Evaluating an Integrated Reproductive Health Program: India Case Study

Lessons from the Field Evaluating an Integrated Reproductive Health Program: India Case Study

This report details the methods and findings of a participatory evaluation of integrated reproductive health programs in two villages in India, with comparisons to a third village that had no reproductive health programming. The results suggest that the integrated approach used by World Neighbors-India and its partners is effective in achieving high rates of reproductive health knowledge and positive practices, improvements in women’s status, and significant benefits from participation in savings and credit groups. Preface World Neighbors has always been committed to learning through program experience. In the area of reproductive health, World Neighbors has had the unique opportunity to contribute to others working in the field by documenting the results of an integrated approach in which reproductive health is a central feature.

The following evaluation study concerns an established World Neighbors’ program which has incorporated a reproductive health component. Previously, the program (in the Gulbarga District of the state of Karnataka in India) had been oriented to dry land sustainable agriculture. While women were included in the farmers’ groups, men were the primary program partners. The reproductive health component was developed based on previous World Neighbors’ experiences in Nepal.

The process of establishing the reproductive health component presented multiple challenges and opportunities for the WN India team and its partners. They continually adapted what they had learned in their previous work with communities to meet these challenges. With strong leadership and a clear process for learning, the program team and partners have constructed a meaningful integrated program that has achieved the important results which are presented here.

This evaluation originally was designed to examine the impact of the reproductive health component and make recommendations for modifications before the program was expanded elsewhere. However, the results of the evaluation were so compelling that World Neighbors decided to produce this document as a means of sharing both the program approach and the evaluation methodology, as both encompass unique aspects that may be valuable to others.

Catharine McKaig, DrPH, MS Reproductive Health Coordinator World Neighbors

Core Evaluation Team Members: Dr. Subhash Gumaste Ms. Laxmi M. Madras Ms. Kellye O’Bryan Dr. Shiva Sharanappa M. Hallad Mr. Subbanna Biradar Mr. Mallikajun Kavalagi Mr. Iranagouda Goudappa Patil Mrs. Mahadevi Kavalagi

The evaluation team would like to sincerely thank the women and men of Nellur, Yelenavadgi, and Khanapur for their participation in these evaluation activities. The BSRDS staff also worked long hours to make the evaluation a success. The on-going work in these villages is truly an inspiration for others.

World Neighbors’ reproductive health programs in India are funded by the Bill and Melinda Gates Foundation. The publication of this case study was also made possible with funding from the Bill and Melinda Gates Foundation. Portions of the evaluation of the reproductive health programs in India were funded by the Summit Foundation.

Catharine McKaig, Evaluating an Integrated Reproductive Health Program: India Case Study; edited by Linda Temple (Oklahoma City: World Neighbors, 2002)

Published by World Neighbors, Oklahoma City, Oklahoma 73120 @2002 by World Neighbors ISBN 0-942716-16-7

Reproducing this publication: We encourage users to copy portions of this publication for personal use and to share with others on a limited scale. However, we request that you cite the original text and that no attempts be made to sell this or any World Neighbors publication without permission. World Neighbors would appreciate receiving copies of any publication which draws on this material.

2 - Evaluating an Integrated Reproductive Health Program Table of Contents Map of Program Area ------4

Executive Summary ------5

Background and Evaluation Rationale ------7

Operational Phases of Adding the RH Component ------9

Evaluation Framework and Methodology A Pre-planning ------10 B. Evaluation design ------10 C. Development of Evaluation Tools ------12 D. Data collection training------12 E. Field work ------12 F. Analysis ------14 G. Report Writing ------14

Evaluation Findings A. Women’s Status Exercise 1: Women’s Status ------15 Findings: Women’s Status------16-20 B. Reproductive Health Exercise 2: RH Historical Matrix ------21 Findings: Reproductive Health ------22-28 C. Capacity - Women’s Groups and BSRDS Exercise 3: Capacity Evaluation for Women Group Members ------29 Findings: Group and Organizational Capacity ------30-32 D. Integration Exercise 4A/4B: SSI-RH with Men’s Groups/SSI-Agri with Women’s Groups ------34 Findings: Integration ------35-37 E. Livelihood Exercise 5: Livelihood Ranking for Women Group Members ------38 Findings: Livelihood ------39-41

Evaluation Results and Limitations A. Responses to Key Questions ------41-44 B. Limitations of the Evaluation ------45-46

Lessons Learned and Conclusions A. Impact of Group Activities ------47 B. The Evaluation Process ------48 C. Discussion and Conclusions ------49

Appendices: Appendix A: Questionnaire ------51-57 Appendix B: Evaluation Training Schedule ------59 Appendix C: Health Services Maps ------61-62

Evaluating an Integrated Reproductive Health Program - 3 Map of the Program Area

Aland Subdistrict

KHANAPUR YELENAVADGI NELLUR

Gulbarga District

Karnataka State

4 - Evaluating an Integrated Reproductive Health Program Executive Summary An evaluation of the reproductive from the wives of agriculture major achievements of the health component of the Bayalu group members and non-mem- groups. Seeme Rural Development bers in a non-intervention village Society (BSRDS) integrated (Khanapur). Approximately 200 2) There were reported changes program took place between women and 60 men from the in indicators of women’s status April 25 and May 16, 2001 in the three communities participated for intervention villages, particu- villages of Nellur, Yelenavadgi, in the evaluation exercises. larly for group members. and Khanapur in the Aland Third, the evaluation incorpo- Women noted positive changes Subdistrict of the Gulbarga rated quantitative and qualitative in decision making, property District in the southern state of methods. Both participatory ownership, girl child education, Karnataka in India. The repro- methods and a short survey and reduction of violence against ductive health component was were used to facilitate the trian- women, all largely attributed to initiated in 1998 by World Neigh- gulation of data for verification the group’s activities. bors, in partnership with and attribution. BSRDS. The objectives of the According to the women, the evaluation were to Key findings from the evaluation: groups have provided them with the confidence to organize to 1) review the reproductive 1) Significant changes were undertake a variety of initiatives health component of the reported in key reproductive ranging from closing bars and BSRDS integrated program health practices and rates for gambling houses to using civil to examine impact, outcome, service use for intervention disobedience to improve water and process; villages. The family planning use supplies. 2) determine the lessons rates observed among group learned for application for and non-group members in 3) There were indications that BSRDS and others; and Nellur (78%-74%) and Yelena- the loans given by the groups 3) develop capacity of NGO vadgi (88%-78%) greatly sur- have had an impact on livelihood staff for self-evaluation. pass the rates of Khanapur, the status for about a third of the comparison village, (53%-48%), group members. According to The evaluation design had three and for rural Karnataka as a the evaluation findings, five key features. First, the evalua- whole (56.6%). The use of members of the Nellur group and tion itself was integrated; the antenatal care (ANC) also six members of the Yelenavadgi dimensions examined included demonstrated similar patterns. group increased their livelihood women’s status, reproductive status. According to the women health, group capacity, organiza- The group and non-group mem- interviewed, while these tional capacity, integration, and bers in the intervention villages changes are small, they are savings and credit. Second, the cited the regularity of visits from significant. design included a comparison the auxiliary nurse midwife village; information from women’s (ANM), the periodic gynecology Women cited two other key group members and non-group camps, and the ongoing work of benefits of their savings and members in two intervention selected group members as credit activities as group solidar- villages (Nellur and Yelenavadgi) trained birth attendants (TBA) as ity or support and freedom from were compared to information moneylenders. Both groups

Evaluating an Integrated Reproductive Health Program - 5 Executive Summary reported that in case of emer- women’s groups and their with Nellur and Yelenavadgi, gency, they would give loans to ongoing support for their activi- where the groups are five years members, even if they knew ties has been invaluable. The old, difficult. those members would not be agriculture group members able to pay the group back. assisted in the formation of the 6) The integrated model ap- women’s groups by encouraging peared cost-effective. The cost 4) The women’s groups and their wives to participate and, in of the women’s group activities BSRDS staff have developed some cases, by convincing averaged about $11 per group capacities to effectively imple- other men to do the same. The member. These activities in- ment, monitor, and evaluate their men’s group members have also cluded capacity building, out- activities. These skills include provided ongoing support in reach reproductive health ser- technical knowledge, communi- terms of assisting with the vices, savings and credit, and cation, and program manage- organization of the periodic leadership development. The ment. The women’s groups are gynecology (gyne) camps and evaluation also demonstrated confident in their ability to sus- the regular discussion of issues the effects of the program tain key activities after the phase (RH, agriculture, and social beyond the group members, out of BSRDS. issues) with the women’s particularly in the area of repro- groups. Individually, the men ductive health. The costs calcu- Although BSRDS didn’t have have also encouraged their lated were inclusive of support any prior experience in repro- wives to attend the gyne camps from BSRDS and WN-India. ductive health, they were able to to receive services. effectively implement the activi- In summary, the integrated ties. In the Gulbarga District, At Nellur and Yelenavadgi, there approach used by World Neigh- BSRDS is now seen as a was apparently good communi- bors-India and BSRDS appears resource for reproductive health. cation regarding dry land agricul- effective as demonstrated by the BSRDS notes that the addition tural (DLA) issues between men outcomes of this evaluation. In of the reproductive health com- and women because of the the two intervention villages, ponent has significantly contrib- existence of both men’s and there are high rates of reproduc- uted to their integrated develop- women’s groups. As a result, tive health knowledge and family ment approach and has there appeared to be improved planning use for both group and strengthened their relationship awareness in women’s group non-group members. The group with village women. members regarding key agricul- members also appear to have tural practices, and women made progress in many areas of 5) In the area of integration, it report using these techniques in improving the status of women, was clear that the linkages their agricultural work. In con- as well as benefiting from the between the men’s agriculture trast, at Khanapur (the compari- savings and credit activities of groups and the women’s groups son village), there was relatively the group. These are remarkable have been important. In particu- low awareness. However since achievements in a relatively lar, the role of the agriculture the DLA men’s group is new short period of three years. groups in the formation of the (one year) it makes comparison

6 - Evaluating an Integrated Reproductive Health Program Background and Evaluation Rationale World Neighbors India (WN-I) began organization and the fact that the the men’s groups of dry land farm- activities in reproductive health (RH) BSRDS area is particularly remote ers. Later the BSRDS Director and in April 1998. These first activities and under-served. For its part, the FA suggested Nellur and Yelena- were initiated with a partner organi- BSRDS was willing to pilot the vadgi for the program sites, because zation, the Bayalu Seeme Rural activities because of the need in the they felt the men’s groups of dry land Development Society (BSRDS), in area and its strong relationship with farmers were doing a fine job. two villages where agricultural WN-I. activities were ongoing. Over the First, the idea of forming groups past three years, WN India has Table 1 shows the timeline of key consisting entirely of women was greatly expanded RH activities with events in the development of the shared with the farmer group mem- eight partner NGOs, currently BSRDS reproductive health compo- bers in the two villages, since it was working in 44 villages with 58 nent, and WN-I expansion of repro- the wives of farmer group members women’s groups. This evaluation ductive health services to other who would address RH and other was intended to allow WN India to partners. The evolution of the RH issues faced by women. In the carefully examine RH activities and component of BSRDS is described meanwhile, BSRDS identified analyze lessons learned for applica- as follows by Dr. Subhash Gumaste, Mahadevi Kavalagi to work as the tion to other WN India supported Country Director, WN India: reproductive health worker. Mahadevi programs. was trained intensively by the WN “When WN India and BSRDS team in technical and facilitation BSRDS was founded in 1993 to considered addressing women’s skills. She was also provided work with marginalized groups in two issues with particular reference to training by Family Planning Associa- sub-districts (talukas) of Gulbarga reproductive health and social tion of India (FPAI) and Denise District in the southern Indian state issues, it was first discussed with Caudill, the WN RH Consultant at of Karnataka. BSRDS has a staff of the Field Assistant (FA) of BSRDS that time. six persons: the director, training who worked in close association with coordinator, accountant (typist), community organizer, field assistant, and reproductive health worker. Table 1: RH Component Development Timeline BSRDS has six major objectives: 1) Date Activity to organize target groups to under- January 1998 Feasibility survey and selection of villages take development activities; 2) to February 1998 WN-I discussions with BSRDS and agriculture group give formal and informal training to leaders in Nellur and Yelenavadgi women, handicapped persons, and April 1998 Funding received for RH component; Ms. Pankaja children without access to schools; Kalmath hired as WN RH Consultant; BSRDS Women’s 3) to create employment opportuni- Groups formed in Nellur and Yelenavadgi ties for the rural poor and establish November 1998 RH Experience Sharing Workshop I facilitated by Dr. training centers for self employment Denise Caudill for youth and women; 4) to plan and February 1999 Cross-visit to Nepal to study RH Integration with implement various rural employment Agriculture (WN-I team and BSRDS staff) and development programs with the April 1999 Cross visit of seven WN-I partners to BSRDS RH cooperation of local groups for the villages to study integration. all round development of the people; July 1999 BSRDS expanded RH to two more villages. 5) to bring about a positive social September 1999 RH Workshop II facilitated by Dr. Denise Caudill. All change to improve the economic partners attended. January 2000 RH components initiated in ten villages in cooperation condition of people; and 6) to sustain with five other NGO partners. all development activities targeted to March 2000 Ms. Mamatha hired as WN RH Consultant the groups. April 2000 Family Planning Association of India (FPAI) Training for RHWs and NGO Directors WN-I selected BSRDS as a partner July 2000 FPAI Training for RHWs and NGO Directors; Laxmi to pilot the RH activities because of Madras hired as WN RH Consultant; BSRDS expands confidence in the leadership of the RH to two additional villages.

Evaluating an Integrated Reproductive Health Program - 7 Background and Evaluation Rationale The BSRDS reproductive health of marginalized farmers or landless group members started attending worker and the field assistant met laborers. the meetings regularly, the reproduc- with the women separately, and with tive health worker assisted them in their husbands, and encouraged As the groups were intended to be identifying and prioritizing RH and them to form a group. Encouraged small in membership, they did not social issues faced by the women, by the idea, in both villages 8-10 allow more members to join groups using flash cards. The groups women came forward to form groups but encouraged them to have a prepared action plans to address the of women. As an entry point activity, separate group. The groups selected prioritized issues. As the leadership a savings and credit group was their leaders who were periodically developed and groups gained initiated. This met some immediate trained in technical and facilitation experience in conducting activities, needs, as for the rural poor women skills by the WN India team. the reproductive health worker money is a big constraint. This Initially, the reproductive health attended the meetings less fre- activity attracted other women of the worker attended the meetings every quently. Thus the groups started village and thus the groups grew in fortnight and guided the groups in working and learned to take owner- size to have 15-20 members. All of conducting meetings and discussing ship of the program.” the members were either the wives issues. After a few months when

Glossary

ANC Antenatal Care ANM Auxiliary Nurse Midwife BSRDS Bayalu Seeme Rural Development Society DLA Dry Land Agriculture EDP Entrepreneur Development Program FA Field Assistant FP Family Planning Gyne Gynecology HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome NGO Non-governmental organization MOH Ministry of Health PNC Postnatal Care RH Reproductive Health RHW Reproductive Health Worker RTI Reproductive Tract Infection SSI Semi-structured Interview STI Sexually Transmitted Infection TBA Trained Birth Attendant WN World Neighbors WN-I World Neighbors India

8 - Evaluating an Integrated Reproductive Health Program Operational Phases of Adding the RH Component The addition of a reproductive Phase 2: Capacity Building of supporting key training events. For health component into established Women’s Groups with help of RH example, she trains and assists the village activities can be described Worker group in self-evaluation of their in three major operational phases. group capacities once every six During the first two phases the During the intensive phase, the NGO months. She also organizes cross- support of the NGO staff, BSRDS RH Worker helps organize the visits to successful groups as and in this case, is essential. These are women’s group. The initial activities when required. the critical phases of establishing of the group include: the women’s groups and developing • Selection of leaders capacities and implementing • Training of leaders (The topics Phase 3: Women’s Groups activities. Program staff estimates include group management, Conduct Activities Independently that it takes about three to four decision-making, record keeping, months to establish a new group. fund management, and This phase is transitional, as NGO The capacity building phase monitoring and evaluation support will eventually phase out. requires about three years. In the techniques. Leaders are also The RH worker visits the group first year, there is intensive guid- trained in technical aspects of every three to six months. The ance and support from the NGO reproductive health and income groups have responsibility for staff to establish a firm basis. In the generation.) planning and implementing activi- next two years the support is ties, monitoring capacities and • Selection and training of trained gradually reduced as the groups progress on action plans. birth attendants strengthen their capacities. In the • third phase the women’s groups Establishment of group rules conduct activities independently • Identification of important group with little support from the NGO. capacities The major activities of each phase • Initiation of savings and credit are outlined below. During this period the RH worker Phase 1: Establishing Women’s attends all group meetings and Groups assists the group in developing and Family size monitoring their capacities and • WN staff hold initial discussions monitoring savings and credit with NGO director and field assis- activities. She also assists the tants. group to identify and prioritize • NGO and WN staff hold discus- reproductive health and related sions with agriculture groups about social issues (see drawings at right, possibility of starting a women’s developed for problem identification). group in the village. She works with the group to develop • WN staff work with the NGO to an action plan to address the issues. Miscarriage identify and train the reproductive The RH worker also assists in action health worker (RHW). plan as indicated. In most cases this includes helping with letter • NGO and WN staff hold discus- writing to health authorities request- sions in the village about the ing regular visits from the auxiliary program. • nurse midwife assigned to the village Women meet together to form a and the organization of the first group of between 15 and 20 mem- gynecology camp. bers. Violence Against Women As groups develop capacities in these areas, the support of the RH worker becomes less intense. She visits less frequently, but continues

