Development Actions by Pooling Resources

The foundation has partnered with a local NGO to implement HBMNC in this area. Young women from the region who have received education up to an undergraduate level or diploma in midwifery or nursing are enlisted for this program. Each of these young women works with about 15 – 16 ASHA workers to enhance their awareness and capacity and ensure that essential care is given to pregnant mothers.

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Introduction

There are foundations which pool together resources from a number of individuals and fund development actions. These are different from those which are endowed by the wealth of an individual, family or industrial house. The former type is useful in multiple ways. It enables middle-class individuals to contribute a part of their income/​wealth towards a notable impact on society. Such individuals would incur a higher share of their resources as transaction costs’ if they were identifying and funding suitable development actions directly. But in this case, transaction costs (or the share of resources to be spent by each individual) come down drastically. These foundations encourage many not-so-rich individuals and families to set aside a part of their resources for social/​development purposes, thus enhancing the availability of resources for altruistic actions in society. It may be noted that the contribution by such individuals is an important part of the funding for charity in developed countries like the USA.

These foundations face different kinds of challenges compared to those that spend money from one individual or corporate entity. Attributing specific actions to the support of a particular individual could be difficult but there can be innovative solutions for this purpose. There may be individuals who are bearing the full cost of an action in a particular locality or for a set of beneficiaries. In which case, the attribution is not a major issue. However, there can be other challenges due to the need to design and implement actions which can easily signal the effectiveness of spending to such (relatively small) donors. For this reason, there could be a focus on those actions which may have tangible outcomes and can be achieved within a reasonable time. However, there are limitations in pursuing only such actions in the development domain. This article discusses this issue based on the experience of such a foundation, which pools resources from several individuals and uses these for improving public health, education and livelihood in India. This article is based on a short-period field-work on the activities of the foundation in the domain of public health in an area near Visakhapatanam in Andhra Pradesh.

Work of the foundation

This is a tribal belt where the levels of maternal and infant mortality are very high. Hence, the foundation decided to extend its Home-Based Maternal and Neonatal Care (HBMNC), a strategy developed by another organization called, SEARCH that works in the tribal areas of Gadchiroli district in Eastern Maharashtra. Their core strategy is to enhance the capacity of Accredited Social Health Activists (ASHA) in these villages so that they can make people aware of certain desirable practices that can be adopted at home and also to persuade pregnant mothers to opt for institutional child-delivery.

The foundation has partnered with a local NGO to implement HBMNC in this area. Young women from the region who have received education up to an undergraduate level or diploma in midwifery or nursing are enlisted for this program. Each of these young women works with about 15 – 16 ASHA workers to enhance their awareness and capacity and ensure that essential care is given to pregnant mothers. It must be noted that most of the ASHA workers in the region are illiterate and have not received adequate training. Hence, there is a need for handholding them. It is the NGO partner which has recruited the girl-volunteers and the cluster and block coordinators to supervise them. The foundation pays the honorarium to them through the NGO. In addition, the foundation has set up a local office with trained personnel to deal with issues related to advocacy and liaison with state government officials in the region.

The authors had detailed interactions with the project team of the foundation and visited a couple of villages where it works to meet the beneficiaries. The project team is highly motivated and sensitive to the needs of the area. They have also established a good rapport with the people in the communities where they work. Though the focus is on women, there is a good rapport with the males of these communities too.

There is a visible change taking place in these communities. Child delivery in almost all cases is in hospitals, even though there are a few home deliveries due to the non-availability of transport or other such reasons. The ASHA workers create awareness among pregnant mothers and among women who are in the child-bearing age (on spacing and use of contraceptives). The set of women with who we interacted showed a high level of awareness regarding the need for institutional delivery of children. Rather than the impact, we focus here on the experience of the foundation in this locality to understand certain challenges faced by such foundations which pool resources to carry out their work.

Issues in focus

In the last two years, the foundation has started a new program focusing on adolescent health in the same region on its own, that is, without partnering with the NGO. This new program indicates two important trends in the functioning of the organization. First, with the decision to start operations on its own, the foundation has become an operational organization in this region. What may have compelled the organization to take this decision and the implications could be important lessons for other such organizations.

