Scaling-Up a Community-Based Approach to SDH: Reflections on the SEWA Experience

Abstract

The Self Employed Women’s Association (SEWA), an organization of women workers across India, addresses the social determinants of health (SDH) in practice, through a community-based approach led by health workers. Initially based in Gujarat, SEWA expanded its health program across five additional states through training and collaboration. Committed to addressing social determinants of health, particularly women’s working conditions, SEWA learned to adapt its approach in each new setting. Its focus on maternal and child health was changed to a focus on water and sanitation, or to eye health for example, depending on women’s needs and gaps in services. Differences in health services in settings such as Bihar, West Bengal and Delhi led to changed roles for health workers as well. Thus, rather than spread a uniform model, SEWA scaled-up a philosophy—and consequently retained a social determinants approach—implemented by health workers. Dynamic, needs-based and community-based programs are required to address social determinants in practice, which in turn calls for changes in approaches to health worker roles and training.