Evaluating an Integrated Reproductive Health Program - 9 Evaluation Framework and Methodology The evaluation took place in several methodologies including a short women socially, economically, and stages: questionnaire to help assess educationally. It was felt that the outcomes and allow for triangulation EDP and SHE programs were not A. Pre-planning of evaluation results. significant factors in the outcomes B. Evaluation Design examined in this evaluation. C. Development of Evaluation The WN-I team worked with BSRDS Tools to identify the villages for the Of note is also the availability of D. Data Collection Training evaluation exercise (see Table 2 health services prior to the program. E. Field work below). A map of the evaluation While the government structure calls F. Data Analysis villages is on page 2. for essential health services to be G. Report writing provided to each village on a weekly The team tried to identify influences basis by an auxiliary nurse midwife from other development sectors in (ANM), according to the accounts of A. Pre-planning the intervention and comparison the villagers, BSRDS staff, and the villages. One of those influences, ANM herself, these services were As it had been planned for some the Entrepreneur Development not regularly provided. time to evaluate the RH experience Program (EDP), was initiated in the with consultant support, in Novem- program villages in 1998 and will ber 2000, Dr. Subhash Gumaste, WN continue through 2002. In this B. Evaluation Design India Country Director, Dr. Catharine program, women from marginalized McKaig, WN RH Coordinator and Dr. castes receive credit for economic During the first day of the evaluation Denise Caudill, Consultant, met to activities. None of the women period, the WN and BSRDS teams discuss the evaluation process. At participating in EDP in Yelenavadgi clarified the objectives of the that meeting two key decisions were and Nellur are members of women’s evaluation and determined the key made. First, it was determined that groups. In the Women’s Holistic questions to be answered during the there was an opportunity to use a Empowerment Program (SHE) in course of the evaluation. The key comparison village to strengthen the Khanapur, begun in June 2000, in questions helped to identify the kind evaluation design. Second, it was addition to credit, stress is also of information required and the also decided to use a combination of placed on empowering selected participatory exercises to be conducted. This was an important Table 2: Evaluation Field Sites step because not all the team members had been involved in O ht re Numb re the earlier pre-planning discus- Numb re fo WN/BSRDS Dev ole pme tn alliV ge fo G or up sion. househ dlo s1 A eitivitc s A eitivitc s Memb sre Although the primary focus of N rulle 231 3 yrd al nd 1 2/6 2/0 0 E ertn erp ne ru the evaluation was on the a cirg erutlu Dev ole pme tn P or arg m reproductive health outcomes, org ups - 15 women orf m savings & credit, agricultural, 1 1/5 2/2 6 m nigra zila ed ca ets s and women’s status outcomes 3 er orp du vitc e er c vie e erc roftid were also examined. he htla org ups econom ci a eitivitc s

Y ele navad ig 294 4 yrd al nd 1 1/5 1/5 1/1 7 E ertn erp ne ru Those participating in this a cirg erutlu Dev ole pme tn P or arg m meeting were the World Neigh- org ups - 15 women orf m bors team, Dr. Subhash 1 1/5 2/1 1/0 5 m nigra zila ed ca ets s Gumaste, Dr. Shiva Sharanappa 4 er orp du vitc e er c vie e erc roftid M. Hallad, Mr. Iranagouda he htla org ups econom ci a eitivitc .s Goudappa Patil, Ms. Laxmi M. Madras, Ms. Kellye O’Bryan, Khanap ru 210 1 yrd al nd 17 Wome s'n H citsilo and Dr. Cat McKaig; and the c( omp sira on a cirg erutlu Enpow re me -tn BSRDS team, Mr. Subbanna alliv g )e org up Sa niv gs & C er tid 1 BSRDS collected this information initially through social mapping in 1994. It was updated in 1998 with a house-to-house survey when the RH activities began.

10 - Evaluating an Integrated Reproductive Health Program Evaluation Framework and Methodology Biradar (Director), Mrs. Mahadevi Objectives of the evaluation: 2.To determine the lessons learned Kavalagi (RHW), and Mr. Mallikajun for application to BSRDS and else- Kavalagi (Field Assistant). 1.To undertake an evaluation of the where (Action Learning). RH component in the BSRDS The following objectives and key integrated program to examine 3. To develop the capacity of NGO questions were identified: impact, outcome, and process. staff for self-evaluation.

Table 3: Key Questions, Information Needed, and Means of Collection

Key Que oits ns ofnI rm oita n Needed How ot C ello ?tItc

Q .1 How has ht e orp arg m effa etc d ht e Changes ni ht e kno elw dge and S vru ey and P picitra yrota M hte ods aw era ness fo org up and no org-n up beha roiv among org up and no org-n up memb sre ? memb .sre

Q .2 diD ht e orp arg m erc eta a demand Numb re fo peo elp u nis g gov nre me tn P picitra yrota m hte od ,s s vru e ,y ANM rof gov nre me tn s civre es? s civre e .s er p er/stro c dro s

Q .3 Wh ta has been ht e elor htfo e m ela * P picitra oita n fo men org up memb sre P picitra yrota m hte ods htiw me s'n and a cirg erutlu org ups ni ad erd s nis g RH ni ad erd s nis g RH si ue .s wome s'n org ups si sues? * P cre e oitp n fo women er g nidra g how men have p picitra eta .d * Kno elw dge fo men er g nidra g RH si sue .s

Q .4 Wh ta has been ht e )a Re orp du vitc e He htla )1 RH impa o/tc ctu ome htfo e orp arg m .i Ado oitp n fo RH key arp citc es .i S vru e ,y org up er c dro ,s a eitivitc s o :n af( m yli alp n nin ,g s efa d vile ,yre p picitra yrota m hte ods )a RH ANC & PNC) )b Sa niv gs and erc tid .ii P cre e oitp ns fo RH utats s ni .ii P picitra yrota m hte ods )c Wome s'n utats s ht e af m yli )b Sa niv gs and erc tid )b Sa niv gs and erc tid .i Amou tn saved and ol ans vig en .i P picitra yrota m hte ods .ii Numb re fo peo elp ben ettife d .ii G or up er c dro s .iii P pru ose olfo an .iii S vru ey .vi P cre vie ed impa tc htfo e sa niv gs and erc tid a ytivitc .v Ben stife ot ht e org up as a wh elo orf m sa niv gs and erc tid a .ytivitc )c Wome s'n utats s )c Wome s'n utats s .i Key p cre e oitp ns fo men .i P picitra yrota m hte ods .ii Key p cre e oitp ns fo women .ii S vru ey rofnI.iii m oita n on wome s'n empow re me tn

Q .5 2 How does ht e we htla birtsid oitu n - C airetir rof we htla ar n nik g P picitra yrota m hte ods htiw key fo org ups comp era ot ht ta htfo e - Househ dlo s ar nked by airetirc rofni ma stn alliv ge?

Q .6 Wh sita ht e capa ytic htfo e org up rofnI m oita n on s e-fle v ula oita n fo org up P picitra yrota m hte od ,s org up er c dro s ot su niats a eitivitc s? capa eitic rofnI.s m oita n on a oitc ns at ken ot w dra s su niats a ytilib

Q .7 Wh sita ht e aw era ness and - Kno elw dge and p picitra oita n ni P picitra yrota m hte ods htiw me s'n and ado oitp n ifo m orp ved yrd al nd imp vro ed su niats a elb a cirg erutlu wome s'n org up ,s s vru ey a cirg erutlu (DLA) arp citc es by women arp citc e .s org up memb sre and no -n memb sre ? - P cre e oitp ns fo men and women abo tu wome s'n elor s ni su niats a elb a cirg .erutlu

2 The team was unable to address question #5 due to the large size of the villages and the time constraints

Evaluating an Integrated Reproductive Health Program - 11 Evaluation Framework and Methodology C. Development of Evaluation These exercises were designed to women who were not wives of Tools be complementary to the question- agriculture group members (23). naire. The participatory exercises Efforts were made to match non- Participatory Exercises are described in the next section. group members on age and eco- Other data collection activities nomic status. The team met to determine the included: 1) reviews of group records participatory exercises best suited (savings and credit, meeting notes, to collect the required information. and gynecology [gyne] camp D. Data Collection Training The following exercises were records), 2) interviews with Ministry identified3: of Health (MOH) officials, and other Six female reproductive health key persons. workers (RHWs), one male RHW, 1. Women’s Status and one extension agent all from 2. RH Historical Matrix Survey Instrument- Questionnaire other partner NGOs served as 3. Group Capacity Evaluation interviewers and facilitators of the 4. Focus Groups/Semi- The WN-I team worked to develop participatory exercises during the structured Interviews the questionnaire instrument based evaluation period. 5. Livelihood Ranking on variables identified during the November meeting and adding A training workshop intended to The table below demonstrates how others they judged to be valuable. It familiarize the RHWs in data the exercises were designed to be was finalized just prior to the collection and the tools took place used with the different groups and evaluation period but not yet pre- from April 26-29, 2001. The major their relationship to key questions. tested. The instrument had a total of areas of the training included: 1) The team used the verification with 22 questions (see Appendix A for a explanation of objectives and key key questions to ensure that exer- copy of the questionnaire). Time was questions, 2) survey methodology cises collected the necessary spent during the training workshop to and practice with the questionnaire, information. review and revise the instrument. and 3) participatory methods and practice. (A copy of the training Table 4: Participatory Exercises in The questionnaire was administered agenda is included as Appendix B.) Relation to Key Questions to six separate groups: a purposeful sample of RH Key tools were field tested with two Wome s'n Me s'n Women group members BSRDS women’s groups who were G or ups G or ups No g-n or up (approximately 40) not conducting RH activities. The Memb sre and an equal tools that were field-tested included: RH cirotsiH la Q1 Q ,1 Q ,2 Q4 number of non- 1) RH Matrix, 2) Women’s Status, M xirta group members in and 3) the questionnaire. The team both Nellur and found the field-testing to be invalu- G or up Capa ytic Q6 Yelenavadgi. In able as it helped familiarize the We htla Khanapur, the team with the methods and also Q ,5 Q4 Q5 Q5 Ran nik g4 questionnaire was allowed an estimation of time S -iS Men ni RH Q7 administered to required for the different exercises. the wives of S -IS Women Q3 members of the ni Ag agriculture group E. Field Work Wome s'n Q4 Q4 Q4 (17) and other utatS s The evaluation field work took place RH Cou elp over an eight-day period from April Q ,1 Q ,3 Q4 Q3 Q ,1 Q ,3 Q4 utatS s 30 to May 8, 2001. The following table describes the dates, villages, 3 RH Matrix and Women’s Status exercises were adapted from Denise Caudill, “We Tried participatory exercises, survey to Measure Ourselves and Find We Have Progressed!”, 1998, WN, BBFW and FPAN. work, and additional interviews 4 Wealth ranking was not used for the entire village to answer question 5. However, the undertaken. team did use wealth ranking as a tool to identify changes in livelihood for women’s group members.

12 - Evaluating an Integrated Reproductive Health Program Evaluation Framework and Methodology Table 5: Field Work Schedule

D iT/eta me alliV ge G or u P/p sre on Ex sicre /e A ytivitc

3 0/0 0/4 1 N rulle Wome s'n G or up Memb sre RH M ,xirta Que oits nn eria Me s'n A cirg erutlu G or ups Focus G or up - S (IS RH) RHW G or up Rec dro Re eiv w

0 0/1 0/5 1 N rulle Wome s'n G or up Memb sre G or up Capa ytic Ev ula oita n Women No -n G or up Memb sre RH M ,xirta Que oits nn eria Key rofnI ma s'tn Wome s'n G or up viL hile ood Ran nik g PHC Ce retn Phy aicis n eivretnI w

0 0/2 0/5 1 N rulle Wome s'n G or up Memb sre Wome s'n utatS ,s Focus G or up - S (IS A )g No -n G or up Memb sre Wome s'n utatS s llA De nifeirb s/g h nira g ses ois n

0 0/3 0/5 1 Y ele navad ig Wome s'n G or up Memb sre RH M ,xirta Que oits nn eria Me s'n A cirg erutlu G or up Focus G or up - S (IS RH) RHW G or up Rec dro Re eiv w

0 0/4 0/5 1 Y ele navad ig No org-n up Memb sre Que oits nn eria Key rofnI ma s'tn Wome s'n G or up viL hile ood Ran nik g A cirg erutlu G or up Lead re eivretnI w

0 0/5 0/5 1 Y ele navad ig Wome s'n G or up G or up Capa ytic Ev ula oita ,n Focus G or up - S (IS A ,)g Wome s'n utatS s No -n G or up Memb sre RH M ,xirta Wome s'n utatS s llA De nifeirb s/g h nira g

0 0/6 0/5 1 ------Re ts day

0 0/7 0/5 1 Khanap ru A cirg erutlu G or up Focus G or up - S (IS RH) W vi es fo A cirg erutlu G or up RH M ,xirta Focus G or up - S (IS A ,)g Que oits nn eria

0 0/7 0/5 1 Y ele navad ig ANM eivretnI w

0 0/8 0/5 1 Khanap ru W vi es fo A cirg erutlu G or up Wome s'n utatS s llA RH siD cus ois n and De nifeirb s/g h nira g

Yelenavadgi Women’s Group: Women’s Status Exercise

Pretesting the questionnaire

Evaluating an Integrated Reproductive Health Program - 13 Evaluation Framework and Methodology F. Data Analysis following topics: 1) reproductive health, 2) women’s Preliminary analysis of the question- status, 3) capacity – naire took place during the evalua- women’s groups and tion. In order to provide timely BSRDS, 4) integration, and feedback to participants, selected 5) savings and credit. The knowledge and practice questions groups summarized the were analyzed for a sub-sample of major findings by topic. On the three villages and presented the second day, the key during feedback sessions in the questions were reviewed and villages. All the questionnaires were answered, and lessons analyzed for the key knowledge and learned and recommen- practice variables and the results dations were identified. Subbanna and Mahadevi, BSRDS, are presented in this report. prepare Data Analysis presentation

A two-day data analysis workshop G. Report Writing was held in Gulbarga with the WN-I team, the BSRDS team, and two of The final phase of the evaluation the RHWs who had participated in was report writing which took place the evaluation. On the first day, the on the last three days of the evalua- group reviewed the notes for each tion period. Below is a calendar of participatory exercise, questionnaire the entire evaluation period. results and interview notes for the

Table 6: Evaluation Calendar: April 25th - May 15, 2001

Sunday Monday Tuesday Wednesday Thu sr day F dir ay S uta dr ay

25 26 27 28 A virr -la alP n nin g niniarT g niniarT g alP n nin g Me nite g niniarT g

29 30 1 2 3 4 5 dleiF Te ts dleiF W kro - dleiF W kro - dleiF W kro - dleiF W kro - dleiF W kro - dleiF W kro - N rulle N rulle N rulle Y ele navad ig Y ele navad ig Y ele navad ig

6 7 8 9 10 11 12 Re ts Day dleiF W -kro dleiF W kro - RHW D ata An yla sis D ata An yla sis Rep tro W nitir g Khanap ru Khanap ru Ev ula oita n W kro shop W kro shop

BSRDS Capa ytic

13 14 15 Rep tro W nitir g De feirb Dep erutra

Rep tro W nitir g

14 - Evaluating an Integrated Reproductive Health Program Evaluation Findings The findings from the evaluation are For each thematic area, the partici- The quotes in each section were presented in summary for five patory exercise is introduced, and in collected during the participatory thematic areas: most cases the findings are pre- exercises. sented in table format which com- A. Women’s Status bines results from both the exer- B. Reproductive Health cises and the survey work for Nellur, C. Capacity-Women’s Groups Yelenavadgi (RH group villages) and and BSRDS Khanapur (comparison village). D. Integration E. Livelihood-Savings and Credit

Participatory Exercise 1: Women’s Status*

Objectives: 1. To identify indicators of women’s status as identified by women 2. To compare women’s status indicators before and after three years of group formation 3. To identify the factors to which women attribute the changes

Steps: • Define the objective of the exercise • Ask the participants to list the indicators for women’s status by discussing among themselves • Ask the participants to prioritize five important indicators from the those identified by using beans • Ask the participants to identify the changes which occurred over a period of three years in each of these indicators as improved, remain the same, or getting worse • Ask the participants to attribute the changes: are they due to group activities, external factors, or both? • Sum up the exercise and share the results with the participants

Materials needed: Cards to list indicators; markers; tape; wall or board to post and prioritize indicators; matrix to list and attribute improvements; beans or stones

sI sue Imp or veme stn birtta etu d :ot

G or up O ht re B hto

* adapted from Denise Caudill, “We Tried to Measure Ourselves and Find We Have Progressed!”, 1998, WN, BBFW and FPAN.

