The Utility of a Realist Evaluation Approach in Interrogating Implicit Assumptions of Maternal Health Interventions: Ensuring Equity and Human Rights of Marginalized Communities in Maternal Health Programming

Session: The Role of Evaluations in Bridging Equities: Experiences from Latin America, Asia and Africa

Presenter: Abhijit Das, Centre for Health and Social Justice
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All programs make implicit assumptions that are critical to the successful implementation of the program.  Taking a realist evaluation approach, we interrogate assumptions in key conditional transfer programs focused on maternal health in India. Using two examples of interventions, we identify the “boundary conditions” under which the assumptions will work—we demonstrate that the underlying assumptions work for the educated urban middle to lower middle class who live in a monetized economy with some access to economic and social security and access to quality services. When a program is being implemented successfully, i.e. the input and output parameters are as expected, we can assume that our initial ‘assumptions’ in terms of health care, social/cultural and economic were appropriate. However when the program doesn’t work, the program manager is left with a dilemma about what needs to be done. The usual approach is to intensify inputs with the assumption that lack of success was a result of lack of adequate inputs or responsiveness to the inputs. However this may not be the case. It is possible that the socio-cultural and economic assumptions made in the first case were ‘wrong.’ For example the tribal woman may not only be far away physically from services, but her community may have a completely different set of beliefs about what constitutes safe conception, pregnancy, delivery and post-natal care.  In such cases intensifying the inputs, and at the same time stigmatizing their actions which are appropriate for their realities, may compound the inequity which is built into a monolithic understanding of what constitutes the appropriate policy or programmatic intervention. The presentation will make explicit the current maternal and neonatal health paradigm that is being promoted in India. The realist approach will demonstrate the “contexts, mechanisms and outcomes configurations” associated with successful implementation of maternal health programs.