2004年-世界发展银行全球_India___Assessing_the_Reach_of_Three_SEWA_Health_Services_among_the_Poor_35页_1mb

Summary of India: Assessing the Reach of Three SEWA Health Services among the Poor

Core Content

This paper evaluates the extent to which three key health services provided by the Self-Employed Women's Association (SEWA) in India reach the poorest segments of the population. The study is part of the World Bank's Reaching the Poor Program, which aims to understand the challenges and opportunities in delivering health, nutrition, and population services to the poor. The three SEWA health services analyzed are:

• Mobile Reproductive Health (RH) Camps
• Tuberculosis (TB) Detection and Treatment Program
• Women's Education Sessions

The research is based on both quantitative and qualitative data collected from urban and rural areas in Gujarat, with a focus on the socioeconomic status (SES) of service users and the reasons behind their access or non-access to these services.

Main Findings

Quantitative Findings

• Urban Areas:
  All three SEWA services are predominantly used by people from poorer households. About half of the clients of each service belong to the poorest third of the population.

  • The RH mobile camps serve approximately 12,500 women annually, with a Rs. 5 consultation fee and one-third of the cost of medicines.
  • The TB detection and treatment program involves 575 patients under treatment at DOTS centers and 23 by barefoot DOTS workers, with 97% sputum conversion rate among those who complete treatment.
  • The women's education sessions reach around 6,000 women annually, with a Rs. 5 membership fee.

• Rural Areas:
  The economic status of those using the RH and education services does not differ significantly from the general population. However, the TB detection and treatment program is less accessible in rural areas due to its urban focus.

Qualitative Findings

• Urban:
  The services are attractive to the poor due to:

  • Proximity to service locations.
  • Delivery by the poor themselves (e.g., barefoot doctors).
  • Promotion efforts in poor communities.
  • Relatively low cost.
  • SEWA's favorable reputation.

• Rural:
  The main barriers to service utilization include:

  • Timing of services conflicting with working hours.
  • Perceived high cost of services.
  • Lack of accessibility and limited outreach.

Key Services and Their Characteristics

Methodology

The study was conducted in Ahmedabad district (population 5.8 million) and Kheda/Anand district (population 3.8 million), where SEWA Health operates intensively. It involved three phases:

1. Phase 1:

   • Conducted six focus group discussions (FGDs) and six in-depth interviews with SEWA Health service users and providers.
   • FGDs included four women each, with two users and two non-users of the services.
   • Interviews were conducted in Gujarati and videotaped with permission.

2. Phase 2:

   • Aims to interview 500 users per service, totaling 1,500 interviews.
   • Data were collected using a questionnaire that included questions about:
     • Service user characteristics
     • Family and household attributes
     • Perceptions of the services
   • The DHS 1998–99 and Vimo SEWA data were used as reference databases to determine SES.

3. Phase 3:

   • In-depth interviews with SEWA Health workers to explore the factors contributing to the success of urban services.

Limitations and Implications

Limitations

• Sample Size: The study collected more than the required number of interviews to ensure reliability.
• Exit Survey Data: The data were collected at the point of service use, which may not fully represent the broader population.
• Comparability: There may be differences in how the reference standard and exit survey data reflect SES due to varying data collection methods and definitions.

Implications

• The study highlights the effectiveness of SEWA's services in reaching urban poor.
• It underscores the importance of accessibility, affordability, and community-based delivery in improving health service utilization among the poor.
• The findings suggest that targeted outreach and community engagement are critical in overcoming barriers to service access.
• There is a need for improved rural outreach, particularly for services like TB detection and treatment, which are less accessible in these areas.

Conclusion

The study provides valuable insights into the reach and equity of SEWA's health services in Gujarat. While urban services are well-targeted at the poorest, rural areas show less effective coverage, particularly for TB services. The research supports the use of community-based and low-cost models to improve access for the poor, and emphasizes the role of local trust, promotion, and proximity in service utilization. The findings can guide future health service design and policy in reaching marginalized populations effectively.