Thursday, October 4, 2018

Three months in: Checking in from Jhalawar

Mahadevan Nambiar

As a student of public policy, the Antara Foundation held a lot of promise because of their approach of building solutions that are can be scalable and sustainable. This would mean that every intervention envisions the foundation working with the government and eventually institutionalizing the solutions it builds. Furthermore, the fellowship offered an opportunity to be on the field, something which was sorely missing from my otherwise sanitized and academic experience.
Primary Health Centre, Dahikhera (Khanpur Block)
For the fellowship, I am placed in the field office located in Jhalawar, Rajasthan. It was an interesting time to be in Rajasthan as the hot sun gave way to clouds full of rain. I was assigned to work on the pilot of the Rajsangam App in the Khanpur block of the district. The work itself was pretty straightforward- I was to assist with the rollout of the app, work on improving the use and adoption rates as well as monitor its progress. The app was the online avatar of the existing AAA platform pioneered by TAF in partnership with Tata Trusts and the Government of Rajasthan.

The catch, for us was that we were asking more of the already pressed frontline workers. An Anganwadi worker (AWW) in the state of Rajasthan has to maintain eleven registers in addition to providing hot cooked meals and take home rations. An Accredited Social Health Activist or ASHA must maintain a diary, counsel pregnant woman and eligible couples, provide Home Based Newborn Care (HBNC) in addition to making ten household visits a day to access their health status. An Auxiliary Mid Wife (ANM) on the other hand is responsible for providing primary healthcare services to the villages which fall under the purview of her Sub Centre, in addition to performing Ante-Natal Check-ups on pregnant women and administering immunization. These three frontline workers, together make the AAA platform.
Village Health and Nutrition Day, Banskhera
In this scenario, the AAA workers would seemingly have no incentive to now work on an app. I expected to encounter roadblocks every day with frontline workers outright refusing to work on the app but surprisingly, that was not the case. What was lacking in most Anganwadi centres and sub-centres was adequate training and close supervision of the work.
Over the last three months, I have spent time in centres largely handholding front line workers as they worked through the app. Hands-on training helped build confidence of the frontline workers with the app. Many of them had not used the app since the training sessions in May. This meant that post-May, there was a drop in the data being fed into the app. In some of the rarer cases that meant starting from the very basics and going further behind and teaching them the basics of the register. On being given individual guidance on the app workflow and how it eliminates the double entry of data which exists in the registers, the frontline workers seemed more open to giving the app a try.
Everything is however not as rosy and the three months have revealed challenges that face us as we move ahead with the rollout. First, the moment we let go and there is a gap between two AWC visits, the app use falls short. Second, on encountering a bug or any unfamiliarity within the app the frontline workers immediately stop using that function of Rajsangam and finally, poor network and connectivity issues means that the data from the app does not get synced until someone from the foundation visits the centre. While the second of these challenges can easily be dealt with more stable and better builds, the first and the third one is concerning especially from a scaling standpoint. As one of the countermeasures, the team introduced the app to the supervisors which would be the first step to institutionalising the process. To date this has shown some limited success wherever the supervisor was hands on and followed up with the frontline workers. In Dahikheda, the sector that I am responsible for, the ASHA Supervisor is one such case and asks to see the claim form in the tablet during the monthly sector meetings. The ASHAs in the sector, probably half-afraid of their claims for work done not being approved, fill their HBNCs at the very least. Connectivity for now is being handled by making regular visits to centres. A silver lining is that some of the frontline workers have not only asked to be taught how to sync the data, they even manage to do it on their own.

Going ahead with Rajsangam would require us to adapt to these changes to tackle the problem of lack of motivation and even possibly develop an incentive structure as the app scales up, while addressing connectivity issues. These challenges are interesting, especially from a policy point of view and I hope to engage with them more deeply in the months to come.
Mahadevan Nambiar is a fellow with the Antara Foundation

Khanpur Musings

Adityavarman Mehta

Having conducted field research on maternal, child health and nutrition outcomes in South Africa, Ghana and Kenya, I was eager to explore these issues in low-resource settings in India. As a sociology and global health student, working for the Antara Foundation in Rajasthan presented a number of captivating intellectual challenges because of the extensive literature on Rajasthan’s skewed sex ratio and abysmal maternal and child health indicators. With the responsibility of eighteen Anganwadi Centers in Khanpur, Jhalwar, I was excited about the potential for discovery afforded by this opportunity.   

