Accredited Social Health Activists (ASHAs) who received a token incentive for the task (US$3 per meeting).3Tripathy P Nair N Siha R et al.Effect of participatory women's groups facilitated by Accredited Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised controlled trial.Lancet Glob Health. 2016; 4: e119-e128Summary Full Text Full Text PDF Scopus (57) Google Scholar Most of the participating women were tribal, and almost half of them belonging to the lowest two wealth quintiles. After 2 years, the primary outcome of neonatal mortality rate (NMR) was significantly lower in the intervention clusters than in the control clusters (30 per 1000 livebirths vs 44 per 1000 livebirths, respectively; adjusted odds ratio 0·54, 95% CI 0·36–0·80). Equally impressive was the reduction in early NMR by 46% (27 per 1000 livebirths vs 37 per 1000 livebirths, respectively; adjusted odds ratio 0·54, 95% CI 0·35–0·84). There are three characteristics worth highlighting about this study in addition to the fact that the intervention was implemented by the public-sector health workers. First, the intervention resulted in neonatal survival dividends in a population where facility births are high (overall around 60%). Previous studies in settings with high facility birth rates were equivocal in this regard.1Prost A Colbourn T Seward N et al.Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis.Lancet. 2013; 381: 1736-1746Summary Full Text Full Text PDF PubMed Scopus (374) Google Scholar Second, the intervention coverage (66%)3Tripathy P Nair N Siha R et al.Effect of participatory women's groups facilitated by Accredited Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised controlled trial.Lancet Glob Health. 2016; 4: e119-e128Summary Full Text Full Text PDF Scopus (57) Google Scholar was higher than that reported in earlier studies.1Prost A Colbourn T Seward N et al.Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis.Lancet. 2013; 381: 1736-1746Summary Full Text Full Text PDF PubMed Scopus (374) Google Scholar Third, the same ASHAs who conducted the women's group meetings were also responsible for postnatal home visits as a part of the home-based newborn care scheme of the national government. It is quite plausible that a closer mother–ASHA rapport and better preparation for postnatal care resulting from interaction at the group meetings could have synergistically augmented the effectiveness of home-based care in the intervention group (home visiting coverage 64%3Tripathy P Nair N Siha R et al.Effect of participatory women's groups facilitated by Accredited Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised controlled trial.Lancet Glob Health. 2016; 4: e119-e128Summary Full Text Full Text PDF Scopus (57) Google Scholar). The latter two characteristics may also partly explain why the neonatal mortality reduction effect was greater than that seen in earlier studies. WHO defines a health system as "all the activities whose primary purpose is to promote, restore or maintain health".4World Health OrganizationThe world health report 2000. Health systems: improving performance. World Health Organization, Geneva2000: 5Google Scholar On this basis, community engagement aimed at improving health should be a part of the health system. But the WHO framework5World Health OrganizationMonitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. World Health Organization, Geneva2010: viGoogle Scholar comprising six "building blocks" of health systems (namely, service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance) excludes community participation. This is a miss. Not surprisingly, community's role in health promotion, generating demand for services, and ensuring accountability is sidelined or underplayed when policies are laid down and programmes implemented. There is another difficulty. Community mobilisation requires skills that are different from those needed to, say, run facilities, treat individuals, or organise immunisation sessions. Professionals who understand sociocultural–behavioural context at the bottom of the pyramid, and are able to engage people and elicit their active involvement, may not necessarily be a part of the front-line health teams. Further, emphasis laid on the indicators of community participation in the programme monitoring frameworks is often low; hence the "not measured" remains "not done" even when such approaches are, on paper, a part of the package of interventions. The study by Tripathy and colleagues3Tripathy P Nair N Siha R et al.Effect of participatory women's groups facilitated by Accredited Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised controlled trial.Lancet Glob Health. 2016; 4: e119-e128Summary Full Text Full Text PDF Scopus (57) Google Scholar yet again makes a convincing case for scaling up of participatory women's groups for learning and action to improve newborn survival in contextually comparable rural settings. Countries that do not have existing village-level functionaries who could act as facilitators for women's group meetings would need to recruit such workers. The investment for capacity, tools, compensation, and supervision will also have to be made. It would be wise to undertake early scale-up of this intervention within national programmes in conjunction with implementation research. This will enable systematic learning and course correction as the coverage is expanded. Implementation research catalyses effective integration of new interventions into the health systems,6Peters DH Tran NT Adam T Implementation research in health: a practical guide. Alliance for Health Policy and Systems Research, World Health Organization, Geneva2013: 18-25Google Scholar and increases the likelihood of their successful uptake in varied settings. For India, this study has a clear, direct, and immediate relevance. NMR in several states and districts continues to be as high as in the clusters where this study was conducted (over 40 per 1000 livebirths). People in these geographic areas are indeed the most needy. Above all, ASHA workers are already deployed there. Implementation of the ASHA-facilitated participatory learning and action cycles with women's groups for improving newborn survival in such populations in India is, therefore, strongly recommended. I declare that I have no conflict of interest. Effect of participatory women's groups facilitated by Accredited Social Health Activists on birth outcomes in rural eastern India: a cluster-randomised controlled trialASHAs can successfully reduce neonatal mortality through participatory meetings with women's groups. This is a scalable community-based approach to improving neonatal survival in rural, underserved areas of India. Full-Text PDF Open Access