Mittal Shah, Kent Ranson & Palak Joshi

Reaching the poorest: SEWA’s experience with reproductive

health camps

SEWA• SEWA is a trade union of women workers in

the informal economy• Started in 1972 by Ela R. Bhatt• Provides services in Ahmedabad City and

11 rural districts of Gujarat state• Main goals: economic security and self-

reliance• Major activities: organizing, banking and

micro-finance, insurance, capacity-building, health care

• 2003 membership in Gujarat: 4,69,306

SEWA Health• Delivering services since 1980

• Aims to serve the poorest

• Current services delivered:– Preventive: health

education and training, ante-natal care, immunization, occupational and mental health activities

– Curative: low-cost medicines, TB treatment, mobile RCH care, traditional medicines

SEWA’s RH camps• Since 1999• Partnership with UNFPA• Targets women of

reproductive age in Ahmedabad City and select villages in 5 rural districts

• 2003: 7,041 women received treatment• 6 part-time physicians and 50 barefoot doctors and managers• Fees: Rs. 5 consultation fee, medicines sold at wholesale price

Research Methodology

Phase I Qualitative

Phase II Quantitative

Phase III Qualitative

Research MethodologyObjectives:

• Explore barriers to RH camp utilization

• Identify indicators of socio-economic status (SES)

Activities:

• FGDs with RH camp users & non-users, including wealth-ranking

• In-depth interviews with service providers & managers

Phase I Qualitative

Research MethodologyObjectives:• Assess SES among RH camp users versus

non-users

Activities:• Exit-survey• Questions about households assets, utilities,

dwelling and land ownership• Randomly selected 1 camp (of max. 3) per

day, and interviewed all users• 535 interviewed

Compared to:• Gujarat population, DHS 1998-99

urban N = 1,709, rural N = 2,223• Used wealth index, principal factors analysis

Phase II Quantitative

Research MethodologyObjectives:• Validate findings of previous

phases, with a focus on “Why did the service reach (or fail to reach) the poor?”

Activities:• In-depth interviews with service

providers

Phase III Qualitative

Findings: barriers to utilization

Demand• High perceived cost• Low perceived quality• Fear of doctors/procedures • Weddings, funerals• Not empowered to make own decisionSupply• Timing of camps• Cost• Exemption policy unclear• Limited continuity of care• Door-to-door promotion misses some

Respondent 1: …If someone doesn’t have a good financial situation, they would not come at all!

Respondent 2: They would think that, “What if they ask for more money in the camp? What would I do?”

FGD with RH camp users and non-users

Findings: perceived cost as a barrier to utilization

The poorest women would go out and do work for daily wages. They would say that “I will have to lose my wages to be able to attend the camp”.

FGD with SEWA Health rural grassroots worker

Findings: camp timing as a barrier

Findings: Top 5 indicators of SES (DHS, urban Gujarat, 1998-99)

Frequency

Rank VariableDHS

(N = 1,709)RH Camps (N = 377)

1 If electricity lighting 94.1% 91.2%

2 If biogas cooking fuel 0.1% 0.0%

3 If gas cooking fuel 57.0% 34.7%

4 If kaccha house 5.3% 18.9%

5 If no toilet facility 23.1% 16.4%

Findings: Top 5 indicators of SES (DHS, rural Gujarat, 1998-99)

Frequency

Rank VariableDHS

(N = 2,223)RH Camps (N = 157)

1 If private pit toilet 12.9% 1.9%

2 If wood cooking fuel 78.0% 89.8%

3 If private flush toilet 6.6% 3.2%

4 If pucca house 23.6% 4.5%

5 If electrical lighting 77.0% 92.4%

Findings: Percentage distribution of SEWA Health urban service users by SES quintile

Findings: Concentration curve, SEWA Health urban services

0

0.2

0.4

0.6

0.8

1

1.2

0 1 2 3 4 5

Quintile

Se

rvic

e u

tili

zati

on

RH Camps

0

0.2

0.4

0.6

0.8

1

1.2

0 1 2 3 4 5

Quintile

Se

rvic

e u

tili

zati

on

RH Camps

Women’s training

TB DOTS

Findings: Concentration curve, SEWA Health urban services

Findings: Percentage distribution of SEWA Health rural service users by SES quintile

Findings: Concentration curve, SEWA Health rural services

0

0.2

0.4

0.6

0.8

1

1.2

0 1 2 3 4 5

Quintile

Se

rvic

e u

tili

zati

on

RH Camps

Findings: Concentration curve, SEWA Health rural services

0

0.2

0.4

0.6

0.8

1

1.2

0 1 2 3 4 5

Quintile

Se

rvic

e u

tili

zati

on

RH Camps

Women’s training

• SEWA Health’s RH camps services more effective in reaching the urban (vs. rural) poor– 71% urban users from lowest 2 quintiles– 43% rural users from lowest 2 quintiles

• RH camps slightly more successful in reaching the poor, among 3 services studied

Policy implications: summary of findings

Why are SEWA Health’s RH camps successful in reaching the poor?

• Mobile approach: delivered to the “doorstep” in high-density urban and remote rural areas

• Service delivery by poor, local women• Combined with efforts to educate and

mobilize (create demand in) the community

• Trust in SEWA• Costs are low

How can SEWA Health’s RH camps better reach the poor?

• Change timings to better suit poor, working women (e.g. evening camps)

• Modify fee-policy to reach poorest– Develop an objective system for granting, for

example, all holders of “below-poverty line” cards

• Collaborate with government facilities, so as to access free medicines and physicians

• Address barriers faced by women– Involve men and senior Hh members in education– Encourage experience-sharing by women who have

been cured