Evaluating an Integrated Reproductive Health Program - 15 Evaluation Findings: Women’s Status A. Women’s Status Nellur and Yelenavadgi have more decision making skills than women Participatory exercises on women’s in Khanapur (where only 28% of status were carried out with wives of agriculture group members “This exercise on women’s status women’s group members and non- and 24% of wives of non-agriculture helped us to know where we are group members in Nellur and group members felt they had and how to continue to increase Yelenavadgi, and with the wives of decision making skills). our status.” Subadra, Yelenavadgi the agriculture group members in Women’s Group Khanapur. Participants identified Property ownership was another and discussed issues they felt were area in which improvements were “We lived a life of animals without related to women’s status. While cited as a result of group activities understanding what women’s several issues seemed to be in Nellur and Yelenavadgi. This is status was, until we formed our context-specific, many similar difficult to verify with the question- group.” Indubai, Yelenavadgi issues were identified across naire data. While the questionnaire Women’s Group groups. These included decision- data showed land ownership to be making, property ownership, partici- higher in the intervention villages “I do not know exactly how much I pation in politics, girl child educa- among non-group members, land benefited from the honorarium, but tion, family planning, reproductive ownership by women is minimal in being a group leader, certainly my health, dowry, right to divorce, both intervention villages and non- position is elevated in society”, violence against women, child existent in Khanapur. The lack of a Bimbai, group leader, Nellur marriage, women’s mobility, and clear baseline and the complexity of Women’s Group. widow remarriage. The groups then the issues of land ownership make prioritized their lists. Results are interpretation difficult. “We had a saying here—whatever presented in Table 7 (pages 16-17); the daughter eats becomes mud issues that were identified but not Women in all three villages cited and whatever the son eats be- prioritized are also indicated. The participation in politics and girl child comes gold.” Yelenavadgi information is complemented with education as important issues. In Women’s Group Member the results of the survey for selected Yelenavadgi and Nellur, these two indicators. were seen to be improving. However, “We are not educated and we were the groups disagreed with regard to afraid to talk to you. If we don’t The groups examined the eight reasons for their improvement. send our daughters to school, they priority issues in more detail and While in Yelenavadgi, group mem- will also be afraid, like us.” Non- determined whether there was bers said the improvement was due group member, Yelenavadgi improvement, no change, or deterio- to the work of the group, the Nellur ration. Those issues that had group members said that women’s “In past years, we would put a bindi improved were re-grouped to identify participation in politics in their on the stomach of a pregnant the reasons for the changes and village was improving due to efforts woman to indicate that the baby, if whether they were attributable to of the government. For girl child a girl, was already promised in group activities, other factors or education, the Nellur non-group marriage.” Member, Nellur both. The results from this step are members said that the situation was Women’s Group. presented in Table 8 (page 18). improving because of government efforts, but the Nellur group mem- The groups noted improvements in bers attributed the decision making attributable to improvement to the group activities in Nellur and Yelena- efforts of the group. vadgi. This is supported by the questionnaire results that indicated All of the five groups in group members have the most the three villages decision making abilities (84% and identified family 91%) compared to non-group planning as an issue members (61% and 76%). Both related to women’s Women’s Group Members, Yelenavadgi group and non-group members in status. As discussed

16 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Women’s Status in the next section, women’s group It is interesting to note that both identified the freedom of women to members had higher rates of family groups in Yelenavadgi and those in travel as important and in two of the planning use than did non-group Khanapur identified violence against groups, it was rated among the most members. Women in Khanapur had women as an issue. The survey important issues. In Yelenavadgi, the lowest rates of family planning results demonstrated that group the women’s group members said use. While improvements in family members were more likely to feel the situation had improved as a planning were generally attributed to they could protest against a husband result of the activities of the group activities, the non-group who beats his wife than non-group women’s group. In the comparison members in Yelenavadgi also cited members or women in the compari- village, it was rated as unchanged. government activities as contributing son village. Improvements in the to improvements. area of violence against women were While the questionnaire showed attributed to the group activities. clear differences in the ability of Similarly, reproductive health was women to travel to neighboring also an issue frequently identified by In the intervention villages, “dowry” villages without asking permission, the groups. Improvements in was identified as one of the most it is not clear how much this indica- reproductive health were attributed important issues by all four groups. tor is influenced by economic exclusively to the group, with the However, none of the groups felt that status. According to staff, for poorer exception of the Nellur non-group there had been positive changes in women mobility is less of an issue, members who also attributed the area of dowry and all four felt since they are often forced to travel improvements to government that the situation was getting worse. to neighboring villages for work. The activities. In Khanapur, reproduc- usefulness of this indicator is not tive health was not identified as an Finally, the issue of women’s clear in the program context and will indicator for women’s status. mobility presents an interesting need to be reviewed. case. All groups in the three villages

Evaluating an Integrated Reproductive Health Program - 17 Evaluation Findings: Women’s Status Table 7: Women’s Status Results:

N ulle r

sI su ni/e cid srota Ran nik gs by imp atro nce 5 Que oits nn eria Res stlu 6

G or up No org-n up G or up No org-n up (N=5 )4 (N=4 )3

De oisic n ma nik g 3 6 36 8( 4%) 33 6( 1%)

P or p ytre own sre pih 7 4 1 5 1( 2%) 11 2( 0%)

P picitra oita n ni p citilo s 7 * 33 7( 7%) 9 1( 7%)

G lri c dlih educ oita n 8 2 -- --

Fam yli alp n nin g8 9 3 28 7( 8%) 37 7( 4%) N=36 N=50

Re orp du vitc e he htla 1 4 -- --

Dow a-yr w era ness 10 8 -- --

viD cro e 2 * -- --

eloiV nce Ag nia ts Women9 -- -- 33 7( 7%) 14 2( 6%)

C dlih m airra ge 5 7 -- --

Mo ytilib * * 41 9( 5%) 31 5( 7%)

Fam yli zis e 6 5 -- --

Pu cilb etorp sts -- -- 35 8( 1%) 14 2( 6%)

5 These results refer to issues identified as important women’s issues and their ranking by importance. Women ranked the top eight issues. Issues with an asterisk (*) were identified as an issue, but not prioritized in the top eight issues. Since different issues were identified by different groups, more than eight priority issues were named. 6Questionnaire results refer to the number and percentage of women responding positively that they did this activity or had this right. 7For the questionnaire - women’s ownership of land 8For the questionnaire - use of family planning; only responses from eligible couples are included. For this indicator only, N=36 for group members in Nellur, 50 non-group members; 42 for group members in Yelenavadgi, 46 for non-group members; 15 group members in Khanapur, 21 non-group members 9For the questionnaire - willingness to protest against spousal abuse

18 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Women’s Status

YelenavadgiY ele navad ig KhaKhanapurnap ru

sI sue /s Ran nik gs by Que oits nn eria Res stlu 6 Ran nik gs by Que oits nn eria Res stlu 6 nI cid srota imp atro nce 5 imp atro nce 5

G or up No org-n up G or up No org-n up W efi s fo Ag G or up No org-n up N=43 N=46 G or up N=17 N=23

De oisic n 1 1 39 9( 1%) 35 7( 6%) 5 5 2( 8%) 6 2( 4%) ma nik g

P or p ytre 8 * 3 7( %) 5 1( 1%) 8 0 0 own sre pih 7

P picitra oita n ni * 7 27 6( 3%) 10 2( 2%) * 4 2( 2%) 1 4( %) p citilo s

G lri c dlih 4 3 -- -- 7 -- -- educ oita n

Fam yli 2 5 37 8( 8%) 36 7( 8%) 1 8 5( 3%) 10 4( 8%) alP n nin g8 N=42 N=46 N=15 N=21

Re orp du vitc e 5 6 ------he htla

Dow yr 6 2 -- -- * -- -- aw era ness

viD cro e * * -- -- 3 -- --

eloiV nce 7 8 37 8( 6%) 7 1( 5%) 4 2 1( 1%) 0 ag nia ts women9

C dlih m airra ge -- 4 ------

Mo ytilib 3 -- 40 9( 3%) 25 5( 4%) 6 5 2( 8%) 7 2( 8%)

Fam yli zis e -- * ------

Pu cilb etorp sts -- -- 30 7( 0%) 17 3( 7%) -- 2 1( 1%) 1 4( %)

Evaluating an Integrated Reproductive Health Program - 19 Evaluation Findings: Women’s Status Women’s Status Observations: had improved and the improvements group members in the areas of were primarily due to group activi- decision-making, participation in Women in the three villages identi- ties. However, women said that girl politics, family planning use, and fied similar sets of issues related to child education and participation in protesting against spousal abuse. women’s status. These included politics improved because of group decision-making, property owner- activities as well as the efforts of Dowry was also identified as an ship, participation in politics, girl- the government. issue in Nellur and Yelenavadgi. The child education, family planning, groups all said that the problem of reproductive health, divorce, and The questionnaire data allowed dowry was worsening, not getting violence against women. triangulation of information and better. illustrated positive differences for With regard to many of these issues, women said the situation

Table 8: Reasons Cited by Women’s Groups for Improvements10

sI sue Imp or veme stn birtta etu d ot

G or up O ht re B hto

Wome s'n N rulle G or up Memb sre N rulle No -n G or up Memb sre 1 er orp du vitc e he htla Y ele navad ig G or up Memb sre Y ele navad ig No -n G or up Memb sre

C dlih m airra ge N rulle G or up Memb sre N rulle No -n G or up Memb sre 2 Y ele navad ig No -n G or up Memb sre

De oisic n ma nik g N rulle G or up Memb sre N rulle No -n G or up Memb sre 3 Y ele navad ig G or up Memb sre Y ele navad ig No -n G or up Memb sre

P or p ytre own sre pih N rulle G or up Memb sre 4 N rulle No -n G or up Memb sre Y ele navad ig G or up Memb sre

5 Fam yli zis e N rulle No -n G or up Memb sre N rulle G or up Memb sre

viD cro e N rulle G or up Memb sre 6 Y ele navad ig G or up Memb sre

P picitra oita n ni Y ele navad ig No -n G or up Memb sre N rulle G or up Memb sre 7 p citilo s

G lri c dlih educ oita n N rulle G or up Memb sre N rulle No -n G or up 8 Y ele navad ig G or up Memb sre Memb sre

Fam yli alp n nin g N rulle G or up Memb sre Y ele navad ig No -n G or up Memb sre 9 acce atp nce N rulle No -n G or up Memb sre Y ele navad ig G or up Memb sre

eloiV nce ag nia ts N rulle G or up Memb sre 10 women Y ele navad ig G or up Memb sre Y ele nvad ig No -n G or up Memb sre

10 Only the issues that were identified as positively changed are included here. In Khanapur, the comparison village, none of the issues identified were rated as improved, so there are no ratings from that group in the table. Also note that not all groups prioritized the same issues, so all issues were not rated by all groups.

20 - Evaluating an Integrated Reproductive Health Program Evaluation Tool: Reproductive Health

Participatory Exercise 2: RH Historical Matrix*

Objectives: 1. To identify key RH issues 2. To identify and analyze changes over time 3. To identify the factors to which women attribute the changes

Steps: • Explain the objectives of the exercise. • With the group, list a few important RH issues and write them on cards (age at marriage, family size, etc.). • Discuss with the people and identify RH issues. In case the participants fail to identify or delay, then complement with the list already prepared (see list below). Discuss each issue with the participants and then decide if it is important. • Discuss and specify the changes in RH issues before and after three years of group formation, for example:

RH issue Before group formation Three years after group formation

Family Planning Only knew about tubectomy Know about many methods

• Classify the changes occurring after three years of group formation as improved, remains same, or getting worse. • Discuss with the participants and decide reasons for changes and attribute them as due to group activities or external factors or both. • Analyze the reasons for changes and document them. • Repeat these steps for each of the identified issues. • Summarize the results at the end of exercise and share with the participants.

Materials needed: Cards to list key RH issues; markers; tape; matrix (above) to identify status of issue before group formation and three years after group formation; an additional matrix like the one used in Exercise 1 to list and attribute improvements.

Initial list of important RH issues: The following issues were identified to use in the field 1. Use of family planning methods 2. ANC/PNC care 3. Safe delivery practices 4. Awareness regarding reproductive tract infections 5. Alcoholism/Gambling 6. Access to government services with particular reference to ANM services

* adapted from Caudill, Denise, “We Tried to Measure Ourselves and Find We have Progressed!”, 1998, WN, BBFW and FPAN.

Evaluating an Integrated Reproductive Health Program - 21 Evaluation Findings: Reproductive Health B. Reproductive Health 3.The women’s group and non-group members in Nellur and Yelenavadgi The Reproductive Health Historical said that access to auxiliary nurse “My own and my husband’s Matrix participatory exercise was midwife services was improved. ignorance made us to have more conducted with women’s group and Most of the participants attributed children, but I will not allow my non-group members in Nellur and the change to group activities, while daughters to repeat this.” Yelenavadgi, as well as with wives the non-group members of Nellur Puttamma, Yelenavadgi Women’s of agriculture group members in said both the group and others Group. Khanapur. The women identified the (anganwadi11 worker, PHC center) key issues with regard to reproduc- were responsible for the change. The “Until this day, we use a sickle or tive health, what the situation was two women’s groups also pointed out a stone to cut the umbilical cord. three years ago, and what the their increased knowledge about the We put our hair in our mouths to situation is now. The results of these services that the ANM is to provide. ease the expulsion of the pla- participatory exercises, along with They said that the use of the “health centa.” Women in Khanapur the results of the questionnaire, are services map” or a guide listing summarized in Table 9. Key findings services, costs, and hours of “Before the gyne camps, we never from Table 9 are summarized as availability had been useful as a knew that uterine prolapse and follows: means to monitor ANM services and STIs were curable”, Group Mem- encourage referrals as necessary ber, Nellur Women’s Group. 1.The use of antenatal care (two (see Appendix C). ANC visits or more) for group and “Early on in the group formation, non-group members is higher in 4.The awareness regarding family we didn’t have any knowledge Nellur (100% to 70%) and Yelena- planning methods was generally high about RH, but now we have the vadgi (88% to 100%) when com- in group members of Nellur and knowledge and discuss these pared to Khanapur (57% to 46%). Yelenavadgi while in non-group issues with our husbands.” Group However, PNC did not show the members the awareness was also Member, Nellur Women’s Group. same pattern. high but not as high as that of group members. In the comparison village, “Most importantly, earlier we did 2.Awareness regarding sexually Khanapur, the family planning not talk about RH issues with our transmitted diseases and AIDS is awareness was low in general, group members, now we discuss also higher for group and non-group except for tubectomies. them in our group and with other members in Neller and Yelenavadgi. people in the village as well.” From the questionnaire we see that The adoption rate of family planning Group Member, Yelenavadgi 100% to 89% of the women in Nellur methods in Nellur and Yelenavadgi Women’s Group and 100% to 83% in Yelenavadagi were high in group members and have heard about AIDS, when also in non-group members. In “Before the formation of the group, compared to Khanapur where 78% Khanapur the adoption rate was we had not heard about ANM to 40% have heard about AIDS. much below that of the adoption services and her job responsibili- Those who have heard about STD’s rates in Nellur and Yelenavadgi. ties. Now we demand services in Nellur are 100% to 79%, in Tubectomy is the most popular from the ANM. All together, we Yelenavadgi 100% to 85% and in family planning method followed by have written a letter to a higher Khanapur 72% to 48%. In general pills and condoms. It is of note that local authority, and we got the there is improved awareness about in Khanapur, tubectomy is almost ANM to visit our village regularly. transmission and prevention as- the exclusive method of family Now women participate in social pects of AIDS and knowledge of planning. issues, too.” Group Member, symptoms in Nellur and Yelenavadgi Yelenavadgi Women’s Group While baseline data is not available villages when compared to Kha- for all women in the program vil- napur. “The ANM doesn’t come here. We lages, the team did examine records have no one to discuss these from the gynecology camps that problems with.” Men’s agriculture 11 The anganwadi is the village worker of the Department of Women and Child group, Khanapur Development whose duties include providing pre-natal education, assisting in supplying contraceptives, and bringing awareness about Family Planning.