Maraita village, where I work with four Anganwadi Centres
According to the 2011 national census, Rajasthan had a sex ratio of 928 females per 1000 males.[1] Although Rajasthan’s sex ratio has improved from 909 females per 1000 males in 2001, the preference for the male child is indisputable. Jhalawar, in particular, has witnessed a more skewed sex ratio compared to other cities in Rajasthan like Jaipur, Kota, Bikaner and Ajmer. Drs. Rashma Gera and Seema Mehta conducted a study to illustrate the sex ratio at birth at tertiary hospitals in Rajasthan. Their evidence indicates that 924.8 females were born per 1000 males in Jhalawar in 2010, but there was a dramatic decline in 2015, with 876 females per 1000 males.[2] These are shocking numbers!

Through Antara Foundation’s fellowship in Jhalawar, apart from contributing to better health outcomes, I wanted to observe local attitudes toward female children during my field visits. Upon analyzing the nutritional status of male and female children in some of Khanpur’s villages, I often found that the likelihood of female children being malnourished was greater than male children. Male children were also given more opportunities to study compared to female children.

Always enjoy my interactions with the kids of Bhairoopura. 

While some frontline health workers argued that the preference for male children was no longer common in their villages, many claimed that they are constantly counseling families insisting on producing children irrespective of the fact that it could potentially endanger the life of the expecting mother. In some cases, I have seen families with eight girls still looking for a male child. Perhaps the most stirring case was of a 35-year-old physically disabled woman who had delivered five girls, but her family was unprepared to relent until she gave birth to a boy.

Working on the Rajsangam app with a frontline worker in Khanpur block
Some of the families insisting on male children argued that children were a blessing from God and it was unacceptable for them to refuse even if it was life-threatening to the mother. In other cases, women were blaming their husbands for multiple pregnancies. Despite the Auxiliary Nurse Midwife’s (ANM’s) repeated attempts at counseling families, effecting a change in their thinking continued to be a challenge. In my interactions with frontline health workers, we talk about explaining the benefits of schemes such as the Rajasthan Mukhyamantri Rajshree Yojana, that incentivize the birth, immunization, and education of the girl child, to beneficiaries. Furthermore, I try to emphasize the importance of ensuring that beneficiaries receive the money that government schemes promise and any assistance that they might need in navigating banking systems because I have spoken with numerous mothers who have talked about their struggles in understanding basic functions such as debit, credit, deposit and withdrawal. Effecting behavior change is a complex process that requires constant reinforcement over a long period of time. In the short-term, using monetary incentives to promote the birth and healthy development of girls can be effective.  

Ultimately, the Antara Foundation’s primary objective is to improve the lives of the people of Jhalawar. In addition to elevating the standard of maternal and child health delivery in Jhalawar, I hope we can work towards eliminating biases against the girl child. A healthy and educated female population will only serve to benefit Jhalawar and eventually, all of Rajasthan. As Karl Marx once said, “Anybody who knows anything of history knows that great social changes are impossible without the feminine ferment.” 

[1] Population Census 2011 (2015). Reference:
[2] Gera, R., & Mehta, S. (2018). Changing Trends of Sex Ratio at Birth at Tertiary Hospitals of Rajasthan. International Journal Of Scientific Research, 7 (7). 

Technology, padharo mhare Anganwadi

Owais Shafiq

Late monsoon drizzles and an overcast sky prevails, the loo has left for better days. Walking through narrow roads of un-finished houses, the Accredited Social Health Activist (ASHA), the Anganwadi Worker (AWW) and the Auxiliary Nurse Midwife)(ANM) each make their way to work with an android tablet in their grasp - a strange sight for most locals in Khanpur block of Jhalawar district.

