| 4. In which ways is the initiative creative and innovative?
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I. Completion of Family Health Survey by 30/4/2010:
The key first step in this regard was the Family Health Survey in rural & urban areas (slum and slum like). The survey work has been successfully accomplished by the health workers. The individual records of around 45 million beneficiaries, covering almost 80% of population of Gujarat have already been entered in the Information system ‘e-Mamta’ in base year. Subsequently, the Family Health Survey updates data every year and currently there is data of 52 million population, i.e. 86% population of Gujarat.
II. Data validation:
• Physical verification byANM/FHW (Female Health Worker) /ASHA (Accredited Social Health Activist)/HV (Health Visitor)
• Cross verification by MO (Medical Officer)/BHO (Block Health Officer )/DPC/RCHO (Reproductive and Child Health Officer /ADHO (Additional District Health Officer /CDHO (Chief District Health Officer)
• Cross verification with voter list, BPL list etc.
The family health survey data was edited after the physical validation.
• A drive was conducted from 1/4/2010 to 30/4/2010 to register pregnant mothers in the e-Mamta system.All women who are pregnant and children of age up to 6 years are being registered and provided a unique mother/child ID. Data entry of service delivery for each beneficiary carried out at respective health facilities. Work plans were generatedfor ASHA/AMW workers to strengthen service delivery.
• The local health workers (ASHA) will gather information regarding the residents in their designated area and identify the target population of pregnant females and infants. This information is then conveyed to the local PHC enabling the data to be entered and stored in the online tracking system. These pregnant women are then tracked and followed for the outcomes. Once a week, usually Wednesdays dubbed as “Mamta Divas,” pregnant females and mothers with infants come to the health centre for their weekly health check- up.
III. Training
• The training of all implementing agencies was conducted at the state and the district levels by the Government of Gujarat. The stakeholders were trained on different components of the programme.
• The state office conducted state level training for superintendents of all community health centres, chief district medical officer, Chief District health officer and urban health officers.
• The state officials conducted regional level training for members of the district and block health teams including RCHO/ADHO/BHO/MO/BHV/BV.
• The regional health teams facilitated training sessions for the grassroots health workers.
• Moreover, SATCOM or satellite communication network services were utilised to facilitate distant interactions with medical and paramedical staff at the state, district and the block level. The Satellite Communication technique - SATCOM programme was organised every month to review the implementation process and provide necessary guidelines
IV. Monitoring and Evaluation
e-Mamta facilitates effective monitoring of the delivery of health services. Regular evaluations are conducted based on the information generated through the system. This includes:
• Child immunisation records, child growth charts (male and female) and other reports. These records are available online and at e-Sewa Kendras.
• Monthly report formats, that contain the aggregates of the services delivered to the individual beneficiaries. On the basis of this information services for different beneficiaries can be planned and tracked.
• Identification details assist effective tracking of the migrated beneficiaries. Family ID, health ID, name, ration card number, RSBY (Rashriya Swasthya Beema Yojna or National Health Insurance Scheme) number, BPL (Below Poverty Line classification) number, mobile number, child’s date of birth are the few parameters that enable individual case-based tracking and identification.
The broad timelines of implementation is as below:
• January- 2010: e-Mamta Conceptualization and data entry modules developed
• May-2010: e-Mamta Project launched all over Gujarat
• July-2010: Presentation in review meeting of NRHM at Bhopal and announced for National Roll out.
