The Society for Nutrition, Education and Health Action (SNEHA) has been working to improve health outcomes among women and children in Mumbai’s informal settlements for over two decades. The mainstay of SNEHA’s approach is to work in close proximity with people in vulnerable urban communities, while also working with public institutions – especially health systems – to address the social determinants of health and ensure that services reach underserved populations. Between 2016 and 2019, SNEHA’s programmes helped reduce wasting among children under three from 17% to 12%, increase early registration of pregnancies from 17% to 36% and reduce unmet needs for contraception among married women of reproductive age from 18% to 11%. SNEHA’s programmes have also helped cut anaemia among adolescents, from 49% in 2019 to 26% in 2020.
Promoting community engagement
Over the years, SNEHA has worked with people to build capacity within communities ‘to expect, demand and negotiate availability and improved quality services from the health systems’, and to undertake responsibility for the wellbeing of their mothers, children and adolescents.+1. Child Health and Nutrition draft proposal 2015 This is accomplished by giving community members the right health messages, referrals to health facilities and information on how to access these services and what to expect. A network of some 4,000 community volunteers recruited and trained by SNEHA, the majority of them girls and women, participate in community events and meetings, disseminate health-related information, assist community members to access health services and support the public health system to deliver routine services. SNEHA staff keep volunteers motivated through training, public appreciation of their efforts and culturally sensitive programming.
Through the Comprehensive Sexuality Education (CSE), young girls and boys are equipped with life skills through sessions on nutrition, menstrual health and hygiene, challenging gender norms, civic education, street theatre and digital safety. Girls face resistance from family – mostly brothers – at home, even as they learn to negotiate to increase their mobility and participation in public spaces. Male volunteers, though fewer in number than females, are encouraged to look beyond gender norms and to be at ease holding conversations about women, child and adolescent health.+2. Ramani, S., Shaikh, N. and Jayaraman, A. Report titled, Institutionalising community participation processes in urban informal settlements: Lessons learnt from community volunteers in SNEHA’s Aahar programme (2016-18)
The opportunity of talking to other people like listening to each other’s good or bad experiences instils a lot of hope. When we see other successful women, we get inspired to be like them. My child will also think that my mother is going out and doing such good work, she will also get inspired to become a good person. I will be able to give them (my children) a good life.(Woman, 28 years, secondary education, homemaker)
The community is closely involved in the recruitment of volunteers, so that volunteers represent the community and not SNEHA. Child health and nutrition programme volunteers are trained in community mobilisation approaches to enable them to better persuade and support people to use available ante- and post-natal care services. They also disseminate and share information about healthy diets, the importance of regular weight checks, home-cooked foods for children and pregnant women, exclusive breastfeeding, immunisation, early registration of pregnancy and family planning methods. If required, they assist new mothers by managing their households and help get their children immunised. Engagement with SNEHA also helps volunteers use the information they gain to improve health and nutrition practices in their own households and challenge gender role stereotypes.
Community volunteerism has been transformational for both women and men. It has given women an identity beyond their households and the opportunity to be part of something bigger. They step out as ‘confident social workers’ and interact with other families in their neighbourhoods, which they could not do previously owing to restricted mobility. Newly gained knowledge, increased mobility, the opportunity to socialise with SNEHA staff and other community members and public acknowledgement of their efforts has helped volunteers gain confidence and make this transition. However, it needs to be acknowledged that their reach is restricted. Patriarchal norms limit them in terms of geography and time. Volunteering is unopposed as long as household chores are not compromised, and volunteers do not venture beyond their neighbourhoods.
Galvanising young people and women to assist their own communities during the pandemic
The effects of the Covid-19 pandemic, and in particular lockdown measures, have significantly affected the communities in which SNEHA works. A survey of 1,567 randomly selected respondents cited severe challenges with access to food, livelihoods and routine health services. With SNEHA’s encouragement and backing, community volunteers have provided material, emotional and psychological support to their neighbours, as well as working with public authorities to deliver services to women, children and families in containment zones, where access is restricted.