Secondly, the decision to work with adolescent girls is part of an attempt to go beyond the strengthening of ASHA workers and training them for HBMNC. This could be based on a realization that there is a need to change practices beyond those adopted during the time of pregnancy and childbirth if the objective is to reduce maternal and infant mortality. This realization and change in strategy are expected from a learning organization. However, the new strategy may have implications on the organization which depends on funds from a specific type of source. These are the two issues that we focus on in this article.

Partnering with local NGO

When the foundation decided to improve the maternal and infant mortality through HBMNC in the area, it opted to work with a local NGO. This decision could be based on a number of considerations, for example, the foundation did not have local contacts to connect with the tribal communities and to identify and select local employees; and managing the relationships at the local level could be difficult for a Delhi-based organization. In specific terms, the NGO hired local volunteers and coordinators at the cluster and block levels who oversee these volunteers. The foundation transferred the money (compensation for these local employees) to the NGO, which made the payments. The NGO leadership was entrusted with the tasks of managing employees and to see that they work according to the agreement between the two partners. In addition, the foundation started a local office in the same area for advocacy and to liaison with the district and state-level officials.

However, there are certain issues which have worked against the smooth relationship between the partners. Some of these are discussed below:

Local contacts

Not all NGOs develop good, local contacts over time. They may have started with a project funded by the government or other funding organizations and recruited local employees or volunteers for a specific period to carry out the activities specified in the project. There could be a budget to meet the overhead costs or surplus that may ensure the financial sustenance of the NGO, which may move from one funded project to another. These activities may not necessarily enable it to develop deep connections within the communities or have a higher stake in the long-term development of the targeted population or region. There could be two related trends:

Some NGOs depend on the government for projects (especially, in a tribal region where there are many schemes for tribal development and the government machinery may not have enough people for implementation). This may discourage them to provide full information (lack of transparency) or take on the government on an equal basis. On the other hand, foundations with access to a sizable amount of resources from non-governmental sources can establish contacts with the government relatively easily and can deal with the officials on an even basis.

Some NGOs are closer to (or like) people’s movements. They may be taking an adversarial approach to the government on certain issues, which can work against their effective participation in certain development actions with specific objectives, like the reduction of maternal mortality or fertility. (Although foundations are less likely to support movements and work towards specific improvements in development indicators. They are much more likely to work in collaboration with the government).

Financial transparency

There are difficulties in ensuring full financial transparency in the relationship between funders (like foundations) and NGOs, discussed here. NGOs may not have an endowment or a core grant and hence, may need money for the maintenance of the core staff (including founders) during the lean periods when there are no projects. Many funding agencies may not accept the demand for such an allocation if it is made transparently. Hence, there could be non-transparent ways of saving money, which may include a certain over-estimation of the budget required for specific projects. There can also be non-transparency in the expenditures of the NGO for this reason.

The funding organization may have an interest in the outcomes of the project (since it is responsible for responding to the queries of donors and the possible implications of the changes in government programs/​policies for the expansion of its own activities). There could be differences in the interests of the funding organization and the local NGO. This is a typical principal-agent problem and it may create certain tensions in the relationship between them.

Monitoring and control

It is the local employees (hired by the NGO) who carry out the activities of the project. The role of the NGO leadership is to oversee the work of these employees. However, the field office of the foundation is physically closer to these local NGO employees and the foundation may have an interest in some level of control’ of the activities of these employees. This kind of a situation is likely to create difficulties due to the two sources of control, and the perception of the foundation that direct monitoring of the employees to achieve its objective is better than accomplishing it through the NGO.

This choice before foundations on whether to work with a partner NGO or directly is a common issue. We have discussed here that there could be multiple factors that may encourage a foundation to be an operating organization. These include difficulties in dealing with NGOs, nature of the impact that the foundation wants to make, long-term plans etc. Foundations must consider these before getting into a partnership with an NGO.

However, there are challenges in becoming (or working as) an operating organization. Certain development activities may require the service of local people, who may not be well-educated for a short period. The working conditions (short-term contracts with relatively low salaries or honorariums) of these people is different from that of the full-time employees of the foundation. It may be difficult to facilitate the transition of the former into the latter, that is, to full-time employment with the foundation due to their low educational and skill levels. These can create conflict situations within the organization. Terminating their work after the project (without other employment options) could be a difficult decision for the leaders of a foundation. Hence, there are pros and cons of becoming an operating organization for a foundation, and these must be taken into account while choosing this model.

