Participatory transformation
Ekjut, along with other key stakeholders, has gained credibility in leveraging the PLA approach to improve health indicators in Jharkhand, and is worth emulating
Over the years, Jharkhand has made remarkable progress with respect to maternal and child health. There has been a reduction in the Neonatal Mortality Rate (NMR) from 49 deaths per 1,000 live births in 2010 to 21 deaths in 2019. The Maternal Mortality Ratio (MMR, number of maternal deaths per 1,00,000 live births) has plummeted by 67.6 per cent from 2010 to 2018. This progress has been possible due to the consistent endeavours undertaken by the state government through programmes such as the Maternal and Newborn Survival Initiative (MANSI) and the Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA) among others. Over and above these, there is a notable programme that complements the government's efforts and leverages the Participatory Learning and Action (PLA) approach to improve child and maternal health outcomes.
The PLA approach is a tool that enables participation among community members, especially women, to identify, address and solve problems by leveraging practical and interactive techniques. This approach is guided by principles of participation, adult learning, problem-solving, respecting the time and agency of women and inclusion of individuals among others. It emphasises open communication and embracing diversity within communities, therefore making it an effective tool to reach the most marginalised sections of society.
'Ekjut', meaning togetherness in many Indian languages, is a civil society organisation (CSO) that aims to build healthier communities among vulnerable populations. It has adopted the PLA approach for improving maternal and child health (MCH) across different states for the last 15 years.
The success of the PLA approach in Jharkhand can be attributed to the concerted efforts of three key stakeholders — the government of Jharkhand (particularly NHM Jharkhand), Ekjut and Children's Investment Fund Foundation (CIFF). After establishing the efficacy and effectiveness of the PLA process through a series of evidences which show a 31 per cent drop in NMR, 62 per cent among the socially underserved communities, the PLA approach has now been scaled up to all districts of Jharkhand under the Facilitated Learning and Action Groups (FLAG) programme. The PLA approach has been adopted by 24 districts covering 32,000 villages and hamlets and engaging around 40,000 sahiyas in the state.
The PLA approach in Jharkhand is facilitated by the sahiyas (Accredited Social Health Activists or ASHAs) and sahiya sathis (ASHA facilitators) who enable community members to discuss, destigmatise and address different health-related issues through monthly PLA meetings. To facilitate these meetings effectively, sahiya sathis and sahiyas are trained and equipped with tools such as visual aids and games to make these interactions more engaging for the community members.
The Jharkhand model uses different innovative processes such as re-clusterisation, which is the process of redefining the villages and the area covered by sahiya sathis, leading to rationalisation of their workload to improve their overall performance; on-the-job training for the sahiyas through the odd-even training arrangements that lead to deeper and wider community reach and quick scale-up; and lastly the PLA dashboard that provides real-time programme monitoring data from villages which helped Ekjut and NHM Jharkhand identify bottlenecks and create systems through which these gaps can be addressed.
As a result of working on the PLA approach for over a decade, Ekjut has established a credible presence amongst policymakers and civil society. In the case of Jharkhand, both NHM Jharkhand and CIFF have acknowledged and recognised the immense value in the community-driven processes Ekjut has built over the years. In addition to Ekjut's commitment, all the three partners share a common goal and aspire to improve the overall Maternal and Child Health (MCH) health outcomes in the state. Under the FLAG programme, NHM Jharkhand led the on-ground implementation via sahiyas in the state; Ekjut, the technical partner, provided consistent field support and trained master trainers, aided in planning, monitoring and evaluation and quality implementation by providing their own resources as sahiya training facilitators; while CIFF supported Ekjut financially and technically for this programme. This shared vision and outcome centricity along with distinct role clarity and support between the partners ensured the success of this partnership.
For NHM Jharkhand, apart from an improvement in the MCH outcomes in the state, this partnership has helped in empowering the sahiyas, significantly reducing training costs and digitising the data through the PLA dashboard. Ekjut's unique on-the-job training model reduced the residential cost of the PLA processes by approximately 90 per cent.
The PLA approach has great potential in solving problems at a community level as it enables members to analyse their own situation, and ensures that the learnings are then translated into action. This approach can also be replicated across various developmental themes with ease. For instance, the PLA approach has been utilised for activities under the Jharkhand Initiative for Adolescent Health (JIAH) to improve adolescent health outcomes on themes ranging from COVID-19, education to nutrition, violence and mental health. Various states such as Odisha, Bihar and Madhya Pradesh have also experienced the benefits of using the PLA approach in improving health, WASH and nutrition outcomes.
Lastly, given the ongoing pandemic, the PLA approach — like the WHO guidelines 2020 — focuses on three priorities for community engagement namely, strengthening existing partnerships, building upon community governance structures, and optimising the role of community care workers engaging with communities for activities including surveillance and data collection and community-based participatory methodologies. Hence, the approach, when adopted by states, will strengthen and improve the health indicators and would additionally re-emphasise the criticality of the ongoing health crisis of COVID-19 and would prove to be beneficial in communicating the required COVID-19 behaviour in the most remote districts of India.
Convergence is the key to solving problems at the field level. Ekjut not only means that, but is demonstrating that public-private partnership can be a game-changer in resolving a number of issues that beset society. They present a wonderful example of Nexus of Good as what they have done is now being scaled and has the potential of scaling even further.
Views expressed are personal
