Developing Countries who struggle to achieve the millennium development goals on gender equality, reduction of mother mortality and infant mortality must try to bring the focus of public healthcare on to “Motherhood” and establish an ecosystem revolving that.

 

In contrast with the Western and other Oriental civilizations, Indian civilization has, for long, been deitifying women as a mark of the special place she occupied in the society. Several of the rituals and norms in the Hindu civilization and worshipping of Goddesses all stand testimony to that. Yet, the fact remains that gender inequality remains the starkest in the Indian society as against most other societies that exist today. As the society claims to be advancing, there are serious issues related to gender equality which in some communities have gone to the extreme levels of a psychic perversion resulting in foeticides and infanticides. As we must regret and deplore such aberrations, the cause of some of these developments is rooted in the system’s inability to provide adequate care; support and protection which cannot be ignored. An institutional framework must emerge to support the average girl child to grow into adolescence, then to womanhood and later to motherhood, thus resulting in healthier mother and child pair that is much more comfortably positioned than their unhealthier counterparts in terms of economic liability.

 

This paper is based on the assumption that India – despite being a signatory to the UN Millennium Development Goals – along with some other countries, is going to miss the targets by a mile or more by 2012.  Interestingly, India had also been working on an ambitious “Access to Healthcare for All”[i] as a part of its 2020 vision and to be achieved by 2015, which is also likely to be missed[ii]. Together, it is obvious that the country is gearing up itself of achieving important milestones in the public healthcare area. This paper aims to highlight some of the possibilities that could accelerate the rate of growth of the health sector through the introduction of innovative and imaginative approach.

 

Schemes too many; target One

 

National Rural Health Mission (NRHM) is the flagship program that has brought the focus of public health investment back at the centre. If an attempt is made to understand the number of schemes and projects that are being promoted by the Government – through the Ministry of Health and Family Welfare and other Welfare departments such as Women and Child Development (WCD), it can be seen that the country has put sufficient thought behind a number of schemes aimed at bridging the inequalities existing in the public healthcare sphere.  Thus a comprehensive intervention that sews up the schemes that are currently patchy and blunted in their impact is urgently required to make the Mission meaningful. Failure of achievement of the goals[iii] set for NRHM could also cast a shadow on the recently introduced urban counterpart – National Urban Health Mission.

 

However, acknowledging the complexity of the challenges involved in effecting access to healthcare, the policy framework of NRHM has certainly proved to be stable. First and foremost is that the targets for Rural Healthcare has been set in a mission mode – meaning that specific time frames have been defined for achieving the goals. Within the larger framework of NRHM, there are more independent verticals formed. The National Mission for Cancer, Blindness, Polio, to name a few. As it appears, the very architecture is one of the reasons for its tardy growth in realizing targets.  On the other hand, there are schemes that work in verticals too. Recently introduced Rajiv Gandhi Scheme for Empowerment of Adolscent Girls – termed ‘SABLA[iv]’, and Janani Suraksha Yojana[v] (JSY) for promoting institutional delivery though sequentially linked but managed by two different agencies and thus lacking its edge is a case in point.

 

Most of the field level activities under NRHM and WCD are to be achieved through the two existing pillars – Anganwadi Workers[vi] and ASHA[vii]. Not only are they overburdened with the plethora of schemes that are being piled on them in quick succession, there is ever decreasing clarity about the larger objectives, goals and target groups among them. This often results in turf wars and unhealthy competition leading to unreliable information gathering and data corruption. Hence there is a need for greater effort to supplement each other and work together keeping the larger goal of healthcare in mind.

 

Before getting into the solutions part, it is worth noting the existing scenario of healthcare that is emerging. The number of Primary Health Centres [viii](PHCs) has gone up substantially. But 24X7 PHCs are still very few. Number of doctors serving rural areas continues to be inadequate. Disciplinary and punitive actions have proved to be counterproductive. The absence of qualified medical practitioners has left room for others - including Rural Medical Practioners[ix] (RMPs) in some states – to fill the space. Similar story goes for para medical staff. Supply chain management of drugs, supplementary nutrition etc are patchy and inadequate.  Many PHCs lack basic diagnostic equipment and facilities. Needless to say, the health-related to MDGs are hard to achieve.

 

Yet, it is so much important that all the three aspects – gender equality, reductions in mother and infant mortality – are not to be discarded if a meaningful and state-supported public healthcare system has to thrive.  In such a state, what is required is an over-arching national “Safe Motherhood” campaign at the centre of the healthcare domain with the SABLA scheme at the anterior end and JSY, Maternal Mortality Rate (MMR), Infant Mortality Rate (IMR), Nutrition campaigns at the posterior end. These can be further emboldened through the campaigns on lifestyle diseases and other urban health issues that can be seamlessly converged. “Safe Motherhood”, does possess an emotional pitch – which can be effectively used by the capacity building and awareness agencies –  that needs to be maintained, while the underlying operational technique is to position the She person at the core of the public healthcare strategies.