Anganwadi Centre - Bhatwasi village

The Antara Foundation, in partnership with the Government of Rajasthan and Tata Trusts, introduced the AAA (ANM, AWW ASHA) program which has been scaled across the state. The AAA program revolves around the idea of the frontline health workers corroborating each other’s data and working together for better service delivery. An AWW in Rajasthan is expected to maintain eleven registers to document the services she provides. These registers include her village survey, immunization, information on pregnant women and more. An ASHA, is responsible for documenting potential medical conditions in the community and determining the nutritional status of children in the community. The third frontline worker is known as the Auxiliary Nurse Midwife or ANM. The ANM is the trained medical professional in this equation and she is required to document her data in bulky Service Delivery Registers. They together form the first point of contact for delivering health based service for rural communities.

To further improve the efficiency of the AAA program, the Antara Foundation created the Rajsangam application. The primary objective of the application is to ensure the seamless exchange of information across all three frontline workers. Rajsangam has been rolled out in the Khanpur block of Jhalawar district, with 347 frontline workers being thoroughly trained in the use of the application through an Android tablet.

Ability of Anganwadi workers to utilise critical functions of the app

Ability of ASHA workers to utilise critical functions of the app

Women in rural India however, often have to live in a world of digital patriarchy, additional to the physical reality. Technology mostly only reaches men, who lord it over women. Lower levels of literacy additionally exclude women from the uprising of a digital India. For instance, ATMs have caused much distress to women in villages. It has completely removed husbands’ need for their consent to withdraw money from their accounts (Only 55% of women in rural Rajasthan own bank accounts that they themselves use – National Family Health Survey NFHS-4). The current Government of India is a strong promoter of a digital India. The digital India Campaign aims at providing government services to its citizens digitally. It encompasses; developing Infrastructure, delivering services and providing digital literacy. The use of enabling technology, in particular information and communications technology, to promote the empowerment of women has also been stated as a target of the Sustainable Development Goal 5 (SDG 5 -Gender Equality).

ASHA and AWW with their respective registers and tablets

While the Rajsangam application has evolved over the last year, time will answer whether it is an effective and sustainable intervention that can improve maternal and child health, and nutritional outcomes. What is undeniable, however, is that Rajsangam has opened the doors for women in rural areas to access modern technology.

Seema Nagar and Seema Sharma, the ASHA and AWW in Chandpura Chaplara, typically work seventeen hour days. They rise by dawn to cook for their children and milk the buffaloes. Milking the buffaloes before dawn, they say, is crucial because it can be done without the constant disturbances perpetrated by fleas. A little later and you would have a tail whack your face or dung on your feet. Having performed these duties early in the morning, Sharma then departs for the Anganwadi Centre. She is expected to update eleven registers that includes information on high-risk pregnancies and malnourished children in her community. She often has to take work home. Seema is a strong promoter of the Rajsangam application. Showing her many registers, she believes her support is obvious. Her work is streamlined and intuitive. Redundancy in record keeping is nonexistent when data is synchronized.

Modern technology belonging to Seema Nagar now makes her feel much empowered. Professionally, she finds her work to be simpler with less drudgery now. She just needs this little object to take along with her while conducting a Home-Based Post-Natal Care (HBPNC). She can click photographs and send them to her supervisors using WhatsApp. She is even part of an ASHA WhatsApp group where apart from sending broadcasts of ‘good morning’ messages, there is a good amount of exchange on individual work done.

Anita Meena, the ASHA for Rajpura village, is a 10th grade graduate, who was married by the age of 16. Given her background, she is proud of the way she has embraced technology. Anita is the only member of her household with a tablet and she is now respected for her expertise in modern technology.

Technology has also empowered Kanti Bai of Bhatwasi village. She claims that her knowledge of technology has elevated her status in her household. She is well-versed with modern touch phones and tablets, while her husband still uses a keypad mobile. Kanti Bai plays games on her Android tablet with her kids and treasures the precious moments it allows them to spend together as a family. With her son’s help, Kanti Bai makes regular WhatsApp video calls to her family.
In Kheda, the ASHA has learned to use hotspot for Internet connectivity and plays her favorite songs on YouTube while cooking dinner.

AWW Rajani Bala trying to connect to the internet using a hotspot
The ASHA from Harigarh II village was introduced to technology for the very first time through the Android tablet provided to her. Her grouse with technology was that she no longer had any money she could access discretely. When she visited the bank, she was able to save money for herself secretly. Now that her salary is deposited directly in her bank account, it is withdrawn by the men in the family. She argues that she longer has any control over her money. New mothers who receive money through government schemes echo her woes. After receiving training during the Rajsangam rollout, she feels confident enough to use an ATM machine independently.

