Meeting community needs for HIV prevention and more: Intersectoral action for health in the Sonagachi red-light area of Kolkata Authors: The Durbar Mahila Samanwaya Committee (DMSC) Theory and Action for Health (TAAH) Research Team1 1 The following members of the DMSC/TAAH team contributed directly to the writing of this paper: Mercedes Mas de Xaxàs, Kevin O'Reilly, Catrin Evans, Donna Higgins, Pamela Gillies, Smarajit Jana CONTENTS I. INTRODUCTION .............................................................................................................. 1 II. SCOPE................................................................................................................................ 1 III. METHODOLOGY ............................................................................................................. 1 IV. PROJECT OVERVIEW..................................................................................................... 2 V. PROJECT CONTEXT 1. Baseline information on India, Kolkata and the Sex workers of Sonagachi ........... 3 2. Key characteristics of the policy environment ........................................................ 5 3. Nature, origins and objectives of SHIP ................................................................... 6 VI. PROJECT APPROACHES................................................................................................. 7 1. SHIP’s key intervention values ............................................................................... 8 2. SHIP’s value- led interventions ............................................................................... 11 a. Building a cohesive and inclusive sex work community .............................. 12 b. Creating mechanisms for decision-making, nurturing ownership and mobilizing for action .............................................................................. 14 c. Challenging social exclusion and reconfiguring power relations at the local level ................................................................................................ 16 d. Providing access to financial resources ......................................................... 18 e. Providing access to cultural resources ........................................................... 20 f. Providing access to social resources .............................................................. 21 g. Relations with the state and government officials ......................................... 22 VII. PROJECT IMPACT ........................................................................................................... 23 VIII. CONCLUSION................................................................................................................... 27 List of Acronyms........................................................................................................................... 28 References..................................................................................................................................... 29 - i - Intersectoral action for health in the Sonagachi red-light area of Kolkata I. INTRODUCTION The Sonagachi Project has been in existence for more than a decade. Over that time, it has grown, formed new bonds, taken on new activities, seized new opportunities and responded to the expressed needs of the communities it serves. It is one of the first large-scale examples of how intersectoral action can have a measurable benefit for HIV prevention. It is also a strong example of how action that is values-based, as opposed to theoretically based, can grow, develop and take advantage of opportunities that present themselves over time. This case study traces the history, delineates the development and the rationale for the approach taken in Sonagachi and highlights the impacts that have been measured. II. SCOPE This case study aims to provide an overview of a community-led intervention that demonstrates how intersectoral action for health can successfully take a bottom-up approach to simultaneously (1) improve the health status of a target group, in this case the sex workers of Sonagachi, and (2) empower them to break barriers and fight for their individual and collective social, economical, and political rights. The case study covers the time period from 1992, the year in which the project was created, to 2007. A note on terminology In the early years, (1992-1995) the project was known as SHIP (Sonagachi HIV/AIDS Intervention Project). In 1995, with the expansion of the scope of SHIP and the creation by sex workers of their own organization, the project adopted the name of Durbar Mahila Samanwaya Committee (which is also known as DMSC or Durbar). The large scale community based effort managed by DMSC is now commonly referred to as the Sonagachi Project. The terminology used throughout the case study reflects this. III. METHODOLOGY The case study is based on the findings of a Bill & Melinda Gates Foundation funded research study that included secondary analysis of existing data from Sonagachi as well as primary data collection and analysis. The methods for studies that were used as secondary data sources included the following: 1) cross-sectional, random sample surveys of sex workers in Sonagachi over a 12 year period -- data were analysed using standard descriptive, inferential, and correlational analysis methods 2) mixed methods studies that used both quantitative and qualitative methods; and 3) qualitative studies that used purposive sampling methods and data reduction strategies including thematic content analysis, and grounded theory methods. Secondary data analysis utilized thematic synthesis and data reduction strategies. Primary data collection used purposive sampling methods and included qualitative methods using focus groups, individual open-ended interviews, and observations. Data analysis relied upon standard data reduction strategies including thematic content analysis and grounded theory methods. Content analysis methods were used to examine the publications produced about Sonagachi over the years of its existence. All of these studies were conducted in Bengali and then interpreted into English. Data and findings were back-translated from English to Bengali and reviewed by teams of sex workers for 1 Intersectoral action for health in the Sonagachi red-light area of Kolkata clarity. Multiple data sources provided the opportunity to triangulate findings and provide a solid foundation for this case study. The team involved in all of the research noted above consisted of academics, the Sonagachi STD/HIV intervention project (SHIP) project advisors and sex workers. This team worked closely with the peer educators, sex workers and staff of DMSC. All non-academic team members were trained in appropriate data collection and analysis methodologies by senior academics on the team (Ph.D.s, M.D.s, J.D.s and Masters levels). IV. PROJECT OVERVIEW In 1992, the All India Institute of Hygiene and Public Health (AIIHPH) was contracted by WHO to conduct research among sex workers in the Indian city of Kolkata. The research showed that the prevalence of HIV was low at 1%, but that sexually transmitted infections (STI) were common: nearly 80% of sex workers reported symptoms. Not surprisingly, condom use was negligible at 1%. Subsequently, AIIHPH initiated in Sonagachi, the main redlight district in north Kolkata, the as Sonagachi HIV/AIDS Intervention Project (SHIP) with a conventional focus on STI treatment, condom promotion and peer health education. SHIP started on a relatively small scale, with the opening of one clinic and the employment of a few of sex workers as peer educators (PE) to provide health education and distribute condoms (Jana et al 2004, Jana et al 1998). From the start it became evident that the sex workers, being poor and marginalised women, had little or no power as individuals to demand condom use from their male clients. Furthermore, sex workers were much more concerned about addressing the more immediate problems they faced, like violence, the health and welfare of their children and the denial of many of their basic rights than they were about HIV/AIDS. Realizing this, SHIP director (S. Jana) determined that the best way to enable sex workers to protect their health was to target the social context in which they lived and worked, meet their immediate needs and empower them both as individuals and members of a community to protect their rights. The sex workers readily embraced this strategy and made it their own by instilling their principles and ideals into this tactic. Responsiveness, egalitarianism, and empowerment are just a few of the strong values that have imbued SHIP from the beginning, which have influenced every strategic decision that has been taken over the years and fostered the growth of the large scale community based effort that is known as the Sonagachi Project. As a result of the needs and concerns expressed by the sex workers, the first 5 years of SHIP were devoted to implementing key interventions to supplement the activities of the clinic and the peer educators, both of which were expanded. Among these interventions were: vaccination and treatment services for the children of sex workers; literacy classes for sex workers and their children; political activism for workers' rights; advocacy with political leaders and law enforcement; community mobilization; micro credit schemes, and cultural programmes. Using participatory methods, by 1995, the project had assisted sex workers to create