With physical distancing one of the critical preventive measures, SNEHA teams were compelled to support volunteers remotely and relied on relationships with communities and public systems built over decades. A directory of phone numbers (of volunteers and their neighbours) compiled at the beginning of the lockdown became the mainstay for maintaining contact. A web-based application was also developed to keep track of who was being called and why. Volunteers who owned smartphones were supported with data pack refills and trained to use online meeting platforms such as Zoom and Google Meet. Gaining digital competency was empowering for volunteers – especially for women. As women became more house-bound than ever and young people lost access to schools and colleges, smartphones became their window to the world. However, few women and adolescents ‘own’ a phone themselves. Some used the phones of their male relatives. We found that more boys than girls owned smartphones independently. Lack of phones compelled young girls and volunteers to make home visits, armed with masks and hand sanitisers, to spread awareness on Covid-19 and identify food security and health service needs within their neighbourhoods. Their association with SNEHA gave them access to more information and thus made them more confident in assisting neighbours in distress. Volunteers stepped in to assist frontline public health workers. Pregnant women from other states stranded in Mumbai were assisted with registrations at municipal maternity hospitals. An integral element of SNEHA’s adolescent and youth programme is a module on civic education that helps young people to understand Constitutional rights and responsibilities and the governance structures responsible for public works. Armed with this information, 64 youth volunteers repeatedly called public helplines and reached out to local authorities to get their areas disinfected or sanitised.
Health messengers during the pandemic
Unsurprisingly there has been a surge of interest in Covid-19 and people have been bombarded with information on their phones and televisions and on social media. Not all of this is correct and there has been a definite requirement to give people accurate, reliable and simplified information. To raise awareness on Covid-19, SNEHA trained selected volunteers to disseminate messages on risks and preventative measures using multiple platforms and media – WhatsApp, podcasts, video clips and voice messages. SNEHA also ensured that volunteers understood the processes in place within public institutions for identification and referral of cases and where relevant information could be found. Volunteers engaged with the community through talks, demonstrations, role plays and street theatre and support groups. They ran information sessions with schools, religious leaders and labour unions to reinforce the application of preventive and safety measures, while assisting with routine health services.
Community volunteers also helped in the screening of suspected Covid-19 cases. Fifteen women were trained to administer a contact survey with 1,165 households to check the spread of the disease, and 76 suspected cases were referred for further management. Dozens of youth volunteers became our eyes and ears on the ground, making time for weekly one-hour online sessions and answering questions such as ‘how do we make people understand that crowding is dangerous?’, ‘how do we stop children from going out and playing together?’ and ‘what should we do if a friend complains of cough and fever?’ Throughout the lockdown, youth volunteers have also distributed sanitary napkins to 2,600 girls and women, and women volunteers have set up 22 condom depots, with stocks of condoms and oral contraceptive pills replenished by public health workers. Some volunteers received online training in record keeping and family planning counselling enabling them to keep track of their community work as well as substitute for health workers or SNEHA staff members who could not access their areas.
Alleviating food insecurity
With many of SNEHA’s intervention sites demarcated as containment zones with severe restrictions on movement, being in constant touch through phone calls and messages helped SNEHA understand community needs and the hardships faced by vulnerable inhabitants. With local shops shut and movement curtailed, programme teams soon realised the urgent need to procure food items. Volunteers and programme team members coordinated with different actors including other NGOs, municipal authorities, the public food distribution network and private shopkeepers to arrange for food kits, particularly for people who were needy and vulnerable, such as pregnant women, and daily wage workers. SNEHA worked closely with municipal authorities to identify vulnerable families in need of food, which was then distributed by volunteers living in the containment zones. They picked up food boxes from the boundaries of the zones and dropped them off at community locations, to be picked up by a community contact. The food distribution effort would not have been possible without the active and unconditional involvement of volunteers – the link between NGOs, municipal authorities and those eligible to receive food kits. Nearly 30,000 families received food relief.+3. Chakraborty, P. (2020) Distribution of fresh fruits and vegetables in Dharavi, India: lessons and learnings from the Covid–19 pandemic. SNEHA (https://snehamumbai.org/wp-content/uploads/2020/09/Documentation_of_Fruits_Vegetables_Distribution_Project_Dharavi_Sept_2020.pdf).
