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

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