Adoption of technology is a very curious phenomenon. Lives and lifestyles change, dynamics change for better or worse. Inclusiveness exists. Not involving women in modern technology will surely develop/add to systemic faults.

In a time where digital world is causing much distress to women, I tried to analyze the amount of digital literacy that the Rajsangam application has brought to the front line workers of Khanpur.
More than 60 % of the AA (ASHA and AWW) (22 respondents, sample n=35) claimed that,

  • They felt more confident with technology.
  • Data sharing with Supervisors had increased.
  • Communication and awareness with family outside the village was significantly more Due to the utilization of a tablet computer.
  • Created participation and involvement of all family members (especially mothers) during informal bonding sessions.

Frontline workers' ability in secondary functions

Owais Shafiq is a fellow with the Antara Foundation

Wednesday, July 18, 2018

Working with scale: Field perspective

Owais Shafiq

Participating in the Antara Foundation’s fellowship program is my attempt to develop a field-based thought process.  At Antara Foundation, scalability is a necessary thought. A scalable solution is one that can be replicated easily to reach a larger population. This approach seems logical to me, because scalability also encompasses program sustainability, replicability, and long-term impact.

The last few months have exposed me to the difficulties of thinking and working with the question - ‘can this solution be scaled’ while on the field.  Spending a significant part of your day in the field with constant community interaction exposes you directly to the cause and effect of many existing fault lines. There is an urge to create a positive impact which brings to life the struggles involved in the scalability approach.  Scalability is a big win and big wins require a significant amount of time. Room for solving what might be micro issues in the grander scheme of things is unavailable. There are multiple scenarios and cases that I have come across that require a more immediate rapid action plan. To be a spectator for issue X and work on issue Y, even though there is a strong co-relation (a common situation in the development sector) is not easy and hits hard on the conscience.

Recently on a visit to Khandi (Khanpur block, Jhalawar district, Rajasthan), Rithika - an Antara Foundation fellow and I noticed on the village map created by the AAA that there was a household with three yellow bindis, (signifying the presence of a malnourished child in the household). We discovered that three daughters were born into the house in three consecutive years. It is fair to assume that this was in a bid to get a male child and hence the reason for the yellow bindis (A common situation in rural Indian households). For me, the fact that this data is being visualized is huge. Putting this on the wall, is the first step to ensure that these three girls make it out of these social barriers healthy and strong. When the front line workers (AAA) visit the house and counsel them on taking care of their children, there could be a behavioral change. The experience made me believe that this kind of behavioral change cannot occur by simple campaigns and drives, from organizations or governments. Systemic changes are the need of the hour. While every case is important and small wins help the human mind to get by, large impact requires a different attitude.
Village map - Khandi
Scalable solutions require patience and a stronger will, while one is working on the field. While the village map did not directly solve the problem of malnourishment among girls in Khandi, it did create a platform to strengthen the health workers in better understanding the situation and taking the necessary steps. A scalable solution has the capacity to deliver high impact systemic changes rather than campaign format interventions with short lived outputs and unsolved root causes.

My first month in this fellowship program has been intensive and moving. I have often felt helplessness and irritation when there is no direct impact created through my work. Simultaneously, I have developed a more mature outlook on how a program needs to be designed and implemented to create a sustainable solution.

Owais Shafiq is a fellow with the Antara Foundation

Thursday, May 31, 2018

In Pursuit Of Stories: Experiences From The First Month Of The Fellowship

Rithika Sangameshwaran

A Community Health Centre (CHC) the third point of contact in the rural public health system

“The maternal mortality rate (MMR) of India is 167 per 100,000 live births and the infant mortality rate (IMR) is 34 per 1000 live births. These are important statistics and you must know them”, the professor instructed a class of about forty listless students aspiring to be public health professionals. I dutifully made a note of those numbers and kept memorising until they became embedded in my head. After all, these are important statistics a public health professional must know. But the thing with statistics is that they are just numbers. Although undoubtedly important numbers, they also make it easy to overlook that there are people- real people behind these numbers. In my opinion, these evolving statistics, while extremely instructive, fail to capture stories. Maybe that is why they are forgettable. I believe that it is always the stories one remembers, not the numbers.

