“Our fear is finished,” but nothing changes: efforts of marginalized women to foment state accountability for maternal health care in a context of low state capacity

BACKGROUND: Women in India are often asked to make informal payments for maternal health care services that the government has mandated to be free. This paper is a descriptive case study of a social accountability project undertaken by SAHAYOG, a nongovernmental organization in Uttar Pradesh, India. SAHAYOG worked with community-based organizations and a grassroots forum comprised of low caste, Muslim, and tribal women to decrease the prevalence of health provider demands that women and their families make informal payments. METHODS: The study entailed document review; interviews and focus group discussions with program implementers, governmental stakeholders, and community activists; and participant observation in health facilities. RESULTS: The study found that SAHAYOG adapted their strategy over time to engender greater empowerment and satisfaction among program participants, as well as greater impact on the health system. Participants gained knowledge resources and agency; they learned about their entitlements, had access to mechanisms for complaints, and, despite risk of retaliation, many felt capable of demanding their rights in a variety of fora. However, only program participants seemed successfully able to avoid making informal payments to the health sector; health providers still demanded that other women make payments. Several features of the micro and macro context shaped the trajectory of SAHAYOG’s efforts, including deeply rooted caste dynamics, low provider commitment to ending informal payments, the embeddedness of informal payments, human resources scarcity, and the overlapping private interests of pharmaceutical companies and providers. CONCLUSION: Though changes were manifest in certain fora, providers have not necessarily embraced the notion of low caste, tribal, or Muslim women as citizens with entitlements, especially in the context of free government services for childbirth. Grassroots advocates, CBOs, and SAHAYOG assumed a supremely difficult task. Project strategy changes may have made the task somewhat less difficult, but given the population making the rights claims and the rights they were claiming, widespread changes in demands for informal payments may require a much larger and stronger coalition.