22 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Reproductive Health recorded users of family planning. support from gyne camp and trained In both villages, women were In 1998 for the group in Nellur there TBAs. unanimous in attributing the were two family planning users; in progress to group activities. Kha- the group in Yelenavadgi in 1998 In Nellur, 72% of non-group mem- napur didn’t have access to these there were three users. During the bers and 64% of group members services. last gyne camps held in January interviewed reported using trained 2001, in the Nellur group there were TBA services and from 100% to In a sub-sample of women who had 14 (93% of group members) family 91% reported using services of the births in the past three years, there planning users and in the Yelena- gyne camp. In Yelenavadgi, 91% of was a clear pattern of use of trained vadgi group there were 13 (86% of group members reported using TBA TBA services and trained medical group members) women who were services compared to 87% of non- assistance. Women in Khanapur family planning users. group members. One hundred were more likely to be assisted by percent of the group members used untrained TBAs or family and 5.The adoption of safe delivery the gyne camp services compared friends. practices was impressive in Nellur to 93% of the non-group members. and Yelenavadagi because of the Table 9, on the following pages, gives complete results of the reproductive health findings.

Evaluating an Integrated Reproductive Health Program - 23 Evaluation Findings: Reproductive Health Table 9: Reproductive Health Results

RH sI sues Res stlu N ulle r Res stlu Y ele navad ig

RH M xirta and Qdue oits nn eria RH M xirta an Que oits nn eria D si cus ois ns D si cus ois ns

ANC P/ NC S civre es

G or up memb sre B erofe : P er gna tn ANC- m ero ht an two stisiv - B erofe : P er gna tn ANC- m ero ht an two stisiv women did t'n go ot 100% women did t'n go ot 88% do A/rotc NM and w ere do A/rotc NM. diD t'n n atto nik g TT PNC- m ero ht an two stisiv - at ke TT ejni oitc n ori,s n PNC-m ero ht an two stisiv ejni oitc n ori,s n at stelb 100% at stelb ro n oitirtu us 82% ro n oitirtu us of o .d of od .s Now I: m orp ved due ot Now I: m orp ved due ot ht e org up org up a eitivitc s

No org-n up B erofe : P er gna tn ANC - m ero ht an two stisiv B erofe : Women did t'n ANC -m ero ht an two -stisiv memb sre women did t'n use - 70% use ANC P/ NC 100% do A/rotc NM, T -T s civre e .s ejni oitc n ori,s n at stelb PNC - m ero ht an two stisiv Now I: m orp ved due ot PNC- m ero ht an two stisiv ro n oitirtu us of o .d - 52% org up a eitivitc .s 53% Now I: m orp ved due ht e org u .p

Aw era ness er g nidra g RH etaler d sid eases

G or up memb sre B erofe : Peo elp used ot Know abo tu IA DS 1- 00% B erofe : Many peo elp Know abo tu IA DS 1- 00% s orfreffu m ht ese Means artfo nsm si ois :n used ot s orfreffu m Means fo s erp a nid g sid eases and ylerar Due ot sexu cretnila o sru e - ht ese sid eases and Due ot sexu cretnila o sru e - we ottn ht e do rofrotc 100% did t'n go ot ht e do rotc 100% ert ta me .tn ertrof ta me .tn IA DS erp ve oitn :n Now I: m orp ved due ot P er ve oitn :n Use fo condoms 1- 00% org up Use fo condoms 9- 8%, Now I: m orp ved due ot Sex htiw one p ntra 1-re 00% Sex htiw one p ntra 9-re 8% org up and hto .sre Do n to know - 0% Do n to know 2- % Know abo tu S sIT 1- 00% Know abo tu S sIT 1- 00%

No org-n up B erofe did t'n know Know abo tu IA DS 8- 9% B erofe ht ey had no He dra abo tu IA DS 8- 3% memb sre abo tu sym otp m ,s Means artfo nsm si ois :n kno elw dge abo tu RH Means artfo nsm si ois :n erp ve oitn n ro Due ot sexu cretnila o sru e - sid ease .s We ht oug th Due ot sexu cretnila o sru e - ert ta me .tn 71% w etih sid ch gra e was 72% common and did t'n Im orp ved due ot org u .p siD ease co :lortn con dis ottire be a siD ease co :lortn Condoms 6- 0% sid eas .e Condoms 6- 3% Sex htiw o yln one p ntra -re Sex htiw o yln one p ntra -re 54% Now im orp ved due ot 56% Do n to know - 23% ht e org u .p Do n to know - 9%

Know abo tu S sIT 7- 9% Know abo tu S sIT 8- 5%

24 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Reproductive Health Table 9: Reproductive Health Results, continued

RH sI sues Res stlu Khanapur

RH M xirta and Que oits nn eria D si cus ois ns

ANC P/ NC S civre es

G or up memb sre B :erofe S civre es era n to av alia .elb ANM W vi es fo Ag G or up Memb sre does t'n tisiv and ht ere si no niart ed TB .A ANC- m ero ht an two stisiv 57% We have no kno elw dge fo TT and ori n at .stelb PNC-m ero ht an two stisiv 43% Now: same utis oita n e .stsix

No org-n up memb sre W vi es fo No org-n up memb sre ANC -m ero ht an two stisiv 4- 6%

PNC-m ero ht an two -stisiv 62%

Aw era ness er g nidra g RH etaler d sid eases

G or up memb sre B erofe : F htro e co lortn fo w etih W vi es fo Ag G or up memb :sre sid ch gra ,e used el aves fo aca ais Know abo tu IA DS 7- 8% cira rofilu m si was vig en ro mango ots nes Means artfo nsm si ois :n eirf d ni ghee and e eta n erhtrof e day .s Due ot sexu cretnila o sru e 7- 8% We have elttil kno elw dge abo tu S ,sIT b tu because fo pov ,ytre we do att'n ke diA s erp ve oitn :n Use fo condoms 5- 6%, me cid ertla ta me .tn Sex htiw one p ntra 5-re 6% Do n to know - 0% Now: Same con oitid n e .stsix Know abo tu S sIT - 72%

No org-n up memb sre W vi es fo No -n G or up Memb sre Know abo tu IA DS 4- 0% Means artfo nsm si ois :n Due ot sexu cretnila o sru e - 40%

siD ease co :lortn Condoms 2- 4% Sex htiw o yln one p ntra 2-re 4% Do n to know - 8%

Know abo tu S sIT 4- 8%

Evaluating an Integrated Reproductive Health Program - 25 Evaluation Findings: Reproductive Health Table 9: Reproductive Health Results, continued

RH sI sues Res stlu N ulle r Res stlu Y ele navad ig

RH M xirta and Qdue oits nn eria RH M xirta an Que oits nn eria D si cus ois ns D si cus ois ns

Use fo ANM S civre es

G or up memb sre B erofe : La kc fo ______B erofe : La kc fo ______kno elw dge abo tu kno elw dge abo tu ANM s' d eitu ,s ANM ANM s' d eitu .s ANM did t'n tisiv did t'n .tisiv Now I: m orp ved due ot Now I: m orp ved due ot org up a ytivitc org u .p

No org-n up B erofe : La kc fo B :erofe ANM ylerar memb sre kno elw dge abo tu etisiv -d o yln rof spe laic ANM s' d eitu .s ANM ______orp arg ms kil e p oilo ______n to nitisiv g er g ylralu immu zin oita .n and orp div e s civre e .s Now I: m orp ved due ot Now: Im orp ved due ot org up a eitivitc .s org up and gov nre me tn (Aganwa ,id PH ,C ANM)

Acce atp nce fo Fam yli alP nnng

G or up B erofe : La kc fo M hte od - Use etar B erofe : La kc fo M hte od - Use etar memb sre kno elw dge abo tu Vase otc my - 3% kno elw dge abo tu Vase otc my - 0% af m yli alp n nin g Tube otc my - 22% af m yli alp n nin g Tube otc my - 57% m hte ods and ht rie us .e O lar sllip - 11% m hte ods and ht rie us .e O lar sllip - 10% Peo elp had many IUD - 8% Now I: m orp ved due ot IUD - 12% c erdlih .n Condoms - 14% org u .p Condoms - 2% Now I: m orp ved due ot La orp sopy - 17% La orp sopy - 7% org up a eitivitc .s O ht -re 3% Co artn ce vitp e Us :e 88% Co artn ce vitp e Us :e 78%

No g-n or up B erofe : La kc fo M hte od - Use etar B erofe : We w ere n to M hte od - Use memb sre kno elw dge abo tu Vase otc my - 2% u nis g af m yli alp n nin .g Vase otc my - 0% af m yli alp n nin g Tube otc my - 34% Now I: m orp ved due ot Tube otc my - 37% m hte ods and ht rie us .e O lar sllip - 12% org up and gov nre me tn O lar sllip - 11% Now I: m orp ved due ot IUD - 6% orp arg ms a( ganwa ,id IUD - 9% org up a eitivitc s Condoms - 10% PHC ce )retn Condoms - 6% La orp sopy - 10% La orp sopy 1- 3% Co artn ce vitp e Us :e 74% Ab nits ence - 2% Co artn ce vitp e Us :e 78%

S efa D vile yre M hte ods

G or up B erofe : D vile yre was Use niartfo ed TBAs 7- 2% B erofe : D vile yre was Use niartfo ed TBAs 9- 1% memb sre sir k ,y absence fo Use fo gyn c-e amp 1-s 00% uns .efa Absence fo Use fo gyn c-e amp 1-s 00% niart ed TBA ,s htriB s ni pa ts 3 ye sra :)9( niart ed TBAs and htriB s ni pa ts 3 ye sra 1( :)7 unhy eig cin con oitid ns niarT ed TBA 3 3( 3%) unhy eig cin con oitid n .s niarT ed TBA 10(59%)5( 3%) Now: Im orp ved due ot He htla W kro re 0 Now: Im orp ved due ot He htla w kro re 1 (6%)7( %) org up Do rotc 4 4( 5%) org u .p Do rotc 5 (29%)3( 3%) U niartn ed TBA 1 1( 1%) U niartn ed TBA 0 Fam eirF/yli nd 1 1( 1%) Fam eirF/yli nd 1 (6%)7( %)

No g-n or up B erofe : D vile yre was Use niartfo ed TBAs 6- 4% B erofe : We used Use niartfo ed TBAs 8- 7% memb sre sir k ,y no niart ed TBA ,s Use fo gyn c-e amp 9-s 1% art oitid n la m hte od -s Use fo gyn c-e amp 9-s 1% unhy eig cin con oitid n ,s htriB s ni pa ts 3 ye sra 2( :)3 unhy eig cin con oitid n ,s htriB s ni pa ts 3 ye sra 1( :)9 no imme etaid erb a -ts niarT ed TBA 12 5( 2%) c tu c dro htiw ots n .e niarT ed TBA 7 3( 7%) ef e nid .g He htla w kro re 0 Now I: m orp ved due ot He htla w kro re 6 3( 2%) Now I: m orp ved due ot Do rotc 5 2( 2%) org up a eitivitc .s Do rotc 3 1( 6%) org up and gov nre me tn U niartn ed TBA 5 2( 2%) U niartn ed TBA 0 stroffe Fam eirF/yli nd 4(1 %) Fam eirF/yli nd 3 1( 6%)

26 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Reproductive Health Table 9: Reproductive Health Results, continued

RH sI sues Res stlu Khanapur

RH M xirta and D si cus ois ns Que oits nn ria e

Use fo ANM S civre es

W vi es fo ag cir utlu er g or up B erofe : S civre es era n to av alia .elb ANM ______memb sre does t'n tisiv and ht ere si no niart ed TB .A Now: utiS oita n si ht e sam .e

W vi es fo no g-n or up memb sre

Acce atp nce fo Fam yli alP nnng

W vi es fo ag cir utlu er g or up N dito e eifitn d as an si sue W vi es fo A rg G or up Memb re s memb sre M hte od - Use etar Vase otc my - 0% Tube otc my - 53% O lar sllip - 0% IUD - 0% Condoms - 0% La orp sopy - 0% Co artn ce vitp eUs :e 53%

W vi es fo No org-n up Memb sre W vi es fo no g-n or up memb sre M hte od - Use etar Vase otc my - 0% Tube otc my - 43% O lar sllip - 0% IUD - 0% Condoms - 5% La orp sopy - 0% Co artn ce vitp e Us 4:e 8%

S efa D vile yre M hte ods

W vi es fo ag cir utlu er g or up B erofe : C ur de and unhy eig cin d vile eire s Th ere era no niart ed TBAs ni ht e alliv g .e memb sre e etsix .d Sup oititsre n kil e p nittu g h niria Gyne camps era n to h .dle mo htu ot af etatilic exp oislu n fo alp ce .atn Newb nro s era erb a efts d o yln erhtretfa e W vi es fo Ag G or up Memb sre day .s The um cilib la c dro si c tu htiw a htriB s ni pa ts 3 ye sra :)7( .elkcis niarT ed TBA 0 Now: No change ni con oitid .n He htla w kro re 0 Do rotc 0 U niartn ed TBA 3 4( 3%) Fam eirF/yli nd 4 5( 7%)

W vi es fo No org-n up memb sre htriB s ni pa ts 3 ye sra 1( )3 W vi es fo no g-n or up memb sre niarT ed TBA 0 He htla w kro re 0 Do rotc 2 1( 5%) U niartn ed TBA 8 6( 2%) Fam eirF/yli nd 3 2( 3%)

Evaluating an Integrated Reproductive Health Program - 27 Evaluation Findings: Reproductive Health Reproductive Health non-group members were higher surpass the rates for rural Karna- Observations: than those of women in the compari- taka. son village of Khanapur. There have been substantial It is also noteworthy that women improvements in use of reproductive For family planning use, it is of note consistently identified “social health services as noted by both the that the contraceptive use rates in issues,” such as alcoholism and participatory exercise and the Khanapur for the wives of the gambling, within the range of survey findings. Women in the agriculture group members and the reproductive health issues. The groups, as well as non-group wives of non-members (53%-48%), broad definition of reproductive members, were using ANM, trained resembled those for rural Karnataka health has been consistently used in TBA, and gyne camp services. (56.6%, National Family Health program activities and is reflected in Group members had higher levels of Survey, 1998-1999). The rates these issues. Women also noted a knowledge regarding family planning observed among group and non- change in superstition or fatalism— methods, AIDS and STIs than non- group members in Nellur (78%-74%) that is, a willingness to take action group members. However, even the and Yelenavadgi (88%-78%) greatly to resolve problems. knowledge and practice levels of

28 - Evaluating an Integrated Reproductive Health Program Evaluation Tool: Group/Organizational Capacity

Participatory Exercise 3: Capacity Evaluation

Objectives: 1. To understand priority capacities as identified by the group members 2. To analyze strengths and weaknesses of the group 3. To generate results that will be used in future exercises with the group

Keep in Mind: • Make sure all group members are present • Spend some time with group members to build rapport • Try to ensure that small children will not enter and disturb the process • Solicit each member’s participation • Three people are needed for each exercise: one to facilitate, one to document, and one to observe • Prepare for the exercise by having all things ready with the facilitation team.

Steps: • Ask the group members to first list the indicators for group capacity • Write down the indicators on separate cards • Ask the participants to prioritize the listed indicators taking care to include the important ones • Introduce the scale of 1-5 (paise) to the participants • Ask them to score for each capacity identified • Identify the weak points and plan to address areas of weakness in the future • Sum up the exercise and share with the participants the overall results

Materials needed: Cards to list indicators; markers; tape; wall or board to post cards

C. Capacity The cost of the reproductive health Nellur: In this village 14 of the 15 component was also examined. group members attended the exercise. On the basis of their In this section, the capacity of the discussion, members were asked women’s groups and the capacity Rating of Women’s Groups list indicators to measure the group’s development of BSRDS in reproduc- by Group Members capacity. tive health were examined. The women’s groups identified and rated In Nellur and Yelenavadgi, capacity Initially they listed ten capacities: 1) their own capacities. The BSRDS evaluation exercises were con- Savings and Credit, 2) Group Reproductive Health Worker also ducted with the group members. In Records, 3) Knowledge related to rated the capacities of the two these exercises, group members group activities, 4) Access to groups and the ratings were com- were asked to list, then prioritize, government services, 5) Unity and pared. key capacities for the group. They cooperation, 6) Second line leader- then individually ranked themselves ship, 7) Leadership, 8) Loan repay- In addition, BSRDS staff identified on how well they felt the group’s ment, 9) Attendance at meetings, and rated their organizational capacity had developed. The results and 10) Sustainability. capacities. They identified advan- for the women’s groups in Nellur and tages and disadvantages of the Yelenavadgi follow.12 integration of reproductive health.