Can you spot the Anganwadi centre?

It has been a month since I moved base to Jhalawar, a district nestled close to the Rajasthan-Madhya Pradesh border. Now that I look back, perhaps it was the pursuit of finding such stories that motivated me to do the Fellowship. And while certainly aplenty, I was simultaneously confronted by stories of despair and hope. India has managed to reduce its MMR from 254 to 167 over a period of seven years, which is no small feat. But the number is still way too high, and lot remains to be done. Simple, well-known public health interventions hold the promise to help reduce MMR in the country. For instance, basic interventions such as organising and maintaining hygienic conditions in the labour room and having skilled staff can significantly contribute to prevention of maternal deaths. Yet, some health facilities I visited were struggling to ensure even these basic requirements for various reasons ranging from shortage of staff to lack of leadership. These stories strengthened my belief that, in public health, the solutions are (almost) always low and not-so low hanging fruit.
An Anganwadi worker with the multiple registers needed for her work

The reduction in MMR tells us about the reduction in maternal deaths but does not tell us the stories of those millions of health workers who made this possible. I witnessed the relentless efforts of health workers who often travelled long, arduous paths to ensure that no mother or child is deprived of the services they deserve. The stories of these health workers, who are women themselves, left an impression on me. These women, like millions of working women around the country, carried the responsibility of their households and the health of the areas they worked in. In all my visits so far, for reasons I am yet to understand, I saw no male health worker.

The cadre of front-line workers (FLWs) responsible for improving health in the country
Working on maternal and child health in rural Rajasthan allowed me to witness brazen inequities which sometimes angered, at other times sobered me. The impassive manner in which people spoke about sickness, death and associated tribulations particularly struck me. It seemed as if they had accepted these as inevitable; not because it did not affect them, but because they probably did not have the luxury to mourn for long. I witnessed first-hand why maternal and child health is unquestionably a gender issue and how caste and class profoundly influence maternal and child health outcomes.

Two Adivasi children playing while those belonging to Dalit community look on
I was taught that availability, accessibility, and affordability is the mantra to alleviate public health problems, achieve universal health coverage, and improve people’s lives. My experiences, however, challenged several such dictums that I held.  It made me question whether this will hold true if the health workers are not empathetic and the health system is oblivious to the needs of the people it serves. The past few weeks have enabled me to ponder about the scalability of public health interventions. I have been trying to understand how to ensure minimum quality when scaling up, contextualise interventions to suit local needs, and what makes for a successfully scaled intervention. In my opinion, the effectiveness of an intervention can be determined not by mere change in numbers, but when stories, individual and collective, change. And I hope that the next 11 months of my fellowship are filled with many such stories.

A child looks on from the Anganwadi centre during Village health and nutrition day (VHND)

Rithika Sangameshwaran is a fellow with the Antara Foundation

Friday, March 16, 2018

Are we empowering them?

