District health society

The Problem

Health is a critical parameter of human development. Therefore, health indicators are crucial in assessing human quality of life. India as a developing country is still facing significant maternal and child deaths with a very slow reduction in child and maternal mortality rate over a period of time. Every year in India 2.4 million children and about 136,000 women die. These numbers represent about one fifth of the global total and only if a dramatic reduction in these futile losses is achieved, can India hope to reach the Millennium Development Goals on maternal and child mortality.A look at the various health indicators reflect the gap between the goals and achievements :-

 Infant Mortality Rate(IMR) –69 in Uttar Pradesh(India), 53 in India, NRHM goal 28
 Maternal Mortality Rate – 440 in UP, 254 in India, NRHM goal is 100
 Full Immunisation –54% (Annual Report NRHM)
 Institutional Deliveries –47% (DLHS-3 2007-08)
 Total births registered –63% (WHO reports)

The situation is further compounded by the fact that health care delivery in India suffers from certain structural deficiencies like :-
 Low penetration of medical services, especially in villages
 Marginal involvement of community and stakeholders
 Inadequate strength of medical and Para-medical staff
 Suboptimal use of technology for ensuring healthcare to all

India's National Rural Health Mission was launched in April 2005 with a strong commitment to reduce maternal and infant mortality and provide universal access to public health services. The second phase of India's Reproductive and Child Health Program (RCH-II) is an integral and important component of this mission. The main objective of the program is to bring about a change in mainly three critical health indicators i.e. reducing total fertility rate, infant mortality rate and maternal mortality rate with a view to realizing the outcome envisioned in the Millennium Development Goals, the National Population Policy 2000, and the Tenth Plan Document, and NRHM goals, 2012. However, there still is still a vast gap between goals and actual delivery of maternal and child health care as is clear from above indicators.
In this background, our health initiative, Aarogyam aims to provide healthcare services to citizens at their doorsteps, with special focus on mother and child to bridge the above gap.

Solution and Key Benefits

 What is the initiative about? (the solution)
Aarogyam is country’s unique end to end digital health mapping and pregnancy tracking system. Aarogyam caters to both Safe Motherhood and Child Survival Components of Reproductive and Child Health program. For the former, it focuses on Ante Natal Care (ANC),Post Natal Care(PNC) and emphasizes on 100% immunization for ensuring the latter. With these objectives, it uses modern ICT techniques for digital health mapping and pregnancy tracking. It therefore, prepares a complete health database with respect to the target group i.e. pregnant/lactating mothers and children in immunization age group. The database so generated forms the backbone through which a software system suo-moto generates automated calls on all aspects of child immunization, ANC,PNC, safe delivery ,pulse-polio campaign etc, on telephone thereby ensuring health care for the entire family at their doorsteps. Having full knowledge of one's family health profile, one can be more informed and empowered to avail the required health facilities. The project also has an interactive platform wherein a citizen can enquire about various health parameters, and lodge a complaint on a given helpline number. .The program is currently running in four districts of Uttar Pradesh state (Baghpat, J.P. Nagar, Ramabai Nagar ,Gautam Buddha Nagar) catering to around 70 lakhs population with the main target group being pregnant women, infants, children due for immunisation and subsequently the entire community therein. Project funds have also been sanctioned in NRHM for all districts of Moradabad Division ,where it has been initiated catering to a population of around 1 crores.

Aarogyam works on a four pronged approach of Proactive, Reactive, Interactive and Educative interventions among the community. It can be thereby visualised in terms of following two modules:-
a) Pregnancy tracking and monitoring module (Proactive and Reactive)

i. Proactive- Aarogyam keeps citizens at the centre of the health model and generates automatic family specific reminder calls/SMS in Hindi encompassing the following areas:
 Immunization details for children from 0-5 years informing them about the place and date of vaccination.
 ANC/PNC details of pregnant and lactating mother based on the due date for TT, IFA tablets etc.
 Institutional delivery and benefits of Janani Suraksha yojna (JSY).
ii. Reactive- In case of pendency the reminder calls are sent to the concerned family,ANM and village pradhan for ensuring the service delivery
iii. Services delivered
• Enabling the digital health mapping and pregnancy tracking system.
• Outbound IVR/ Hindi SMS disseminating personalized information w.r.t mothers and children for - BCG, DPT, Polio, Measles vaccines etc.
• Audit Trails - Regular pendency reminder calls to family, ANM, Pradhan (Village Heads) for ensuring 100% immunization, ANC, PNC etc.

