As the election dates have just been declared for Uttarakhand along with Uttar Pradesh, Punjab, Goa and Manipur, this is as good a time as any to shine a spotlight on an exciting initiative Uttarakhand has embarked on. A new state formed in 2000 (which is fairly young in the Indian federal scheme of things) its challenges are unique. From limited revenue sources (tourism, its mainstay, has taken a hit since the 2013 flash floods; hence it is dependent on central assistance massively) to a hilly terrain and lack of trained personnel, the state has many hurdles.
In the case of healthcare, the challenges get amplified considering the human resources in health has reached crisis levels pan India. In a re-analysis of District Level Health Survey (DLHS-4) data done by IndiaSpend recently, they found, health facilities are fewer than required, which means that the actual shortfall in personnel is much higher.
Their other findings:
• In 30% of India’s districts, sub-centres with ANMs serve double the patients they are meant to.
• As many as 65% of hospitals serve more patients than government norms mandate; the number rises to 95% if we include hospitals with a gynaecologist on staff.
• Almost 80% of all public hospitals serve twice the number of patients that government standards specify.
Putting these statistics in the context of India’s slow progress in reducing maternal and infant mortality, the fact remains that 8 in 10 babies were born in hospitals in 2011-12, up from 41% in 2005-06, according to government data, India continues to have the highest rate of infant mortality among the emerging economies i.e. the BRICS nations (Brazil, Russia, India, China, and South Africa). The human resources for health challenges are further aggravated for states like Uttarakhand, considering their difficult terrain. Add to it, its routine unstable governments since formation, health and development planning and delivery is onerous.
Uttarakhand has embarked on an exciting initiative, because of the challenges, not in spite of them. In collaboration with the global healthcare non-profit IntraHealth International, it has launched an initiative called mSakhi. They are inspired by mSakhi’s performance in the neighbouring state of Uttar Pradesh, which is also going to hustings. MSakhi is an Android-based app freely downloadable, which is designed for the frontline workers in the health and nutrition sector i.e. Accredited Social Health Activists (ASHAs, also stands for hope), Auxiliary Nurse and Midwife (ANM) and Anganwadi Workers (AWWs).
This app doubles up as a register which combines the multiple registers that these workers have to fill and maintain and a job aid cum trainer. It schedules home visits for the field workers i.e. ASHAs and AWWs once they register a pregnant woman and hand holds them through their care and counselling sessions at the homes of the pregnant women both for the expectant mothers and their family members.
In a mountainous state like Uttarakhand where mobility is a serious issue, hence the state leadership is serious about any and every support which guarantees workers and citizens friendly portability. This mobile phone based app is a light, intensive solution since it proposes to replace kilos and kilos of paper-based registers. But more importantly for the low and semi-literate frontline health and nutrition workers, it also helps in scheduling their field trips, their movement maps and their inter-personal counselling sessions with accessible, colloquial Hindi prompters on the phone’s device. It also proposes to de-duplicate data by cohering the registration generated by the health and nutrition verticals.
The state has chosen to roll out the pilot in Pauri-Garhwal district in the hard-to-access block of Dugadda. The philosophy behind the choice of the block is simple i.e. demonstrate the success in the most difficult sites, and if it takes off there, the successful pilot will be the best rationale for state-wide scale up, as shared by Dr Archana Srivastava, Additional Director for National Programmes in the State’s health directorate.
The innovation marketplace is full of ideas, from mobile apps that offer counselling services for students experiencing mental health issues to platforms that offer mothers incentives for positive health-seeking behaviours. There are, however, no guarantees their intended end-users will adopt these innovations and reach to scale.
To put the challenge in context, the number of promising innovations or initiatives that never go beyond pilot, or mobile health apps that never gain more than a few thousand downloads, in the mobile health space, only 12 percent of the 27,000 apps available in the United States can be found in 90 percent of user downloads, according to a 2015 study by the IMS Institute for Healthcare Informatics, as pointed out in a Devex report by Jenny Lei Ravelo.
The reasons for these poor uptakes vary. Some innovation experts point to design, others to financing. But there are other reasons, such as lack of understanding and foresight on the part of the provider or developer. A number of innovations in maternal and child health, for example, may be developed with good intentions, but attaching an expensive price tag can defeat the original purpose, especially as such innovations are more likely required in cash-strapped health facilities serving underserved communities.
Knowledge gaps are another barrier. Health care workers in low-cost settings are accustomed to doing things manually might find difficulties or resist adopting new technologies that would require a series of training.
Hence, Dr Gauri Bisht, head of IntraHealth programme in Uttarakhand and Dr Meenakshi Jain, country director, IntraHealth International India are very clear that pricing of the hardware i.e. mobile phones and tabs at an affordable and competitive rate is essential for scale-up and sustainability. They also believe in intensive training and hand holding of the health workers so that, they not only switch to a user-friendly technology but generate cleaner data and take pride in it. The data created by ASHAs, AWWs and ANMs, is the backbone of maternal child health programming and planning in India.
Dr Jain also believes, an app in a phone is not a replacement for trained health personnel, hence addressing the human resources challenges in health comprehensively, is a natural focus of IntraHealth too.
The state programme leadership helmed by Shri SS Negi, health minister and Dr Niraj Kharwal, Mission Director, NHM, Uttarakhand, are keen on scaling up pilots after rigorous field testing. Shri Negi believes piloting for pilot/innovation sake is an academic luxury, ill-afforded by state exchequer operating with public funds. Hence, selecting challenging locales, providing power and internet connectivity ecosystem to run the pilot in hard-wired conditions is important to take an informed public policy decision about scale up.
Considering demonetisation has given an adrenalin rush to the conversations around digitisation and consequently data insecurity, the state is planning ahead with conversations with the National Informatics Centre for data protection and main-streaming into the state data systems. The federal government is linking most social protection and public service programmes to Aadhaar (in spite of the federal Supreme Court hearing a matter on the same), the mother and child tracking data generated with their Aadhaar numbers are being sought to be protected by the state with sincerity, unseen before.
It is also keen to create the data interpretation and usage capacity in-house, so the cleaner data of mSakhi doesn’t just become a talking point in national conclaves, but the real-time, cleaner data is used for better health delivery purposes in the maternal-child health interventions and beyond.
Beyond piloting the exciting innovation mSakhi (which stands up to the literal meaning of its name i.e. mobile Sakhi or friend), the state is also putting the pre-requisites of data protection, integration (with state health data) and interpretation (re-analysis, reading and usage in place). It is also linking it to the apps on breast feeding called Stanpan Suraksha and the ANM’s programming app ANMOL.
It is also a state with a fully staffed Public Service Commission, helmed by the ex-Chief Secretary, Mr Alok Jain. He is clear that health delivery is the gold standard of public service delivery, hence communicating service entitlements to create demand and accountability expectations from amongst citizens is equally important, especially to break the shackles of service provider hubris. The commission is going all guns blazing to connect with the state citizenry on specific services and access points and availability time and process. A much-needed intervention too. They see the mSakhi intervention as instrumental in boosting better public service delivery, but they are also keen on similar apps/online platforms to be created for citizens to demand service providers’ accountability. This is an epiphany moment on how one innovation is unleashing imagination and ambitions of others.
It seems the new and small state of Uttarakhand is getting the narrative right at many levels!