Assessing the Reach of Three SEWA Health Services Among the Poor Public Disclosure Authorized
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HNP DISCUSSION PAPER Reaching The Poor Program Paper No. 4 Public Disclosure Authorized India: Assessing the Reach of Three SEWA Health Services Among the Poor Public Disclosure Authorized About this series... This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank’s Human Development Network. The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. M. Kent Ranson, Palak Joshi, Mittal Shah, and Yasmin Shaikh The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual authors whose name appears on the paper. Enquiries about the series and submissions should be made directly to Public Disclosure Authorized the Managing Editor Joy de Beyer ([email protected]) or HNP Advisory Service ([email protected], tel 202 473-2256, fax 202 522-3234). For more information, see also www.worldbank.org/ hnppublications. THE WORLD BANK 1818 H Street, NW Public Disclosure Authorized Washington, DC USA 20433 Telephone: 202 477 1234 Facsimile: 202 477 6391 Internet: www.worldbank.org E-mail: [email protected] October 2004 India: Assessing the Reach of Three SEWA Health Services among the Poor M. Kent Ranson, Palak Joshi, Mittal Shah, and Yasmin Shaikh October 2004 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network. The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual author(s) whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Managing Editor. Submissions should have been previously reviewed and cleared by the sponsoring department, which will bear the cost of publication. No additional reviews will be undertaken after submission. The sponsoring department and author(s) bear full responsibility for the quality of the technical contents and presentation of material in the series. Since the material will be published as presented, authors should submit an electronic copy in a predefined format (available at www.worldbank.org/hnppublications on the Guide for Authors page). Drafts that do not meet minimum presentational standards may be returned to authors for more work before being accepted. The Managing Editor of the series is Joy de Beyer ([email protected]). The Editor in Chief for HNP publications is Alexander S. Preker ([email protected]). For information regarding this and other World Bank publications, please contact the HNP Advisory Services at [email protected] (email), 202-473-2256 (telephone), or 202-522-3234 (fax). © 2004 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii Health, Nutrition and Population (HNP) Discussion Paper India: Assessing the Reach of Three SEWA Health Services among the Poor Kent Ransona, Palak Joshib, Mittal Shahb and Yasmin Shaikhb a Health Policy Unit, London School of Hygiene and Tropical Medicine, and Self- Employed Women’s Association Insurance (SEWA) London, England b Self-Employed Women’s Association Insurance (SEWA), Ahmedabad, India Paper prepared for the Program on Reaching the Poor with Effective Health, Nutrition, and Population Services, organized by the World Bank in cooperation with the William and Melinda Gates Foundation and the Governments of the Netherlands and Sweden. Abstract: This is a study of how well health and related services provided by a large, prominent Indian non-governmental organization have reached the very poor. The Self- Employed Women’s Association (SEWA) is a trade union of informal women workers located in Gujerat State. The services are three primary components of SEWA’s health program: its mobile reproductive health camps, tuberculosis detection and treatment program, and women’s education program. The project’s quantitative component compared the economic status of women attending each of the three services with that of the general population. Information about the economic status of approximately 1,500 women attending the services was collected through interviews at service provision sites. Information on the general population’s economic situation came from pre-existing household data sets: a Demographic and Health Survey (DHS), and a survey by SEWA’s insurance project. In urban areas, all three SEWA services were used predominantly by people from poorer households; about half the clients of each service belonged to the poorest third of the population. In rural areas, the economic status of those who used the two services offered (reproductive health and women’s education) did not differ significantly from that of the general population. The project’s qualitative component featured focus group discussions about the reasons why the services did or did not reach the poor groups for whom they were designed. In urban areas, the reasons identified for the services’ attractiveness to the poor included proximity, delivery (in part) by the poor themselves, promotion efforts in poor communities, relatively low cost, and SEWA’s favorable reputation. The barriers identified in rural areas were the timing of service, which coincided with working hours, and the services’ perceived high cost. Keywords: India, Gujerat, Self-Employed Women’s Association, SEWA, health service inequality, tuberculosis, reproductive health Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. iii Correspondence Details: Kent Ranson, Keppel Street, London, WC1E 7HT, England. Telephone: +44 207 927 2431. Fax: +44 207 637 5391. Email: [email protected]. iv Table of Contents FOREWORD...................................................................................................................vii ACKNOWLEDGMENTS..................................................................................................ix Research Questions .......................................................................................................1 Health Services Available in the Study Area.................................................................. 2 SEWA’s Health Services ................................................................................................ 2 Potential Constraints to Utilization of SEWA Health’s Services ................................... 5 Methodology....................................................................................................................5 Phase 1 ............................................................................................................................ 6 Phase 2 ............................................................................................................................ 6 Phase 3 ............................................................................................................................ 8 Nature and Source(s) of Data.........................................................................................8 DHS Database................................................................................................................. 9 Vimo SEWA (or SEWA Insurance) Data....................................................................... 9 Findings about Distribution .........................................................................................10 Urban Findings.............................................................................................................. 10 Rural Findings............................................................................................................... 11 Findings about Reasons for the Distribution .............................................................13 Limitations.....................................................................................................................17 Reference Standard Databases...................................................................................... 17 Sample Size................................................................................................................... 17 Exit Survey Data........................................................................................................... 17 Comparability between Reference Standard and Exit Survey Data ............................. 18 Implications ...................................................................................................................18