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Lifecycle linkages for women and girls across multiple sectors: a review of the literature Dr Andrew Harmer and Meghna Ranganathan 15 February 2012

DFID Human Development Resource Centre HLSP, 10 Fleet Place London EC4M 7RB T: +44 (0) 20 7651 0305 E: just-ask@dfidhdrc.org W: www.hlsp.org


DFID India – Lifestyle Linkages for Women and Girls

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Contents List of Abbreviations ................................................................................................. 2   1  

Executive summary ............................................................................................ 3  

2      

Context ................................................................................................................. 5   Objectives of the report ................................................................................. 5    Methods ........................................................................................................ 6  

3  

Education inter-sector linkages ........................................................................ 8  

4  

Other sectors’ impact on education ................................................................ 10  

5  

Nutrition inter-sector linkages ......................................................................... 11  

6  

Health inter-sector linkages ............................................................................. 12  

7  

Social infrastructure inter-sector linkages ..................................................... 14  

8  

Innovative financing inter-sector linkages ..................................................... 15  

9  

Physical Infrastructure ..................................................................................... 18  

10   Empowerment ................................................................................................... 21   11   Conclusion ........................................................................................................ 27  

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List of Abbreviations HDRC DFID ER WHO MeSH IMSEAR WHOLIS R4D CGC ODI CVD GoI VAW LEB OOP NCD CCT CBHI ARV

Human Development Resource Centre Department for International Development Evidence Rating World Health Organisation Medical Subject Headings Index Medicus for South-East Asia Region World Health Organisation Library Information System Research for Development Child Guidance Centre Overseas Development Institute Cardiovascular Disease Government of India Violence against Women Life-expectancy at Birth Out of Pocket Non-communicable Diseases Conditional Cash Transfers Community-based Health Insurance Anti Retroviral

Note on Evidence Rating (ER) Where appropriate, each reference was graded for strength of evidence, as follows: 1 - Systematic Review and Meta analysis 2 - Randomised Controlled Trials with definitive results 3 - Randomised Controlled Trials with non- definitive results 4 - Cohort Studies 5 - Case-control studies 6 - Cross-sectional surveys 7 - Case reports 8 - Non-systematic reviews, secondary analysis of survey data, qualitative or mixed methods 9 - Reviews of intervention studies. The ER has been added to the reference, so the standard format (Arokiasamy 2009) becomes (Arokiasamy 2009, ER6), meaning that this study was a cross-sectional survey, and less robust than, say, (Fewtrell et al 2004, ER1). References such as review articles have not been rated.

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1 Executive summary DFID India commissioned a review of evidence of the impact of interventions or changes at one stage of a girl or woman’s lifecycle, and outcomes at other stages; and of interventions in one sector which have an impact on other sectors. DFID also wanted to identify the synergies that have the most potential for DFID India to meet its objective of transforming the lives of women and girls. A literature search identified 95 studies that illustrated multiple sector linkages at seven stages of life: birth, early childhood, childhood, adolescence, adulthood, marriage and pregnancy. We have summarised these by strength of the evidence (from 1 = very robust to 9 = weak); by the size of the impact (large, medium or small); and by the sector or sectors, and stage or stages, at which the effect is evident. We found extensive evidence of inter-linked development effects that impact both positively and negatively on girls’ and women’s health at the different stages of the lifecycle. Many of these are well-known: •

the nutritional status of the mother during pregnancy and before conception has an impact on several stages of a newborn’s life, from birth-weight to cognitive development in early childhood to performance in school. An integrated response to health and nutrition, including a health worker visit within 3 days of birth, appears to have the biggest impact. girls who are enrolled and succeed in school are more likely to be higher income earners in their adult life. Their mother’s education has a positive effect on their early childhood, though less so on their development when they are infants. completing secondary education benefits women in adult life through improved literacy and improved confidence to participate in community life. Factors such as girl’s mobility, freedom from violence at home and control over economic resources contribute towards empowerment. Early marriage is strongly associated with higher fertility, with birth intervals of less than 24 months, with more pregnancies being unwanted, and with a pregnancy being terminated.

However, we found surprisingly few examples of quantifiable synergistic effects. Computer-aided modelling showed positive synergy when family planning, safe abortion and increased numbers of skilled birth attendants are combined. Interventions that combined conditional cash transfers and nutrition with early child development interventions were also identified as ‘promising’. Conversely, the effect of combining water access, sanitation and hygiene was found to be no greater than the effect of each individual sector on its own. What we did find in the fairly limited literature were strong indications that some more recent changes, such as cable TV and mobile phones, as well as microfinance, are having unexpected impacts. Cable TV helps to empower rural women Jensen & Oster measured indicators of women’s empowerment in annual surveys of rural households in Bihar, Goa, Haryana, Tamil Nadu and Delhi, and found that the introduction of cable TV in the village was associated with significant changes in attitude (such as the acceptability of domestic violence towards women, and son preference) as well as lower fertility. Their analysis also suggests that exposure to cable increases school enrolment of younger children. ‘Changing the underlying factors behind low levels of education, women's status and high fertility has proven to

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be very difficult; introducing television, or reducing any barriers to its spread, may be less so’. (Jensen & Oster, The power of cable TV, NBER 2007, ER6). Mobile phones are breaking down barriers There is good evidence that texting HIV+ve people to remind them to take antiretroviral therapy, or women to remind them to do breast self-examination, works well. Simply texting supportive, motivational messages to rural health-workers also seems to work. Given that men are generally more reluctant than women to seek healthcare, it is striking that 80% of the calls to a pilot scheme offering ‘call a local doctor’ were from men. The effect of microfinance on women’s empowerment is mixed. Self-Help Groups can achieve dramatic changes in women’s empowerment (Swain and Wallentin 2007, ER5), but the potential empowering effect of loans procured by women can be diluted if women do not own a share in the family’s productive assets and if patriarchal structures persist within the home (Garikipati 2008, ER6). In addition, a randomized evaluation study found no evidence to suggest that microcredit empowers women or improves health or educational outcomes – although the study was conducted over a short time period (Banerjee and Duflo, 2009, ER2). Having fewer children has a bigger effect than education One study found that while women’s education showed a strong effect on child mortality, the effect was greater for women with fewer than three children. The effect of such low parity on reduction of neonatal, post-neonatal and child mortality was two to three times higher than the effect of the mother’s education on child mortality. Furthermore, they found a large positive association between lower parity and number of years of schooling (Arokiasamy 2009, ER6). Little evidence that social health insurance works An unpublished systematic review of social health insurance in low-middle income countries found “no strong evidence to support widespread scaling up of social health insurance schemes as a means of increasing financial protection from health shocks or of improving access to health care” (Acharya et al 2011, ER1) Little evidence for synergistic effects of inter-sectoral working. This does not mean that synergistic working is not effective. Rather, it points to a gap in our understanding of synergy, and also an opportunity to explore further. Linking conditional cash transfers and nutrition with early child development interventions was identified as ‘promising’ in one study (Engle et al 2011, ER1). On the negative side, a systematic review and meta-analysis of water, sanitation and hygiene interventions found that combined interventions were no more effective in delivering development outcomes than single-sector interventions (Fewtrell et al 2004, ER1).