Priyadarshini Roy

It was the cusp of winter and summer in Jhalawar- February 2018. I was looking forward to the field trip this time, especially after the long hiatus. The country side is always refreshing. New ideas come to mind effortlessly, and one feels completely rejuvenated. It is also a good time to take stock of strategies/activities that the government is implementing or we, as an organization are supporting. More often than not, it is gratifying to know that your efforts are in the right direction, while sometimes it makes you sit up and question whether things are really going the way you had envisaged.
I was visiting a Village Health and Nutrition Day[1] (VHND) at an Anganwadi Centre (AWC) in Khanpur block of Jhalawar. The Auxiliary Nurse Mid-wife (ANM) was carrying out her routine activities like immunization, ante natal care, etc. Intermittently, young children below 6 years were being weighed. Little babies, oblivious of what was coming cooed and giggled in their mothers’ arms until a sharp needle was thrust in their tiny bodies. Then came the shrilling cries, which were silenced soon after the mothers put them to their breasts. Mothers who came for the first time did not know the trick to calm their children. However, the ANM was quick to advise.
Visit to the AWC, for the women beneficiaries, who attended the VHND, seemed like an outing. All of them were dressed in their fineries, replete with accessories and make-up- kohl, lipstick and in some cases even rouge! At the fag end of the session, a young woman came in to ask for medicines for her child who had fever. Let’s call her Raveena[2]. The ANM asked the child’s age and gave two tablets with precise instructions for use.  As soon as Raveena left, the ANM proudly mentioned that she was able to convince the young woman to undergo sterilization as she already has three children.
I had noticed Raveena- she was fair with light eyes- uncommon in this part of Rajasthan. She did not appear to be more that 22-23 years old. And, she was sterilised. I asked the AWW about her age. The response was a lot of other information but her age. Apparently, Raveena had a child marriage. When she came of age, her parents married her off to a much older man for money, in May 2013. She had her first child in May 2014, the second one in September 2015 and the third one in July 2017. The ANM thought that at this rate she would get pregnant again (as her youngest was weaning). Hence, the best option would be to convince her for a permanent method. And Raveena relented.
Though the government of India offers a basket of contraceptive choices (the most recent entrant being the injectable contraceptive), data shows that couples prefer permanent methods (sterilization) over temporary methods. It is largely female sterilisation (36%) while male sterilisation is almost nil (0.3%). Reasons range from fear of losing virility to inability to do strenuous work, even when the procedure for males is much simpler (without anaesthesia) and quicker. The recuperating time is also much less in case of males.
In villages, the primary responsibility to promote contraceptives rests with the ANM and ASHA. They are incentivised for uptake of contraceptive methods which is skewed towards permanent method and long acting methods (IUD- Intra Uterine Devices- primarily for spacing between children). So, the natural tendency is to promote the method that gets higher incentive. Similarly, the beneficiaries are also offered cash incentives for undergoing sterilization. The incentives for men are double of what a woman receives. Yet the numbers tell adifferent story. A general rule followed is that only couples who have completed their family should be counselled for adopting a permanent method and only if the last child is above a certain age. This is to enable the couple to have children if something untoward happened.
The following day was earmarked for data integration between the three front line workers – ASHA, ANM and AWW of a village in Pirawa block of Jhalawar. I started probing the ANM about the age of women who have been recently sterilized. She said that young women are choosing this method even after one child- given that it is a boy. They do not prefer other methods and their husbands refuse to use any protection- temporary or permanent. I asked her what she thought about the trend- very young women getting sterilized. “Madam, I have three villages in my jurisdiction. In each of these villages, I have a case where the woman had got sterilised after the first child and all three of them have lost their only child. One was less than a year old, who fell into the well. The other two were bitten by snake- a toddler and a seven-year-old. I got to refer all of them for reversal procedure. All these women are in their early-to-mid-twenties.”
Adoption of contraception, especially by women, is empowering as we all know. It enables them to be in control. However, it seems that it is also important to choose the right method at the right age. Else, it may be disempowering. In our effort to increase uptake of family planning methods, we must not lose sight of long term socio-economic effects on the woman and her family. Let’s take Raveena’s case. What if, God forbid, something happened to her husband? She would find it difficult to remarry. Or if she lost a child? The eldest one is not even four. In other cases, what if the reversal surgery is unsuccessful? Will the couple reconcile to being childless for life or would the husband remarry (and leave this woman)? What happens to the woman- no one would want to marry her given that she cannot have children? Will she have the wherewithal to fight the situation and take care of herself? It is agonising to even imagine what such women might have to go through.
This, to me is a peculiar situation- all stakeholders- beneficiary, service provider, beneficiary’s spouse and family and the government, all seem to have taken a step in the right direction without realising the risks involved. We need to watch closely and prevent such a situation to arise. We need to begin early- delay the age of marriage, delay the first pregnancy, encourage use of long acting methods to space children and/ or till they are of a certain age and then propose a permanent method, if needed at all. The workers at the village level need to be reoriented accordingly so that their interactions range from unmarried adolescents to their parents to couples who have completed their families.
Last, but not the least. We often tend to ignore the needs of men- their queries need to be addressed. They need to be motivated too- preferably by men who have undergone the procedure themselves. Our approach needs to be more inclusive of men. A mechanism to involve fathers and husbands needs to be devised to have a more effective family planning program.
[1] VHND is a pre-fixed day of the month when the ANM provides mother and child health services at the AWC of the village. Beneficiaries are identified by ASHA during home visits through the month.
[2] Not her real name.