b) Grievance Redressal and Information dissemination module (Interactive and Educative)

i. Interactive –Through in-dial 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 in-dial facility.
ii. 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 (ie, cholera or dengue fever) campaigns, Prenatal Diagnostic Tests (PNDT), JSY, and the burden of disease in a particular region among others. In addition to this Aarogyam sends periodic Behavior Change Communication (BCC) messages to the beneficiaries.
iii. Services Delivered
• Inbound Information retrieval of Health parameters and schemes
• Complaint lodging and redressal
• Community Broadcasting

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
Synergy with various departments and active involvement of all stakeholders is another crucial component of the project as illustrated in :-

1.Role of the nominees:- Under the guidance and motivation of Chief Secretary, Uttar Pradesh, the then DM Baghpat (Mr. Mayur Maheshwari) and then DM-JP Nagar (Ms. Ritu Maheshwari) have demonstrated excellent leadership qualities to conceptualize and implement the innovative model. They proposed and implemented the solution in their respective districts and in the process ensured the participation of different departments and stakeholders and motivated them enough to work and perform together. It is their leadership quality which resulted in successful implementation of approach and also a consistent growth in health indicators in very small span of time.

2.Participation of Integrated child development scheme (ICDS) workers i.e. AWWs (AnganWadi Workers) , who have played a crucial role not only during generation of baseline data by ensuring coverage of each and every household ,but their continuing support is critical in gap identification and service delivery at village level.
3•ASHA: i.e. Accredited social health activist, who is the face of the health department at village level with 1 ASHA worker for every 1000 population , have assisted the team in baseline survey and they are also motivating the communities on entire approach. The presence of ASHAs helped the department to reach to the beneficiaries.

4•Village Pradhan: They are the elected public representatives at the village level. Being a community face at village level, Pradhans have also been actively involved in the entire effort. The system informs them also on the health service status of the particular village and routes pendency calls to them which increase their responsibility towards communities in terms of primary health care services.

5•Basic Education: The network of school teachers and shiksha mitras(contractual teachers at village level) has been utilized to spread awareness about the project through school health programs ,nukkad nataks etc.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
Mothers and children constitute a significantly large proportion of the country's population. This group is exposed to the risk of child bearing in case of mothers and growth, development and survival in case of infants and children. Therefore, it is a high risk group requiring special care and attention.
With this backdrop, the Purpose of Aarogyam is to develop a technology based health care delivery program to ensure:-
• 100% immunization for children in 0-5 years of age group.
• Tracking each pregnancy with the help of a technology based monitoring system
• Complete ANC/PNC care including early registration of pregnancy,3 ANC, TT mother, institutional delivery, promotion of Janani Suraksha Yojana(JSY) etc.
• Development of a replicable model of technology based Pregnancy tracking and Child immunization system
• Generation of awareness in community about health services and inducing a change in their health behavior by reinforcing the messages.
With above specific priorities, the project uses ICT and mobile phones as a tool to generate telephone calls, sms (in Hindi for wider appeal) to the families of target group on/before the due dates of immunization schedule. Hence, the model has “Knowledge is power” as the underlying theme wherein, have-nots are converted to haves through information dissemination. It therefore becomes a potent vehicle for people living in low socio economic brackets to access healthcare at their doorsteps through the feedback mechanisms inbuilt in the system.
As far as strategy for implementation is concerned, Aarogyam is a unique Mobile-Governance health initiative. Its innovativeness is in its being:
• The first outbound IVR application in government health care delivery mechanisms.
• It is also a pioneer in terms of establishment of a scientific and comprehensive Pregnancy tracking system.
• The digital database so captured makes it a powerful community broadcasting medium for various educative campaigns not only in health like pulse polio and JSY, but also in public welfare schemes of other departments like Total Sanitation Campaign, Education, Flood/Epidemic alerts etc.
• The inherent advantages of Integrated Voice Response Technology, add to its innovativeness in terms of
a. Ease of access,
b. Wide range of people covered
c. Use of Vernacular to spread awareness,
d. Applicability to illiterate people
e. Zero cost to people
f. Less human Endeavour

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The Mode of transformation for Aarogyam can be visualized in various phases as in:

Phase- 1 Baseline Study
A comprehensive baseline survey of district with respect to family health indicators like age, gender, class, parity, immunization details of children ,database of pregnant mothers and their expected date of deliveries(EDD), and their phone numbers was conducted, with interdepartmental coordination especially Health and ICDS Department. The survey captures village wise database encompassing all crucial determinants of health.

