“My phone informs me now, of when to go for the vaccination, and I ensure that; I neither have any record nor do I remember if my elder son received all the vaccinations”                                             --A lactating mother (beneficiary)

 

“I registered a complaint with the phone number (of Aarogyam) I had seen on a billboard in Baghpat, regarding my grandson’s pending vaccination and within a few days ASHA visited us and guided us through the vaccination process”                                                                        --Beneficiaries mother in Baghpat

 

“I receive calls on my phone informing me of the list of women and children due for checkups or vaccination in my village and I ensure that they do visit the ANM for the same”                                                 --A village head in Baghpat

 

Background

 

Every year, in India, roughly 30 million women experience pregnancy and 27 million have a live birth (MoHFW[i], 2003c). Of these, an estimated 100,000 maternal deaths and one million newborn deaths occur each year.

 

According to UNICEF (2008), about 9.7 million children died before the age of five years in 2006, globally. Of these, 2.1 million died in India. That means that every fifth child that dies is Indian, half of them die as newborns during the first month of life. In addition, millions of more women and newborns suffer pregnancy and birth-related ill health. Thus, pregnancy-related mortality and morbidity continues to take a huge toll on the lives of Indian women and their newborns.

 

The main reasons behind high Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR) in India as identified by National Family Health Survey (NHFS)-II, are as follows:

·         Deliveries not attended by trained personnel (inadequate medical staff)

·         Women not seeking Antenatal Care(ANC)

·         Deficient Postnatal care (PNC)

·         Under-utilization of existing services

·         Women lacking awareness of the importance of pregnancy care and delivery

·         Lack of awareness of the location of health services

·         The poor quality of services, including poor treatment by health providers

·         Lack of decision-making power  of women within the family

·         Teenage pregnancy and their risk of dying

 

The situation is further compounded by:

·           The marginal involvement of community and stakeholders in the health system leading to one-way supply based approach

·           Suboptimal use of technology for ensuring healthcare to all and

·           Challenges in monitoring public health service’s delivery mechanism

 

With a strong focus to provide effective healthcare to rural population in the states which have weak public health indicators or weak infrastructure, National Rural Health Mission (NRHM) was introduced in April 2005 in eighteen states of the country. The goals of the mission include reduced IMR and MMR.

 

‘Aarogyam’ is a Sanskrit word which means "complete freedom from illness”. Aarogyam is an ICT based responsive system which ensures and involves active participation of all key stakeholders viz. local administration, health facilities and doctors, frontline health workers (ASHA (Accredited Social Health Activists), ANM (Auxiliary Nurse Midwife), and AWW (Angan Wadi Workers)), village heads and beneficiaries, to ensure that a pregnant woman is provided with ANC, PNC and complete immunization throughout the continuum of care.

 

Aarogyam maintains a village wise database of all the beneficiaries (pregnant/lactating women, children up to 5 years) of an area, which gets continually updated with new data generating on the field with the help of front line health workers. The database thus generated is the backbone of the software system used by Aarogyam. This system generates automated alerts in the form of vernacular voice calls/SMS to the beneficiary thus enabling the beneficiary with vital information at their door step.

 

The system not only provides beneficiary with the information to be acted upon but also ensures that the services are delivered to the beneficiary by generating automated alerts (vernacular voice calls/SMS) for the ANM and Block level health officials, informing them of due services in their area.

 

Aarogyam uses a mapped database where each beneficiary is mapped with a village including the village head (pradhan), related health officials including frontline workers and health facilities. This multi dimensional mapping gives Aarogyam the capacity to monitor and take proactive corrective measures on its own, even in the absence of human interface. e.g. if a woman is due for TT(Tetanous Toxoid) and she does not receive one, Aarogyam will not only report this to the beneficiary but also to the village head and related health workers and subsequently to the health facility. Competent district authorities can also monitor and evaluate the performance and pendency at any level of the system, thus strengthening accountability and transparency. Aarogyam also has an Interactive Voice response system(IVRS), whereby you can register a complaint or can enquire about various health related information.

 

Aarogyam ensures that the government not only empowers its people with information and knowledge on basic mother and child health care but also reaches out to them with responsive health care delivery. 

