1. Pahel – towards empowering women Supported by The David and Lucile Packard Foundation 2011 -2015

2. Pahel: Aims and Objectives Building leadership skills in elected women representatives (EWRs) from Panchayati Raj Institutions (PRI), so that they:  Participate effectively in meetings of PRI and community action for health processes (NHM)  Take actions to improve health services relating to Family Planning and Reproductive and Maternal Health  Address development issues in their constituencies.

3. Project coverage PartnerDistrictBlock DORDAurangabadDaudnagarObra IDFMuzaffarpurGaighatMinapur NirdeshSitamarhiDumraRunnisaidpur 1200 EWRs from all three levels of PRI – Gram Panchayat, Panchayat Samiti and Zila Parishad

4. Strategies – Capacity development of EWRs (three day trainings on PRI structures/processes, gender inequality and public health delivery system in the context of FP/RH) to support better participation in Panchayat meetings and more pro-active role around issues of health, education, etc – Support to take planned, concrete actions on improving FP/RH/MH services and uptake, based on evidence generated through administration of checklists – Mentoring through collective forums, Mahila Sabhas – Working with Departments of PRI and Health at district level to help fill the gaps and implement solutions

5. Activities Training – on role and responsibilities, gender, health and education issues/services Mahila Sabha – quarterly meetings to build solidarity platforms Support to participate - in Panchayat meetings and interface with officials Use checklists - to monitor health services in their areas and raise findings at Panchayat meetings Convergence meetings at district and block level to place their findings before officials Exposure visits inside and outside the state Pilot IVRS mShakti for monitoring services

6. Focus on Monitoring Health Services Four levels VHSND, HSC, PHC and DH- (based on Indian Public Health Standards and NRHM guidelines) – Infrastructure – Personnel – Community Participation – Availability of equipment, drugs and other supplies – Provision of services – Quality of logistical arrangements

7. Checklist Administration Process Orientation and training on different components of checklists, service provision at various levels, women’s entitlements and the role of stakeholders Initial handholding support by field animator during the visit to the facility Checklists administered in pairs or groups of 3-4 Observation and verification against available records before entry in checklist Group Debriefing after facility visit Move to pictorial checklist in round 3 Checklist administered in 2012, 2013 and 2015

8. Actions based on checklist findings Data analysed and distilled into specific asks Raised in Panchayat meetings, Gram Sabha and the VHSNC Presented annually at block and district level convergence meetings

9. Annual Convergence meetings at Block and District emerge as a forum for advocacy and engagement(EWRs, department of Health, ICDS and PHED) Rajiya Devi, Mukhiya Minapur Panchayat of Muzaffarpur district informed regarding the non availability of free medicine at the PHC Sunita Devi- Ward Member of Raghopur panchayat, Muzaffarpur, raised the issue of insufficient supply of vaccines on VHSN Day Raheja Khatoon of Bawandiha Gram Panchayat, Aurangabad, asked for oxygen availability to be made mandatory in the ambulances for referral cases to Patna. A pregnant woman from her Ward died en route to Patna because of non-availability of oxygen facility in the ambulance Civil Surgeon commits to two ambulances available at each PHC (Obra and Daudnagar) in Aurangabad and Urged Mukhiyas to follow up on JSY payments Civil Surgeon issued an order to the Medical Officer In-Charge of Dumra and Runnisaidpur PHCs and relevant ANMs, to work with the Pahel local NGO partner, Nirdesh for utilisation of untied funds.

10. EWRs taking action in other areas beyond Health Other social issues Girls’ education Child marriage Entitlements under various government schemes Functioning of the PRI Regularity of meetings Transparency Accountability of officials, Usage/disbursal of funds.

11. End line Findings: Increase in knowledge of responsibilities as PRI – Improving general health services went up by 71% (from 8% to 79%) – Improving family planning, went up by 56% (from 14% to 70%) – Ensuring availability of safe drinking water, increased by 70% (from 12% to 82%) Increase in awareness of different components of reproductive health from 20% (baseline) to 52% (endline)

12. Results: Participation and Raising Issues EWRs raising issues of FP/RH during various meetings went up from 19.5 to 42% EWRs meeting with ANMs, and ASHAs 4.3 and 6.3 to 46 and 51% Participation in VHSND has increased from 29% in the Baseline to 81% 62% EWRs are attending an average of two VHSNDs in a quarter as against baseline of 29% attending at least one of the last three VHSNDs in last three months 83% EWRs are attending at least one meeting - Panchayat level meetings and meetings with officials every quarter

13. Self Assessment – agency, mobility I make sure that ante natal check ups are conducted as per procedure and that the weighing and blood pressure machines are functional – Savitri Devi, Mukhiya In this man’s world educated people like the Block Development Officer and other officials would not notice me. Now I can ask them to do their work- Prabha Devi, Ward Member I want to be the Mukhiya in the next elections and work for my Panchayat – Meena Devi, Ward Member Now people refer to my son as the Ward Member, Hena’s son, which is something unusual in our society – Hena Jha, Ward Member

14. Checklist Finding Comparisons: A few Samples

15. Findings: VHSND level - Supplies Overall availability of supplies during VHSND improved from an average of 45% availability during round 2 to 56.3% during round 3

16. Findings: VHSND level - Services Provision of ANC services Overall increase from an average of 52% during round 2 to 70% during round 3 Duration of VHSND VHSNDs being held for 5-6 hours increase from 53% during round 2 to 69% during round 3

17. Findings: HSC level – Supplies Functional supplies Overall availability of supplies at HSC improved from an average of 56% availability during round 2 to 60.1% during round 3

18. Findings: HSC level – ANC Services Provision of ANC services Improved from an average of 50% during round 2 to 57.6% during round 3

19. Learning from implementation experience High levels of illiteracy of EWRs, barriers of patriarchy, lack of exposure and skills overcome over time through sustained mentoring PRIs a transient cohort to a certain extent, but EWRs motivated by a desire to be valued by family, wanted respected in the community Most impact at level of Panchayats – regular monitoring of VHSND and HSC Only local solutions, like the use of untied funds, functioning of VHSNC,etc. For larger systemic issues like appointment of doctors, availability of lady doctors, electricity, running water, advocacy at State level is critical Over time a positive and constructive relationship established EWRs with the frontline workers (AWW, ASHA,ANM)has enabled them to work together to improve services and uptake Capacity Strengthening is a core input and needs engagement and mentoring

20. Scale and Sustain, Share and Replicate

21. Collaboration: Centre for Catalyzing Change and PFI Aim to test efficiency of low cost tech solution as a supplemental add on mShakti: IVRS pilot

22. I know I have the power to demand improvements in our schools and health centres. I take my community members along with me when I go to the District Headquarters to meet officials. Akhbari Khatun, Ward Member, Gaighat village, Muzzafarpur district