Groping in the dark
Three women form the cornerstone of health delivery in every village in India. The problem is they don’t talk easily, or on time, to each other. And children, in dire need of their attention, are the ones who most often pay the price. Let me introduce you to these three women as well as one child who needs their combined attention.
Rani, 3, lives in House 58 in a small village of 1,000 people, somewhere in northern India. She attends the government’s village preschool, known as the Anganwadi Centre. It is run by Manju, the Anganwadi worker, who finds one day that Rani’s weight is much lower than it should be. She marks that information in one of her 11 voluminous registers, and increases the quantity of food in the mid-day meal that Rani gets at the Anganwadi. She is not required to report the case to a health worker.
Vimla, known as ASHA (accredited social health activists), mobilizes village communities towards the health system. Her job also includes spotting malnutrition cases. The government requires that ASHA visit 10 houses per day in serial order. It might be weeks before Vimla gets to Rani in House 58. Ideally, Manju should have immediately shared the data about Rani with Vimla, and she in turn should have quickly sought out Rani and done a double check using a different method of measuring malnutrition. The two of them should have got their data quickly to the key health worker Priya, known as the ANM (auxiliary nurse midwife). Priya visits the village monthly, and will deal with Rani’s case or refer her to the appropriate government health facility beyond the village.
The problem starts because the three ‘A’ women come from different work streams. Manju is from the women and child development (WCD) ministry. Vimla is the government’s social health activist who comes from neither Health nor WCD systems, and is paid on incentive. Priya is from the health system, governed by the health ministry. The three women have different supervisory systems, record keeping methods, and work cultures. At worst, they may work in isolation. It is not necessarily their fault, because they work in a tough environment. There may be a broken weighing scale, inadequate training, or just too many registers. Meanwhile Rani may slip into severe malnutrition, a life-threatening condition. This sad situation repeats itself hundreds of times every day.
There is a simple solution being implemented at scale in Rajasthan—the AAA platform based on village mapping. Villages in northern India often lack any kind of reliable map. Manju, Vimla and Priya get together to create a detailed map of the village—not a trivial task. The map is then digitally printed on a large durable sheet, using Panchayat funds. The three front line workers share their data, and stick bindis on the map, against specific houses. A red bindi could mark a house where the woman has a high-risk pregnancy; yellow bindis mark houses of severely malnourished children like Rani; green bindis for newborns needing urgent attention. Several other colours denote normal cases. The village map, populated with bindis of different colours is updated monthly, and kept in the Anganwadi centre, with identities protected.
There are 54 bindis on the map of the village of a 1,000 people. Of these, there are three high-risk pregnancies, six severely malnourished children, and five newborns requiring urgent attention. The three women now together make a household visit calendar that prioritizes the 14 highest-risk cases. ASHA will see that she goes to Rani’s House 58 the next day, as opposed to two weeks later if she had followed her serial visit routine.
This AAA platform is a tool for joint problem solving with speed and quality. Only 14 cases account for the village’s poor record on maternal, neo-natal and infant mortality, and severe malnutrition. This should be an easily manageable number between three people working as a team. At the same time, it builds community awareness and participation. Rani’s grandmother visits the centre every week, to check on her grandchild’s progress. “No grandchild of mine will go hungry,” she asserts.
In two districts of Rajasthan, the AAA workers, together with the village community mapped every one of their 2,700 villages in just six months, with minimal supervision. We believe this will be possible state-wide, because the community at the front line of health delivery, is involved.
If a manual system like the AAA platform works so well, why not digitize it, and have a tablet or smartphone app, that shoots information between the AAA workers in real time? That solution exists, but is crying out for someone to recognize the problem. But that is another story.
Ashok Alexander is founder-director, Antara Foundation. His Twitter handle is @alexander_ashok.
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