Individual interventions, collective lessons: Developing mid-range theory on women's groups to improve health.

Background: Interventions with women's groups have been widely implemented to improve health outcomes in low- and middle-income settings, particularly India. While there is a large evidence base on the effectiveness of single interventions, it is challenging to predict whether a women's group intervention delivered in one setting can be expected to work in another. Methods: We applied realist principles to develop and refine a mid-range theory on the effectiveness of women's groups interventions, summarised key lessons for implementation, and reflected on the process. We synthesised primary data from several interventions in India, a systematic review, and an analysis of behaviour change techniques. We developed mid-range theories across three areas: maternal and newborn health, nutrition, and violence against women, as well as an overarching mid-range theory on how women's groups can improve health. Results: Our overarching mid-range theory suggested that effective interventions should: build group or community capabilities; focus on health outcomes relevant to group members; and approach health issues modifiable through women's individual or collective actions. We identified four key lessons for future interventions with women's groups, including the importance of skilled and remunerated facilitation, sufficient intensity, supply-side strengthening, and the need to adapt delivery during scale up while maintaining fidelity to intervention theory. Conclusions: Our experience demonstrated the feasibility of developing mid-range theory from a combination of evidence and insights from practice. It also underscored the importance of community engagement and ongoing research to 'thicken' mid-range theories to design effective and scalable women's groups interventions in India and similar settings.

'We are the bridge': an implementation research study of SEWA Shakti Kendras to improve community engagement in publicly funded health insurance in Gujarat, India.

INTRODUCTION: India's efforts towards universal health coverage include a national health insurance scheme that aims to protect the most vulnerable from catastrophic health expenditure. However, emerging evidence on publicly funded health insurance, as well as experience from community-based schemes, indicates that women face specific barriers to access and utilisation. Community engagement interventions have been shown to improve equitable utilisation of public health services, but there is limited research specific to health insurance. We examined how existing community-based resource centres implemented by a women's organisation could improve women's access to, and utilisation of, health insurance. METHODS: We conducted an implementation research study in Gujarat, India to examine how SEWA Shakti Kendras, established by the Self-Employed Women's Association, worked to improve community engagement in health insurance. SEWA organises women in the informal sector and provides social protection through health, insurance and childcare services. We examined administrative data, programme reports and conducted 30 in-depth qualitative interviews with users and staff. Data were analysed thematically to examine intervention content, context, and implementation processes and to identify enablers and barriers to improving women's access to health insurance through SEWA's community engagement approach. RESULTS: The centres worked through multiple channels-doorstep services, centre-based support and health system navigation-to strengthen women's capability to access health insurance. Each centre's approach varied by contextual factors, such as women's digital literacy levels and rural-urban settings. Effective community engagement required local leadership, strong government partnerships and the flexibility to address a range of public services, with implementation by trusted local health workers. CONCLUSION: SEWA Shakti Kendras demonstrate how a local, flexible and community-based model can serve as a bridge to improve utilisation of health insurance, by engaging women and their households through multiple channels. Scaling up this approach will require investing in partnerships with community-based organisations as part of strategies towards universal health coverage.

Understanding the role of female sterilisation in Indian family planning through qualitative analysis: perspectives from above and below.

Since the 1990s, the global approach to family planning has undergone fundamental transformations from population control to addressing reproductive health and rights. The Indian family planning programme has also transitioned from being vertical, target-oriented, and clinic-based to a supposedly target-free, choice-based programme that champions reproductive rights. Despite contraceptive choices being offered and voluntary adoption encouraged, there is a heavy reliance on female sterilisation. Community health workers, known as ASHAs, are responsible for on-ground implementation of family planning policies and are incentivised to promote sterilisation as well as other methods. This study explored perspectives to understand of the role of female sterilisation in Indian family planning and whether policy is reflected in implementation. Secondary ethnographic data from Rajasthan, which included twenty interviews and five group discussions, were used to understand the perspectives of ASHAs. Primary data included five key informant interviews to understand the perspectives of experts nationally. Data were analysed thematically with a combination of deductive and inductive coding. Themes that emerged included choice, population control and coercion, family planning targets, quality and experience of services, historical factors and social norms. Despite the official policy shift, there appears to be narrow implementation which is still target-driven, relies heavily on female sterilisation, while negotiating between achieving population stabilisation and upholding reproductive rights. There is a need to emphasise spacing methods, ensure a rights- and choice-based approach and encourage male participation in reproductive health decisions.