12The evaluation team assumed that the initial capacity of the groups was zero, since they did not exist prior to the establishment of the RH component. However, it would have been ideal to have a baseline self-assessment in order to compare change over time.

Evaluating an Integrated Reproductive Health Program - 29 Evaluation Findings: Group and Organizational Capacity They prioritized capacity indicators Table 10: Group Capacity Rating by Nellur Women’s Group and chose seven on which to rate themselves. They used a five-point scale of 10 to 100 paise to rate their nI cid ota r 10 25 50 75 100 capacity. The results are presented in Table 10. .1 U ytin and coop oitare n 64% )9( 35% )5( Yelenavadgi: Twelve of the 15 group members were present at the .2 Second nil e 71% 1( )0 28% )4( time of the exercise. From their el ad sre pih discussion, they listed 14 capacities. After listing the capacity indicators on cards, all participants .3 Respon ytilibis 57% )8( 43% )6( prioritized and selected five priority indicators by using tamarind seeds. The results are shown in Table 11. .4 G or up Rec dro s 50% )7( 50% )7(

When asked why members rated .5 Kno elw dge ni org up 35% )5( 64% )7( themselves so high, they said that a eitivitc s they have a lot of awareness through different types of trainings organized by WN and BSRDS. Other .6 Sa niv gs and erc tid 50% )7( 50% )7( comments from the groups included:

.7 Su niats a ytilib 43% )6( 57% )8( Reproductive Health Activities Women said that with the help of the RH program in the village, everyone has come to know issues related to RH. They said that after integrating Table 11: Group Capacity Rating by Yelenavadgi Group this program, most of the couples (group members) use family planning methods. nI cid ota r 10 25 50 75 100 Savings and Credit After forming the group, participants say they have come to know from .1 Loan er payme tn 100% 1( )2 their small savings that they can achieve anything. According to .2 Access ot 17% )2( 83% 1( )0 group members a remarkable gov nre me tn s civre es change has been their liberation from moneylenders. Many participants say they have become free .3 U ytin and coop oitare n 17% )2( 83% 1( )0 from moneylenders where earlier they borrowed from them exten- sively. .4 Sa niv gs and erc tid 100% 1( )2

Group Sustainability .5 Kno elw dge ni org up 8% )1( 92% 1( )1 The groups said that even without a eitivitc s external support (BSRDS), they would carry on their activities. In Nellur, the women’s group said

30 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Group and Organizational Capacity they would be able to hold gyne Yelenavadgi group. This was be- “As group members we are closer camps, send TBAs for training, give cause of trainings and awareness than sisters and share our happi- the group leader a small honorarium, campaigns. She felt that through ness and sorrow.” Chandamma, and from their initial savings, group gyne camps and other activities, the Yelenavadgi Women’s Group. members would bear the cost of the group has come to know what their doctor’s honorarium, transportation, responsibilities are and the responsi- “The group has made us realize and incidentals. “Our group is bility of others as well. Overall, she that we too have a voice.” Group strong.” said she felt that Yelenavadgi was Members of Yelenavadgi regarding the stronger group because of the having succeeded in getting the Women’s group members in Yelena- responsibility for activities that they services of the ANM in their village. vadgi also felt that they could have taken on. continue many of their activities “This capacity exercise helped us without the support of BSRDS. They to know more about our weak- would conduct gyne camps with Rating of NGO Capacity nesses and strengthen them.” individual savings and interest on Group Member, Nellur Women’s loans earned. In addition, they could BSRDS also rated its capacities Group. use their assets, like spraying pump with regard to where they are now, and seed cum fertilizer drill, to earn and where they were three years Now the family as a whole is ad- income. ago. Participating in this exercise dressed and even the agriculture were Subbanna Biradar, BSRDS information and practices are more Director, and other BSRDS staff, widely shared.” Rating of Group Capacities including Mallikarjun Biradar, by RHW Mallikarjun Kavalagi, and Mahadevi Planning: The BSRDS team cited Kavalagi. multiple trainings as a reason for The team also asked the BSRDS their improvement here. The RHW (Mahadevi Kavalagi) for her Vision: Subbanna described how trainings were conducted by World evaluation of Nellur and Yelenavadgi the vision of the BSRDS has Neighbors and other agencies as group capacities. She gave ratings developed into integrated program- well. very similar to those of the groups ming: (Tables 12 and 13). According the Implementation: Similarly WN-I, as RHW, knowledge about group “Before the RH component”, he said, well as other partners, has provided activities was rated at 100% for the “we worked with only farmers and training to support staff in implemen- their family wasn’t in the picture. tation. Also, staff has become more

Table 12: Reproductive Health Worker Capacity Table 13: Reproductive Health Worker Capacity Rating - Nellur Rating - Yelenavadgi

nI cid ota r 10% 25% 50% 75% 100% nI cid ota r 10% 25% 50% 75% 100%

.1 U ytin and coop oitare n X .1 U ytin and coop oitare n X

.2 Respon ytilibis X .2 Second nil e X el ad sre pih .3 Sa niv gs and erc tid X .3 Respon ytilibis X .4 Loan er payme tn X .4 Rec dro kee nip g X .5 Kno elw dge abo tu X org up a eitivitc s .5 Kno elw dge abo tu X org up a eitivitc s .6 Access ot X gov nre me tn s civre es .6 Sa niv gs and erc tid X

.7 Su niats a ytilib X .7 Su niats a ytilib X

Evaluating an Integrated Reproductive Health Program - 31 Evaluation Findings: Group and Organizational Capacity experienced over time, greatly Table 14: BSRDS Capacity Rating increasing their abilities to implement. Capa ytic 10% 25% 50% 75% 100%

3 ye sra Monitoring and Evaluation: In this oisiV n Now respect, the BSRDS team feels it ago has made a big improvement over 3 ye sra alP n nin g Now the past three years. Before the ago integration of RH, they say they 3 ye sra were weak. But with the WN training Im elp me oitatn n Now in participatory methods, they have ago greatly increased their capacity to 3 ye sra Mo nirotin g and ev ula oita n Now monitor and evaluate their activities. ago They attribute this change to the WN Su niats a /ytilib Reso cru e 3 ye sra training and support. They say other Now organizations haven’t stressed this gen oitare n ago aspect like WN. The training in 3 ye sra Lead sre pih Now participatory methods for RH ago (particularly capacity ranking) was 3 ye sra applied to other program areas as arT nsp era nc nif/y an laic and ag ;o well. adm vitartsini e manageme tn Now

Sustainability/Resource Develop- 3 ye sra S ellik ,d exp eire nced ffats Now ment: Three years ago, BSRDS ago was a young organization and had 3 ye sra less capacity to generate resources. Own sre pih fo orp arg m Now Now they have successfully gener- ago ated resources from the government Co nidro oita n htiw don sro 3 ye sra Now through the Entrepreneur Develop- and hto re agen eic s ago ment Program and the watershed programs. Subbanna says he is only rating it at 50% as it still needs to Skilled, experienced staff: Three Seventy-five BSRDS groups have improve. (Currently, BSRDS has no years ago, not many BSRDS staff gotten loans from banks. other funding sources for RH). had a high level of experience or field exposure. Over the past three The advantages and disadvantages Leadership: BSRDS has helped to years, staff confidence and effec- of integration of reproductive health establish two Federations and two tiveness have been built through were also discussed, as well as BSRDS priorities for its reproductive baby NGOs. Subbanna is recog- trainings and cross-visits, many of health work. nized as an able leader by other them supported by WN. NGOs in the district. In terms of Advantages of Integrating RH into second line leadership, Mallikajun Ownership of program: Over time Program Activities: Biradar attends meetings in staff has been given more responsi- 1) Integrated development- holistic Subbanna’s absence and other staff bility, resulting in a stronger feeling 2) Increased women’s involvement- also fill in. of ownership. They have also developed more trust in the leader- work with both men and women 3) Increased cooperation between Transparency/financial and ship. staff members – ag and RH administrative management: They 4) Agriculture facilitates contact rate this at 100% and say that Coordination with donors and other agencies: BSRDS is recog- with wives of group members BSRDS has from the beginning been nized in the local area as a leader 5) Increased cooperation between transparent. BSRDS does serve as and has linked communities with men and women – gyne camps a model for other NGOs. government services and banks. where men help

32 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Group and Organizational Capacity 6) ANM services are well known in BSRDS Future Priorities for RH BSRDS attributes the changes in the communities now 1) Integrate RH into other monitoring and evaluation to WN 7) Improved relations between men community groups India supported training. and women 2) Facilitate access to 8) Communities solve problems laproscopies rather than Also of note is the capacity that such as water/transportation tubectomies (issue of cost BSRDS has developed in reproduc- 9) Women’s groups share with here). tive health. Three years ago it was men’s groups- they met once 3) Would like to expand to the an organization without experience every two months to share more remote villages. in reproductive health, and now issues/concerns 4) Would like to also cover BSRDS is recognized at the district- 10) It has built staff capacity adolescents level as a resource in the area. through training “BSRDS is 5) BSRDS wants to identify an OB/ Government departments ask for recognized as a resource in GYN to be a resource person Subbanna Biradar’s input (Director RH.” BSRDS) as a resource person. 11) BSRDS has benefited from RH Group and NGO Capacity workshops and sharing with Observations: Although BSRDS staff cited many other NGOs. important advantages of incorporat- 12) The RH component has helped Both women’s groups rated their ing reproductive health into its them achieve their mission of capacities highly. As these are program, they also noted the “socio-economic development of established groups, almost three increased workload. As stated the poorest of poor.” years old, it isn’t surprising. Unity earlier, while agricultural work is and cooperation, savings and credit, seasonal, RH is year-round and Disadvantages of Integrating RH leadership, and knowledge of requires organization and careful into Program Activities activities were give high ratings by follow-up. 1) Initial 3-6 months faced some the groups themselves as well as problems as some members of the RHW who supports them. It is The cost of the RH component was the farmers groups were clear from the groups’ comments also examined. The annual budget opposed to sending their wives they have made substantial for the RH component for BSRDS to meetings. progress in these group capacities— and the percentage of the annual 2) Workload has increased for from non-existent to their current budget for the WN program support staff. Ag promoters are doing high ratings. However, the team for the RH component attributable to more RH work. Agriculture work noted some discrepancies between BSRDS support (primarily staff is seasonal so there is time to their ratings and our record review of salaries and training costs) were do RH work. the groups’ savings and credit combined. The total was $2,542.00. 3) RH work requires a lot of follow- activities. Neither of the groups had up, particularly for family 100% repayment of loans and there BSRDS support $1,740.00 planning and gyne camps. were some gaps in their record WN Program support 802.00 4) Although BSRDS hasn’t had this keeping. Total $2,542.00 problem, a lack of cooperation from the PHC center could be a According to their perceptions, As the RH component supports 13 problem. BSRDS has improved in all areas of women’s groups, this averages key capacities. The biggest areas of $196 per group. As each group has improvement have been in skilled an average of 18 members per staff and monitoring and evaluation. group, the annual cost is $10.86 per group member per year.

Evaluating an Integrated Reproductive Health Program - 33 Evaluation Tool: Integration Participatory Exercise 4A: Semi-structured Interviews (SSI) - RH with men’s groups

Objectives: 1. To assess the participation of men in the integrated program 2. To determine the awareness level of men’s group members 3. To assess the benefits of integration of RH program with the existing livelihood programs

Questions to be asked:* • Have you heard of RH? • Which are the RH related activities? • What are the problems related to RH? • Have you had contact/communication with RH groups? If yes, in what way? • Have you heard of family planning methods? If yes, list them. • What RH related problems do you have in your family? • How do women support your work? • Have you discussed improved DLA practices with the women? • Are there changes in the women’s status? • Have you discussed with your wives the problems related to RH? If yes, list them. • What are the benefits you’ve gained from the RH group? • Do you know about spacing?

Materials needed: Matrix to list questions and responses (see Table 16, page 34):

Responses orf m Responses orf m Responses orf m Que oits ns Me s'n G or ups ni Me s'n G or ups Me s'n G or ups ni N ulle r ni Y ele navad ig Khanapur

Participatory Exercise 4B: SSI-Agri with women’s groups

Objectives 1. To assess the participation of women in agricultural activities 2. To determine the awareness level in women’s group members 3. To assess the benefits of integration of agricultural program

Questions:* • Have you heard of improved dry land agriculture (DLA)? • Have you participated in DLA? • Have you adopted improved DLA practices? • Do you discuss seed treatment regarding the use of good seeds in your family? • Do you discuss integrated pest management? • Have you established live hedges? • What type of communication do you have with the men’s group? • Has your group developed sustainability?

Materials needed: Matrix as in Exercise 4A to list questions and responses (see Table 17, page 35).

* The questions were developed by the team, based on the stated objectives of the evaluation.

34 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Integration D. Integration In Khanapur, agriculture group members acknowledge there is a need to form a women’s RH group. The Nellur and Yelenavadgi women’s groups have developed some capacity to sustain their activities, facilitating the NGO phase out from their groups over the next year.

The men’s groups in both Nellur and Yelenavadgi were well-informed about reproductive health issues and the activities of the women’s groups. Women also cited examples of how men supported RH activities including assisting with Men’s Agriculture Group Members, Yelenavadgi the gyne camps and group meetings. “My problem is my wife’s problem and her problem is my problem. As a family we have to share.” Annarao Biradar, Group Leader, Men’s Agricul- As the Khanapur agriculture group ture Group, Yelenavadgi is relatively new (1 year), it makes comparison with Nellur and “Our participation in selecting improved farming activities has made our Yelenavadgi difficult. While the husbands realize that we too can contribute for the betterment of our wives of members have some farming.” Women’s group members, Yelenavadgi Women’s Group knowledge about improved DLA practices, there is obviously more “Before we had this (the women’s) group, I never talked about reproductive knowledge and involvement in health with my wife. Now I even discuss it with my sisters and other family Nellur and Yelenavadgi. While the members.” Nellur Men’s Agriculture Group groups in Nellur and Yelenavadgi attributed their involvement in RH “Before the RH component, we worked with only farmers and their family and agriculture to the interactions wasn’t in the picture. Now the family as a whole is addressed and even the between the groups and improved agriculture information and practices are more widely shared.” Subbanna communication between couples, it Biradar, BSRDS Director is difficult to attribute the changes in agriculture solely to the RH Guided discussions were carried Integration Observations: group. out both with women’s group members and men’s group mem- For Nellur and Yelenavadgi, there bers to better understand the appears to be improved awareness relationships between the groups, and practices related to both RH the men’s role in reproductive and dry land agriculture (DLA) in health, and the women’s role in both men’s and women’s groups. agriculture. The findings for Nellur, When compared to Nellur and Yelenavadgi, and Khanapur are Yelenavadgi, Khanapur has less presented in Tables 16 and 17. awareness in either area.

Evaluating an Integrated Reproductive Health Program - 35 Evaluation Findings: Integration Table 16: Men’s Responses to Reproductive Health Questions

Khanapur Ag Que oits ns N ulle r G or ups Y ele navad ig G or ups G or ups

.1 Have you he dra Yes Yes No fo RH?

.2 W cih h era ht e RH Gyne camp ,s AN ,C PN ,C F ,P Gyne camp ,s TBA niniart ,g AN ,C None etaler d a eitivitc s? s efa d vile yre PNC

.3 Wh eta era ht e S ,s'IT anem ,ytilitrefni,ai Uns efa d vile yre arp citc e ,s S s'IT Do t'n know orp elb ms etaler d ot weakness RH?

.4 Wh ytta pe fo We sid cuss ht e si sues ni o ru We sid cuss si sues ot g hte .re We N A/ commu cin oita n do org ups htiw ht em. We sla o sid cuss abo tu RH etaler d si sue .s you have htiw ht e supp httro rie a eitivitc s and E reilra we did t'n sid cuss RH RH org ups? sid cuss si sues ni o afru m eili .s si sues htiw o afru m yli memb ,sre now we do erf .yle

.5 Have you he dra Ye .s P re mane ut:tn be otc m ,y Ye .s P re mane ut:tn be otc m ,y Ye T.s ube otc my affo m yli alp n nin g? al orp scop ,y vase otc m ;y al orp scop ,y vase otc my fI s ,o wh ta Temp :yraro condom ,s I,sllip U ,D Temp :yraro condom ,s I,sllip U ,D m hte ods? Depo Depo

.6 Wh ta RH etaler d ,ytilitrefnI weaknes ,s anem ,ai S ,ytilitrefni,s'IT weakness ,ytilitrefnI ciffid ytlu orp elb ms do you sid ch gra e ni d vile yre have ni yo afru m yli ?

