A partnership between female community health and nutrition workers in Rajasthan, India
Piyush Mehra is Chief Executive of the Antara Foundation. He has led maternal and child health and nutrition programmes in India for over three years, with a further ten years’ experience in South East Asia and the Middle East.
Karthik Ram is a Senior Associate with the Antara Foundation, responsible for communications. He has over five years’ experience in maternal and child health and nutrition, education and strategy.
Background
With over 68 million citizens, Rajasthan is one of the eight states in India that are known as ‘Empowered Action Group’ (EAG) states; i.e. they have high levels of deprivation. Rajasthan’s child health and nutrition data1 shows that 23 per cent of children under five years old (CU5) are wasted and 39 per cent are stunted and over 70,000 children under one year of age are estimated to die each year. The state authorities have acknowledged the issue and aim to become a beacon for health and nutrition services. To this end, the Akshada Programme, a partnership between the state government, philanthropic organisation Tata Trusts and the non-profit Antara Foundation, aims to scale up improvements rapidly in maternal and child health and nutrition (MCHN) in Rajasthan.
Village services
Three different groups of female workers – Accredited Social Health Activist (ASHA), Anganwadi Worker (AWW) and Auxiliary Nurse Midwife (ANM) – are responsible for driving health and nutrition service delivery in India’s villages. While ASHAs and AWWs typically cater for 1,000 people each, the ANMs serve 5,000 people across several villages. Each of the female worker categories has a distinct role:
- ASHAs are the first point of contact for the community. They counsel the community via home visits and mobilise attendance at events like village health and nutrition days;
- AWWs run Anganwadi Centres (AWCs), through which they provide nutrition services to pregnant and lactating women (PLW) and young children, including mid-day meals for children aged 3-6 years old; take-home rations for children aged six months to three years and PLWs; and nutrition counselling on Infant and Young Child Feeding (IYCF) to pregnant women and mothers; and
- ANMs provide basic diagnosis, treatment and referral to health centres for pregnant women.
Although they should serve the same beneficiaries and their roles should be complementary, coordination is often lacking between the three cadres of staff. This is mainly because they work for different government ministries: AWWs and ANMs are employed by the Women and Child Development (WCD) and Health Ministries, respectively. In Rajasthan, the WCD Ministry pays ASHAs a fixed payment, while the Health Ministry pays them a performance-based incentive (for referrals to reproductive and child health services, etc.). Different record-keeping formats and methods make it difficult for them to speak a common language, which is essential for coordination; thus they often differ in identification of beneficiaries.
The case of Radha
Radha (not her real name) is an 18-month old child with severe acute malnutrition (SAM) in a village in northern India. When she visited the local Anganwadi Centre, the AWW discovered that Radha was underweight. There are two issues. Firstly, the AWW cannot validate whether Radha is malnourished without measuring her mid-upper arm circumference (MUAC) to confirm SAM, which only the ASHA is equipped to do. However, the ASHA would only reach Radha’s house after several days, following the prescribed linear visit plan (houses 1-10 on day one, houses 11-20 on day two, and so on). The AWW also lacks the technical knowledge to determine whether Radha should be referred for treatment of SAM. The ANM, a trained nurse, is best suited for this but, in the absence of a clear information flow between the three, there is a risk of children like Radha slipping through the net.
Triple A: A shared platform
A practical solution was to bring the three frontline workers together under one platform, known as triple A or ‘AAA’ (a combination of ASHA, AWW and ANM). In 2016-17, AAA was established in 2700 villages in Rajasthan’s Jhalawar and Baran districts over a six-month period. This massive effort was driven by the workers themselves, aided by a 13-member Akshada team, and made possible by working closely with the government system. A joint order was issued by the state’s health and integrated child services departments calling for AAA workers to coordinate efforts on MCHN through sharing records, coordinating use of village maps and household visits, regular joint meetings and better planning and surveillance.
The first step was establishing a common database and a focus on high-risk cases. Previously, each group had a different method of record keeping: AWWs organise people by families; ASHAs use households; and ANMs work on a record of fertile, married couples (where the wife is of reproductive age). Under AAA, groups worked together to create a joint village map of household and family coverage. On these maps they numbered houses and affixed ‘bindis2’ to denote various categories of beneficiaries and track them, prioritising those at highest risk – red for high-risk pregnancies, yellow for children with MAM and yellow with a red dot for SAM. Through this system the data is visually represented. AAA also enlisted members of local government, teachers and other influencers to validate their maps. This enabled the community to better appreciate the AAA’s work and raise their standing in the villages.
Coordinating actions
With some guidance from Akshada programme officers, the AAAs realised that maps could be used to plan their work. Using an algorithm, they scheduled visits based on community needs. Home Based Newborn Care (HBNC) visits, children released from Sick Newborn Care Units (SNCUs) and Malnutrition Treatment Centres (MTCs) were prioritised. Thus, the ASHA is present when and where she is most needed.
Importantly, the AAAs meet every month, following the village health and nutrition day, to review each other’s work and data, plan for the next month and conclude with a peer learning session. Their new bond has also enabled them to undertake joint visits to difficult households like Radha’s.
In the post-AAA world, Radha’s nutritional status is confirmed by the ASHA and AWW since they share information. They alert the ANM, who offers medical advice during a joint visit, which is taken seriously by families. The AAA marks Radha’s house with a yellow and red ‘bindi’ on the village map. The ASHA also factors this into her household visit calendar and visits Radha’s house more frequently.
Measuring impact
Impact is being measured via the active monitoring and evaluation of indicators (e.g. household visit calendars showing priority given to high-risk beneficiaries; care indicators, such as antenatal care registrations and visits; process indicators, including AAA meetings conducted by programme officers) and health system strengthening (adoption by the state). Limited monitoring data (from March to April 2018 for Anganwadi centres, covering ten per cent of the population of Jhalawar district) has shown that SAM identification against estimates increased from 1.1 per cent in March to 2.6 per cent in April alone; the percentage of children whose MUAC was measured increased from 52 per cent in March to 62 per cent in April; and MAM identification against estimates increased from 4.7 per cent to 10.6 per cent in the same period.
AAA is benefitting the community in that beneficiaries are no longer left literally ‘off the map’ and team accountability ensures every household is covered. Care is delivered to those who need it most and in a timely manner. Village mapping and curiosity about ‘their bindi’ has helped transform the community into empowered consumers of health and nutrition services. Tools like the village map also have wider potential in local governance.
Next steps and key learnings
In December 2017, the AAA platform was adopted by the state government for scale-up. Over 100,000 ASHAs, ANMs and AWWs across the state are being trained via video-conferencing: the next challenge is how to provide maximum support for this massive endeavour. Moreover, an exciting technology to enable real-time data sharing between the three women is also being implemented in certain areas.
The AAA process has provided a number of lessons, such as the fact that the true value of data in aiding village health and nutrition workers is only realised when it is shared. Furthermore, co-opting the community determines the ultimate success of an intervention; and partnering with government is imperative for interventions to be scalable and sustainable. The common thread is that three female cadres working together can improve nutrition outcomes at the village level.1Health and nutrition data from National Family Health Survey 4, 2015-16; Population data from Union Census, 2011.
2Coloured dots worn on the forehead by women from some Indian communities.