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.

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

Tuesday, July 25, 2017

Lessons in nutrition

Priyadarshini Roy

Most of summer of 2015 was spent in villages of Jhalawar, a district in Rajasthan. It was only a month that our flagship program, Akshada, was launched. The main objective of the program is to improve the maternal health, child health and nutrition indicators. Hence it was important to speak to the mothers to understand practices around health and nutrition.
Every day we would meet groups of women. Younger women with babies in their arms were eager to interact. The older women would typically trickle in later and make statements – often complaining about ideas like ‘rest during pregnancy’ by the doctors. They thought such advice had ‘spoilt’ the younger women. They would often say that now-a-days young women do not have the kind of strength that they possessed in their youth.
I would ignore such statements because they were not responses to our questions- what do young mothers feed their children, what do they have during their pregnancy, are there any foods that they avoid during pregnancy, etc. However, similar responses from the older women, village after village got me thinking. I added a few questions and things to observe in my discussion guide from week two.
During the focus group discussions, I started noticing the difference. Most of the younger women in their colourful attire looked frail, tired and weak. They lacked that energy which is often synonymous with youth and being pregnant. The older women despite their slow and assisted movement, appeared well-nourished and not over-weight. Their wrists were broader and they seemed to have substantial muscle mass, as compared to the younger lot.
We started probing and comparing food habits during pregnancy of younger and older women. There was a significant change in diet over the years. The older women ate what they grew- whole grains and greens. Their diet comprised of curd and buttermilk in good quantities. On the other hand, the younger women bought cereals from the market, which was more than often not grown in their villages. In a couple of decades or so maize, millets, barley were replaced by wheat and rice. Today’s diet included more of processed food, especially in case of children in the weaning age-group.
Some basic ways of life had changed drastically. Majority of farmers are growing cash crops. Therefore, their daily diet had changed. With better access to cities, processed food has made its way into the lives of families in rural areas. And how! When a young mother was asked what does she feed her 8- month old child, besides breastmilk, she said “One packet of Takatak and a few Parle-G biscuits. He eats all of it. Does not want to have roti”. Takatak is the Kurkure equivalent in rural Jhalawar. This is what we heard in almost 75% of the villages that we visited. The older women told us that they ate maize rotis and maize porridge during pregnancy and when weaning a child, they would give them small and diluted portions of the same diet. Locally grown grains and vegetables were the main ingredients.
A lot had changed in two and a half decades- agricultural practices, food habits, perception of nutritious food, etc. It was also clear that providing interventions during the 1,000 days is just not enough. A comprehensive strategy needs to be deployed to tackle undernutrition. Policies related to agricultural practices are as important as pricing/taxing policies of junk food to create an environment, where healthier options are available. For example- farmers to compulsorily retain a fraction of their land to grow traditional food crops, fruits and vegetables. Only then can the remaining land be used for commercial production. Fast foods that have no or very little nutritious value should be taxed at a higher rate to discourage intake.
Lesson learnt: Do not ignore statements or comments made by onlookers during a focus group discussion as they may provide cue to rich data. When we began, I was clearly not listening!

Priyadarshini Roy is Director-Programs with the Antara Foundation

Tuesday, July 4, 2017

Nursing is my superpower

Ratan Kunwar 

It is a typical summer day in Jhalawar, Rajasthan. The journey to the field is long and bumpy and yet the landscapes, so well anchored in time, offer an extravagant simplicity beyond any polished beauty. We are here to meet and better understand the work and life of Ratan Kunwar, a young ANM posted in Moondla sub-center of Khanpur Block in Jhalawar District of Rajasthan. She has been providing healthcare services for over a year now.
How did you get involved in this work?
I was lucky to have been given a proper education, unlike many girls in my village. When I graduated, the next step was finding a job to earn for my family. Who knew that one day, following my friends to fill out a form for healthcare services would change my life for the better.
What is a work day in your life like?
I live with my elder brother and his wife, so I wake up at 5:30am every day to help my sister-in-law with household chores. After that I set out on my scooter to the field, covering about 70-80 km every day. I am in-charge of 11 villages and take care of the VHND (Village Health and Nutrition Day) where I perform vaccination of pregnant women and children. My work also includes tasks such as counselling high risk pregnant women, home-based post-natal care, and motivating couples to maintain a gap of three years between two kids. I return by 5PM to 6PM in the evening.
What are some challenges that you face in carrying out your work?
In a population of 5,257, there is a substantial population (1,230) of scheduled tribe and scheduled castes. For most part of the year, they migrate from one place to another in search of work. This makes it difficult to track them for vaccination as they keep changing their phone numbers as well.
One case where you felt you were instrumental in saving a life?
Once during a woman’s ANC check-up, I discovered that she had an increased blood pressure. Her sonography revealed that her baby had died in the womb (intra-uterine death). I referred her to the district hospital in Jhalawar, which is more equipped with skilled staff to deal with such cases. She insisted we deliver the foetus there but I counselled that her life would be at risk if she does so. In the end, she delivered her foetus safely at the Jhalawar district hospital. She was understandably distraught and blamed us for the death of her baby but I am only thankful that I could save at least one life that day. Her life.
How do you believe we can achieve substantial improvements in maternal health?
I think that a regular training of the frontline workers can improve things in the villages. I oversee 11 villages and I don’t mind confessing that I need help. Having another ANM would ensure that not a single beneficiary is left out.
Before Ratan got posted in Moondla, the position lay vacant for two years. When she joined, she was welcomed with phrases such as, “finally someone is coming to vaccinate our women and children” and “we were unaware of the government’s provisions and services”. It is these sentiments of people which motivate her to continue her work and provide better healthcare.