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2 Context There is growing interest amongst development donors to maximise positive synergy from inter-sectoral working. Evidence from analysis of global health initiatives, global health development goals, and developing countries’ health systems, suggests that linking traditionally separate development sectors together can potentially achieve better results (WHO 2008; Waage et al 2010; Balabanova et al 2011). Recognising this potential, DFID India has conceptualised linkages between the multiple sectors it supports in terms of a woman’s lifecycle from birth to pregnancy (Fig.1). Figure 1: Girls and women in India: A lifecycle approach Girls and women in India –

Breastfeeding; infant care; Mgt of childhood Diseases; 0-2 nutrition

a Life Cycle Approach

= life cycle = interventions = life cycle change

Antenatal, maternal, & Newborn health services Family Planning, Behaviour Change Comm

Pregnancy

Skills for work Access to finance and markets Self Help Groups

Violence prevention; Ante natal screening; Counselling Empowerment: Understand rights, entitlements, social support

Early childhood

Birth

Work opportunities, Better incomes and livelihoods; Childhood

Reduced drudgery and better quality of life.

Marriage

Complete primary education

Adolescence

•Delay marriage and pregnancy Complete secondary •Life skills for own and family’s health education •Work skills •Confidence & strategies for decision making in HH and community •Reduced risk of violence.

There are many examples in the literature of linkages between sectors that impact on a woman’s life. For example, education appears to be a major factor behind improving women’s livelihood and health chances. Furthermore, improvements at one stage of a woman’s life have been shown to yield positive effects for that woman later in her life (intra-generational effect), or for her children (inter-generational effect). Thus, malnutrition, violence within the home, or low educational attainment diminish a woman’s chances to improve her life and impede the life-chances of any future offspring – thereby sustaining a cycle of poverty that is repeated for successive generations (Walker et al 2011, ER1). To our knowledge just one study has explored how different sectors might combine (or conspire) to multiply (or confound) development effects (Waage et al 2010), and no study has reviewed inter-sector linkages that effect girls and women’s lives.

2.1 Objectives of the report 1. To review secondary evidence on the impact of intervention or change at one stage of the life cycle for girls and women, and outcomes at other stages (e.g. education on nutrition, water on education, microfinance on nutrition, health on livelihoods), and provide short summaries of evidence and it’s quality, identifying areas where the evidence is strong or weak. 2. Identify the synergies that have the most potential for DFID India to meet its objective of transforming the lives of women and girls.

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2.2 Methods The number of potential inter-sectoral linkages is limited only by imagination, requiring a trade-off between ambition and feasibility1. For this report, sector linkages were derived from an initial scoping exercise, guidance from DFID India’s Operational Plan 2011-2015, and consultation with DFID India sector staff (Table 1). The breadth of issue-areas, absence of database index terms (MeSH), and wide variations in methods employed in the literature made it impractical to attempt a Cochrane-style systematic review. Nevertheless, we developed a rigorous and replicable search strategy for the literature review. Table 1: Sectors reviewed DFID Pillar/Strategic priority 1-2: Wealth creation; PPPs 3. Access to low-carbon energy 4. Health 5. Nutrition 6. Water and sanitation 7. School education 8. Governance

Sectors explored Innovative financing (microcredit, self-help groups, conditional cash transfers, health insurance) Environment; technology (indoor air pollution) Maternal health; child health; mental health Nutrition of mother, fetus, and child Water; sanitation Maternal education; primary and secondary education Women’s empowerment/autonomy; girls’ clubs Mobile technology; media; transport; electricity, housing

To ensure consistency across sectors, search terms were agreed between the Principal Investigator (PI) and Research Assistant (RA). For example, the following generic search using the database PubMed was employed: (((((india [Title/Abstract]) OR indian[Title/Abstract]) AND impact[Title/Abstract] OR intervention[Title/Abstract]) AND women[Title/Abstract]) OR girls[Title/Abstract]) ) AND nutrition[Title/Abstract] Inclusion criteria were applied to focus the scope of the search. We included only studies that: • Assessed impact of intervention or change; • Included the effect of one sector on at least one other sector; • Were directed at women or girls; • Were inter or intra-generational; • And had a significant India (or if evidence was sparse then south Asia) component. A couple of interventions from outside Asia are also included for illustrative purposes (for example, the microfinance study, IMAGE, from South Africa or the MPESA mobile health project in Kenya). Studies that were broader in scope but seminal (for example, a study of mothers’ education in 175 countries by Gakidou et al 2010, ER6) were mined for further references. No constraints were placed on date or language but where possible we sought to match early findings with contemporary research 1  Ambitious

multi-sector systematic reviews are feasible: Atun et al’s 2009 study of global health reviewed 8,274 potential articles.   DFID Human Development Resource Centre #301613 6


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(for example, Cleland and van Ginneken 1988, ER6 and Cleland and van Ginneken 2008). In addition to PubMed, we utilised the following databases: IndMED; IMSEAR; Google Scholar; Economic and Political Weekly; WHOLIS; R4D; CGD; ODI; Population Council. The literature review identified 95 studies that inter-link multiple development sectors: education, nutrition, health, social infrastructure (hygiene, sanitation and water), innovative financing (microcredit, conditional cash transfers and health insurance), physical infrastructure (transport, electricity, mobile technology and media), and empowerment Box 1: Interpreting the tables The tables provided in this report show sector linkage effect, size of effect, whether that effect is +ve or –ve, the type of study, the stage of the lifecyle where the effect occurs, and a reference. We have attempted to rank order this using a well-known hierarchy (Greenhalgh 1997). We use this hierarchy 1-7 to rank study designs. Thus: 1 - Systematic Review and Meta analysis 2 - Randomised Controlled Trials with definitive results (confidence intervals that do not overlap with clinically significant level) 3 - Randomised Controlled Trials with non- definitive results (a point estimate that suggests a clinically significant effect, but with confidence intervals overlapping the threshold for this effect) 4 - Cohort Studies 5 - Case-control studies 6 - Cross-sectional surveys 7 - Case reports We have used an additional two categories that do not fall within this hierarchy: 8 - Non-systematic reviews, secondary analysis of survey data, and studies that have used qualitative methods or are mixed methods 9 - Reviews of intervention studies. We have 3 categories to indicate the strength of effect identified in the study: large, medium or small. In addition, we have labelled the studies as being positive or negative. Most studies do not record a mothers’ married status, and not all pregnant women are adult. Therefore, we have added a category ‘adult’ to the stages of the lifecycle, and only add ‘marriage’ or ‘pregnancy’ where this is the focus of the study.