Phase -2 Implementation Phase

 The above information forms the master database, which is then fed in a customized software and linked to Integrated Voice Response System (IVRS). The technique uses analogue/digital card to read all the uploaded data and devolve it to the beneficiaries.
 Next step is Establishment of multiple phone lines and initiation of health helpline for the citizens to get an update on health services and to register their complaints.
 Establishment of required institutional mechanisms at district (central server) and block level, ensuring updation at CHC level and linkage with the master database.
 Capacity building/ training of service providers and data entry operators on the software, with clear delineation of their roles, responsibility and accountability.
 Awareness generation through IEC/BCC (Films, Songs, Nukkad Natak, Pamphlets, Hoardings) about the project.
 Group and individual counselling, home visits in specific cases.

Phase 3- Monitoring and Evaluation
• Development of a Web based Monitoring portal www. aarogyam.co.in
Which provides web-interface for service providers as well as citizens .Herein, the project objectives/strategy/mode of operation is made clear for use of citizens. Apart from that, various MIS reports which is an integral component for review of online system as in:
- Mother report
- Pending child immunization
- SMS report
- Impact report
- ANM/Pradhan Call report
- Polio report
- Complaint reports etc.
are uploaded for effective monitoring by district level officers right from district magistrate to chief medical officer.
• Regular monthly meetings with key stakeholders to assess the progress.
• Generation of audit trails- Aarogyam automatically generates pendency list w.r.t unfulfilled targets for medical officers, ANMs, Pradhans and beneficiaries, based on which call alerts and SMS are sent to all stakeholders every 10 days till the services are reported as delivered by the system.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words

A. Database
The biggest challenge for the scheme was to create an accurate database. Therefore, initially data collected for the polio programme was used in this scheme and later on the information was updated by ANMs, AWWs and ASHAs. There was reluctance on the part of target families, village pradhans and even ANMs to share their telephone numbers. This was overcome by continuous visit to target houses, hosting Gram Sabha meeting and demonstrating to them, the potential uses of new schemes.

B. Increased workload and accountability for service providers
Most difficult aspect was motivating health personnel from top to bottom-i.e. Medical officers to ANMs to be a part of the programme and overcome their inertia. The ANMs and Pradhans did not play a proactive role initially because of the increased workload and accountability. Their inertia was overcome and active participation ensured by conducting repeated trainings and regularly motivating them by awards at different functions, whenever desired targets were achieved.

C. Awareness Generation: - To ensure that people attend to our calls, and do not mistake them for commercial calls, it was necessary to generate awareness about the scheme amongst all. Initially some calls were not being picked up or people could not understand them properly. Hence, a systematic campaign was launched to generate awareness about the project. Wall paintings were done in all village primary schools, depicting the working of the project and our in-dial telephone numbers. Calls after being sent to beneficiaries, their feedback was recorded manually and changes incorporated, if required. Simultaneously, different stakeholders-village pradhans, Ashas, and ANMs were fully involved in the process and through regular gram sabha meetings, scheme was popularized. Working of the scheme was demonstrated at all important village level functions of the district. Pamphlets were distributed and road side/office place hoardings launched. The result was a tremendous increase in awareness of the project, a jump in the in-dial calls, and queries and almost 95% reception of out-dial calls.