.7 How do women They supp tro o rafru m ni g They supp tro o rafru m ni g They supp .tro supp tro yo ru w kro ? a eitivitc s kil e h vra e nits g and a eitivitc s kil e c niyrra g of o ,d seed wee nid .g ert ta me ,tn .cte

.8 Have you Yes Yes Ye ,s we have sid cussed im orp ved Exam :elp Compo ,ts man ,eru Exam :elp compo ,ts man ,eru sid cusse .d DLA arp citc es htiw sub etsis nce raf m ni PI,g M, and sub etsis nce raf m ni PI,g M, and ht e women? llaf olp niw g llaf olp niw g

.9 A er ht ere Yes Yes No changes ni wome s'n Exam :elp De oisic n ma nik g ni ht e Exam :elp De oisic n ma nik ,g utats s? af m ,yli sa niv g ,s and educ oita n rof sa niv gs and erc ,tid and .slrig p cru ha nis g and s ele nitc g seeds

1 .0 Wh ta era ht e Aw era ness ni af m yli alp n nin g Aw era ness ni af m yli alp n nin g N A/ ben stife yo v'u e m hte od ,s RH si sue ,s S ,s'IT AN ,C m hte od ,s RH si sue ,s S ,s'IT AN ,C g nia ed orf m ht e RH PN ,C access ot gov nre me tn PN ,C access ot gov nre me tn org up? s civre e ;s ANM com ni g ot ht e s civre e ,s ANM com ni g ot ht e alliv ge alliv ge

36 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Integration Table 17: Women’s Responses to Agriculture Questions

Khanapur w vi es Que oits ns N ulle r G or ups Y ele navad ig G or ups fo Ag G or up

.1 Have you he dra Ye ,s women do p picitra eta by Ye ,s women do p picitra eta by Ye ,s women ifo m orp ved yrd al nd d nio g gil reth w kro kil e wee nid ,g d nio g gil reth w kro kil e wee nid g p picitra ,eta b ottu a a cirg erutlu (DLA ?) so niw ,g seed ert ta me ,tn .cte and at nik g me sla ot o ru el ss re e etx tn Do you p picitra eta husbands ni ht e .dleif ni DLA?

.2 Have you Yes Yes Some peo elp have ado etp d im orp ved Exam :elp So niw g a orc ss ht e Exam :elp So niw g a orc ss ht e ado etp d ht ese DLA arp citc es? ols p ,e e ats silb hme tn vilfo e ols p ,e e ats silb hme tn vilfo e arp citc e .s hedge llaf,s olp niw ,g use fo hedge llaf,s olp niw ,g use fo compo ts man PI,eru M, use fo compo ts man PI,eru M, use fo im orp ved im elp me .stn im orp ved im elp me erttiurf,stn e alp nitn .g

.3 Do you sid cuss Yes Yes Ye ,s we have seed ert ta me tn Exam :elp We c ello tc a good Exam :elp We c ello tc a good sid cussed .ti er g nidra g ht e use fo v yteira fo seed .s v yteira fo seeds good seeds ni yo ru af m yli ?

.4 Do you sid cuss Yes Yes Ye ,s we have etni etarg d pe ts Exam :elp F lla olp niw ,g use fo Exam :elp Use ol c ylla av alia elb sid cussed T(.ti hey manageme ?tn drib p cre he ,s sub etsis nce n laruta pe dicits e .s did t'n qu eto raf m ni ,g .cte exam elp ).s

.5 Have you Ye .s rafllA m sre have vil e Ye .s rafllA m sre have vil e hedge .s O yln two raf m sre e ats silb hed vil e hedge .s have e ats silb hed hedges? vil e hedge .s

.6 Wh ytta pe fo They me te once a gintrof otth The org ups me te p oire cid ylla N A/ commu cin oita n do sid cuss si sues and sh era v( eira ot)s sid cuss rofni m oita n you have htiw ht e rofni m oita n on a eitivitc .s They and sh era rofni m oita n on me s'n org up? sla o supp tro us ni o ru a eitivitc s a eitivitc .s The men supp tro us ni kil e gyne camp .s o ru a eitivitc s kil e org up me nite gs and gyne camps

Evaluating an Integrated Reproductive Health Program - 37 Evaluation Tool: Livelihood Ranking

Exercise 5: Livelihood Ranking for Women Group Members

Objectives: 1. To determine the distribution of group members in wealth categories 2. To identify any changes in wealth in the past three years

Steps: 1. Select 2-3 informants, preferably group leaders or persons who know all group members well 2. Describe objectives 3. Ask participants to separate group members by two categories - poor and better off 4. After they complete the two lists ask them to define their criteria for poor and better off 5. Ask them to review the poor category and divide it into poor and very poor 6. Ask them to divide the better off category into better off and much better off 7. Discuss the criteria the used for these categories 8. Identify any individuals that have changed categories since the formation of the group and then discuss why

Materials needed: Cards with names of all group members; title cards: poor, very poor, better off, much better off; markers; tape; wall, board, or floor to post cards.

Woman carrying wood in Yelenavadgi

Reproductive health workers verifying questionnaires Nellur Women’s Group: Reproductive Health Historical Matrix Exercise

38 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Livelihood E. Livelihood Ranking and Members who moved from poor to Savings and Credit better off with group loans are 1.Radha - She has taken a flour mill To review the process and out- on lease. “I can comes of the savings and credit 2. Irramma - She started vegetable identify component, the team reviewed the vending. each and group documents and conducted every livelihood-ranking exercises with Members who were very poor and utensil the women’s groups in Nellur and remained the same are: money Yelenavadgi. 1. Saraswati - Her husband spends leader all his earnings on drink and she is took from 1.Livelihood Ranking working as a laborer. our 2. Bhagyavanti - She is physically parents Livelihood ranking was conducted handicapped and she earns and and with key informants from the Nellur looks after her parents. grandpar- and Yelenavadgi women’s groups. 3. Mohanbai - She works as a ents and The results were later cross- laborer and spends money for has in his checked with BSRDS staff who medical treatment. house—just to provide a small verified them. The results from 4. Kallamma - She does not have loan.” Shantamma, Yelenavadgi these exercises follow. any land, works as laborer, is a Women’s Group widow, and lives alone. Livelihood Ranking - Nellur 5. Renuka - Works as a laborer, has “While helping our fellow group Women’s Group; 15 members a big family, husband is a drunkard. members who are badly in need of 6. Indubai - Works as a laborer, has help, we value the person, not the For the classification of the mem- a big family, is in ill health. money.” Shantamma, Yelenavadgi bers under these categories,criteria Women’s Group such as number of acres of field, Five members have increased their house, and animals owned were economic status as a result of loans “I am more interested in my taken into consideration. from the group. While members children’s education and not being acknowledge that these increases called ‘well off’.” Pattamma, The following three group members are not large, they also point out Yelenavadgi Women’s Group have moved from very poor to poor they do represent an improvement in categories by taking loans from the quality of life. group. 1. Rajbi- She has taken a loan to purchase a goat. Very Poor Poor Better Off Well Off 2. Hasinbi - She has started a coconut vending business in front Hasinbi Rajbi Bhimavva Mehbubi of the mosque. Kallamma Parakka Irramma 3. Iravva - She has taken a loan to Renuka Hasinbi Iradha purchase a goat. Bhagyavanti Iravva Yellamma Indubai Saraswati

Nellur group members whose names are in italics have moved up a level.

Evaluating an Integrated Reproductive Health Program - 39 Evaluation Findings: Livelihood Livelihood Ranking - Yelenavadgi Very Poor Poor Better Off Well Off Women’s Group; 15 members Yellamma Parakka Puttamma Basamma For the classification of the mem- Bhimavva Shantamma Bhagyavanti Hanumavva bers under these categories the Radha Kallamma Renuka following criteria such as number of Sarada Mallamma acres of field, house, animals owned Saraswati Mehbubi were taken into consideration. The group also considered the number of Yelenavadgi group members whose names are in italics have moved up a level. children in a household as influenc- 6. Mehbubi - She has taken a loan Remarks ing livelihood status. for her daughter’s marriage; remains 1. Most loans have been for goat in same place. purchases (48%) and health ( 37%) The following group members have 2. Four have not repaid the loans moved from very poor to poor Overall, six members have changed 3. Members have taken more time categories by taking loans from the categories as a result of the group repaying loans than originally group. loans. Again, the changes are small agreed. 1.Parakka - She has taken a loan to but significant according to the 4. Rupees 776 was earned as construct a house. women. interest 2. Shantamma - She has taken a 5. In several cases, because of loan for farming activities which 2.Savings and Credit necessity and seriousness (usually resulted in increased yield. health-related), a few members 3. Kallamma - She has taken land The team reviewed the records from received second loans though they on lease for farming. two groups each in Nellur and have not repaid the original loan. 4. Mallamma - She has taken a loan Yelenavadgi, with the following 6.Improvement is needed in loan from the group and with the aware- results: disbursement and repayment ness given has utilized the loan to her benefit. Nellur Group #1 – Formed in 1998; Yelenavadgi Group #1 - formed in 15 members 1998; 15 members Two members have moved from better off to well off. For the most part, the group was Both groups were saving 25 rupees 1. Basamma - with loan taken does saving regularly, although there were per month per person. The savings tailoring (sells). gaps during festival months when appeared regular. 2. Hanumavva - with the loan taken there were no savings. For most does sugarcane extraction. members, the savings were made up later. The loan distribution is as Those remaining in the very poor follows: category are: Yelenavadgi Group #I 1. Yellamma - has no land or house, Nellur Group #I Numb re Amou tn works as laborer, husband is Purpose Numb re Amou tn fo fo alcoholic. Purpose olfo an fo fo ol ans ol ans 2. Bhimavva - laborer, is a widow olfo an ol ans ol ans and has lost her daughter and son. )1 He htla 6 2( 7%) 7500 3. Radha - has lost her father and )1 He htla 10 3( 7%) 9600 2( 6%) mother due to AIDS, works as a 5( 0%) laborer and has to look after her )2 Ass ste 12 5( 5%) 7850 sister. )2 Educ oita n 1 4( %) 500 4( %) 2( 7%) 4. Sharada - has no land or house, nI)3 come 3 1( 1%) 2500 nI)3 come 01 4( %) 1000 has to spend on her children’s gen oitare n 1( 3%) gen oitare n 3( %) education. 5. Saraswati - has taken a loan for )4 Go ta 13 4( 8%) 6500 )4 O ht sre 03 1( 4%) 12800 children’s health. p cru hase 3( 4%) 4( 4%) TOTAL 27 19100 TOTAL 22 29150 LOANS 1( 00% 1( 00%) LOANS 1( 00%) 1( 00%)

40 - Evaluating an Integrated Reproductive Health Program Evaluation Findings: Livelihood Remarks have increased their livelihood While the women’s groups rated their 1. Loan records are well maintained status. While these changes are savings and credit activities as 2. Interest rates are not uniform small (no one moved two catego- strong in the capacity section, there 3. Though marked profit because of ries), the changes are significant are areas for improvement with improper loan repayment according to the women interviewed. regard to regularity of savings and 4. People have spent the loan documentation. However, the amount for other reasons and less The findings from group record decisions made with regard to loans on health (27%) reviews and participatory exercises were transparent and judged to be 5. No one has taken a loan for also demonstrate the range of needs fair by group members. Women education that these women face. Loans are appear to have a strong sense of often taken for “non-productive” unity and compassion. For ex- Livelihood and Savings and purposes such as household needs ample, although several of the Credit Observations: or health. These are judged as poorer women had not been able to needed by the group. Borrowing from repay their loans, group members There is evidence that the loans the group at lower interest rates were clear that in case of need given by the group have had an allows women to avoid having to (particularly for health) they would impact on livelihood status. Accord- borrow from village moneylenders. give them another loan whether they ing to the evaluation findings, five (In Yelenavadgi, money lenders would be able to pay it back or not. group members from Nellur and six charged 5% per month, whereas the group members from Yelenavadgi group was charging 3%).

Evaluating an Integrated Reproductive Health Program - 41 Evaluation Results and Limitations This section responds to the seven was a little less in non-group mem- vadgi confirms that the demand for key questions posed at the begin- bers. her services have increased. ning of the evaluation (page 9) and also provides a discussion of the Key Question 2) Did the program “There has been a remarkable limitations of the evaluation. create a demand for government change due to the women’s group. services, specifically reproductive Before women were not using ANC, health services? getting tetanus toxoid injections or A. Responses to Key Questions having their children immunized. The evaluation demonstrates that They also didn’t realize the symp- Key Question 1) How has the the program has created a demand toms of RTIs. The gyne camps program affected the awareness for government services in Nellur have really helped women under- (RH) of group and non-group and Yelenavadgi. The participatory stand about these problems. Now, members? exercises indicated that both because of BSRDS work, women members and non-members of the come to be treated for RTIs, UTIs The program has had a consider- women’s groups were using ANM and for ANC and PNC care.” able effect on knowledge and use of services for antenatal, postnatal, Nirmala D. Lalii, ANM responsible reproductive health services, and family planning services. for Yelenavadgi village. particularly as concerns ANC/PNC, Information from the survey also RH-related diseases, and use of indicates that women in RH group family planning for both group villages are using services to a Key Question 3) What has been members and non-group members. greater extent than those where the the role of the men’s agriculture In general, the program helped program does not exist. Finally, the groups in addressing RH issues? group members become more interview with the ANM for Yelena- aware of RH issues. This effect From the discussion with both men’s agriculture and women’s RH groups, it is clear that the participa- Table 18: RH awareness of group and non-group members tion of men in addressing RH issues has helped significantly. Specifi- N ulle r Y ele navad ig Khanapur cally, men were said to have assisted in the following ways:

W vi es fo W vi es fo • No -n No -n no -n Cooperation and assistance in G or up G or up org up org up org up org up forming women’s groups. memb sre memb sre • Helping to address the social issues identified in the women’s M ero ht an two 100% 70% 88% 100% 57% 46% ANC stisiv groups. • Discussion and use of family M ero ht an two 100% 52% 82% 53% 43% 62% planning methods both in groups PNC stisiv and with spouses Fam yli • Supporting efforts to increase 78% 74% 88% 78% 53% 48% alp n nin g use access to government services • Discussing with women’s groups Gyne camp 100% 91% 100% 91% N A/ N A/ use AIDS and STIs and how to control them Use fo TBA • 72% 64% 91% 87% N A/ N A/ Supporting initiatives to improve s civre es women’s status Kno elw dge fo • Helping organize gyne camps and 100% 79% 100% 85% 72% 48% S sIT encouraging their wives’ participation Kno elw dge fo 100% 89% 100% 83% 78% 40% IA DS

42 - Evaluating an Integrated Reproductive Health Program Evaluation Results and Limitations Key Question 4) What has been the impact/outcome of program Chart 1: Family Planning Use activities on reproductive health, 100% savings and credit, and women’s status? 12345 12345

12345

50% 12345

12345

12345 a) Reproductive Health 12345 12345

12345

12345 While, in terms of reproductive 0% 12345 health, the scope of the evaluation Group Non-group NFHS was limited to the outcome level, Nellur Khanapur there were substantial differences in 1234

1234

1234 reproductive health indicators Yelenavadgi 1234 Karnataka between group and non-group (NFHS) members and those of the comparison village. Chart 2: ANC and PNC Use 120%

For family planning use, it is of note 1234 1234 1234

100% 1234 1234 1234

1234 1234 1234 1234

1234 1234 that the contraceptive use rates in 1234 1234 1234 1234 1234 80% 1234 1234 1234 1234 1234

1234 1234 1234 1234 1234 1234

Khanapur, the comparison village 1234 1234 1234 1234 1234 1234 1234 60% 1234 1234 1234 1234 1234 1234 1234 1234

1234 1234 12341234 1234 1234 123412345 1234 1234

1234 1234 1234 12345 1234 1234 (53%-48%), resemble those for rural 1234 1234 1234 1234 1234 1234 1234 1234 1234 12345 1234 1234 1234 1234 1234 1234 1234 1234 40% 1234 1234 1234 12345 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 1234 12345 1234 1234

1234 1234 1234 1234 1234 1234 Karnataka (56.6%, National Family 1234 1234 1234 12345 1234 1234 20% 1234 1234 12341234 1234 1234 123412345 1234 1234 12341234 1234 1234 12341234 1234 1234 123412345 1234 1234 12341234

1234 1234 12341234 1234 1234 123412345 1234 1234 12341234

Health Survey, 1998-1999). The 1234 1234 1234 12345 1234 1234 0% 1234 1234 1234 rates observed among group and Group Non-group Group Non-group Group Non-group non-group members in Nellur (78%- Nellur Yelenavadgi Khanapur

12345

74%) and Yelenavadgi (88%-78%) 12345

12345 12345 More than 2 ANC visits greatly surpass the rates for rural 12345

12345

12345 Karnataka. This relationship is 12345 12345 More than 2 PNC visits portrayed in Chart 1. 12345

For ANC visits, there are also clear Table 19: Savings and Credit Activities (all groups) differences between the groups as demonstrated in the following graph. N ulle r Y ele navad ig As shown in Chart 2, the women’s # fo Amou tn # fo Amou tn fo group members are more likely to Reason of r Loan have more ANC visits than non- ol ans olfo ans ol ans ol ans group members. Women in the comparison village of Khanapur are He htla 10 3( 7%) 9600 5( 0%) 6 2( 6%) 7500 2( 3%) the least likely to have had ANC care. PNC visits were most frequent for group members, but women in Educ oita n Khanapur had a similar ratio of PNC 1 3( %) 500 4( %) 0 0( %) 0 0( %) visits compared to non-group members. nI come Gen oitare n 3 1( 1%) 2500 1( 3%) 2 9( %) 2000 6( %) b) Savings and Credit and Livelihood Table 19 illustrates the reasons for which loans were taken and the amount of the loans for two groups: Ass ste g( o ta er nira )g 13 4( 8%) 6500 3( 4%) 11 4( 8%) 6850 2( 0%) one in Nellur and one in Yelenavadgi.