   

Fig 1. Life cycle depiction of healthcare based on MDGs. Source: Author

 

Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (SABLA) leads to full womanhood and motherhood. It includes Sanitation, Hygiene, Life skills and Vocations skills. Mother and Child Healthcare (MCH) programs include Ante Natal Care, Nutrition, Mapping of the expected date of delivery (EDD), promotion of institutional delivery and post partum care. Further, it advances into vaccination, immunization, nutrition and Early Infant Diagnosis (EID) for possible life threatening infections such as HIV.

 

“Safe Motherhood” campaign has two sides – the policy framework and the operational framework.  The policy framework must be rooted in the already announced policy of national convergence of health and health-related interventions such as sanitation, hygiene, immunization, nutrition.  Operational framework must focus on mapping of pregnancies through effective mechanism that will lead to tracking of the pregnant women and resulting in institutional delivery.  Reduction of Mother Mortality Rate is possible through increased institutional delivery. The same is true for post-partum care and therefore, reduction in infant mortality rate also.

 

Anganwadi Workers, conventionally, have been expected to perform a part of this. Remaining part was expected to be managed by the ASHA.  However, operationally both these stakeholders are far from perfection in imparting their responsibilities. Besides, the rate of attrition among ASHAs is very high – with as high as 60% in some regions – that leaves a continuing gap in the support machinery.

 

Mapping Motherhood successfully

 

A lot has been talked about public healthcare in the developing world and thus it leaves no room for further scope and imagination. The challenge lies in effecting these programmes successfully. Some statistics can throw light into this fact.  Health Department of Madhya Pradesh in 2008 discovered that the number vaccinations as reported by the health workers was more than the number of vials department had dispatched. Pregnant woman taken to the Primacy Health Centre (PHC) by the ASHA worker in Manza, Punjab disappeared after she was told that she was anaemic and needed supplementary nutrition. Services of mobile medical unit could not be made available for the woman in labour in Rajasthan. Though the woman could be taken to the hospital through other means, and managed to save her life with extra units of blood, the child could not be saved. In a country where 51 births are registered every minute[x], hundreds of such cases will be there.

 

Without a strong, cost effective and acceptable tool, it will be difficult to string the various stages of healthcare.  Government of Gujarat has implemented “e-Mamata” a web-enabled platform for recording the Mother and Child Health (MCH). Developed by the National Informatics (NIC) this tool aims to capture the details of antenatal care (ANC) electronically. E-Mamta is surely the right step towards imparting the mother and child health more meaningfully and can cut down on the lag in data gathering. E-Mamta is a management tool to reduce IMR/MMR/ Total Fertility Rate (TMR) and provides name based services:

The Programme is divided into four phases;

 

1. Data entry of all the individuals of Gujarat is to be done in E-Mamta (As per Family Health Survey)
2. Verification, cross verification and validation of the data
3. Registration of mother and child (A unique id will be generated for every mother & child)
4. Tracking of services through monthly work plans and follow up of the left outs.

 

 e-Mamta will work through nodes such as e-Gram Centres, District Hospitals,  PHCs and  Community Health Centres (CHCs). In Gujarat, there are over 13,500 e-Gram centres and is  a unique feature of the state. Gujarat being an advanced state, can hope to yield dividends from this platform. However, as efforts are on to scale up a similar initiative across other states, where the issues of mother mortality and child mortality are high, this solutions needs to undergo modification. In the existing format – web-enabled decentralized data gathering using e-Gram and other computerized health facilities – the system appears more top-down, as it does not reach the field workers’ hands – the anganwadi workers and ASHAs. Secondly, the infrastructure deficiencies such as electricity and connectivity severely restricts the use of the software on an online mode in most other  parts of  the country. Once left to offline, there is the danger of complacency and lag in data updating, which will once again defeat the purpose. It has been generally observed that field workers have apathy towards proper documentation owing to a series of factors ranging from their discomfort in maintaining records to the lack of proper space for data maintenance .

 

Broad-basing of affordable technologies

 

Experience from a comparable, but complex intervention currently under implementation could throw up some solutions to this problem. Under the Global Funds support, a pan-India prevention of parent to child transmission (PPTCT) program is being rolled out for HIV/AIDS. Bearing in mind the negative factors such as fear, stigma, discrimination as well as need for life-long adherence to medication, the PPTCT program is more demanding. Moreover, to ensure the prevention of transmission of the virus from mother to child, the mother-baby pair is monitored and supported for eighteen (18) months. To manage the program on the ground level, thousands of outreach workers are deployed. The number of outreach workers (ORWs) is based on the case load of pregnancies prevailing in each of the vulnerable states/districts.

 

Owing to several socio-economic and cultural norms in the society, mapping pregnancy in general and mapping the HIV +ve pregnancy in particular is a daunting task. Solutions based on mobile telephony has been found delivering very encouraging results. As a dedicated health worker in the domain of HIV/AIDS the health volunteer (Outreach Workers) have to ensure that the lost-in-follow up (LFU) cases are minimum; positive pregnant women stick to their routine medical examinations; adherence to medication and finally persuaded to go for institutional delivery for the benefit of the mother and the child. The conventional method demands that for each case, the outreach worker has to have a data matrix containing more than seventy (70) fields. This is very cumbersome for a semi-literate or barely literate health worker. Also, filling up the fields takes time, which results in the lag of data dissemination to higher agencies such as the District AIDS Prevention and Control Units (DAPCUs) , the State AIDS Control Societies (SACS) and National AIDS Control Organization (NACO). As a corollary, the quality of the data becomes suspect.