Ratan Kunwar is an Auxiliary Nurse Midwife in Moondala, Rajasthan

Tuesday, November 1, 2016

Mobilising adolescent girls to improve healthcare

“Many girls in my class have dropped out this year, but I will complete my studies,” says 15-year old Vimal with a bright smile.  “I want to be a police officer when I grow up. I want to do something which will make everyone in the village proud of me” she says. Others in the group of about 15 girls slowly speak up as well, and each reveals a similar ambition. Some want to be teachers, others want to be nurses, but almost all of them express a desire to make a difference by serving the communities they live in.
When we tell them, about Akshada, the maternal and child health program that we run in Rajasthan, they are quick to respond with interesting questions and observations they have on the topic.
“Kya aap tika-karan karwaenge” (will you get children immunized); “garbhvasta mei hari sabzi khani chahiye (one should eat green vegetables during pregnancy); “kya aap unn bachon ka illaj karenge jinka vazan kam hai (will you treat those children who weigh less)?
They were not only keen to know what we were attempting through our program, but also remarkably insightful about the issues and challenges that we were most likely to face, saying, for example, that it would be difficult to explain changes in approaches to elders in the community.  When Vimal followed us till her school compound to ask us whether we will be back and as promised tell her more about our work, we knew we had to come back.
In the weeks to follow many such interactions led us to believe in the vast potential of adolescent girls in villages in Rajasthan to be change agents. Like Vimal, there are hundreds of girls who are aspiring to finish school, to be recognized, to be aware of the problems facing their communities, and to do something for their communities.
In some of the villages in Rajasthan that the Antara Foundation serves, we are starting to co-opt several of these change makers as part of our ambitious Akshada program aimed at bringing about dramatic improvements in health outcomes in the state.
Chief among our initiatives over the first year of the program has been an effort to focus the work of frontline healthcare staff on the neediest beneficiaries. Looking ahead, we believe that a large part of the success of our mission will come from generating community involvement to drive demand for healthcare services. This will help not only in holding the delivery mechanism accountable for the quality of healthcare service delivery but also in driving demand for services from beneficiaries, especially those who currently cannot—or will not—participate in consuming healthcare services. For example, by some estimates, as few as 25% of pregnant women receive all four antenatal check-ups that they are supposed to receive during the course of their pregnancy.
The barriers to receiving these check-ups are real—from a loss of income from daily wages, to real or perceived discrimination at service delivery points. However, improved healthcare outcomes require that we have more informed and empowered beneficiaries who demand and receive all the services needed to ensure safe deliveries. The lives of mothers and children depend on it, not to mention the integrity of families and future wage-earning capacities.
This is where we think Vimal and her fellow adolescent girls have a major role to play. These adolescent girls, some still in school, others having recently dropped out, were all very excited, when we spoke with them about it, at the thought of partnering with us to help support their local communities. Armed with training from us and from frontline healthcare workers on some of the basic concepts of maternal and child health, many of these girls have already become force-multipliers for our program.
They are helping ensure pregnant women in their mohallas (neighbourhoods) regularly take their iron and folic acid tablets. They are helping ensure that any young children showing signs of malnourishment are given appropriate care and treatment at the earliest. They are shadowing the frontline worker on her regular rounds in the community, helping potentially train a future cadre of such workers.  Above all else, they are becoming aware and empowered themselves as young women who will one-day start families of their own.
If you have thoughts or suggestions on other ways to empower communities, we would love to hear them. Please do drop us a message via this blog, or via our social media channels. We look forward to hearing from you.

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 A...