Factors affecting outcome

The primary objective of the program is the reduction of neonatal and maternal morbidity and mortality with HBMNC as the solution where institutional care is not available or accessible. However, since there have been improvements in the availability of public services even in the remote parts of the country, HBMNC may not be relevant in areas where child delivery has moved from home to hospital. However, since the training of ASHA workers on HBMNC is a relatively tractable and tangible initiative that can be monitored relatively easily, it may enable the organization to source funds from individuals. This may encourage the foundation to continue with HBNMC.

HBMNC is useful when a female is in the process of childbearing, delivery and infant care. However, the maternal and neonatal morbidity depends on many other factors. We discuss these in the following sub-section.

Intersectionalities in public health

All too often, we are tempted to box a development initiative as a public health intervention’, a livelihoods program’, or an education project’. While categorization has its own advantages, namely, ease of monitoring, receiving grants, accountability to donors, and tackling bigger development issues in bite-sized projects, the compartmentalization cannot be water-tight. Identifying and harnessing the intersectionalities (here, we specifically refer to how different social categories, such as gender, caste, language, class, etc., overlap to form identities within a community or a given location) when tackling a given development challenge helps an organization better contextualize and acknowledge ground realities and successfully implement the intervention to achieve its goals. This holds true, especially when dealing with traditionally marginalized or vulnerable communities.

Language and education: Understanding this gap

There is an abundance of literature linking positive health outcomes to higher levels of education. Education and knowledge are important factors that can help reduce infant and maternal mortality rates among tribal communities. But the lack of interest in schooling among girls in this community is partly driven by communication and learning barriers arising from the fact that the medium of instruction in educational institutions is different from their mother tongue.

Since a significant percentage of the tribal population, especially women, cannot read, key trainings and vital program information are relayed to them through audio-visual means. In this scenario, it is vital that the information being presented to them is in a medium that they are most familiar with and understand. To this point, the organization has delivered several photographic and model-based trainings, which to a large extent, are able to overcome the language barrier. However, it is still important to ensure that the best possible material and trainings are delivered in a fashion that the beneficiaries, understand and retain these. While the jury is out on what makes a good translation, it can be said that the potential for missing or misunderstanding certain points in translation is significantly high, especially when the translator has not been trained for work in this domain.

Therefore, the key challenge after identifying and acknowledging language intersectionality in public health is not how the tribal population in the region can be assimilated into the mainstream’, but rather how a mutual relationship between the tribal population and mainstream society can be developed as a way to empower the tribal population and improve health outcomes.

Need for community engagement and role models

Role models that look like us, speak like us, and are from the same communities as us, have a better chance of galvanizing positive social change within our communities. For example, high dropout and low literacy rates among tribals, particularly women, make it highly unlikely that the teachers teaching in local schools are tribal women from their own communities.

In addition to motivating social change, building a strong community network has several advantages. It enhances the legitimacy of and trust in the organization and of its new initiatives, thereby reducing future transaction costs. A better community network also enables quick and efficient dissemination of information and provides a safety net for the tribal women. Additionally, role models and community networks imbue a sense of trust and collectivism that might give women the courage to voice behavioural trends, program-related concerns or their needs. These, in turn, enable a foundation working with them to understand the true impact of their interventions.

Agency and gender

One of the most vital intersectionalities is that of gender – how gender dynamics affect the outcomes of the HBMNC initiative. In our interviews, we noted that most women lack agency over their sexual and reproductive lives. This lack of agency also extends to birth control and contraceptive usage. Therefore, interventions regarding contraceptive use or child spacing, when given to women only, are woefully incomplete. The foundation addressed this by starting a training program for adolescent boys to tackle stigmas, behaviours, and internalized narratives. While this initiative is an incredible step in tackling the existing gender imbalance early and bringing about a mindset shift, the impact of this intervention will not be observed for several years to come. Therefore, it is vital to also conduct similar trainings for men, primarily young and recently married men, to work towards reducing the high fertility rate. Involving both men and women in the conversations regarding reproductive and sexual rights and safe practices will not only increase contraceptive use and child spacing (and in turn, reduce infant and maternal mortality) but also lay the foundation for organically challenging gender hierarchy and gender imbalance.