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3 Education inter-sector linkages Table 2: The effects of girls’ and women’s education on different sectors Sector linkage effect

Size of effect (type of study)

Stage of lifecycle

Reference

é Maternal education ON ê child

Large, +ve (1, 6, 8)

Childhood (less effect in infancy)

é

Maternal education AND é sanitation AND é water ON ê infant mortality

Medium, (6)

Childhood; adolescence

é Maternal education ON é daughter’s

Large, +ve (6)

Childhood

Desai 1998; Gakidoe et al 2010; Cochrane et al 1980 Cleland and van Ginnelen 1988; Desai and Alva 1998 Afridi 2010

Large, +ve (4)

Adolescence

Pells 2011

Large, +ve (4)

Childhood

Pells 2011

Large, +ve (6)

Childhood

Kunwar and Pillai 2002

Mixed, –ve (6)

Pregnancy

Prabhat 2006

é Maternal education ON ê fertility

Large, +ve (6, 8)

Birth

é Proximate education ON ê domestic violence ê Maternal education and ê income ON ê domestic violence

Large, +ve (6)

Adult

Large, –ve (6)

Adult

Dreze et al 2001; Sekher 2001 Ackerson et al 2008 Babu and Kar 2009

é Maternal education AND community ON ê domestic violence é Multiple interventions ON é early

Large, +ve and -ve (6)

Adult

Boyle 2009

et

al

Large, +ve (1)

Early childhood

Engle 2011

et

al

Health education for women ON é women’s hygiene and sanitation Health education for women ON ê neonatal mortality

Large, +ve (6)

Adult

Large, +ve (4)

Birth

Cairncross and Shordt 2005 Barnji et al 2004

School education ON é children’s hygiene behaviour

Large, +ve and -ve (6)

Childhood

Matthew 2009

Community education ON é youth health needs

Large, +ve (23)

Adolescence

Balaji 2011

é Maternal education AND income ON é women’s autonomy

Medium, (6, 8)

Adolescence; adult

Jejeebhoy and Sathar 2001

mortality

+ve

primary education

é Maternal education AND ê poverty AND é gender ON é daughter’s secondary education é Maternal education ON é years of schooling é Parental education ON é nutritional status of primary school children

ê Maternal education and ê income ON sex ratio

childhood development

+ve

et

et

al

al

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Figure 2. Impact of Mother’s Education

Maternal education has a clear positive effect on child mortality: a one-year increment in a mother’s education was found to correspond with a 7-9% decline >5 mortality, with education exercising a stronger influence in early and later childhood than infancy (Cochrane et al 1980, ER1). Subsequent studies have confirmed this finding (Cleland and Ginneken 2008; Gakidou et al 2010, ER6). Increasing a mother’s education from below primary to at least primary education will increase a daughter’s schooling by more than 6 months, or almost two-thirds of a year of schooling (Afridi 2010, ER6). A rare longitudinal study found that increased enrolment of girls in school in India did not necessarily equate to better educational outcomes, with girls performing less well in vocabulary and maths than boys. The authors found that socioeconomic factors such as poverty and gender were strong confounding variables in their analysis (Pells et al 2011, ER4). There are clear long-term economic impacts of making sure that girls (and boys) stay at school for longer: simulation models suggest that increasing preschool enrolment to 25% or 50% would produce a benefit-to-cost ratio ranging from 6·4 to 17·6, depending on preschool enrolment rate and discount rate (Engle et al 2011, ER1). There is a direct relationship between parents’ literacy and the nutritional status of their children. The proportion of under-nourished children decreased to 30.3% and 15.8% when the mother’s educational standard improved above primary level (Kunwar and Pillai 2002, ER6). Educating mothers about healthy diets and the importance of nutrition during pregnancy reduces neonatal, perinatal and infant mortality; it also reduces morbidity, and incidence of vitamin A deficiency in preschool children (Bamji 2004, ER4). The evidence for the effectiveness of hygiene education is mixed. Interventions

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• •

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have shown some improvements but soap and toilet use among school children remain unchanged (Matthew 2009, ER6). Community level education interventions are effective in addressing adolescent health needs (Balaji 2011, ER 2-3). Whilst higher maternal education, and to a lesser extent economic activity may indicate autonomy, the effect is most apparent in more egalitarian Southern states (Jejeebhoy 2001, ER6)

4 Other sectors’ impact on education Table 3. Other sector effects on girls’ and women’s education Sector linkages Size of effect Stage of effect (type of study) lifecycle

Reference

é Nutrition of infant ON é primary and secondary education é Maternal nutrition ON é early childhood development including education ê Parity (fertility) ON é school attendance

Large, +ve (1, 4)

Early Childhood; adolescence

Victora et al 2008

Large, +ve (1)

Early childhood

Walker et al 2011

Medium, +ve (6)

Early childhood

Arokiasamy 2009

é Childhood nutrition ON é primary education é Sanitation (toilets) ON é primary and secondary education Mobile technology ON é mothers’ health education and é health worker motivation

Large, +ve (1, 9)

Childhood

Large, insufficient evidence (1)

Childhood to adolescent (4-18)

Khera 2006; Kristjansson et al 2009 Birdthistle et al 2011

Mixed, +ve (6, 9)

Adult

Sharma et al 2011; Ramachandran et al 2010

There is strong evidence linking maternal and child nutrition (and childhood illness more generally), educational attainment, improved cognitive capacity and/or school attendance (Martorell, Horta, Adair et al. 2010, ER4; Bobonis, Miguel & Sharma 2004, ER2; Victora 2008, ER4; Walker 2011, ER1). One study found that the effect of environmental factors weakened the association over time (Landon 2006). Health interventions delivering iron supplementation, improving the overall health of mothers, infants and children, and programmes to increase birth weight and infant weight gain (including by promoting breast-feeding) were all found to deliver positive results on education. No association was found between diarrhoea or E. histolytica infection and malnutrition in school children in Bangladesh (Tarleton et al 2006). One study showed that 1/5 of school children contracting tuberculosis discontinued their studies (Rajeswari, Balasubramanian, Muniyandi et al. 1999, ER8). India’s mid-day meal scheme for primary school children, introduced in 1995, has resolved many of its initial problems (Khera 2006, ER9). A Cochrane review conducted in 2007 found that children who were fed at school attended school more frequently than those in control groups, which translated to an average increase of 4 to 6 days a year per child (Kristjansson et al 2007, ER1). Whilst not specific to India, a randomised control trial (RCT) in Guatemala found that participants only benefitted if nutrition supplements were given during the

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first two years of life (Stein et al 2008). One study found that while women’s education showed a strong effect on child mortality, the effect was greater for women with two or fewer children. The authors found that the effect of low-parity on reduction of neonatal, post-neonatal and child mortality was two to three times greater than the effect of women’s education on child mortality. Furthermore, they found a large +ve association between lower parity and number of years of schooling (Arokiasamy 2009, ER6). The provision of separate toilets for girls at school is probably a necessary, if not sufficient, intervention to impact on girls’ educational outcomes. The most recent systematic review did not find evidence for or against the impact of such interventions on girls’ education and recommended a further systematic review to establish whether any water, sanitation and health (WASH) programme had impacted on girls’ educational outcomes (Birdthistle et al 2011, ER1). RCTs have been conducted in India to determine the effect of mobile and other technologies on health education for mothers as well as health worker motivation and learning. Text messaging was found to be more effective than pamphlets in providing oral health education (Sharma et al 2011). Use of video in village settings to motivate health workers and encourage learning showed some positive effects (Ramachandran 2010, ER6).