 

The mobile based solution, on the other hand uses a web-enabled platform for processing. Outreach Workers, after due training, are given mobile handsets that are pre-loaded with the software that used local language interface. Through ‘Yes/No’ and ‘1, 2, 3’ options, the outreach is able to fill up most of the required fields that are developed at the back end server. As a result, the outreach worker is able to file the information or update the files of any specific client almost instantaneously. As the back-end is web-enabled, all designated stakeholders, such as NACO or SACS are also access the latest available information from the ground with more accuracy and realism.

Fig 2.Tecnology architecture demonstrating the mobile-based application that connects different stakeholders of public healthcare system.  Source: Author

 

While such application can manage the data part quite efficiently, there is also a need for awareness and sensitization of some of the basic issues like sanitation and hygiene among the adolescent girls and women. With the mobile technology assuming the frontline of information management, more can be achieved through “push” mode of information through the same platform. Infrastructure Leasing and Financial Services (IL&FS)  has successfully launched sex education and health education programmes by partnering with telecom companies such as Airtel and Tata Telecom, where interactive voice recorder (IVR) services have been made available to subscribers. Realising that sex education in schools are still at an evolving stage, and that open and uninhibited discussion on the subject is difficult in classrooms, a service called “Mobile Swasthya” and “Sparsh” have been launched. The first phase of the project is in Maharashtra. Mobile Swasthya, which is a general health education service in the “pull” mode gives information on some of the selected general health information. “Spartsh” is the sex education service over mobile phone format   Experience proves that the “push” mode information dissemination slowly gives way to “pull” mode which is an indication about the increasing acceptability of the service.

 

Operationalising ‘Mother Development Goals

 

NRHM data shows that from 2005-06 (Starting year of the Mission) there are about 750,000 ASHAs have been recruited. As per norms, the ideal number of ASHAs required is well over one million. However, with high rate of attrition and possibility of vacant ASHA positions in some parts, it may be safe to assume that the ‘live’ ASHA number is close to eight lakhs.  Similarly, after the launch of the Mission, the number of PHCs also has gone up by 44%, implying that the basic health infrastructure is on the rise. Government of Odisha[xi] has initiated decentralization of the health infrastructure by allowing eligible private players to manage the newly established PHCs under the guidelines issued by the state. This experience is yielding positive results in terms of reliability in service, availability of doctors and medicines. To work around the scarcity of qualified medical practitioners, the Odisha model has roped in retired General Practitioners (GPs) and other practitioners as consultants.

 

By developing a suitable mobile application for the use of Anganwadi workers, ASHAs and Auxiliary Nurse Midwives (ANMs), a wide reaching network can be established. This network, as in the synergized format – with cross-cutting functionaries like AWWs and ANMs – can be locally linked to the PHC for initial consultation. The network using mobile applications can share information regarding, pregnancy, nutrition, Expected date of delivery, arranging for mobile medical units, institutional delivery and finally safe motherhood.

 

While some may doubt at the efficacy of the creation of an elaborate network as mentioned above, the fact is that most of the components of this eco system are very much in place. All it takes is to intelligently and cohesively sew these pieces for a beautiful picture to emerge. Millennium Development Goals have been finalized after considerable discourses and discussions, and hence they are bound to have a great bearing in improving the public healthcare scenario of all nations in general and developing and middle income countries in particular. Owing to the several socio-economic and cultural inequalities that persist in countries like India, the challenge will appear daunting. Nevertheless, those goals have to be pursued untiringly. In the Indian context, convergence of some of the existing schemes and building an over-arching technology framework could help achieving the targets faster and more efficiently. A seamless data flow management system in the bottom up mode has to be designed for timely and accurate information gathering that could further lead to time-to-time analysis - as in possible case of an epidemic -  and interventions.

 

Gujarat has led from the front through its e-Mamta platform which aims to track the mother and child health (MCH). While e-Mamta sets connectivity and power are to pre-requisites, a more user friendly mobile-based application could strengthen the mother and child health initiatives much more stronger as the primary data gets fed into the back-end servers right at the point of origin. Lesser advanced states, therefore, must consider the option of mobile-based applications that can be integrated into other back-end programs that might be driving the overall health management information systems (HMIS). Mobile phones becoming so common place, the Anganwadi Workers and ASHAs can feed in the data, after they are trained on the application. If the pregnancy mapping, tracking and finally mother-baby pairing – with a lot many factors such as periodic testing of the mother, ensuring institutional delivery, preventing lost-in-follow up (LFU) – can be successfully managed through mobile technology, similar efforts should work well for general healthcare as well.