Thursday, November 29, 2018

My First 100 Days: Chronicles of a Clueless Economics Student

Cearet Sood

The importance of the First 1000 Days was only a concept that I had studied in my second year of college, as a part of the Indian Economic Development module. Infant Mortality Rate, Maternal Mortality Rate were just definitions to me, meant to be reproduced in examinations. I was taught their relation to Gross Domestic Product and per capita growth. Economics, at university level in India, is taught without emotion. We learn everything as it is. As it exists, without ever questioning it.

This lack of discourse, instead of demotivating me, encouraged me to find answers for myself. Post college, I studied liberal arts. There, I had to unlearn a few things which I had been taught as an economics student. Never assume things or preexistence of knowledge and never take things as they come- always question, protest, demand, rage - do whatever it takes to initiate change. If you want to be a changemaker, you have got to start from the start. By this, I mean to say that one needs to understand and appreciate the complexities involved in fighting the existing reality and building new models which will bring about a change. Numerous inefficiencies in health, education, security, food exist but our criticism counts if we do something about it.

With this in mind, I joined The Antara Foundation with hopes and dreams of shaking things up in the public health domain. My first few weeks were spent in digesting the information about the existing health system, government schemes, and TAF’s  interventions. After that, I started making field visits to Anganwadi Centres in the sector allotted to me- Panwar. A sector is the third tier in the rural demography (District -> Block -> Sector -> Village). Panwar’s population is around 19000. I was assigned to the technology intervention; we have developed an application and provided Frontline Workers with tablets. This has been done with the intention of making the process of data collection easier.  It has made coordination between the three FLWs easier, as data flows easily among them, making possible a three-way cycle. It makes data monitoring easy for us as well, as we have proper documentation and therefore, better identification of beneficiaries. 

The 'Honey Singh pose' is a favourite among kids
I understood the economics/data collection part of it: baseline data collection (pre-intervention data), operational data (to see how the intervention is playing out). What I took time to understand are the stories behind these data points. These stories are the reason why I don’t dread waking up every day. How my health workers have reached the point they are at now, how some of them have overcome difficult personal problems, how they have managed to study so much, and how they take care of the children and other MCHN beneficiaries that come to their AWCs. They work at home, they work in their fields (literally), and they work in AWCs/SCs/PHCs/CHCs. Their ability to juggle their responsibilities and still do everything efficiently is inspiring to me. Their warmth and hospitality never fails to amaze me. I have learnt a lot from them, and I hope I continue to do so.

Smiling through the bad lighting
Another thought that came to my head was how we’ve been conditioned to focus on the end result, and never the journey that takes us to it. Here, I realized that the journey is just as important. During under-graduation, I had been trained to look at what the statistics and regression lines tell me. While, they are crucial for such interventions, I have been fortunate to learn the other part as well.

Another important part of this journey has been the result of my mild disdain for practical pursuits, which in this case would be to understand and memorize the directions to my AWCs. Sadly, my navigation skills aren’t quite up to the mark. When brainstorming about the title of this blog post, my coworker suggested Lost in Panwar, which does make a lot of sense because a minimum of 10-15 minutes of my time goes into finding the places that I’ve visited at least thrice now. This experience seems worth mentioning as nothing is more embarrassing than the fact that even your FLWs don’t trust you when it comes to finding your car. The good, and the bad, both need to be out.

Jhalawar in July (which is when I joined) is beautiful. Jhalawar, in other months is also beautiful. You just need to know where to look. The first two things I noticed here were the # of cows, and the # of flowers. Both these categories fascinated me to no end. Like a typical city person, I clicked pictures at every instance I could find in villages. They were just keepsakes- to remind me of a simpler world every time stuff gets complicated in office (Beat Plans, Open Data Kit, Sharepoint graphs.. you get the drift). Jhalawar has helped me in living more simply and slowly.

Fast forward to November: one lesson learnt is that it takes time to ‘shake up things’ (first job lessons, people). It’s been a heartwarming experience. Babies have taken selfies from my camera, ladies have offered me tea and sweets unfailingly- every time, school children have played games with me.

Mother-son duo showing the way to the AWC
For an economics student, this has been an eye-opening experience. I have learnt that we cannot understand things in silos. Everything is interconnected and interlinked. Our systems comprise of humans, after all. It is imperative to look at these systems holistically and not mechanically, as we have been used to doing. 