 

Objectives

 

With the problems and issues identified, the Aarogyam scheme was envisaged as an ICT based health care delivery system for Pregnancy Tracking and Digital Health Mapping with the following objectives:

1.      Tracking each pregnancy with the help of technology based monitoring system.

2.      Ensuring complete ANC/PNC care including early registration of pregnancy, 3 ANC visits, TT, institutional delivery and promotion of Janani Suraksha Yojna (JSY)

3.      Ensuring 100% immunization for pregnant women & children in the age group 0-5 years.

4.      Bridging the gap between goals and present-actual values for MDG[ii] 4 and 5 indicators.

 

5.      Developing healthcare delivery into a two-way demand based interactive eco-system.

6.      Involving community at village level to generate awareness about health services.

7. Taking health information to community’s doorsteps.

 

How Aarogyam Works: Data collection and processing

 

 

 

Every month the data collection formats are filled by ANMs and are submitted to the block Primary and Complete Health Care i.e. PHC/CHC, where the data entry operator consolidates village wise data in pre-formatted excel sheets. Once the excel sheets are prepared they are sent to the district chief medical officer’s (CMO) office where the Aarogyam software is currently installed. The data entry operator at the CMO office enters block-wise data into Aarogyam as per the excel sheets.

 

ANMs maintain the Aarogyam (JBSA) register, which contains village wise beneficiary details with expected date of delivery and dates of actual and expected ANC/PNC visits and immunization etc. Initially the complete data of the Aarogyam register is entered into the Aarogyam database and then only the incremental data is updated. The incremental data is captured in three pre-formatted forms using the block and village code. These forms are for new pregnant women (first time) registration form, new child (first time) registration form and another form for Updating existing registered beneficiaries. Each beneficiary is given a unique id (8 digits) the id consists of Block id (1st two digits) + Village id (2nd two digits) + beneficiary id (last four digits). Same id is used for tracking a mother and her child in the system.

 

Stakeholders Participation

• ANM: The ANM plays a critical role of not only the data aggregator of her area but also as someone who ensures timely and non-compliance services as entered in the system.
• Village Pradhan: Village Pradhan is the face of community at village level. Aarogyam keeps the Pradhans informed of the service delivery and pending status in their villages which enables them to ensure primary care health service delivery to the village beneficiaries.
• ASHA: ASHAs motivate the community on the entire Aarogyam approach , however,the presence of ASHAs is vital in reaching out to the beneficiaries.
• ICDS: The AWWs (Angan Wadi Workers) have a crucial role  to play in Aarogyam as they were not only responsible for creation of detailed master database of the baseline data by ensuring coverage of each and every household but also support in gap identification and service delivery at the village level.
• Basic Education: The network of school teachers and shiksha mitras has been utilized to spread awareness about the project through school health programs etc.

Aarogyam Modules:

 

Aarogyam works on the four pronged approach of proactive, reactive, Interactive and educative interventions among the community. It consists of two primary modules:

 

I.              [I] Pregnancy tracking and monitoring module (Proactive and Reactive)

 

1.Proactive- Aarogyam keeps citizens at the centre of the health model and uses an Interactive Voice Response System (IVRS), which automatically generates family specific reminder calls/SMS’s in Hindi encompassing the areas pertaining to the Immunization details for children from 0-5 years informing them about the place and date of vaccination and also the ANC/PNC details of pregnant and lactating mothers based on the due date for TT, IFA tablets etc along with institutional delivery and benefits of Janani Surakhsha yojna (JSY).

2.Reactive- In case of pending cases, the reminder calls are sent to the concerned family and village pradhan for ensuring the service delivery, ANMs are also sent reminder calls for all uncovered families per village. This enables Aarogyam to ensure that all beneficiaries receive the desired services.-

 

3. Services delivered:

• Enabling the digital health mapping and pregnancy tracking system
• Outbound IVR/ Hindi SMS disseminating personalized information with respect to mothers and children for vaccinations etc.
• Audit Trails - Regular pending reminder calls to family, ANM, Pradhan (Village Heads) for ensuring 100% immunization, ANC, PNC etc.

 

  Retrieval of Health parameters and schemes, Complaint lodging and redressal; and Community Broadcasting.