In one distant suburb, populated by vulnerable migrant families, a 19-year-old volunteer gathered the details of families that had lost their income owing to the lockdown. She wrote letters to the elected representative seeking food relief, and pushed the SNEHA team to ensure that 140 families could access food through the Public Distribution System (PDS). The PDS runs shops that procure grains from public granaries and supplies them to vulnerable people at subsidised prices. Over 750 volunteers – mostly women – have been trained on how the PDS works, and how to support people in understanding and claiming their entitlements. They interact regularly with PDS officials and visit the local fair price shops to ensure regular distribution of subsidised food grains, discourage corruption and help families obtain new food cards. Volunteers helped almost 3,000 families with no cards to access free food grains under emergency arrangements introduced by the government.
Addressing violence and providing psychosocial support
Domestic violence in Mumbai increased during the lockdown, as perpetrators and survivors were confined in close proximity for long periods. Services for women in distress were often delayed or unavailable and there was a conspicuous lack of coordination between the various executive departments in the state, including the health department, the police and government-run shelters.
A large community volunteer base of 700 women and men provided the first response to survivors of violence. They connected survivors to support networks, accompanied them to police stations, rescued women and girls being subjected to severe violence in their homes and provided psychological support. They ran community kitchens which provided cooked food to migrants and collected money from religious institutions to provide ration packets to families in their neighbourhoods. Thirty youth, trained as ‘barefoot counsellors’, formed a network to identify adolescents in distress, provide emotional support and refer them to clinical psychologists where required.
Coming closer amidst crisis: what did we achieve together?
The pandemic has been a testing time for everyone, but it has also given SNEHA the opportunity to work closely with community volunteers to test the sustainability of its programmes when field presence was not possible. ‘We learned that we could count on community ownership and collaboration if the situation demands it.’ Volunteers moved rapidly from being participants to collaborators to community leaders tackling crises head on. Continued support to the public health system was reinforced, even as the need to invest in working with other public departments such as the PDS and those assisting the vulnerable through welfare schemes emerged as central to SNEHA’s work. SNEHA was able to achieve this thanks to its long presence in the community and the rapport it had built with community members.
Youth volunteers helped us reach a woman who was denied entry into a public toilet after one of her relatives was taken away to a quarantine centre to rule out Covid-19 infection. They ensured that counsellors from SNEHA rendered psychosocial support to her. The police was informed and they beseeched the woman’s neighbours to be empathic towards her access to basic amenities .(SNEHA staff)
Although a joint response was stitched together, there were still many knots. The first challenge was motivating SNEHA staff to adapt to working online or via phones. Mostly women, they are used to intimate conversations with community volunteers. It was extremely difficult to continue these from their homes – cramped one-room tenements with no privacy. Keeping volunteers engaged and willing to perform routine tasks was not easy. Continuous efforts had to be made to motivate them, through giving information, training or appreciation, especially as there was no monetary compensation for their efforts, just the satisfaction derived from helping their neighbours and their community.
Working on mental health was most challenging, with telephone counselling unsuited to principles of confidentiality. Access to routine adolescent health services was severely curtailed during the pandemic. Young people were in need of assistance and yet it wasn’t possible to have conversations on sexuality or sexual and reproductive health with them as they didn’t feel comfortable expressing their concerns at home via phones or online platforms.
In one of the world’s most populous cities, what has worked is collaboration between people, civil society and the authorities. Non-profits like SNEHA engendered community ownership to build local response, while the creative use of technology, creating spaces for volunteers to express their concerns and fears and supporting the public health system were key to crisis management. Through youth and women as spirited contributors, we managed an unprecedented crisis, highlighting how building and strengthening community stewardship lays the path towards sustainability.
Dr. Anuja Jayaraman is the Director of Research at SNEHA
Dr. Rama Shyam is Programme Director for Empowerment, Health and Sexuality of Adolescents at SNEHA
Dr. Nayreen Daruwalla is Programme Director for Prevention of Violence against Women and Children at SNEHA
Dr. Harvinder Palaha is Programme Director for Maternal and Newborn Health at SNEHA
Pragya Dixit is the Documentation Coordinator at SNEHA
Sushma Shende is Programme Director for Child Health and Nutrition at SNEHA
Dr. Shanti Pantvaidya is the Executive Director of SNEHA