O ht re purposes 0 0( %) 0 0( %) 4 1( 7%) 15800 4( 9%)

Evaluating an Integrated Reproductive Health Program - 43 Evaluation Results and Limitations The following patterns were noted in The findings from the group record With regard to many of these terms of group loans. reviews and participatory exercises issues, women in the two interven- also demonstrate the range of needs tion villages said that the situation 1.Greater numbers of women have that these women face. Loans are was improving (with the notable taken loans for health. often taken for “non-productive” exception of dowry). Women said 2.Fewer loans have been taken for purposes such as household needs the reasons for improvement were income generation activities. or health however these are judged primarily because of group activities. 3.In the two groups, only one loan as needed by the group. Borrowing However, girl child education and was taken for education. money from the group at lower participation in politics were said by 4. In Yelenavadgi, four large loans interest rates allows women to avoid some of the women to have im- were taken for other purposes having to borrow from village proved because of group activities (marriage and household repairs). moneylenders who charge much as well as the efforts of the govern- higher interest rates. (In Yelenavadgi, ment. Changes in Livelihood Status money lenders charged 5% per month, whereas the group was The questionnaire data allowed There is evidence that the loans charging 3%). triangulation of information and given by the group have had an illustrated positive differences for impact on livelihood status. Ac- c) Women’s Status group members in the areas of cording to the evaluation findings, decision-making, participation in five group members from Nellur and Women in the three villages identi- politics, family planning use, and seven group members from Yelena- fied similar sets of issues related to protesting against spousal abuse. vadgi have increased their liveli- women’s status. These included The following graphs illustrate hood status. While these changes decision-making, property owner- indicators of women’s status, are small (no one moved more than ship, participation in politics, girl- decision making, participation in one category) the changes are child education, family planning, public protests and attitudes toward significant according to the women reproductive health, divorce and protesting wife beating. The positive interviewed. violence against women. trends among group members are notable.

Chart 3: Decision Making Chart 5: Protest Wife Beating 100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% 0% Group Non-Group Group Non-Group Nellur Yelenavadgi Khanapur Nellur Yelenavadgi Khanapur

Chart 4: Participation in Public Protests 100% 80% 60% 40% 20% 0% Group Non-Group Nellur Yelenavadgi Khanapur

44 - Evaluating an Integrated Reproductive Health Program Evaluation Results and Limitations Key Question 5) How does the Key Question 7) What is the nies and this may have had an livelihood distribution of the awareness and adoption of im- effect particularly on the participa- groups compare to that of the proved dry land agriculture (DLA) tory exercises. villages? practices by women’s group and non-group members? 2)The team’s preparation time was Due to time constraints, we were very limited. Because of other unable to address this question in Questions were asked at Nellur, demands on time and the cancella- the villages. Yelenavadgi and Khanapur regarding tion of the consultant who had been awareness and adoption of improved scheduled to assist with the evalua- DLA practices. At Nellur and tion, the preparation for the evalua- Key Question 6) What is the Yelenavadgi, there is good communi- tion was very limited. This particu- capacity of the groups to sustain cation on these issues between men larly had an effect on the first week activities? and women because of the exist- of the evaluation period, as the team ence of both men’s and women’s had to plan almost at the same time Both Nellur and Yelenavadgi groups groups. As a result, there appears as the training for data collection. have improved their capacities. to be improved awareness in Both of these groups are now in a women’s group members regarding 3)It was not possible to field test the position to sustain their activities the following agricultural practices: questionnaire and modify it in with little outside support from advance of the data collection BSRDS. As BSRDS phases out 1.Fall plowing training. The lack of pre-testing from these villages over the next 2.Seed treatment meant that significant time was year, they will have the opportunity 3.Subsistence farming spent in answering interviewers’ to work with the women’s group in a 4.Live hedges questions, adjusting the question- phased manner to ensure their 5.Use of compost manure naire, and practicing questionnaire capacities are at the necessary 6.Growing of fruit trees administration. levels. Women also said they used these 4)There was no general baseline According to the groups, they have techniques in their agricultural work. information available for this evalua- developed capacities through the In contrast, at Khanapur, there is tion. The design of evaluation following activities: comparatively low awareness. attempted to compensate by the • Regular savings addition of the comparison village • Loans to needy members However since the DLA men’s group and collecting perceptions of trends • Regular decision-making is relatively new (one year) it makes through the participatory exercises. • Loan repayment comparison with Nellur and Only in the case of family planning • Awareness about RH and DLA Yelenavadgi, where the groups are use for the women’s groups was activities five years old, difficult. there clear baseline information. • Keeping records • Developing second line leadership 5) While it was invaluable to have a • Assuming responsibility B. Limitations of the Evaluation comparison village, BSRDS was unable to match one with the same The groups said without external It is useful to note the limitations of the length of time of the agriculture support (BSRDS), they would carry this evaluation exercise. These group with that of the RH villages. on their activities. include: The agriculture group in Khanapur had only been established a year In Nellur, the women’s group said 1)The evaluation was conducted ago, compared to those in Nellur and they would be able to hold gyne during marriage season. This may Yelenavadgi that have been estab- camps and from their initial savings, have limited the participation of lished for five years. This made group members bear the cost of the women in the villages visited. While comparison regarding agricultural doctor’s honorarium, transportation, the team adjusted its schedule to practices and the role of women in and incidentals. They also said that ensure maximum participation, there agriculture difficult. they would continue the honorarium were significant demands on villag- for the group leader, but at a lesser ers’ time to attend marriage ceremo- amount. Evaluating an Integrated Reproductive Health Program - 45 Evaluation Results and Limitations 6)The entire analysis of the 22 7)In all the villages, the women smaller groups of women and may questions on the questionnaire was participating in the participatory not be representative of the larger not available to the team at the time exercises were a sub-sample of groups. of analysis or report writing. The those interviewed for the question- team did an analysis of nine ques- naire. For the group members, 8)The sample for the questionnaire tions that were judged the most Group 1 in Nellur and Group 1 in was purposeful in that women were relevant. The team used this prelimi- Yelenavadgi participated. The non- selected based on being a group nary data to respond to the key group members were self-selected. member or a non-member. As such, evaluation questions (page 9). Thus the information from the it may not be representative of the participatory exercises is from village as a whole.

46 - Evaluating an Integrated Reproductive Health Program Lessons Learned and Conclusions A. Key Findings and Lessons larly decision-making, participa- useful in assisting BSRDS and Learned: Impact of Group tion in politics, and protesting the groups to ensure that key Activities against spousal abuse. Women services are provided. group members attribute these 1. The role of men through the changes largely to the group, but The groups, BSRDS and the agriculture group in the formation also acknowledge the role of the communities have united to of the women’s groups and government in politics and girl- leverage government services, support for their activities has child education. such as road repairs, bus been invaluable. The agriculture services to villages, water group members helped to sup- According to the women, the supply, and janata houses port the formation of the groups have also provided (housing for the poor). women’s groups by encouraging women with the confidence to their wives to participate and in mobilize to undertake a variety 6. Both men and women report some cases, convincing other of initiatives ranging from closing that there has been an increase men to do the same. They have bars and gambling houses to in couple communication due to also provided ongoing support in civil disobedience to improve the the groups. Improved communi- terms of assisting with the water supply to the village. cation was reported with regard organization of gyne camps and to reproductive health, agricul- regular discussion of issues, 4. There is evidence that the ture activities, as well as other (RH, agriculture, and social loans given by the groups had issues such as girl-child educa- issues), with the women’s an impact on livelihood status for tion, drinking, gambling and groups. Individually, they have a third of the members. Accord- violence against women. also encouraged their wives to ing to the evaluation findings, attend the gyne camps. five group members from Nellur 7. As a result of group activi- and seven group members from ties, unity has been increased in 2. Where there are women’s Yelenavadgi have increased the villages. The group activities groups, there is increased their livelihood status. While have brought people together to awareness and improved RH these changes are small (no one address common problems, like practices compared to villages moved two categories), the the need for government ser- where there are no groups. This changes are significant accord- vices. is clear from the evaluation ing to the women interviewed. findings. In villages where there 8. The gyne camp services are groups, even non-group 5. The groups have had signifi- have been important in creating members have higher rates of cant success in improving awareness regarding reproduc- awareness regarding RH and access to government services, tive health issues, particularly improved use of services than particularly the services of the reproductive tract infections and women in villages without ANM. The groups wrote letters uterine prolapse. The continua- groups. to the PHC centers, with the tion of gyne camp services is help of BSRDS, asking for seen as a priority by group 3. Women’s groups appear to regular ANM visits, and the members and in Nellur, women have had an impact on indica- ANMs have complied. The have contributed from their tors of women’s status, particu- “health service map” has been savings in order to ensure the

Evaluating an Integrated Reproductive Health Program - 47 Lessons Learned and Conclusions camps continue after BSRDS loans from the group, at lower B. Key Findings and Lessons phases out. interest rates, was of great Learned: The Evaluation assistance, particularly during Process 9. The role of the trained daiyas emergencies (often health- (TBAs) in increasing awareness related). 1. The team felt they had regarding safe delivery practices increased their knowledge about as well as providing linkages to 12. Awareness regarding STIs the evaluation process and health services has been impor- and AIDS has been increased participatory methods as well as tant. The ANM, PHC physician, through joint men and women data analysis. and gyne camp doctor all report group activities. The linkages that the trained TBAs play a between the men’s and women’s 2. The principle of triangula- valuable role in ensuring that groups have allowed them to tion—comparing facts and women get necessary services. discuss sensitive issues that figures using various methods— A majority of women interviewed were not previously discussed was found to be very useful. in Nellur and Yelenavadgi, both openly. This has been particu- group and non-group members, larly important with regard to 3. The evaluation also under- report using trained TBA ser- STIs and AIDS and has facili- lined the importance of planning vices. tated partner treatment in the and pre-testing instruments, case of infections detected particularly the questionnaire. 10. Although BSRDS didn’t have during the gyne camps. any experience in reproductive 4. The evaluation process health, they were able to effec- 13. BSRDS acknowledges the required a great deal of team- tively implement the activities. In importance of trainings and work. the district (Gulbarga), BSRDS cross visits in helping develop is now seen as a resource for its capacity in reproductive 5. The team noted a need for RH. BSRDS notes that the health. These experiences have caution and privacy when asking addition of the RH component also contributed to improving sensitive questions. has significantly contributed to staff capacity in other areas as their integrated development well. 6. Due to the evaluation, sev- approach and has strengthened eral members felt they had their relationship with village 14. Community leaders (both increased knowledge about women. men and women) and BSRDS report writing and facilitation staff have developed capacities skills. 11. A very positive result of the to effectively implement, monitor savings activity has been the and evaluate activities. These 7. The selection of villages for decrease on dependence on skills include technical knowl- evaluation is critical. If a com- moneylenders in the villages in edge, communication, and parison is being done, villages case of emergencies. Women program management. need to be matched on basic repeatedly noted that taking characteristics.

48 - Evaluating an Integrated Reproductive Health Program Lessons Learned and Conclusions C. Discussion and Conclusions crease awareness about RH For World Neighbors pro- issues in non-group members. grams elsewhere, the team felt The team noted the many One idea is that each member the following to be most strengths of the BSRDS RH agrees to share information applicable: component in discussing les- regularly with another woman in sons learned. There were four a neighboring household. 1) The broad approach to suggestions for opportunities for reproductive health engages improvement. 4. As this evaluation was not women, families and communi- able to examine in detail the ties in a significant process of social change. 1. An area in which the pro- effects of the RH program on gram could be strengthened and agriculture, WN India should look 2) The gynecology camps and which also is one of BSRDS’ for an opportunity to evaluate trained birth attendants can play priorities is the increased partici- this aspect in the future. With an important role in initiating pation of adolescents in activi- WN India’s strengths in agricul- reproductive health service use. ties. ture, such a study would be a unique opportunity to address 3) Health service mapping has 2. The group record keeping this important aspect of inte- assisted community members to needs to be improved in some grated programming. monitor the quality of govern- areas, particularly gyne camps ment services. and savings and credit. During this last year of BSRDS support The team felt there was a great 4) The capacity building under- to the groups, additional time deal of potential for replication of taken with women’s groups should be spent reviewing and the integrated model in Karna- seems to result in self-confidence that encourages women helping to strengthen group taka and elsewhere. Although to address wider social issues. record keeping. the predisposing factor of the presence of agriculture groups is 5) The savings and credit 3. The evaluation noted that limited, several basic factors activities assist women to gain knowledge and use of RH such as the potential respon- access to cash for many basic services were higher for group siveness of the government to needs, including health. members than non-group mem- NGO initiatives, the community bers. The existing strategy for interest, and the capacity of 6) The support and involvement reaching out to non-group NGOs to work in integrated of the male agriculture groups members has been to establish programs are widespread. It provided a basis on which to new groups. However, because should be noted that WN-India is develop dynamic women’s of the difficulty with regarding to currently working with a partner groups. savings and the time constraints (VISHALA) which has no agri- of women, it seems unlikely that cultural activities and that this 7) The integration of reproductive health with other livelihood all women in a village will be able experience may be of compara- activities (sustainable agriculture to join a group. Thus, it is sug- tive interest. and shepherding) betters com- gested that an alternative strat- munication between couples and egy be developed to help in- involves women in decision- making.

Evaluating an Integrated Reproductive Health Program - 49 50 - Evaluating an Integrated Reproductive Health Program Appendix A - Questionnaire BSRDS RH EVALUATION

“Namaste, My name is ______and I am working with ______. We are conducting this survey about the health of women and children in this village and we would very much like your participation.

We will be using this information to evaluate our program activities and anything that you say will be kept strictly confidential and not shown to other persons. We hope that you will participate as your experience is very important.

Do you have any questions?