D. Another major challenge was in terms of technical training/inputs as ANMs were not well equipped to handle loads of health information daily. Hence continuous weekly rounds of training were conducted for ANMs and data operators, whereby they learnt the feeding of survey formats, data collection sheets as well as the process of continuous updating/uploading of data.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
People and Resources
a. Human resources

As far as HUMAN RESOURCES are concerned, Aarogyam is being run by all existing staff & District level officers right from Chief Medical officer (CMO) and Additional CMO (RCH) at top level, to ANMs/ASHAs at the lowest level, Additional requirement is only of data entry operators at district and block levels. Under ambit of NRHM, data entry operators have been engaged, and trained for feeding, updating and uploading the database both at central server as well as PHC level as well as for updation and maintenance of Application software and database, Creation of automatic backup of Application Software and database. A full time team is in place for effective monitoring of the project. District level review committee headed by District magistrate continues to monitor the progress with supportive supervision

b. Financial Model ( Funding pattern , Business model PPP etc) defined and implemented

Costing of the project has been purely through utilization of available funds/grants under National Rural Health Mission, provided by the Government. Costs incurred on the project can broadly be seen in two aspects. Onetime costs i.e. costs incurred, initially at time of project start up & recurring costs i.e. yearly running costs of the project :

One time costs:
1. Baseline Survey Rs. 1,70,000
2. Awareness Generation Rs. 3,60,000
3. Training and capacity building Rs. 80,000
4. Technology setup at district & Block level Rs. 10,00,000
Total One time costs:- Rs. 16,10,000

Recurring costs:
5. Monitoring and documentation Rs. 30,000
6. Stationery and miscellaneous costs Rs. 1,00,000
7. Human resources:- Rs. 4,80,000
Total Recurring cost- Rs, 6,10,000
Total Expenditure (per year per district) Rs.22,20,000

C. Technology

The software applications have been developed via out-sourcing. A comprehensive baseline survey of district wrt family health indicators was conducted, with Interdepartmental coordination esp Health-ICDS Department wherein family details concerning all health indicators were collected. These include, name, address and age of family members, immunization details of all children wrt their expected dates as well as actual dates of immunization/pregnancy, details of pregnant mothers wrt ANC status and PNC coverage, location and phone no of each family and finally assigning a unique family ID to each family. This whole information was then uploaded on specially designed software to have health indicators of each family on computer. The details have been uploaded on IVRS. The technique uses analogue/digital card to read all the uploaded data and devolve it to the beneficiaries through AUTOMATIC FREE OF COST AUTO-DIALERS AND SMS.

For data protection various strategies have been implemented as in backups made on optical device, replication of data to an off-site location, data is in a distributed environment and hence easy to restore, surge protectors, UPS and backup generator for server, fire prevention alarms and extinguishers, anti-virus software and other safety measures.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
Sustainability of Aarogyam is citizen driven. It can broadly be viewed in three aspects:
a. Systemic Sustainability:-

A project is successful only if it becomes System based rather than individual based. This has been ensured by:-
• Institutionalization of the project by state government in various districts and divisions as mentioned below.
• Development of the cadre of trained and skilled staffs for data interpretation, entry, analysis and documentation. Under ambit of NRHM, data entry operators have been engaged, and trained for feeding, updating and uploading the database both at central server as well as PHC level.

• District level review committee continues to monitor the progress with supportive supervision

b. Technological Sustainability:-

Aarogyam, has inbuilt measures of sustainability as once database is uploaded, auto dialers and sms need not be worked upon. They are automatically conveyed to the beneficiaries. However, it has to be regularly updated after immunization/polio rounds. The model has inbuilt sustainability as the technology is IVRS based ,easy to use, has ease of access and uses Hindi characters for wider acceptability.

c. Behavioural sustainability:

• Improved health behavior in the community which is supplemented through mass awareness generation (Folk media, TV ads, posters /banners etc).

• Demand driven involvement of Panchayati Raj Institutions and local populace

The project is easily replicable. It has few inbuilt advantages in consideration of the use of IVRS technology which make it easily replicable-

1. Ease of access
2. Applicable to illiterate people
3. Less human Endeavour
4. Apart from above, strengthened community-service provider linkages for participatory planning, delivery and monitoring of services can sustain the programme.
5. Above all, The Project has won various prestigious awards both at national and international levels which bought it recognition motivating others for its replication:-

• WINNER : National E-Governance Award 2011-

• WINNER : NASSCOM Social Innovation Honours-2010 – adjudicated by an eminent jury consisting of Mr. Narayan Murthy (former chairman of Infosys Ltd), Mr. Jerry Rao (founder of Mphasis Ltd) etc.