5 Nutrition inter-sector linkages Table 4: Inter-sectoral effects of girls’ and women’s nutrition Sector linkages effect Size of Stage of effect (type lifecycle of study) é Health (physical illness, gynaecological symptoms, tobacco) AND é poverty ON ê mental ill health é Mental health ON ê nutrition (birth weight) AND ê cognitive development é VAW ON ê women’s health

Large, (4)

+ve

Adult

Large, (4)

–ve

Early adult

Large, -ve (4, 6

Adult

ê Parity (fertility) ON ê child mortality

Large, (6)

+ve

Birth; childhood

Child marriage ON é fertility AND ê maternal mortality

Large, (6)

-ve

Childhood; adult

Reference

Patel et al 2006

childhood;

early

Patel et al 2003

Sudha et al 2011;Chowdhury 2008 Goldie et al 2010 Raj et al 2009

We noted earlier the impact that nutrition has on education at various stages of a child’s educational development. In addition to impact on education, undernutrition is linked to poor cognitive function, short stature/stunting, and a range of non-communicable health problems in later life including cardiovascular disease (CVD) and type-2 diabetes (Bhargava et al 2004, ER4; Victora et al 2008, ER4). The risk of malnutrition is higher in young children born to mothers married as minors than in those born to women married at a majority age (Raj 2010, ER6) Low birth weight is a marker of sub-optimal foetal development and has led researchers in India to conduct pioneering work linking foetal development to health and other social development complications in both children’s and adult life (Kinra et al 2008, ER5). The focus on foetal nutritional development has led to a body of work recommending intervention studies in women before conception

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(Fall et al 2009, ER4). Studies have established a link between nutrition and delayed pregnancy, such that the higher the age at which women have their first child and the earlier the start of breast feeding of newborn children, the less is the prevalence of child malnourishment (Nair 2007, ER6). Government of India (GoI) interventions such as the Integrated Child Development Services were found to be an appropriate mechanism for tackling child malnutrition (Nair 2007, ER6). Integrating nutrition and health programs also appears to have positive results for neonatal mortality. An evaluation of a large-scale community-based integrated nutrition and health programme in two rural Northern districts found that neonates who received a postnatal home visit within 28 days of birth had 34% lower mortality than those who received no postnatal visit, after adjusting for sociodemographic variables. Three-quarters of the mortality reduction was seen in those who were visited within the first 3 days after birth (Baqui et al 2008, ER9).

6 Health inter-sector linkages Table 5. Inter-sectoral effects of girls’ and women’s health Sector linkages effect Size of Stage effect (type lifecycle of study)

of

Reference

é Health (physical illness, gynaecological symptoms, tobacco) AND é poverty ON ê mental ill health é Mental health ON ê nutrition (birth weight) AND ê cognitive development

Large, +ve (4)

Adult

Patel et al 2006

Large, –ve (4)

Patel et al 2003

é VAW ON ê women’s health

Large, -ve (4, 6

Early childhood; adult Adult

ê Parity (fertility) ON ê child mortality

Large, +ve (6)

Birth; early childhood

Child marriage ON é fertility AND ê maternal mortality

Large, -ve (6)

Childhood; adult

Raj et al 2009

é Empowerment AND é education ON é reproductive health AND ê violence against women

Large, +ve and –ve (4)

Lee-Rife 2010

é Health status (LEB and IMR) on é economic growth (productivity)

Large, +ve (8)

Adolescent; adult; marriage; pregnancy All stages

é Per capita income ON é health status

Large, +ve (8)

All stages

Duriasamy and Mahal 2005

é OOP ON é disease (TB, NCDs)

Large, -ve (1, 6)

Sudha et al 2011;Chowdhury 2008 Goldie et al 2010

Duriasamy and Mahal 2005

Mahal et al 2010; Garg and Karan 2009

Poverty (low income), being married rather than single, tobacco use, experiencing abnormal vaginal discharge, and chronic physical illness are all factors independently associated with the risk for common mental disorder (Patel 2006, ER4). Postnatal depression was a large, and independent, predictor of low birth weight and was significantly associated with adverse mental development quotient scores later in life (Patel 2003, ER4).

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There is strong evidence that violence against women (VAW) has negative impacts on women’s health, particularly sexual and reproductive health, and also suicide (Chowdhary 2008, ER4). Two studies suggest that acceptance of the justification of such violence decreases the chances of the woman seeking health care (Sudha & Morrison 2011, ER6; Sudha, Morrison & Zhu 2007, ER4). Sexual violence is also found to be a significant predictor of HIV infection amongst women in India (Ghosh, Arah, Talukdar et al. 2011, ER6), but it should be noted that it is one of numerous influential factors. There is a large, positive association between abortion and violence. Preventing unwanted pregnancies and reducing barriers to abortion so as to minimize the risk of discovery may be important steps to empower women and ensure their safety (Lee-Rife et al 2010, ER4). If introduced early enough, and with sufficient intensity, a combination of family planning, fertility choice, safe abortion, and scaled-up, sustained, and integrated maternal health services, is as cost-effective as childhood immunization or treatment of disease. On its own, family planning might reduce maternal deaths by 35%. When combined with safe abortion, increased skilled birth attendants and improved care, nearly 80% of maternal deaths could be averted (Goldie et al 2010, ER6). Evidence supports a strong association between per capita income and the health status of a population (as measured by Life Expectancy at Birth (LEB) and infant mortality). A 1000 rupee increase in per capita health expenditure would lead to a 1.3% increase in LEB, while a 10% increase in per capita income is required to increase the LEB by about 2%. (Duraisamy and Mahal, 2005, ER8). The authors also found an inverse relationship between poverty and LEB. It was not, however, possible to infer any cause-effect or simultaneous relationships among these variables. Out-of-pocket (OOP) expenses caused by both communicable diseases (tuberculosis) and NCDs (cancer and heart disease) have significant economic impact, causing both loss of wages and an increase in poverty levels (Garg and Karan 2009, ER6). In one study, tuberculosis caused an average loss of 3 months’ wages (Rajeswari, Balasubramanian, Muniyandi et al. 1999, ER8), while another estimated losses to be equivalent to 3.3% of GDP in 2004 (Mahal, Karan & Engelgau 2010, ER1).

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7 Social infrastructure inter-sector linkages Table 6. Girls’ and women’s access to water, sanitation and hygiene Sector linkages effect Size of effect Stage of Reference (type of lifecycle study) Caste discrimination ON é access to water at school

Large, - ve (6)

Childhood

Water Aid 2011

é Hygiene (hand washing) ON health (diarrhoea)

Large, + ve (1)

All stages

Fewtrell and Colford 2004

Clean water (diarrhoea)

Large, +ve (1)

All stages

Fewtrell and Colford 2004

Medium, (1) Medium, (6)

+ve

All stages

+ve

Adult

Fewtrell and Colford 2004 Jose et al 2011

Medium, (6)

-ve

Childhood

Duflo et al 2008

supply

ON

health

é Sanitation ON health (diarrhoea) é Sanitation AND clean water supply AND clean cooking fuel ON women’s nutrition AND gender discrimination é Home environmental pollution (smoke stoves) ON ê child health

Despite progress towards national targets, access to water and sanitation remains highly inequitable in India. Locally, caste discrimination also prevents access, with a survey of 565 villages across 11 states showing denial of access to water facilities for scheduled castes in 45-50% of the villages. Discrimination extends to schools, where caste children are not allowed to drink water from common sources (WaterAid 2011, ER6). A systematic review and meta-analysis of water, sanitation and hygiene interventions to reduce diarrhoea in developing countries (not India-specific) found that hygiene interventions, especially those promoting hand washing, were effective. The review found limited evidence for sanitation interventions but it suggested a positive effect. Water supply interventions did reduce diarrhoea but mostly when household connections were provided and when water was not stored in the home. The review also noted that multifactorial interventions (i.e. water supply + sanitation + hygiene education) were effective, but no more so than single-sector interventions (Fewtrell et al 2004, ER1). A woman’s social environment can impact negatively on her nutritional status, health (through lack of clean cooking fuel) and also entrench gender hierarchies within the home (Jose and Navaneetham 2011, ER6). Children, too, are affected by their home environment: a study of traditional stove ownership found that children in households using a mix of biomass and cleaner fuels have a higher risk of acute lower respiratory infections (ARI) than children in households using only cleaner fuels (Duflo et al 2008, ER6).