Unemployment, alcoholism, and recreational sex: The vicious cycle

This learning is important when trying to contextualize and design programs aimed at reducing fertility rates and improving child spacing. Unemployment is another external factor that might impact fertility rates amongst women in these villages. Across the villages that we visited, almost all the men were unemployed (they are usually employed only seasonally during the harvesting season), with only a handful of them holding a job. Lack of work, combined with a prevalence of alcoholism, creates a situation in which the couple might indulge in unprotected and frequent sexual acts, further compounded by women’s lack of agency in this matter (both when it comes to copulation and the use of contraceptives). In some cases, men’s feelings of lack of control over their lives manifested in them controlling and demanding certain sexual behaviours from their wives, which, based on the existing gender dynamic, is an element under their control.

Additionally, we noted that while women were open to using oral contraceptives, there was the issue of access and for some, the fear of being found out by their husbands. Therefore, while oral contraceptives are a great way of restoring some amount of reproductive agency back to the women and giving them a say in family planning, they are only a part of the solution. Further, addressing livelihood concerns among the tribal population through vocational trainings and skilling workshops would help them seek jobs in the nearby towns, thus, engaging them productively and providing a source of reliable year-round income. This would also allow parents to have the monetary resources to properly feed, raise, and educate their children, the positive impact of which would be seen in the future generations.

As this intersectionality suggests, reducing maternal and neonatal mortality and encouraging safe reproductive practices (including contraceptive use and child spacing) can only truly be achieved by working at the intersection of education, livelihood, and public health. In this regard, by targeting adolescent youth, including boys, the foundation is attempting to address the complexities of this public health challenge before it manifests.

Local terrain, agriculture and lack of nutritious diet

An overall, general lack of adequate nutrition, specifically, in pregnant women and new-borns, is a vital factor that affects the HBMNC program. During our visit to the village, we noted that the key source of employment is agriculture and the main food source is the local grains grown in the region along with Ragi malt. Far from being a nutritional and balanced diet, the current diet leaves the tribal population just short of constant hunger. Open defecation is also widespread which can cause water-borne diseases and malnourishment.

Through various government initiatives and efforts of NGOs, pregnant women are able to avail a portion of eggs and iron supplements from the local Anganwadi centres. However, an organic and local fortification of a diet and nutrition intake is an important factor in reducing infant and maternal mortality rates in the long run. We noted that although all the villages had some cattle, milk from the cattle was not a part of their daily diets. In one of our interviews, the villagers voiced their concerns regarding the lack of good and reliable food sources.

Malnutrition not only directly impacts maternal and neonatal mortality; it also indirectly affects the entire population by reducing their productive capacity for physical or mental labour. Understanding the local terrain and geography and harnessing it to fortify diets using naturally growing local crops or cultivating indigenous crops best suited to the terrain that are able to satisfy the nutritional needs of the community, is vital for ensuring a sustainable improvement of local diets. The use of generic diet plans by various nutrition-based interventions, ignorant of the geographic realities of the region and population, makes the population dependent on such interventions, which may or may not be available in the long-term. Therefore, making the tribal populations self-sufficient in their dietary needs, aids governments and organizations achieve their impact more efficiently and sustainably.

In essence, there are multiple factors that seem to work towards a higher level of neonatal/​maternal mortality/​morbidity in the area. (There could be other relevant issues such as the lack of access to land and forest resources, the quality of education which may prevent them from getting jobs which require education and so on, and we have not explored these issues adequately). If a foundation wants to improve the situation of the targeted population significantly and on a sustainable basis, it may have to work on some of these issues. However, the ability to work on these other factors depends on several conditions. Does the foundation have a long-term interest in working in the region? Is it aiming at a comprehensive/​integrated development of the area? Both these depend on its ability to get financial resources for such purposes, which may not be very easy for a foundation which sources money from one or more individual (relatively small) donors who may be interested in providing a relatively small amount of money for a short period for a visible impact. This is possible only if a foundation is able to get the support from a donor or donors who are willing to contribute for changes on several aspects, over a longer period of time (even if these changes are not visible in the medium term).