Do you agree to participate? Yes H No H

Interviewer’s name ______Date of interview: HHHHHH

Village: ______ Household number: HHHH

Family name: ______Street:______Religion: H

Caste:______1. SC 2. ST 3. Other

1. How many people are usually living in your household? HH

niL e Name R oitale n Sex Age M latira fI age 6 ye sra or mo er N .o w hti head M= ;1 c( om -telp S utat s F=2 ed ye )sra Educ oita n Occup oita n c( om etelp d ye )sra

1 2 3 4 5 6 7 8

Religion: Hindu=1; Muslim=2; Christian=3; Other=4 Code for column 3: Head =01; Wife/Husband=02; Son/Daughter=03; Son-in-law/Daughter-in-law=04; Grandchild=05; Parent=06; Parent-in-law=07; Brother/Sister =08 ; Brother-in-law/Sister-in-law=09; Niece/ Nephew=10; Other related=11; Not related=12 Code for column 6: Currently married=1; Widowed=2; Divorced/Seperated/Deserted=3; Never married=4 Code for column 8: Cultivator=01; Agricultural labourer =02; Non-agricultural labourer=03; Business=04; Sal- ary=05; Housework=06; Student=07; Not working=08; Other=09

Evaluating an Integrated Reproductive Health Program - 51 Appendix A - Questionnaire 2. Line number of (Respondent) woman in household list:

Line number of husband in household list: (98, if husband is not a usual resident)

Date of birth Woman Husband

Month Year 3. Date of your marriage

4. Date of your effective marriage (Gauna)?

5. BIRTH HISTORY a. Have you ever given birth 1. Yes 2. No H (If No, skip to Q.6) b. If yes, please give DETAILS OF ALL PREGNANCIES

.IS Mo htn & Ended alP ce fo B htri Name fo c dlih Sex S llit fI n ,o Cause fo n .o ye ra fo ni d vile yre etta nded by vila e? mo htn & de hta p er gnancy ye ra fo o ctu ome de hta

1 2 3 4 5 6 7 8 9 10

Codes: Column 3: Live birth=1; Spontaneous birth=2; Still birth=3; Induced abortion=4 Column 4: Home=1; PHC=2; Govt. hosp.=3; Pvt hosp.=4; Other=5 Column 5: Untrained dai=1 ; Trained dai=2; Health worker=3; Doctor=4;Family members /Friends only=5 Column 7: Male=1; Female=2 Column 8: Yes=1; No=2

6. a. Are you currently pregnant? Yes=1; No=2 H ( If 5a= No and Q. 6a= No skip to Q11) b. If yes, Number of completed months c. How many times you had gone for the ANC check up during this pregnancy? H d. How many tetanus toxoid (TT) injections have you received for this pregnancy? H e. How many iron folic acid (IFA) tablets have you taken for this pregnancy?

52 - Evaluating an Integrated Reproductive Health Program Appendix A - Questionnaire MATERNAL HEALTH 7. Have you given birth in the past 3 years? Yes =1 No=2 (If No, skip to Q 11) H

8. If yes, during your last pregnancy a. How many times did you go for the ANC checkup? H

Place of visit Service provider Month of pregnancy

b. How many TT injections had you received? H At which months?

c. Did you receive IFA tablets? Yes=1 No=2 H If yes, how many?

9. How many times you had gone for the PNC check up? H

Place of visit Service provider Months after delivery H H H 10. Did you want to become pregnant at that time? H a.Wanted at that time only b. Wanted little later c.Wanted no more children d.Cannot say

11. Family Planning Yes=1; No=2

Fam yli He dra ?tifo Used? Du oitar n fo use Cu err yltn fI n ,o vig e alP n nin g (mo htn )s u nis g? er ason of r M hte ods sid co nitn u oita n

1 2 3 4 5 6

Vase otc my

Tube otc my

La orp scopy

IUD/Copp re T

O lar lliP

Condom

P oire cid ab nits ence

W hti ard w la

O ht re

Note: If column 2 is yes, go to column 3; otherwise skip to next method. If column 3 is yes, go to column 4; otherwise skip to next method. If column 5 is yes, skip to next method.

Evaluating an Integrated Reproductive Health Program - 53 Appendix A - Questionnaire 12. Interviewer has to check from the previous table that she is currently using any FP method, and write the method she is using ______

a.If no, ask the reason for not using any method? ______

b. If currently using spacing methods OP or condom, ask place of supply H 1.Government services 2.Gyne camps 3.Medical shops 4.Other (please specify)

13. Have you faced any gynecological or reproductive related health problems? H Yes=1; No=2 (If No, skip to Q 14)

If yes, what type of problems ______

______

Had you received any treatment for it? Yes=1; No=2 (If No, skip to Q14) H

If received, from whom? 14. Are you a member of any RH group? Yes=1; No=2 (If Yes, skip to Q 15) H If no, Is someone in your family a member of RH group? Who?

15. Is your husband a member of an agriculture group? Yes=1; No=2 (If Yes, skip to Q 16) H

If no, is someone in your family a member of agriculture group? Who? 16. Have you taken loan from RH group or any other group? Yes=1; No=2 H (If No, skip to Q 17)

If yes, what did you do with that money? ______

Did it increase your income? Yes=1; No=2 H

If yes, by how much? (Per year) If no, why? ______H 17. Do you discuss with your husband the RH issues discussed in the group? H (Yes= 1; No=2)

Does your husband discuss with you about the agriculture activities discussed in the group? H (Yes= 1; No=2)

18. Have you ever discussed with your husband about any of the FP method? H (Yes= 1; No=2)

Have you ever discussed with your husband about your family’s size? H (Yes= 1; No=2)

54 - Evaluating an Integrated Reproductive Health Program Appendix A - Questionnaire 19. Women’s empowerment Yes=1; No=2

P citra sralu Ye /s No

1 Do you own al nd ni yo ru name?

2 Do you have cash ni yo ru name?

3 Do you own orp du vitc e ass ste kil e an a in m ?la

4 Can you make sm lla househ dlo p cru hases on yo ru own? <( 100 R ).s

5 Can you make gral re househ dlo p cru hases on yo ru own? >( 100 R ).s

6 Can you at ke de oisic ns etaler d ot yo ru c erdlih n on yo ru ow kil,n e educ oita n ro m airra ge?

7 Can you ni v vlo e ni m roja househ dlo de oisic ns?

8 Can you move ola ne ni yo ru alliv ge?

9 Can you go ola ne ot hto re alliv ges?

10 Can you go ola ne ot yo ru m hto s're alp ce?

11 Can you go ot yo ru ne era ts m kra te alp ce ola ne?

12 Do you ni v vlo e ni yo ru alliv ge p citilo la a eitivitc s?

13 Do you p picitra eta ni pu cilb etorp sts ?

14 Can you a erg e rof etorp nits g ag nia ts a husband who be sta h re efiw ?

20a. Have you heard of an illness called AIDS? Yes=1; No=2 (If No, skip to Q 21) H (Record all the answers ) If Yes, How is AIDS transmitted? (mark all mentioned) HHHHHH 1.Sexual intercourse 2.Needles/blades 3.Transfusion of blood 4.Mother to child 5.Other ______6.Don’t know How one can avoid AIDS? (mark all mentioned) HHHHHH 1.Using condoms during sex 2.Sex with only one partner 3.Checking blood before blood transfusion 4.Sterilizing needles and syringes 5.Avoiding pregnancy if a woman has AIDS 6.Other______7.Don’t know

Evaluating an Integrated Reproductive Health Program - 55 Appendix A - Questionnaire 20b.Have you heard of any sexually transmitted infection? H Yes=1; No=2 If yes, do you know the symptoms of it? HHHHH (mark all mentioned) 1.Wound/Ulcers on genitals 2.Foul discharge/ white discharge 3.Itching/Irritation on genitals 4.Burning urination 5.Other______

21. Agricultural Activities a.Does your family have any land? Yes=1 ; No=2 (If No, skip to Q 21,d) H

b. If yes, does your family grow the following crops?

C or ps G or w? fI( NO, s pik ot ne tx orc )p Use of r househ dlo purpose?

C ere sla

P slu es

O li seeds

Veg ate elb s

stiurF

c.Do you follow improved agricultural practices? Yes=1; No=2 H If yes, 1.Do you have contour live hedges in four yields? H

2.Do you practice fall plowing? H

3.Do you practice mixed cropping? H

4.Do you planted fruit trees in your field? H

5.Do you practice IPM? H

6.Do you apply compost in your field? H

d.Do you engage in agricultural activities? Yes=1; No=2 H If No, skip to Q.22

If Yes, check which activities: 1.Sowing H 2.Weeding H

3.Harvesting H

4.Threshing H

5.Winnowing H

56 - Evaluating an Integrated Reproductive Health Program Appendix A - Questionnaire e. If yes, for how many months do you get to work? (If =1. skip to Q 22) H 1.12 months 2.9 -11 months 3.6 -8 months 4.3- 5 months 5.Less than 3 months

f. If it is not for 12 months, what do you do for the rest of the period? H 1.Non-agricultural work (Goundi, Brick making, etc) 2.Artisan (Pot making, Basket making etc) 3.Tailoring 4.Animal husbandry 5.House work 6. Other

22. Are you helped by the following group activities? Yes=1; No=2

a.Have you got services from Gyne camp? H b. Have you attended TBA Training? H

c.Do you attend group meetings regularly? H

d.Do you participate in Savings and Credit? H

e.Do you have access to Government Service? H

f. Have you benefited from trained TBAs? H

Evaluating an Integrated Reproductive Health Program - 57 58 - Evaluating an Integrated Reproductive Health Program Appendix B - Evaluation Training Schedule

4/26/01- Day One- Afternoon Session

1. Introductions – Subhash 2:00 – 2:10 2. Icebreaker — Laxmi 2:10 – 2:30 3. Objectives and key questions - Patil 2:30 – 3:00 4. Expectations – Hallad 3:00 – 3:15 Break 3:15 – 3:30 5. Questionnaire – Subhash 3:30 – 4:15 6. Questionnaire Methodology - Cat 4:15 – 4:30 7. Practice with Questionnaire 4:30 – 5:30 8. Suggestions and Modifications – Patil 5:30 – 6:00

4/27/01- Day Two

1. Review of Day One- Laxmi 10:00 – 10:15 2. Clarifications and Modifications of Questionnaire- Patil 10:15 – 11:00 3. Participatory Methodology - Cat 11:00 – 11:15 4. RH Historical Matrix- Hallad and Laxmi Presentation 11:15 – 11:45 Break 11:45 – 12:00 Practice 12:00 – 1:00 Feedback 1:00 – 1:15 Lunch 1:15 – 2:15 5. Capacity Evaluation- Patil 2:15 – 3:45 Break 3:45 – 4:00 6. Women’s Status- Dr. Subhas 4:00 – 5:55 7. Evaluation of Day 2- Kellye 5:55 – 6:00

4/28/01- Day Three

1. Review of Day 2- Laxmi 9:00 – 9:15 2. SSI – Group Men – RH- Laxmi & Patil 9:15 – 10:45 Break 10:45 – 11:00 3. SSI – Group Women – Ag -Dr. Subhash 11:00 – 12:30 4. Questionnaire Revision & Clarification- Hallad 12:30 – 1:30 Lunch 1:00 – 2:00 5. Wealth Ranking- Hallad 2:00 – 2:45 6. Gallery Walk- Dr. Subhash 2:45 – 3:00 (RHW’s copy steps for participatory exercises) 7. Calendar Presentation- Patil 3:15 – 4:00 Break 4:00 – 4:15 8. Wrap–up - Dr. Subhash 4:15 – 5:00 9. Evaluation – Kellye 5:00 – 5:15

Evaluating an Integrated Reproductive Health Program - 59 60 - Evaluating an Integrated Reproductive Health Program Appendix C - Health Service Maps

In the WN-India Karnataka program, linkages with health services are essential. One way in which the women’s groups learn about the Ministry of Health services that are available in their area is through health service maps. These maps, or guides, were developed by Laxmi Madras, WN RH Consultant. They describe in detail the location of the health services, the staff, the hours, the costs and the types of services provided by various levels of the Ministry of Health nearest each village. Thus community members know and can monitor the services that should be available at each level.

Health service maps can be developed for many levels of health care. Below are examples of the health service maps for Nellur, outlining 1) services provided at the nearest primary health care center (PHC), and 2) services provided by the auxiliary nurse-midwife (ANM) outreach worker. A health service map could also be done to describe services provided at the referral hospital.

Name of organization: BSRDS Village: Nellur PHC Center: Kadaganchi Distance from village: 7 kilometers Transport available: Yes Cost of transport: Rs.6

Information about Kadaganchi PHC Centre

No. of doctors on duty: One

Doctor on duty: 8am to 12 noon 3pm to 5pm

Staffing pattern: Male health workers Three ANMs Three Staff nurse One 1st division assistant One Pharmacist One Clinical officer One Cleaners Two

Area covered by PHC: 13 villages (Nellur, Kadaganchi, Dharmawadi, Basavantwadi, Aalur, Vijapur, Bamanhalli, Ladachincolli, Ladachincolli Tanda, Dannur, Dannur Tanda)

Operating theatre: Yes Surgery preformed: Tubectomy only- once a month Emergency equipment/treatment: None. Serious emergencies are referred to Gulburga, Alanda government hospital. Number of in-patient beds: 13 ANC, PNC & Immunization clinic: Thursdays Subcenters: 3

Evaluating an Integrated Reproductive Health Program - 61 Appendix C - Health Service Maps

ANM Services: Area covered: 5 villages (Nellur, Donnur, Donnur Tanda, Ladachincolli, Ladachincolli Tanda)

Services: Identifying and registering of pregnant women Immunization Provides information on family planning methods Supplies contraceptives Provides ANC/PNC Distribution of ORS packets Provides information about MTP

Frequency of visits to villages: Once a week (4 times a month)

ANC Services: Identifying and registering pregnant women Administering TT injections Providing IFA tablets (iron- folic acid) Providing information about nutrition Physical check for anemia (eyes)

Emergency obstetrical care: No

Refers emergencies to: Gulberga/Aland government hospital

Antenatal IFA tablets: 100 tablets for pregnant women

Postnatal IFA tablets: If woman diagnosed as anemic- 100 tablets

Information about family planning: 1) Permanent- Tubectomy, vasectomy and laproscopy 2) Temporary- condoms, oral pills and IUDs

Contraceptives provided by ANM: oral pills, condoms; refers for permanent methods and IUDs

Takes medical kit to village: Yes

Equipped with emergency drugs: No, the Ministry of Health has not supplied her with the necessary drugs

Safe delivery kits: Earlier the ANM provided. Currently there is a shortage from the MOH and she does not provide them. She gave them to pregnant women at 7th or 8th month or to the TBA.

TT injection schedule: 1st injection at 3rd month 2nd injection at 5th month if a woman gets pregnant within one year of last delivery, she gets a one booster dose at the 5th month.

62 - Evaluating an Integrated Reproductive Health Program More Lessons from the Field Responding to Reproductive Health Needs: A Participatory Approach for Analysis and Action (2001) This report and training guide documents experiences from two training of trainer workshops that were conducted over a two year period in Nepal. The workshops were designed to help trainers gain the skills to assist communities in identifying and addressing reproductive health needs. The guide is well illustrated with graphics and photos, and includes 15 training exercises with clear explanations of procedures for facilitating the workshops. 54 pages, available in English, Spanish, and French. $10.00, plus shipping.

Gender and Decision Making: Kenya Case Study (2000) This report presents the methods and results of a series of workshops focused on gender and decision making at the household level. Conducted by World Neighbors’ staff with participants from Makueni District, Kenya, the workshops helped community members discuss and analyze how decisions about family resources and childbearing were being made, and what impact these patterns had on men’s and women’s well-being. 22 pages, available in English. $5.00, plus shipping.

Integration of Population and Environment (1998) This collection of articles explores the creative ways in which World Neighbors and other organizations are addressing population and environmental issues at the community level. Articles include case studies of integrated programs as well as discussions on organizational needs and funding trends.

These papers were originally presented at the American Public Health Association’s 125th Annual Meeting in 1997. The authors represent a range of organizations involved in efforts to link population and environment, including Population Action International, The Summit Foundation, The University of Michigan Population-Environment Dynamics Project, World Neighbors, and World Wildlife Fund. 69 pages, available in English. $5.00, plus shipping.

Integration of Population and Environment II: Ecuador Case Study (1998) This publication presents the findings of a three-year Operations Research Project carried out in partnership by World Neighbors and the Ecuadorian family planning organization CEMOPLAF. The results support a compelling argument for implementing an integrated approach which combines reproductive health and agricultural/ natural resource management programming to address population and environment issues at the community level. Published by the University of Michigan Population- Environment Fellows Program. 26 pages, available in English. FREE!

These and other World Neighbors publications can be ordered by calling 405/752-9700, faxing 405/752-9393, by sending an e-mail to [email protected], or by ordering on-line at www.wn.org

Evaluating an Integrated Reproductive Health Program - 63 World Neighbors is a World Neighbors affirms the health, family planning, water grassroots development determination, ingenuity, and and sanitation, environmental organization working in inherent dignity of all people. conservation, and small partnership with the rural By strengthening these funda- business. poor in hundreds of villages mental resources, people are throughout Asia, Africa, and helped to analyze and solve Founded in 1951 and rooted Latin America. World Neigh- their own problems. Success in the Judeo-Christian tradi- bors brings people together is achieved by developing, tion of neighbor helping to solve their problems and testing, and extending simple neighbor, World Neighbors is meet their basic needs. By technologies at the commu- a non-sectarian, self-help supporting community self- nity level and by training local movement supported by reliance, leadership, and leaders to sustain and multi- private donations. World organization, World Neigh- ply results. Neighbors does not solicit nor bors helps people address accept U.S. government Program priorities are food funding. the root causes of hunger, production, community-based poverty and disease.

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