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8 Innovative financing inter-sector linkages Table 7: Inter-sectoral effects of innovative financing for girls and women Sector linkages effect Size of effect Stage of Reference (type of lifecycle study) Microfinance ON ê emotional stress AND é well-being

Large, +ve (6)

Adult, marriage, pregnancy

Mohindra et al 2008

Microfinance ON é family planning AND é immunisations AND é essential service package Microfinance ON ê women’s health and ê decision making

Large, +ve (5)

Marriage and pregnancy

Amin 2001

Large, –ve (6)

Adult, marriage and pregnancy

Mohindra et al 2008

Microfinance ON ê infant mortality

Large, –ve (5)

Amin 2001

Microfinance ON ê health AND ê education AND ê household decision making

Large, –ve (2)

Marriage, pregnancy, child and adolescence Marriage and pregnancy and child and adolescence Marriage and pregnancy

Microfinance empowerment

ON

é

women’s

Mixed, +ve and -ve (5, 6)

et

al

al

Banerjee et al 2009

Swain and Wallentin 2007; Garikipati 2008 Pronyk et al 2006

Microfinance ON ê intimate partner violence AND é HIV knowledge

Large, +ve (2)

Microfinance ON ê intimate partner violence AND é empowerment

Large, +ve/-ve (2)

Conditional Cash Transfers immunization coverage

é

Large, +ve (2)

Conditional Cash Transfers ON ê maternal and neonatal deaths AND é utilisation of maternal health services Community Based Health Insurance ON é health protection from ill-health

Large, +ve (6)

Pregnancy

Lim et al 2010

Medium, (8)

Adolescence, marriage and pregnancy

Sinha 2006

ON

+ve

Adolescence, Marriage and Pregnancy Adolescence, Marriage and Pregnancy Early childhood (1-3 years)

et

Kim et al 2007

Banerjee et al 2009

et

al

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Figure 3. Impact of Microfinance

Microfinance Overall, the effects of microfinance on health are relatively indirect. A small but growing number of studies globally that integrate microfinance with other nonfinancial services seem to support the argument that financial services from microfinance institutions have some positive impacts beyond the direct financial benefit. Thus, microcredit has been associated with a number of positive outcomes for women and girls: • Significant increase in contraceptive use, a decline in fertility and an increase in dissemination of information and utilization of essential services package (ESP) in the broader community, though not a significant difference in reduced infant mortality (Amin et al 2001, ER5). • Significant reduction (55%) in intimate partner violence for participants in an integrated programme in South Africa (IMAGE), as well as other +ve health outcomes (Pronyk et al 2006, ER2). There was also strong evidence of women’s empowerment and decision-making agency (Kim et al., 2009). • Self-help groups (SHG) can reduce the odds of exclusion, with early joiners to these groups less likely to report emotional stress and poor life-satisfaction compared to non-members. SHG participation had little effect on increasing health self-assessment or reducing exposure to health risks. • The effect of microfinance on women’s empowerment is mixed. On the one hand, SHG effect on changes in women’s empowerment can be dramatic (Swain and Wallentin 2007, ER5). On the other, the potential empowering effect of loans procured by women can be diluted because of a woman’s lack of co-ownership of her family’s productive assets and persistent patriarchal structures within the home (Garikipati 2008, ER6). DFID Human Development Resource Centre #301613 16


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Finally, a randomized evaluation study found no evidence to suggest that microcredit empowers women or improves health or educational outcomes – although the study was conducted over a short time period (Banerjee and Duflo 2009, ER2).

Conditional Cash Transfers (CCTs) Our review found just two rigorous studies with an India focus. A clustered randomised controlled evaluation found that small non-financial incentives had a large positive effect on utilisation of immunisation services, whereas improving reliability of services increased utilisation only modestly (Banerjee, Duflo, Glennerster, & Kothari, 2010, ER2). A second evaluation, this time of the Janani Suraksha Yojana CCT scheme to incentivise women to give birth in a health facility, found it had a significant effect on increasing antenatal care and facility births by helping to overcome financial constraints that prevented women from going to hospital for delivery (Lim et al 2010, ER6) Community-based health insurance (CBHI) We identified one India-focused, qualitative, study of CBHI that drew on focus group interviews. An unpublished systematic review of social health insurance in low-middle income countries found “no strong evidence to support widespread scaling up of social health insurance schemes as a means of increasing financial protection from health shocks or of improving access to health care” (Acharya et al 2011, ER1)

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9 Physical Infrastructure Table 8. Inter-sectoral effects of physical infrastructure on girls and women Sector linkages effect Size of Stage of Reference effect (type lifecycle of study) Transport (road building and access) ON é maternal health (pregnancy, mortality) Transport (services) ON êmaternal AND child mortality

Medium, (7)

Pregnancy; adult

Pendse 1999

Small, +ve (8)

Pregnancy (peri-natal)

Babinard and Roberts 2006;

Travel (distance) ON ê maternal AND child mortality

Small, +ve (8)

Pregnancy (peri-natal)

Gabrysch and Campbell 2009

Road networks ON é utilisation of health services Road traffic injuries ON ê maternal or girls’ injuries Rural electrification ON health

Small, +ve (6)

Adult

Large, -ve (1)

Adolescence (mostly males) All stages

Lalmalsawmzauva and Nayak 2008 Hyder 2006

Mobile phone SMS reminder ON ARV adherence Mobile phone SMS reminder ON breast cancer Mobile phone consultation

+ve

Medium, +ve (6) Small, pilot underway (2) Large, +ve Small, +ve (6)

Visual media (tv, radio, adverts, film) ON health (tobacco, TB)

Small, +ve (6)

Visual media (cable, satellite) ON VAW AND sex ratio AND fertility Visual media (cable, satellite) ON education enrolment

Large, +ve (6) Small, +ve (6)

Adolescence adult Adult

-

Adult (80% male) Adolescent; adult Adolescent; adult Adolescent; adult

Mathur and Mathur 2005 De Costa et al 2010 Khokhar 2009 Bali and Singh 2007 Viswanath et al 2010; Sharma 2007 Oster 2008 Oster 2008

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Figure 4. Impact of Infrastructure