Working with government 

Non-governmental organizations (including foundations) may follow different strategies to work with governments. Small NGOs may work on specific projects of the government, and this could be a source of funding for such organizations. However, foundations which have their own private sources of funding, may design and implement their actions independent of governmental programs. There are many charity organizations which help sections of people directly – giving scholarships to students, running hospitals and so on.

However, some foundations may want to bring about a systematic change in society. They are aware that their work alone (irrespective of the resources that they have) is not going to make a systematic change in social domains, such as education or healthcare, which require the involvement of government (and the transformation of governance or the delivery of public services). The role of such organizations could be two-fold. In certain cases, these may work directly with the people and encourage them to demand better services from the government. The other option could be to carry out certain innovative and effective practices in specific localities in collaboration with the government and persuading and expecting the government to scale up so as to make visible changes in the public system as a whole. However, working with the government to bring about a systematic change has a number of challenges.1

It consumes a lot of time and the outcomes remain uncertain. This is complicated by transfers of officers in the government (these can be arbitrary and frequent). There are also limitations in the way the government (especially in countries like India) learn from and scale up the actions that it has carried out in collaboration with an external partner like a foundation.2

These delays and uncertainties may create problems for foundations which pool resources from several relatively small donors. Each one of them, though may be willing to support direct actions where the beneficiaries and the change in their situation are visible; may not be willing to support the time and energy of personnel required to work with the government.

Concluding observations

Our observation is that the organization has been able to mobilize resources from individual donors and use these with the goal of enhancing the quality of life and welfare of underprivileged communities in the region. However, a few more steps are needed to enhance its effectiveness.

Other interventions required

Training ASHA workers on HBMNC or interacting with adolescent girls are important, but these may not make a substantial improvement in the life of people (including the reduction of maternal and infant mortality). It may require actions on other fronts as well, such as the nutritional intake of people, completion of schooling by girls, reduction of the fertility rate, delay of first pregnancy, adequate spacing between childbirths, and so on. Interventions in livelihood combined with programs for behavioural change may be needed to enhance the nutritional intake among these people. There is also a need for community-based gender sensitization to give women greater say in reproductive choices and to minimize their desire for male children, which leads to more number of children. There can be a visioning of social transformation in the area and specific actions can be designed with that vision. The organization may have to look for donors who may be interested in a long-term and integrated engagement in the area. This may require newer ways of engaging with or convincing donors since the outcomes of these actions could be intangible and of long-term in nature.

Enhancement of engagement with government

The level of engagement with the government may have to be enhanced. There must be a periodical assessment of the experiences and lessons and these may have to be communicated to government agencies. There is a need to work with them closely to facilitate changes in the policies and programs that enhance the welfare of the targeted people. Working with local governments can facilitate the scaling up of the development actions.

Empowerment and employment

A foundation’s decision to carry out operations on its own (without depending on the partner NGO) is useful but may require strengthening of the leadership team so that the responsibility to manage the daily operations will not take away the energy and time from advocacy and working with the government. There must be a plan for the empowerment and long-term employment or livelihood of girls and others from local communities who are part of the project. There can be education/​training programs catering to their needs, which would enable them to get jobs (or other sources of livelihood) when the project ends. This is important for the wellbeing and reputation of the organization and in creating role models in these tribal communities.

Authors

V Santhakumar, Professor, Azim Premji University, Bangalore

Pallavi Deshpande is an Economics graduate from Claremont McKenna College. She served as an American India Foundation (AIF) Clinton Fellow from 2019 – 2020 where she worked on developing educational and vocational programs for people with visual impairment from marginalized backgrounds in Andhra Pradesh. She is interested in working at the intersection of education policy, local governance and programs, and gender.

Akansha Singh currently works as Program Associate for ECHO at Equalize Health. She is responsible for executing and providing operational support to coordinate the program ECHO and engage with different stakeholders. She did her MA in Development from Azim Premji University. Akansha worked with the American India Foundation where she was supporting (monitoring and evaluating) their public health projects.

Subrat Kumar Mishra, Program Manager, Students Affairs, Azim Premji University

Featured photo by Shruti Parthasarathy on Unsplash