Knowledge Brief 6 Improving Women’s Leadership for Strengthening Health and Nutrition Outcomes in Nagaland, India Lessons from a Process Evaluation of Community Action for Health and Nutrition While reserving the co-chair position for women in health committees provided some benefit in terms of improving women’s participation in decision-making, other interventions such as better definition of roles and responsibilities, additional leadership training, and support groups for co-chairs, are needed to further reinforce this important first step. Introduction Methods Under the term “communitization,” in 2002 the state This process evaluation of project implementation government of Nagaland transferred responsibility was based on a mix of primary and secondary for local services to Village Councils and sector- data sources. These included a survey of Health specific Committees. In the health sector, Village Committee Chairs and Co-chairs, facility-based Health Committees were made responsible for health providers and frontline workers, namely management of local health services, including salary ASHAs and Anganwadi Workers, from purposively payment as well as use of small funds transferred selected committees (n=35) implementing by the state government. Some 1,300 Village Health the project across 11 districts. In addition, a 2 Committees have been constituted and their level qualitative study included in-depth interviews with of functionality varies widely, with many hardly Chairs and Co-chairs of ten committees3 and key active. In 2016, the World Bank-financed Nagaland informant interviews with project staff and Chief Health Project included a US$15 million component Medical Officers in five districts.2 Ethnographic to provide technical and financial support to observations of the functioning of four committees strengthen implementation of the communitization in two districts were done. Project documents and strategy.1 With the objective of improving reports were reviewed. participation and leadership of women for planning and managing health and nutrition services in the community, the project mandates that all Findings committees appoint a woman Co-chair, in addition to a Chair (who could be a man or woman). The This brief focuses on the findings of the process project was initially piloted in 30 villages across evaluation with respect to the project’s efforts to two districts, and has been scaled-up in a phased improve the participation and leadership roles of matter since late 2017 to about 450 sites in all women. The brief describes the evaluation’s findings 11 districts of the state. on the extent to which the mandate of appointing July 2019  |  Page 1 a woman Co-chair was implemented by the health feeling the sense of authority to assign tasks to committees, the challenges associated with creating members of the committee, a sense of agency not this position, and the experiences of the female Co- shared by 45 percent of the Co-chairs. Although chairs participating in this initiative. women in Nagaland have historically enjoyed a high social position,4 women conform to traditional Appointment and training of gender roles, and are expected to perform a range Co-chairs of household tasks including meal preparation, household cleaning and maintenance, and child Although all sampled committees (n=35) had named care. As a result, in some instances the Co-chairs a woman Co-chair, committees reportedly struggled were unable to participate in committee activities to fulfil this mandate effectively. In many instances, due to their existing household commitments. this was due to low and aging village populations, as well as low literacy levels among women, resulting Perceptions About the Role of the in lack of suitable candidates. In the absence of a Co-chair well-defined appointment process for the Co-chair, often non-transparent processes were followed. The female Co-chairs reported to value their role As a result, many women Co-chairs were appointed and experience in the committee, saw themselves to committees without their knowledge. In many as agents of change and believed that their role other cases, the appointment was either made directly benefitted women, in particular by bringing during project training sessions or shortly after. to the table perspectives, needs and concerns of Thus, only about 60 percent of Co-chairs received mothers. Many reported gaining experience and training (as compared to 77 percent of male Chairs) confidence from their appointment. On the other and did not engage with some of the initial decision- hand, the male Chairs presented a range of opinions making for the project, namely the development of on the requirement for female Co-chairs, perhaps the first action plan. reflecting debates around the reservation of political positions for women in the state. Some argued that a Responsibilities and Perceived woman Co-chair was necessary to raise awareness Autonomy for improving maternal and child health and nutrition, while some stated that the most capable individuals As per project guidelines, there are no differences for the job should be appointed as Chair and Co- in responsibilities between the Chair and the Co- chair, regardless of their gender. chair. In practice however, Co-chairs were found to be assigned tasks that were secretarial in nature, such as maintaining records and taking meeting Conclusion notes, while decision-making power rested with the Chair, who was responsible for conducting The evaluation found that while reserving the Co- the committee meetings and managing the bank Chair position for women provided some benefit account. In addition, there were stark differences in in terms of improving women’s participation in self-perceived autonomy between the male Chairs decision-making, it is clear that other interventions and female Co-chairs, with 85 percent of the Chairs are needed in order to build on this first step. Page 2  |  July 2019 Clear and Equal set of Responsibilities Support Groups for Co-chairs The evaluation recommends appointing two chairs, While additional skills and leadership can be imparted rather than one Chair and Co-chair, with clearly though trainings and workshops, creating a truly defined roles and responsibilities to ensure that both enabling environment would be far more complex. men and women have equal responsibilities. However, the project can initiate the formation of support groups of Co-chairs from neighboring Leadership Training for Co-chairs committees, such that they could discuss their problems with their peers, collectively brainstorm To ensure that the reservation of the post of Co- solutions and generally support each other. chair is not just notional, the project should aim to strengthen the capacity of the Co-chairs as The Nagaland Health Project is dedicated to well as build an enabling environment for them to strengthening leadership of women for improving function in. For example, the project could design health and nutrition outcomes and has taken and organize additional training and leadership the above-mentioned recommendations under programs, including competency-based workshops advisement for inclusion in implementation of the for Co-chairs. District-level project staff could project. To begin with, it has committed to work also provide additional mentoring to Co-chairs with the State chapter of the National Health Mission for planning activities based on needs of the to write a clear set of roles and responsibilities for community and their implementation. the committee chairs. Footnotes 1 World Bank. 2016. Project Appraisal Document on a Proposed Credit in the Amount of US$48 Million to the Republic of India for a Nagaland Health Project. November 28. http://documents.worldbank.org/curated/en/719521482375675651/pdf/INDIA- NAGALAND-PAD-11302016.pdf 2 Committees were selected from villages and facilities that had completed at least one project-supported planning and financing cycle and were also included in the sample frame of the 2014 project baseline survey. 3 Ten committees across five districts, including six at the facility level and four at the village level, were purposively selected based on their recent performance (timely reporting, strong leadership, innovative action plans) in the project. 4 Shimray, U. A. (2004). Women’s work in Naga society: Household work, workforce participation and division of labour. Economic and Political Weekly, 1698-1711. July 2019  |  Page 3 © 2019 The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved This work is a product of the staff of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Attribution Please cite the work as follows: “World Bank. 2019. India: Nutrition Determinants and Strategies in Nagaland, Knowledge Brief - Improving Women’s Leadership for Strengthening Health and Nutrition Outcomes in Nagaland, India – Lessons from a Process Evaluation of Community Action for Health and Nutrition. © World Bank.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@ worldbank.org. Acknowledgements This work was led by Patrick Mullen and Aarushi Bhatnagar, with contributions from Young Eun Kim, Mohini Kak, Bathula Amith Nagaraj, Neesha Harnam, Avril Kaplan and Mamata Baruah, under the oversight of Rekha Menon. The World Bank team would like to thank the Directorate of Health and Family Welfare and Department of Social Welfare, Government of Nagaland, the Nagaland Health Project team, Oxford Policy Management Ltd., the Kohima Institute and all study participants for their contributions. This material has been funded thanks to the contributions of (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government’s official policies or the policies of the World Bank and its Board of Executive Directors. Page 4  |  July 2019