(Fig) Aarogyam at work (Interactive and Educative)

 

I.              [II] Grievance Redressal and Information dissemination module (Interactive and Educative)

 

Interactive –Aarogyam allows beneficiaries to interact with the system through a dial-in option on a helpline number, one can gather maternal and child health care information e.g. child vaccinations, antenatal care, postnatal care, institutional delivery, birth preparedness, and Janani Suraksha Yojna (JSY) among other topics. A beneficiary can also lodge specific health related complaints using the dial-in facility.

Educational- Aarogyam provides educational support to various health campaigns such as Directly Observed Treatment Short Course for Tuberculosis (DOTS), pulse polio campaigns, gender-equality, anti-epidemic (i.e. cholera or dengue fever) campaigns, Prenatal Diagnostic Tests (PNDT) and the burden of disease’s in a particular region among others.  In addition to this Aarogyam sends periodic Behavior Change Communication (BCC) messages to the beneficiaries.

Services Delivered

Inbound Information retrieval of Health parameters and schemes, Complaint lodging and redressal; and Community Broadcasting

 

(Fig) Aarogyam at work (Interactive and Educative)

Implementation methodology

 

Baseline Survey conducted was a comprehensive survey of the district with respect to the family health indicators like age, gender, class, parity, immunization details of the children, Simultaneously a database of pregnant women with their expected date of deliveries (EDD) and children in the age group 0-2 yrs was prepared along with the services availed by them till that time, this was done with interdepartmental coordination especially health and ICDS department. The survey helped in creating the village wise database of beneficiaries along with vital health indicators and status.

 

Establishing standard operating procedures (SOP) and orientation of required institutional mechanisms at district and block level was done so as to streamline the data capturing, consolidation and reporting processes. Standardization of required formats, periodicity of reporting, roles and responsibility of the field workers and accountability of health officials were fixed, delineated and informed.

 

Capacity Building (Trainings) of ANMs, Data entry operators and other block and district level health staff was done so as to introduce them to the initiative, its objectives, use and possible impact.

 

Community Awareness was generated through IEC and BCC activities like films, songs, nukkad nataks(street plays), pamphlets, hoarding etc. about the project. ANMs and ASHAs disseminate information regarding the system to the beneficiaries in the villages.

 

Monitoring and Evaluation

 

1.      Development of web-based monitoring portal which reflects total disposal of grievances, pending complaints office wise, call alerts status and SMS’s sent on daily basis etc. This portal is regularly accessed by key officials including Chief Medical Officer (CMO) and District Magistrate (DM).

2.      Regular monthly meetings are held with key stakeholders to assess the progress.

3.      Generation of audit trails where Aarogyam automatically generates pending lists with respect to unfulfilled targets for medical officers, ANMs, Pradhans and beneficiaries; based on this list call alerts and SMSs are sent to all stakeholders every 10 days till the services are reported as delivered by the system.

 

 

Salient Features and Sustainability

 

Aarogyam has ensured transparency in service delivery besides helping the general public, frontline workers and others to have an understanding of all provisions and entitlements of health services. The health data of each household/individual is being entered and put on the web for monitoring by concerned officers. The results give a clear picture on health service status, efforts made by department and status of compliances. The approach also ensures the participation of different stakeholders at different levels such as ICDS, ASHAs, teachers and village pradhans.

The model has ensured participation of stakeholders and motivated them to work and perform together developing a team spirit and thus support the leadership which conceptualized and implemented the system.

 

Technological sustainability:

 

Aarogyam has inbuilt measures of sustainability, once the database is uploaded, auto dialers and SMS work on their own, without manual intervention. Aarogyam is IVRS based, easy to access and use. Hindi is used as a language of communication (calls/SMS) which is understood by all.

 

Systematic sustainability:

 

Aarogyam has been able to become an integral part of the system, and this has been ensured by the Expansion of the project by Uttar Pradesh government, to more districts and divisions along with training and regular capacity building of staff and front line workers for data collection, data entry, analysis and monitoring. Data entry operators have been appointed at block PHC level for collation of data and uploading the data in central server at district. District level review committees continue to monitor the progress of Aarogyam with supportive supervision.

