Auxiliary nurse midwife (ANM) Rekha Tewari still remembers December 3, 2014, when she made a presentation before Rajasthan’s Chief Minister Vasundhara Raje on how a tablet had shifted her focus from quantity to quality of the healthcare delivery system, primarily targeted at saving the lives of women and children.
Rekha, posted at Borda health subcentre under the Jhalra Patan block of Jhalawar district in southeastern Rajasthan, told Raje how the device had made her work easy as the CM, who represents this area in the state Assembly, listened on. “I don’t need to lug a bag full of registers now,” the ANM said.
That event set the tone for what Raje would announce in her next budget: provide tablets to all ANMs in one district of each of the seven divisions in the state before end of this fiscal. The districts have been chosen — Banswara, Jhalawar, Churu, Dholpur, Jhunjhunu, Pali and Tonk — and the process to procure tablets is underway before 6,546 frontline health workers (FHWs) in these districts log in to an Android application. But a silent revolution is already on in rural Rajasthan in as many districts — though on a smaller scale.
Rekha is one of the first eight ANMs in Jhalawar to receive the tablet. District’s chief health and medical officer Dr Sajid Khan thought of making one subcentre totally paperless. Borda was chosen for it. In September this year, all eight ANMs of Donda primary health centre (PHC) were given tablets.
Meanwhile, in the western part of the state, the experiment was extended to accredited social health worker (ASHA), a community-level worker introduced in the healthcare delivery system when National Rural Health Mission (NRHM) was launched in India in 2005. In Rajasthan, ASHA is called ASHA Sahyogini because she is a joint worker between the department of medical and health and the department of women and child development.
Devaki, 27, an ASHA Sahyogini in Jasol village of Barmer district in western Rajasthan, says earlier it was very difficult to convince women, mostly uneducated, about the need for vaccines or the ill-effects of malnutrition on their babies. Not anymore — the moment she punches in her haemoglobin into the device, a red message pops up. “I show her a video to explain how low haemoglobin would affect her and her baby’s health and she understands it instantly,” she adds.
Devaki is one of the 25 ASHAs in Barmer’s Balotra block to have been given tablets for digital empowerment under a pilot project e-ASHA by Unicef and the state health department. The FHWs were trained for two days to operate the app — e-Jan Swasthya — to provide maternal and child health services successfully.
In one block each in Jalore, Barmer, Dungarpur and Banswara and in a few PHCs in Jhalawar, Pali and Udaipur, the e-revolution has been under way for about six months now.
ANMs and ASHAs, who had to carry about 10 kilograms of a number of registers — one for reproductive child health, another for monthly report forms, yet another for high-risk pregnancies (HRP) — are now performing their duties with a 400-gram tablet.
Traditionally, an ANM collects information from villages and notes it down in a diary before she can fill up the bulky registers. Conventionally, at the end of a week, the same data is punched into a computer at the PHC. It has been noticed that three frontline functionaries — ANMs, ASHAs and “anganwadi” workers — fill same data about the same set of people in their respective registers but the information don’t match.
The focus of ANMs, therefore, is keeping the records complete as they are many and it’s a time-consuming, tedious process — quantity — and not on quality of services that they are meant to deliver. Despite huge investments in setting up of monitoring mechanisms, the monitoring remains weak because of poor-quality and incomplete data.
With the e-Jan Swasthya installed in tablets, data digitisation is happening at source in a very user-friendly, less cumbersome manner. “We are aware of the resistance some of the elderly health workers could offer to technology — since many of them have had no exposure to smartphones — we have made the app in such a way that much less needs to be typed; most of the information is fed with the help of radio buttons and drop-down menus,” says Dr Amit Agarwal, health specialist at Unicef’s Rajasthan office, the man who is the brain behind this initiative.
Dr Agarwal says the application developed for National Health Mission Rajasthan, by an innovation hub set up at State Institute of Health and Family Welfare with the technical support of Unicef, has transformed the functioning of many of ANMs and is changing their thinking from quantity to quality.
No nation can grow and move towards development in other sectors without healthy citizens, especially women and children. In India, many interventions have been tested and found very useful for not only saving the lives of women and children but also making them grow to their full potential. Governments developed policies to deliver these interventions — by ANMs and ASHAs — but it is not easy in the complex ecosystem and cultural and traditional social fabric of rural areas.
There are multiple obstacles which stop optimal delivery of these life-saving interventions — some of them are: poor skills of ANMs despite multiple trainings as these are difficult to remember and weak communication skills of these FHWs with family members.
Technology has removed all these obstacles. Madhu, another ANM under Donda PHC in Jhalawar, says, “It took us a while to get used to the device, but we soon learnt to handle it completely. We use the tablet, especially the videos, extensively. Women are attracted to the audio-visual messages and follow them intently. Videos on immunisation, gender discrimination, exclusive breastfeeding, etc, are a big hit with the women. I can see that most women who watch these videos make sure that they follow all the advice. Information in the tab is given in sequences, making it possible for us to identify high risk pregnancies at an early stage. This helps us prepare both the woman and her family, which helps cut down the risks.”
Dr Agarwal says the application covers the key components of care during pregnancy, care after birth for mother and newborn, care of young children and monitoring and tracking of the their growth. It helps in timely identification of deviation from normal progress during pregnancy as well as after the birth of the child.
“It also helps in better communication of messages which are auto-generated depending on the situation of the woman and child. It also helps in tracking of the growth of every child, which will lead to timely identification of undernourished children. The app generates the work plan and due list for ANMs so that no woman and child is left.
“Most often ANMs forget to provide services to the eligible couple using family planning methods. This application will automatically remind both to the user and ANMs regarding services to be provided for family planning to the eligible couples,” he adds.
The app has a feature for an automated SMS generated at the time of registration as well two days prior to next service due date. This will help in improving the coverage and continuity of coverage of key Maternal and Child Survival Interventions.
NRHM mission director in Rajasthan Naveen Jain is upbeat about the pilot in seven districts of each division of the state. “We will provide tablets to 4,042 ANMs and 2,504 ASHA Sahyoginis in these districts. The procurement process is underway. We shall be able to launch it fully by the end of October,” he says.
Rajasthan has already won accolades on national platforms for introducing online payments to ASHA through ASHA Soft. The web-based system has reduced the delay in payment to these health workers, which was demotivating them.
“We were feeding data at the PHCs in ASHA Soft, the obvious way forward for it was to do that remotely with a hand-held device. We will soon be the first state to have enabled our FHWs with technology,” Jain adds.
Dr Agarwal says that during a presentation in March this year, the Government of India was so impressed with the e-Jan Swasthya app that it decided to replicate it in two other states — Maharashtra and Himachal Pradesh. The announcement is likely later this year.
Rajasthan’s domain knowledge is surely going to lead the healthcare delivery the digital way.
Rakesh Kumar is a writer based in Jaipur, India