• WINNER- UP State E-Governance Award 2011

• WINNER :- FIEO Telecom Technology Award 2011 by Ministry of Commerce
• WINNER : M-billionth awards south-Asia 2010
• Finalist- Stockholm Challenge Award 2010

Above aspects very well demonstrate Aarogyam's reliability. Already the project is being replicated at state and national levels:-

 An integral component of the project, Pregnancy Tracking System, has been taken up in all 75 districts of the state of Uttar Pradesh, catering to a population of around 200mn.

 Secretary Health GOI has seen and highly appreciated the project, Director NIHFW, have visited both the districts and have recommended scaling it up on a national level.

 Already the program is running in four districts (Bagpat, J.P. Nagar, Gautam Buddha Nagar, Ramabai Nagar) catering to around 70 lakhs population. Project funds have been sanctioned in NRHM for all districts of Moradabad Division (Moradabad, Rampur, Bijnore, JP Nagar), where it has been initiated.

 Different NGOs like Intra Health Foundation (A Bill and Melinda Gates Foundation), Rotary Foundation, Public Health Foundation of India, etc. have visited the project and are keen to replicate key approaches/practices from this project in their own fields.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The initiative has started giving positive results and learnings in terms of health service delivery mechanism. The scheme has benefited more than 1.5 lakh target group families so far in the 4 districts of Bagpat, JP Nagar, Ramabai Nagar and GB Nagar of UP. So far, more than 1.25 lac automated calls and SMSes have been sent under the system. Major benefits are:

1. Improved responsibility and accountability of service providers: Instant messages and calls to service providers have made them (ANM/MOs) more responsible and accountable. The web based monitoring portal (www.aarogyam.co.in) gives a snapshot of achievers and underperformers. This helped to ensure the timely high quality delivery of health care services to the communities.

2. Improvement in measurable indicators: So far as measurable indicators are concerned, there is a positive trend over a period of time. Across the board in figures of child and mother immunization, we are seeing positive trends emanating with the implementation of aarogyam. For District Bagpat, there has been commendable improvement over a period from Jan 2008 to Jan 2011:-

Immunization Apr-2007 -Jan 2008 Apr-2010 -Jan 2011
Polio 19914 33964
DPT 19914 33964
BCG 22637 34419
MEASLES 21838 33934
TT Mother -1 20314 39525
TT Mother -2 18374 38280

3.The best result has been in terms of Improving access to health services through knowledge empowerment of the henceforth left-outs, economically/socially impoverished families. Sitting at home one gets specific knowledge about one’s health profile, and this has resulted in a tremendous hike in demand for health related services especially wrt immunization.

4.User friendly approach: It follows a user friendly approach in which an illiterate person can also take initiatives to update himself/herself on health service provisions and status. It is also easier for health department to inform their community level workers (ANMs, ASHAs) on health gaps and priorities.

5.Incorporates Community feedback: It was evident during several field visits of health and other officials that community’s response on the idea is very enthusiastic. Their feedback on technology based information and monitoring system was positive and they are looking forward to get more benefits from the technology based system.

6.Transforms administration through more 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.

7.Improved efficiency of process and effectiveness of outcome: Awareness can be created in no time and there is no need to have too many people to spread a message. At the field level the efficiency of workers has been improved as they are being informed about their duties on phone on regular basis. At the district level, top officials are now better equipped to monitor the progress as well as coverage through web monitoring system. Field Officers are found to be more efficient in data analysis and compliances of complaints.

As far as lessons learnt are concerned, it very well demonstrates:-
1. Importance of delegation of powers to key stakeholders so that their inputs can play a pivotal role in effective execution of the scheme.
2. In-built feedback mechanisms, concurrent evaluation supported by a series of audit trails should be inherent in any system which has to sustain.
3. Role of vernacular and user friendly technology are very critical to ensure success of any initiative with a citizen interface.

Contact Information

Institution Name:   District health society
Institution Type:   Government Agency  
Telephone/ Fax:  
Institution's / Project's Website:   www.aarogyam.co.in
E-mail:   mayurmaheshwari@yahoo.com  
Postal Code:  
City:   KANPUR
State/Province:   UTTAR PRADESH
Country:   India

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