 

Behavioral Sustainability:

 

Improved health behavior in the community is observed, which is supplemented through mass awareness generation (folk media, Television advertisements, posters/banners etc.)

 

Impact

Aarogyam has benefitted more than 1.4 lakh families so far (ie.upto Dec-2010) in the three districts viz Baghpat, JP Nagar and GB Nagar of U.P. Two lakh more families would be added in four other districts where the scheme has been initiated. So far more than 175,000 automated calls and SMS’s have been sent by the system.

 

Major Impacts of Aarogyam

 

Improved responsibility and accountability of service providers:

 

 Instant messages and calls to service providers (ANM, MO I/c etc.) have resulted in more accountability besides better and timely service delivery to the community.

Improvement of the measurable indicators: There has been a positive trend in the measurable indicators over the period of time when Aarogyam was put in use. Indicators like TT Mother, BCG[i], DPT[ii], DPT Booster, measles etc. have shown a significant positive trend. Achievement in child immunization is also very encouraging and showing consistent improvement.

Community Feedback:

 

Community feedback has been an enormous success in the program. Community has started to understand more about not only the types of health services available to them but also how to avail them and report any non-compliance to the health and district administration.

 

User Friendly approach:

 

With vernacular messages literacy is no more a hindrance for availing health services and information. Free of cost information delivery and grievance redressal has empowered communities in demanding services.

 

Focus on preventive Medicare:

 

The model has helped health department to refocus its strategy on preventive healthcare whereby on the basis of the health indicators reported and demand generated along with the complaints lodged in, corrective actions can be timely taken for achieving better results.

 

Knowledge empowerment: Economically and socially impoverished and illiterate families can also now not only get information about their health profile and services required but also demand the services especially regarding ANC/PNC and immunizations. Aarogyam ensures that the services are delivered to such sections of society at their doorstep.

 

Better Monitoring and Evaluation: Individual level health indicators’ tracking has enabled the system to facilitate in monitoring and evaluation of the program implementation strategies and achievements.

Effective Planning: Better planning of community level health programs especially ANC/PNC checkups and

 

Immunization drives are possible with the system e.g. ANMs can be now informed of the number of beneficiaries to expect at the each session, this will not only result in reduced waste of vaccines but also more accurate head count.

 

Existing Constraints and Challenges

 

Increased work load on ANM: The existing system has different registers for ANM’s. At times having similar data not only increases data redundancy but more importantly results in increased work load for the ANM. Similarly regularly filling and submitting data updates to the system at block office is a time consuming mechanism, sometimes resulting in extra ANM visits to the block.

 

District level feeding: At Present, in Aarogyam data entry is done at the district level and this data comes in the form of excel sheets. However, challenges are faced due to data inconsistency and delay’s in data entry along with inability of block level operator’s to correct/modify data with no easy access to block reports.

 

Automated job-chart/ work-schedule: Non availability of advance job-charts or work schedules based on the Aarogyam data is another issue which needs attention. Such a system for ANMs/ASHAs can help them plan their community work better.

 

Change of mobile numbers: 

To keep up with a change in the mobile numbers of various stakeholders is another issue which needs a solution. In the absence of any paper based reporting/schedules, the system struggles to meet the desired output if the key stakeholders change their mobiles numbers’ unreported.

 

Mobile/Landline coverage:

Mobile and landline coverage among the most vulnerable people and their involvement in the system continues to remain a challenge.

 

Conclusion

 

Despite the challenges, Aarogyam through information communication and technology can improve the lives of the poor while capitalizing on the mobile advantage. Aarogyam can assist India in realizing success in MMR and IMR paralleling its recent economic growth.

 

Recommendations

 

The following points that can be considered to make Aarogyam a more comprehensive system:

 

• Involvement of ASHA's and voice calls/SMS at the frontline level will reduce burden on ANM’s creating a provision for better results.
• Use of Iconic messages, besides Hindi text messages can have a greater impact on illiterate beneficiaries.
• The Aarogyam register (JBSA register) should be made more comprehensive removing the need for maintaining an additional set of registers by the ANM.
• Timely reporting can become easy, if the data entry into the Aarogyam is done at the block level rather than following the current process at the district level.
• A dedicated call centre to answer and manually manage some critical components of the application can be effective

II.