Armida Fernandez: lessons in scaling9 min read . Updated: 23 Aug 2013, 08:05 PM IST
SNEHA employs 360 people and works across the slums of Mumbai in 12 municipal wards
In 1977, Armida Fernandez, a young pediatrician and neonatologist, was put in charge of newborn babies in the intensive care unit (ICU) at the Sion municipal hospital in Mumbai. “I saw a whole lot of babies die," Fernandez recalls. “In the unit where premature babies were brought in from the outside, 70% died. I said, ‘You know, something is happening and we need to find out what.’"
The problem was sepsis, a blood infection that can cause death, brought on, she suspected, by unhygienic conditions in the unit. The first thing Fernandez did was to throw out all the incubators, then the powdered milk, the humidifiers and the baby bottles. She set up India’s first human milk bank and in came room heaters, blankets, baby oil and the mothers—to work as nurses.
The hospital administration was uneasy, to say the least. “I broke all traditional practices in intensive care," Fernandez says. “They used to say no entry of the mother into ICUs. I said every mother will be a nurse, I felt the babies survived because of them, I changed the policies of the unit to suit what we did, all these measures helped...you don’t need a lot of money."
Her conviction paid off. The infant mortality rate dropped from more than 70% when she started to 12% by the mid-nineties. That was when Fernandez decided to take her practises and team out into communities where they could make more impact. With the Ph.D students to whom she was teaching neonatology, or care of newborn infants, she started taking field trips into the nearby slums, talking to mothers about basic neo-natal care.
“I kept saying no more hospitals for me, I need to be in the slums," says Fernadez, 70. “Looking at babies and facing death, I’ve realized that hospitals are not the answer. They are part of it, but you need to work to keep people out of them in the first place."
Today, Fernandez, who eventually became dean at Sion, has moved the focus of her work out of the hospital and into the slum community Dharavi, where she has set up the non-government organization (NGO) SNEHA, which works in the field of maternal and infant health, prevention of violence against women and children, and health and nutrition.
SNEHA employs 360 people and works across the slums of Mumbai in 12 municipal wards and has started working in Thane, Bhayandar and Kalyan. It is funded by corporate entities (United Parcel Service, IDFC Ltd, Mahindra & Mahindra Ltd, and Tech Mahindra), venture capitalists (Sequoia Capital), and philanthropic foundations (the Wellcome Trust, Sir Dorabji Tata Trust, Bombay Community Public Trust, Dasra and GiveIndia).
As it approaches its 15th birthday, it would be fair to say that the organization has achieved scale.
However, the challenge of achieving this scale has been almost as daunting to Fernandez as was her original objective. When she took her first steps, although she had been working as a neonatologist for more than 20 years with an experienced and dedicated team and knew her community well, Fernandez was at a loss.
“I didn’t know what an NGO was," she says. “We were all professors, and when I got the first money I said, ‘What shall I do with it?’"
With the help of a friend, who had left some money for the project, and a social worker, Fernandez created the basics of an organizational structure.
“We put my whole department on the board of trustees," she said. “I didn’t know what that was then—I know now. Slowly it became more professional and I got more people. The first interviews lasted for a minute or maybe two. I chose my programme directors in those few minutes and those people are still with me today."
Fernandez’s faith in the future of SNEHA may have been redoubtable, but it was hard to make outsiders see it that way. “I know some funders from the US ran away because they said, ‘What is your funding plan for the next 10 years?’ and I said, ‘The Lord will provide.’"
The problem Fernandez faced is common to many social entrepreneurs in India and one that has not been properly addressed, according to Bain and Co.’s India Philanthropy report of 2013.
“Foundations and experts expect to have a clear and structured view on impact," the report found. “Though this measurement is highly desired, it is difficult to measure in the field, particularly in India."
While Fernandez knew that her model was working, it was hard to measure its exact impact, she says, especially as most of the messages she was spreading would need time to take hold.
“When you work in a hospital you feel a sense of fulfilment, you save lives, it’s an immediate gratification. With the slums it’s a different feeling. You watch people grow, you don’t get the pleasure of saving one single life, you are not really counting but you have to have the courage to say, ‘Does what we do make a difference or does it not make a difference.’"
It’s a question of time and repetition, Fernandez says. But there are ways of trying to measure impact and participation levels. From 2003-07, the NGO underwent a “randomized control test" with the Wellcome Trust, which funds research to promote health.