Priyadarshini Roy is Director-Programs with the Antara Foundation

Friday, December 22, 2017

Fellowship diaries: Adolescent girls driving community acceptance

Aditi Rao

Our fellow, Aditi Rao, worked on Jagori Kishori, our adolescent girls program in Jhalawar and Baran districts of Rajasthan. In this post, she chronicles stories of three girls who have inspired her:

Never Back Down

We often attribute most issues to a gap in knowledge. However, there are several circumstances where it is not a lack of awareness, but an absence of bargaining power that leads to these problems.

Radha is the Adolescent Girl (AG) Leader in Danta, Pirawa. Optimistic that the programme will bring about a change in the status of maternal health in her village, she carries out her duties with great dedication. On one of her visits, she noticed the beneficiary, a heavily pregnant woman, lifting something heavy. She advised her not to do so, and to take some time out to rest every day. To her surprise, the woman shot back, saying that she is aware of the do’s and don’ts, but cannot argue with her mother-in-law, who dictates the terms in her 'household.

Most people would have marked this as a dead-end and moved on, but Radha was determined to carry out her task. With the Auxiliary Nurse Midwife’s (ANM’s) help, she visited the mother-in-law and explained to her what inadequate rest and stressful workload, including heavy lifting, could lead to. The ANM took her through examples of cases which had negatively affected both the mother and the child. On listening to their stories, the unwilling mother-in-law slowly changed her mind, leading to a much better lifestyle for her pregnant daughter-in-law.

The focus of the programme may be on spreading messages of awareness, but it has, as a by-product, made leaders out of shy, quiet girls who are adopting a never say die approach to tackle societal evils, so that they may be part of a larger movement to change the status quo.
Building Acceptance, One Person at a Time

The traditional structure of our village societies is inherently damaging to women, who have no say in their own lives. This translates to their maternal behaviour, where they are forced to work hard while pregnant, eat last and not take enough rest. The only way to eliminate this problem is to alter the existing mindset, which is not an easy task by any means. However, small victories are often much larger than we realise, and this was evident in community meetings held through the Jagori Kishori Programme.
In Fatehgarh, Pirawa, one girl was hesitant to join even though she was interested in the programme, because her father was uncomfortable with it. However, after a visit from the Akshada program officer and the ANM, he reluctantly agreed. A short while later, he watched his daughter confidently perform a skit in front of a large village gathering during a community meeting. That was when he was completely won over.When he was invited on stage to collect the certificate for her work, he expressed appreciation for the programme, and gratitude that he had been urged to give his daughter permission. He acknowledged that the programme could be very beneficial in a place like Fatehgarh, which is located on the state border and home to several social evils like trafficking and addiction to drugs and alcohol, with minimal attention to maternal care.
Another instance from Harnavada, Dag saw a father volunteer to speak in front of the community without any prodding. While speaking, he declared that he was proud to have a daughter associated with the programme and concluded that it can only lead to positive results in the village’s health situation.
While these may seem like small examples coming from independent individuals, their open acceptance of the programme in front of the community meeting speaks volumes. To come out in support of a new idea and openly acknowledge it as a positive step is gutsy indeed. This act could prove to be one of the key pieces in solving the jigsaw puzzle that is maternal health care, by urging more people to take a step towards building more accepting and aware societies. After all, change starts with one person.

A Watchful Eye

In Harnavada, Dag, Ram Kunwar keeps a watchful eye on the women and children of her community, making sure to record insightful and important observations. Off-late, she’s noticed one particular child constantly exhibiting signs of a possible deformity and experiencing constant bouts of illness. Upon some questioning, she found out that the child had not been vaccinated in time. There were also some vaccinations that had been completely missed out. Concerned, she has brought this issue to the notice of the ANM, who hopes that she will be able to help the little seven-month old.
Without her notification, the ANM has admitted that she might never have found out about this issue, as she herself is an outsider in the village. Now that she has received the information, she is looking forward to work with the AG to actively monitor the child. Driven by her own small success story, Ram Kunwar has expressed an interest in carrying out with the program even after she leaves school.

Aditi Rao was a fellow with the Antara Foundation

Three months in: Checking in from Jhalawar

Mahadevan Nambiar As a student of public policy, the Antara Foundation held a lot of promise because of their approach of building solu...