Empathy, joy, gratitude is what my FLWs and the community has taught me. I can only hope I can offer something as precious back. Then, I’ll have fulfilled my hopes of attempting to make a change.

MCHN: Maternal and Child Healthcare, and Nutrition
FLWs: Frontline Workers
AWC: Anganwadi Villages
SC: Sub Centres
PHC: Primary Health Centre
CHC: Community Health Centre

Cearet Sood is a fellow with the Antara Foundation

Tuesday, November 27, 2018

Questions I wish to answer

Prerna Gopal

As women, we are always expected to be careful of our surroundings, of who we talk to, and even how we conduct ourselves. Our path is often blocked by the constant fear of finding ourselves in situations that lead to trouble. Thus, things that come easily to the other half of society often elude our grasp, making it all the more difficult to survive in a man’s world. Being raised in a liberal family that sees no difference between men and women, makes me question the marginalization of women, every day.

I came across a situation during my field visit to a sector called Manoharthana in Jhalawar, Rajasthan. An inebriated man walked into a sub-centre, that was being run by an Auxiliary Nurse Midwife (ANM) and also had a few male patients present. He threatened all those who sat in the clinic and forced them to tend to his self-induced problem. Eventually, the other male patients managed to pacify this nuisance of a man and handled the situation as they felt necessary. It may seem like a fairly inconsequential event to many. However, the anger and dismay I felt at that moment were stronger than others could potentially fathom. I was told that such incidents were routine and all health workers have to deal with them, particularly female health workers. 

During another such visit to the Harigarh Primary Health Centre (PHC), I was involved in an interesting conversation with the ANM present there. Apparently, there was a sterilization camp being organized at the PHC a few days later. Many questions popped into my head when I heard of this event which prompted me to ask about her experience while trying to promote vasectomies and other forms of sterilization.

“Aadmiyon se baat nahi karte hum. Kya pata woh humme kya samjhe aur humein kya mushkile hon”
(“We do not talk to men. They might misunderstand us and we might land into trouble with them”)

Primary Health Centre, Harigarh (Picture: Rithika Sangameshwaran)
Her answer made me wonder what the female front-line workers (FLWs) feel every time they go for health visits around the village advocating for important public health issues like contraception, reproductive health, and maternal health. How comfortable are these women talking about such things in public? Especially when they stand the risk of being stigmatized and labelled uncultured for merely uttering these terms. Perhaps this might be just the smallest of their worries. They might even be subject to physical harassment or worse.

A study conducted in Udaipur, Rajasthan looking at the performance of ASHAs identified multiple socio-cultural challenges1. These include lack of support from family members, economic struggles, lack of adequate remuneration, and caste/religion-based discrimination. This study reiterates the importance of societal structures and systems in the functioning of health departments and workers. Particularly with regards to female FLWs including ANMs, Anganwadi Workers (AWW), and Accredited Social Health Activists (ASHAs) who work within a social system that forever burdens women with problems that are essentially not even theirs to start with. It feels no remorse while burying them deeper and deeper, into a dark chasm. Yet, the general consensus is that health workers are lazy, uninterested, and even incompetent. But is that really true?

Even though there might be exceptions to this, I feel we must introspect and ask ourselves how often we pause and think about the consequences of our ignorance. In other words, what are the implications of our ineptitude to alleviate these women from their worries? These women yearn for a world where the combination of their chromosomes does not predetermine their chances at a safe future or their competency. We can only achieve this if we start looking at health in tandem with other wider social and economic determinants and gauge their impact on the functioning of health service delivery.

By writing this article, I do not intend to justify or even excuse the work done by these health workers. I merely wish to find out what role do young individuals like myself play in addressing these inequalities? How do we bring about a social movement where one’s health is prioritized over everything else? How do we build institutions and systems that are strong enough to stand the test of time and eliminate all forms of malady? Perhaps, these are the questions I would be trying to answer during my year-long fellowship with the hope that maybe one day we can build a safe haven for every woman, man, and child. 

(1) Reetu Sharma, Premila Webster & Sanghita Bhattacharyya (2014) Factors affecting the performance of community health workers in India: a multi-stakeholder perspective, Global Health Action, 7:1, 25352, DOI: 10.3402/gha.v7.25352

Prerna Gopal is a fellow with the Antara Foundation

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

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