PROPELLING SOCIAL INCLUSION
•
235
demand may reflect an assertion of dignity and a rejection of bad treatment by service providers. When probed on why they think institutional births are unnecessary, 1 percent of tribal women say they deliver at home because there is no female provider at the health center, 2 percent say they do so because they do not trust the facility, 5 percent say that they are held back by their husbands and family, 5 percent complain of the facility not being open, 17 percent speak of it being too far and inaccessible because of no transport, and 23 percent say it is too costly. Only 7 percent say it is not customary to opt for an institutional birth (World Bank 2011a). Underlying the proximate reasons for poor outcomes are complex phenomena that are not immediately visible. Staying with the example of high numbers of maternal deaths among tribal women in India, this report argues that the poor health of a tribal woman is rooted in the low power she has relative to almost everyone else. Issues of land and forests are central to her situation. Once viewed in this way, it is clear that a supply-side push for better health facilities is a blunt instrument with which to address high levels of maternal mortality. An intervention would benefit from “asking why” at different steps of the diagnosis of a poor outcome (figure 7.3). Questions could include the following: • What is the wrong or the intractability that is being addressed, or what went right that needs to be deepened? Why? • Whom does the intervention or service seek to include, or who is at risk of being left out? Why? • Why are those groups or areas at risk of being left out? What are the channels through which inclusion can take place? Why? • What innovations can be put in place to ensure inclusion? What can be done differently? There are several ways to ask the right questions and identify the channels through which to intervene. In some cases, an ex ante analysis can help. For example, a Poverty and Social Impact Analysis (PSIA) of charcoal sector reforms in Tanzania found that a rise in charcoal prices could result in cutbacks in both food and nonfood expenditures in households, with particularly negative impacts on women and children. It therefore suggested putting the burden of higher prices on the dealer-transporter-wholesaler networks, which could cope with them. In other cases, program or project managers can opt for consultations with the group to explore why they think a problem (such as high mortality