While it was easy to see progress in nutrition, using the percentage of reduction in cases of malnutrition, some ideas weren’t working as well. Whereas “in rural areas, self-help groups have been an effective way of changing behaviour", in urban slums, “these groups don’t work because it’s not homogenous," Fernandez says. “I put up posters on immunization and lots of women hadn’t even read them, some had misinterpreted them. If you want a woman to look at a poster you have to stand in front of it and explain it to her."
Social change, by nature, is not easy to quantify. Even while ideas and good practises are taking hold and communities change their approach to health and hygiene issues, the numbers are not forthcoming. At the same time, donors are impatient for results that can be measured.
Based on the interviews that Bain did for their report, the survey found that “donors tend to focus on the changes that their giving creates in the lives of beneficiaries. They seek quantitative metrics, such as the number of students enrolled, and audited results of NGOs’ activities to asses impact".
Nevertheless, from one single social worker in 1999 to 360 people today, the organization has grown rapidly, if haphazardly.
“We didn’t really have a blueprint or a plan like that, it grew like seeds planted. Down the line people came in pro bono (for the public good) and said you need to have a mission statement and a vision. With Dasra’s help we now have a business plan and it’s actually grown beyond expectations of the plan... It’s very professional now," Fernandez says.
Deval Sanghavi, co-founder of Dasra, a strategic philanthropy foundation that works to help NGOs scale themselves, among other things, says that while institution building is crucial when an organization needs to grow, “at the beginning it is important that an NGO has an innovative culture and tries various initiatives which may not be possible if there are too many processes in place". However, Sanghavi adds, “donor funding is also usually unavailable for institution building until a proven model is place"—it’s a predicament that many NGOs face at some point.
In the last month, a new incentive to professionalize the running of NGOs has come about in the shape of the new companies law, which mandates companies to set aside a certain amount of money for corporate social responsibility (CSR) initiatives.
Companies worth more than ₹ 500 crore or with revenue of more than ₹ 1,000 crore, or net profit of more than ₹ 5 crore would have to spend at least 2% of their average net profits of the preceding three years on CSR.
While there is no penalty for non-compliance, most philanthropists and NGO workers agree that the incentive will mean a new focus on the part of corporate entities to spend their money wisely and impactfully. The new regulation will mean that the top 100 companies by annual net sales in 2012 will spend ₹ 5,611 crore on CSR activities, compared with the ₹ 1,765 crore that they are spending now, according to a March report published in Forbes India magazine.
This means increased pressure on NGOs to present themselves and their work clearly with rigorous attention to transparency and accountability to attract the attention of corporate donors, according to SNEHA’s chief executive officer Vanessa D’Souza, who came on board in March 2013.
D’Souza was an obvious choice to take over as SNEHA CEO after the departure of its previous head Wasundhara Joshi. She had quit her job at Citibank NA, where she had worked for 21 years in consumer, corporate and private banking, in 2007 to spend more time with her children.
In 2010 she had started volunteering at SNEHA and that period, she says, coincided with “the time they wanted to scale and tap the corporate sector to receive funding from their CSR budgets. That’s when I was approached. We set up meetings with corporates, got marketing materials together for funding various programmes and more than anything else just building the brand of SNEHA in the corporate world".
D’Souza was well placed to look at the venture with the eyes of the corporate donors they were trying to attract. “I could see there was a huge amount of potential there to add value in terms of the running and a slight mismatch between the expectations of the corporates and the social sector," she said.
In the last six months, to bridge that gap, she says, she has worked on strengthening the organizational structure of the NGO, including human resources training and capacity building. She also targets potential donors carefully towards areas of SNEHA’s work that will fit them best in terms of time commitments and sectoral preferences.
“There is a gap in the way the social sector is perceived by the corporate sector," she says. “NGOs have a lot of resource constraints that the corporates don’t really understand. So they have very unreal expectations, there is a lot of expectation management that has to be done."
For Fernandez, the next step is to combine her learning from SNEHA with the kind of institutional change she wants to see in hospitals, where, she feels, young medical students approach maternal and childcare as an exam to be passed.
“They are not motivated to feel," she says. “SNEHA works closely with all the medical colleges and we use doctors and nurses from those colleges. I think they can do more. In every programme there should be an additional thesis for community programmes."
Even now, the poorest mother most reassured by the presence of doctors, says Fernandez, “She wants to see the white coat," she says.
This is the third in a series in which Mint looks at programmes for public good that are trying to acquire larger scale to make a greater impact on society as the Indian philanthropic community matures.
For the earlier stories, go to www.livemint.com