Few studies were found which had either an India or a female focus. The one systematic review of road traffic injuries we identified found that young males were the most commonly affected group, and that there was a lack of populationbased data (Hyder 2006, ER1). Distance from health services, rather than transport per se, appears to be a more serious problem for women in labour. According to a review of delivery service access (Gabrysch et al 2009, ER8), the vast majority of studies that include distance reported less use of skilled attendance at delivery in women living far away from a facility. An unpublished study found both surface road density and better road network connections had substantial influence on mothers’ health-seeking behaviour and utilization of health facilities (Lalmalsawmzauva 2008, ER6). Poor electricity supply means more time spent collecting solid fuel and less time for girls to to spend on education. A more reliable electricity supply also means schools stay open longer. In some states, UNICEF and others are providing solar-powered lamps to schools and women’s literacy groups to promote education for girls (UNDP 2011, ER6). Reading newspapers appears to reduce women’s oral (chewing) tobacco consumption (Viswanath 2010, ER6); women are more likely to be TB-aware from exposure to health advertisements (Sharma 2007, ER6); installation of cable TV is positively associated with reduced incidence of domestic violence, and there is some evidence to suggest it increases school enrollment for younger children (Oster 2008, ER6)

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Figure 5. Impact of Mobile Telephones

Mobile and other technologies have a mixed but positive effect on multiple sectors. There is good evidence that texting HIV+ve people to remind them to take anti-retroviral therapy, or women to remind them to do breast selfexamination, works well. Simply texting supportive, motivational messages to rural health-workers also seems to work. Given that men are generally more reluctant than women to seek healthcare, it is striking that 80% of the calls to a pilot scheme offering ‘call a local doctor’ were from men.

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`

10 Empowerment Table 9: Summary of data from studies to show inter-sectoral effects on girls’ and women’s empowerment Sector linkage Size of effect Stage of Reference (type of lifecycle study) Maternal autonomy ON é breast feeding and infant growth

Medium, +ve (4)

Maternal autonomy ON é child growth Maternal autonomy ON é new-born low birth weight

Large, +ve (6)

Maternal autonomy ON é health

Medium, +ve (8)

Pregnancy

Empowerment ON é education AND é autonomy Empowerment ON ê gender prejudice AND ê VAW

Large, +ve (6)

Adult

Mixed, +ve (6)

Mothers

Environment ON é empowerment

Small, +ve (8)

Adolescents

Brady 2003

Family planning ON é empowerment AND é employment

Medium, +ve

Adult

Francavilla & Giannelli 2011

Large, +ve (8)

Early childhood (infants at 3-5 months); adult (lactating mothers) Early childhood (infants); adult Early childhood (new-borns); adult

Shroff 2011

et

al

Shroff et al 2009 Chakraborty and Anderson 2011 Gabrysch and Campbell 2009 Santhya and Haberland 2008 Santhya and Haberland 2008

Mothers with higher financial autonomy were more likely to breastfeed 3-5 month old infants (Shroff et al 2011, ER6). With access to money and freedom to choose to go to the market, mothers were significantly less likely to have a stunted child, after controlling for household socio-economic status and mother's education (Shroff 2009, ER6). Low maternal autonomy is also an independent predictor of low birth weight (LBW) in babies, after adjusting for other factors (Chakraborty 2011, ER8). A visit by a family planning worker has been associated positively and significantly with a woman securing paid work (Francavilla & Giannelli 2011,ER6) Partnerships between non-government organisations (such as that between the Population Council and SEWA in Gujarat) can intervene effectively to help empower adolescent girls. Participation in this ‘livelihoods’ intervention enhanced girls’ decision-making skills, self-esteem and social skills (Kalyanwala 2007, no ER). Another intervention - the First Time Parents Project - had a significant, positive net effect on most indicators reflecting married young women’s autonomy, social support networks, partner communication and knowledge of sexual and reproductive health (Santhya 2008, ER6). The net effect of the intervention was mixed with regard to changing gender stereotypes, and had no effect on attitudes towards VAW. Creating safe supportive spaces for girls is feasible (Brady 2003, ER8).

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Identifying inter-sectoral linkages and synergies Our review has identified a large number of linkages between different sectors. Policy makers are beginning to recognise inter-sectoral effects. For example, a recent call for an Indian nutrition strategy argued that multiple non-nutrition sectors would need to be considered (Haddad 2011, ER6). However, it is important to emphasise that inter-sectoral linkage (identifying how improving one sector can benefit others) is not the same as synergistic thinking. The assumption underpinning synergy is that because sector w is shown to have positive effects on multiple sectors x, y and z, then it follows that an integrated policy combining all 4 sectors will have a better outcome for the target population than if each sector addressed the problem on its own. Surprisingly, very few studies in our review quantified synergistic effect, preferring instead to show positive (and negative) links between sectors. On the positive side, computer-based modelling has identified synergistic effects on maternal mortality when family planning, increased numbers of skilled birth attendants and improved treatment and care are combined (Goldie et al 2010, ER6). Linking conditional cash transfers and nutrition with early child development interventions was identified as ‘promising’ in one study (Engle et al 2011, ER1). On the negative side, a systematic review and meta-analysis of water, sanitation and hygiene interventions found that combined interventions were no more effective in delivering development outcomes than single-sector interventions (Fewtrell et al 2004, ER1). Arguably, the most important factors that affect a woman’s life are structural rather than sectoral and thus much more difficult to address, at least in the short-term. For many girls, the experiences of early childhood are shaped by multiple sectors: education (their own and their mother’s), nutrition, sanitation, home environment, health, and fertility. None of these sectors can be seen in isolation: fertility has clear education and nutrition dimensions, while structural forces such as poverty and gender-relations also have an impact on fertility. Sectoral reform will only work in conjunction with structural reform. What follows is a summary of the most important sectoral linkages identified in this review, mapped against the stages of DFID India’s lifecycle of birth, early childhood, childhood, adolescence, marriage and pregnancy. For each stage, we provide illustrative examples, taken from the literature, of successful interventions. Table 10: Illustrative examples of interventions by sector linkage Linkage Stage of Intervention lifecycle Educational training ON Adult Health and Nutrition maternal Entrepreneurs and education/practice AND Mobilizers (HNEM) peri/neo-natal mortality (‘arogya karyakartas’) Preschool enrolment ON Early Parenting interventions early childhood childhood and centre-based development programmes Lower maternal Childhood; Routine screening and education AND lower adult treatment for violence income ON VAW related injuries and trauma Maternal nutrition Pregnancy Integrated Child

Reference Bamji et al, 2004

Engle et al, 2011 Babu and Kar, 2009

Nair 2007

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ON delayed pregnancy Health education classes ON sanitation

Development Service Adult

Hygiene education in schools ON sanitation AND water

Childhood

Nutrition (mid-day meals) ON primary school attendance Maternal nutrition ON neonatal mortality

Childhood

Sanitation AND Water ON health

Various

Microfinance ON adult women's health AND women's decisionmaking Microfinance ON family planning AND immunizations AND Essential Service Package of reproductive, maternal and child health services Microfinance ON intimate partner violence AND HIV knowledge Conditional Cash Transfers ON maternal and neonatal deaths AND utilisation of maternal services Mobile phone ON health

Marriage; pregnancy; adult

Health (tuberculosis) ON income AND education

Childhood; adolescence; adult Adolescence

VAW AND media campaigns Social and economic empower-ent ON livelihood skills

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Birth (Neonate)

Multifaceted hygiene promotion (hand washing ) intervention UNICEF-supported School Sanitation and Hygiene Education (SSHE) (1999–2003) Mid-day school meals

Large-scale communitybased integrated nutrition and health programme Water quality interventions to reduce diarrhea Microcredit program within a self-help group

Cairncross and Shordt, 2009 Matthew et al 2009

Khera 2006; Kristjansson et al 2009 Baqui et al 2008 Fewtrell and Colford, 2004 Mohindra et al 2008

Marriage; pregnancy

Integration of microcredit with family planning, ESP and EPI

Amin et al 2001

Adolescence; marriage; pregnancy Pregnancy

The Intervention with Microfinance for AIDS and Gender Equity Incentives for poor women to give birth in a health facility

Pronyk et al 2006

Adult

SMS health reminder for breast cancer Iron supplementation and de-worming

Khokar, 2009

Changing gender norms among young men SEWA Project Livelihoods skills-building intervention, Gujarat

Plan 2011

Adolescence

Lim et al 2010

Bobonis et al 2004

Kalyanwala 2007

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Figure 6. Examples of interventions by sector linkage to lifecycle stage

Birth The evidence reviewed suggests that survival rates of children at birth and in infancy are improved if the child has access to a stable parental environment, adequate nutrition, clean water, sanitation, and health treatment (vaccinations) and care from midwives or health workers. The most important inter-generational factor affecting the health of a newborn child is the nutritional status of its mother. Innovative work in India has the potential to challenge conventional understanding of a woman’s lifecycle, arguing that interventions (dietary education and supplements) before conception may be the optimum time for healthy foetal development (Fall et al 2009, ER4 and interview with author). An integrated response appears to be the most effective response. An integrated health and nutrition service, that ensures a health worker visits a mother within 3 days of birth, has been shown to significantly reduce neo-natal mortality (Baqui et al 2008, ER6). Early childhood (0-8yrs) and childhood (8-12) There is not always a clear distinction between early childhood and childhood in the literature. However, providing a stable, continuous, and quality primary education is perhaps the most important outcome from policy directed at girls during this stage in their lives. The evidence suggests that girls who remain—and succeed—in school are more likely to be higher income earners in adult life, and provide better life

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chances for their own children (Lake 2011; Walker et al 2011, ER1; Engle et al 2011, ER1). A mothers’ education has a positive effect on early childhood, though less effect on infants (Cochrane 1980, ER1). However, low parity effect on reduction of neonatal, post-neonatal and child mortality was more effective in one study than education effect on child mortality reduction (Arokiasamy 2009). Supporting early childhood development is cost effective, as one study reported: “Increasing preschool enrolment rates to 25% could yield an estimated US$10.6 billion through higher educational achievement, while a 50% increase could generate $33.7 billion” (Lake 2011). Mechanisms for achieving positive outcomes for early childhood development include early learning centres and quality parenting programs. The best model for maximum impact is integration of these mechanisms into existing community-based programmes across a broad range of sectors - health, nutrition, education, water and sanitation, and protection. Adolescence (13-18 yrs) For one author, adolescence is “a time when the world expands for boys and contracts for girls, and gender disparities in opportunity and expectations become particularly pronounced” (Brady 2003, ER8, p155). Completing secondary education is most likely to yield dividends for women in later life through improved literacy, a better understanding of their rights, and increased confidence to participate in community life and respond to physical violence and abuse (WHO 2010). At adolescence, girls are beginning to access social services and becoming financially independent. Livelihood may be enhanced through access to credit/microcredit, though the evidence is mixed. Empowering adolescent girls will help to inform their decisions around parenthood (Verma et al 2006, ER5). Gender equality has been shown to form part of a virtuous cycle of early schooling and income levels that inform individual and household level decision-making (Harmer 2011). Factors such as girls’ mobility, freedom from violence in the home, and control over economic resources were identified as contributing to these different experiences (Jejeebhoy and Sathar 2001, ER6). Marriage The most important time for women to be empowered appears to be just after marriage, and this emerges as a strong determinant of woman’s empowerment in later life (Lee-Rife 2010, ER4). Child marriage is strongly associated with higher fertility rate, repeat childbirth in less than 24 months, multiple unwanted pregnancies, pregnancy termination, and sterilization (Raj et al 2009, ER6). A combination of family-planning education, access, and support services are required for these young mothers, but also for their husbands and families. Pregnancy Early interventions are very important. If introduced early enough, and with sufficient intensity, a combination of family planning, fertility choice, safe abortion, and scaledup, sustained, and integrated maternal health services, is as cost-effective as childhood immunization or treatment of disease (Goldie et al 2010, ER6). Distance from delivery services is a serious contributing factor to perinatal mortality, not least because it limits midwife visits. One study found that 75% of the mortality reduction was seen in newborns who were visited within the first 3 days after birth (Baqui et al 2008, ER9). DFID Human Development Resource Centre #301613 26


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The timing of a pregnancy is determined by, and impacts upon, multiple sectors. As literacy rates improve, women begin to make more informed decisions about when to start a family, and may be empowered to resist familial and partner pressures to start too soon. Delayed pregnancy and early breast-feeding will have a positive effect on the child’s nutritional status (Nair 2007, ER6).

11 Conclusion Our review has identified a large number of linkages between different sectors, and provides a body of evidence to show how and when sectors affect each other. But it is important to emphasise that inter-sectoral linkage (identifying how improving one sector can benefit others) is not the same as synergistic thinking. Our review found little evidence showing the synergistic effect of inter-sectoral working on the lives of women and girls in India. This does not mean that synergistic working is not effective. Rather, it points to a gap in our understanding of synergy, and also an opportunity to explore further. What is needed to address this deficit? Water, sanitation and hygiene have enjoyed an historical association (if not necessarily synergistic), but there are many more combinations of sectors that have the potential to make equally good development bed-fellows. Well-designed studies that address cross-sectoral linkages and targeted systematic reviews and that seek to identify and assess the effectiveness of multiple sector interventions would be a useful addition to the literature. Computer-simulated modelling which work for combinations of health, family planning and number of health workers could also be usefully applied to other inter-sectoral combinations. Lastly, as with so many other topics, understanding synergy will also require quality data that disaggregates by age and sex – thereby making girls more visible to policy makers and donors. (Levine et al 2008).

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Lagarde M and Pamer N (2008), ER8. The impact of user fees on health service utilization in low- and middle-income countries: how large is the evidence? Bulletin of the World Health Organization, 86(11), 839-848. Lalmalsawmzauva KC and Nayak DK (2008), ER6. Maternal Health Care Utilization in India: Role of Surface Road Networks. Landon (2006), (No ER: Folder not in file and unable to determine study design) The developmental environment: influences on subsequent cognitive function and behaviour. In: Gluckman P, Hanson M, eds. Developmental origins of health and disease. Cambridge: Cambridge University Press: 370–78. Lee-Rife SM (2010), ER4. Women's empowerment and reproductive experiences over the lifecourse. Social Science and Medicine; 71(3):634-42. Epub 2010 Levine, R et al (2009) Girls Count: A Global Investment & Action Agenda, Washington: Centre for Global Development Lim, S. S., Dandona, L., Hoisington, JA, et al (2010), ER6. India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet, 375 (9730), 2009-23. Mahal, Karan & Engelgau (2010), ER1. The Economic Implications of NonCommunicable Diseases for India, Health, Nutrition and Population (HNP) Discussion Paper, World Bank Mandal NK (2007), ER6. Impact of religious faith & female literacy on fertility in a rural community of West Bengal, Indian Journal of Community Medicine Vol. 32, No.1. Martorell R, Horta BL, Adair LS et al (2010), ER4. Weight gain in the first two years of life in an important predictor of schooling outcomes in pooled analyses from five birth cohorts from low- and middle-income countries. J. Nutr. February 2010 vol. 140 no. 2 348-354 Maselko J & Patel V (2008), ER4. Why women attempt suicide: the role of mental illness and social disadvantage in a community cohort study in India. J Epidemiol Community Health 2008;62:817-822 Mathew K, et al (2009), ER6. The sustainability and impact of school sanitation, water and hygiene education in Kerala, Southern India. Waterlines. 28(4): 275-292. Mathur JK and Mathur D (2005), ER6. Dark homes and smoky hearths: Rural electrification and women Economic and Political Weekly. Volume 40, No. 7. Pages 638-43 McNay (2003), ER6. Why are uneducated women in India using contraception? A multilevel analysis, Popul Stud (Camb). 2003; 57(1) Mohindra, K., Haddad, S., & Narayana, D. (2008), ER6. Can microcredit help improve the health of poor women? Some findings from a cross-sectional study in Kerala, India. International journal for equity in health, 7, 2

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Nair KR (2007), ER6. Malnourishment among children in India: A Regional Analysis, Economic and Political Weekly; 42(37):3797-3803. Oster E (2008), ER6. The Power of TV: Cable Television and women’s status in India. The Quarterly Journal of Economics (2009) 124 (3): 1057-1094. Patel (2003), ER4. Postnatal depression and infant growth and development in lowincome countries: a cohort study from Goa, India. Arch Dis Child 2003;88:34-7. Patel V, Kirkwood B et al (2006), ER4. Risk factors for common mental disorders in women Population-based longitudinal study, British Journal of Psychiatry, 189, 547555 Pells K (2011), ER4. Poverty and Gender Inequalities: Evidence from Young Lives, policy paper. Last accessed on 26th November, 2011. http://www.younglives.org.uk/files/policy-papers/yl_pp3_poverty-and-genderinequalities Pendse (1999) “Maternal Deaths in an Indian Hospital: A Decade of (No) Change?” Reproductive Health Matters – Special Issue on Safe Motherhood Initiatives (1999): 119-127. Plan (2011), ER8. Because I am a girl. So, what about boys? The State of the World’s Girls Prabhat et al (2006), ER6. Low male-to-female sex ratio of children born in India: national survey of 1·1 million households, Lancet, 367, pages 211-218 Pronyk P, Hargreaves J, Kim J, et al (2006), ER2. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. The Lancet; 368:1973-83. Raj A, Saggurti N, Balaiah D et al (2009), ER6. Prevalence of child marriage and its effect on fertility and fertility-control outcomes of young women in India: a crosssectional, observational study. Lancet; 373 (9678): 1883-9. Raj A, Saggurti N, Winter M et al (2010), ER6. The effect of maternal child marriage on morbidity and mortality of children under 5 in India: cross sectional study of a nationally representative sample.BMJ; 340. Rajeswari R, Balasubramanian R, Muniyandi M et al (1999), ER8. Socio-economic impact of tuberculosis on patients and family in India, The International Journal of Tuberculosis and Lung Disease. Volume 3, Number 10, October 1999, pp. 869877(9) Ramachandran (2010), ER6. Mobile-ising health workers in rural India, Mobile-izing Health Workers in Rural India. In Proceedings of ACM Conference on Human Factors in Computing Systems (Atlanta, Georgia), April 10-15. Santhya KG and Haberland N (2008), ER6. Empowering married young women and improving their sexual and reproductive health: Effects of the First-time Parents Project. Population Council. Sekher (2001), ER8. Fertility transition in Karnataka Economic and Political Weekly 36: 51, 4742-4752. DFID Human Development Resource Centre #301613 33


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Sharma AK (2007), ER6. Impact of mass media on knowledge about tuberculosis control among homemakers in Delhi, International Journal of Tuberculosis and Lung Disease; 11(8):893-7 Sharma et al (2011), ER9. Mobile-phone text messaging (SMS) for providing oral health education to mothers of preschool children in Belgaum City, J Telemed Telecare Shroff et al (2009), ER6. Maternal autonomy is inversely related to child stunting in Andhra Pradesh, India, Matern Child Nutr. 2009 Jan;5(1):64-74. Shroff MR, Griffiths PL, Suchindran C, et al (2011), ER6. Does maternal autonomy influence feeding practices and infant growth in rural India? Social Science and Medicine; 73(3):447-55 Sinha T, Ranson, MK, Chatterjee M et al (2006), ER8. Barriers to accessing benefits in a community-based insurance scheme: lessons learnt from SEWA Insurance, Gujarat. Health Policy and Planning, 21(2), 132-42. Sudha S and Morrison S (2011), ER6. Marital violence and women's reproductive health care in Uttar Pradesh, India. Women’s Health Issues; 21(3):214-21. Sudha s, Morrison S & Zhu L (2007), ER4. Violence against women, symptom reporting, and treatment for reproductive tract infections in Kerala state, Southern India. Health Care Women International 28(3):268-84 Swain, R. B., & Wallentin, F. Y. (2007), ER5. Does microfinance empower women? Evidence from self help groups in India. Uppsala Universitet, Dept. of Economics Working Paper 2007:24. UNDP (2011) Human Development Report: Sustainability and equity: A better future for all. New York: Macmillan, p54. Vennam U, Komanduri A et al (2009) Early Childhood Education Trajectories and Transitions: A Study of the Experiences and Perspectives of Parents and Children in Andhra Pradesh, India Working Paper Number 52. Young Lives, Department of International Development, University of Oxford. Victora CG, Adair L, Fall C et al (2008), ER4&1. Maternal and child undernutrition: Consequences for adult health and human capital. The Lancet, 371(9609): 340–357 Viswanath K, Ackerson LK, Sorensen G, Gupta PC (2010), ER6. Movies and TV Influence Tobacco Use in India: Findings from a National Survey. PLoS ONE 5(6): e11365. Walker et al (2011), ER1. Inequality in early childhood: risk and protective factors for early child development, Lancet WaterAid (2011), ER6. Off-track, off-target: Why investment in water, sanitation and hygiene is not reaching those who need it most. http://www.wateraid.org/documents/Off-track-off-target.pdf

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The DFID Human Development Resource Centre (HDRC) provides technical assistance and information to the British Government’s Department for International Development (DFID) and its partners in support of pro-poor programmes in education and health including nutrition and AIDS. The HDRC services are provided by three organisations: HLSP, Cambridge Education (both part of Mott MacDonald Group) and the Institute of Development Studies. This document is issued for the party which commissioned it and for specific purposes connected with the captioned project only. It should not be relied upon by any other party or used for any other purpose. We accept no responsibility for the consequences of this document being relied upon by any other party, or being used for any other purpose, or containing any error or omission which is due to an error or omission in data supplied to us by other parties.

DFID Human Development Resource Centre HLSP, 10 Fleet Place London EC4M 7RB T: +44 (0) 20 7651 0305 E: just-ask@dfidhdrc.org W: www.hlsp.org


Lifecycle linkages for women and girls across multiple sectors: a review of the literature.  

HLSP DFID Report

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