• August-2010: Training to state Nodal officers& State data entry Managers in four batches of all the state in Delhi & Gandhinagar.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Efficient planning, delivering and monitoring of policies, programmers, schemes in Government sector is no different proposition. The following are the stakeholders for e-Mamta implementation:
• Citizens, the main beneficiaries:
• All eligible pregnant women
• Children (0-6 years)
• Adolescents (10-19 years)
• Contributors to the initiative
o State level:
• State Rural Health Mission
o Role: Conceptualization and Implementation across the State, facilitated National Roll-out
o Role: Implementation across the State
• Commissionerate of Health
o Role: Conceptualization and Implementation across the State, facilitated National Roll-out
o Role: Up gradation and Implementation across the State
• Health, Medical Services, Medical Education and Research
o Role: Implementation across the State
• National Informatics Centre (NIC): Developed the eMamta software application and provided training to the Departments officers and field functionaries. NIC played an important role in providing ongoing support and maintenance of the application
o Role: Software Development, Training
• Implementation staff, including District, Block, village level officers and field functionaries
o 1168 Public Health Centers
o 7274 Sub centers
o 318 Community Health Centers
o 28 sub -district Hospitals
o 26 District Hospitals
o 11 Government Medical College affiliated hospitals
o 8 Corporations
o All Villages of Gujarat –Accredited Social Health Activists -ASHAs
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| 6. How was the strategy implemented and what resources were mobilized?
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The funding for the initiative was done by Government of Gujarat and under National Rural Health Mission (NRHM) program. The technology support was provided through National Informatics Centre (NIC), Gujarat.
The Human resources involved were as below:
• Female Health Worker and ASHA (Accredited Social Health Activist) workers
• State Medical Officer
• Chief District Health Officer
• Additional District Health Officer
• Block Health Officer
• Reproductive and Child Health Officer
• Data entry operator at Primary Health centres
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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• Citizen centric health services delivery
Identification of the recipient of the services and ensuring timely delivery of services to the beneficiaries was a pre requisite. Principle of Name based tracking ensures each family, pregnant woman; pregnancy event and children are provided a unique identity number. The unique number provides for tracking of essential MCH services through uniquely designed products of the application namely- Work plan for the provider (Female Health worker) and auto SMS for due services to pregnant woman and families of children, besides reports, computerized Hb./weight chart, immunization cards, growth charts etc.Timely and customized SMS alerts are sent to the beneficiaries, informing them about services to be availed.
• Information in public domain
The system has enabled increased public access to crucial health related information. The database is available to all service providers and recipients through a common source. It facilitates access to information on the services available, service providers, service recipients and non-recipients, records of the beneficiaries of government schemes and related benefits, details about the incentives paid to the health workers and such. The database ensures effective monitoring and evaluation of primary health care facilities.
• Policy planning and management
Access to a comprehensive data set based on valid denominators has greatly benefited effective preparation of state/district/block level health action plans. This information base enables detailed analysis of data in way that facilitates accurate identification of the gaps in service. It has enabled program managers to adopt a more focused approach to policy formulation and planning.
• Skilled workforce creation across levels
Through 'e-Mamta', there is continuous thrust towards creating a pool of trained and skilled workforce that can revive and inculcate a sense of responsibility towards good health and wellbeing and most importantly a commitment towards safe motherhood and child survival at the grassroots.
• Inter-department communication
'e-Mamta’ has replaced the traditional cumbersome system of manually sending the health data from sub centre to state centre, which required up to 25-30 days. Now, with detailed work plans, the communication amongst different implementing agencies is more convenient as all the information is available at a single point. Since the entire process is automated and ICT enabled, information dissemination takes very little time. The data can be accessed easily through GSWAN or internet connection (broadband/WiFi/data card) at any place and time.
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| 8. What were the most successful outputs and why was the initiative effective?
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To monitor the services and information delivery to the intended beneficiaries, the e-Mamta system has some inherent provisions:
• State level Empowered Committee monitors the project at regular intervals and provides valuable inputs and guidance to strengthen the implementation strategy from time to time
• District level Project Team monitors the work execution at District, Block and Village level on a weekly basis. The District Collector (Magistrate) and District Health Officer coordinate the monitoring and execution of the work and motivate the field health workers
• The facility of SATCOM programme is being utilized for uniform transformation of instructions at grass root level health officials. District e-Mission team and state e-mission team are formed for regular monitoring of work process and monitoring of dropouts.
• The system has unique Family ID, Mother ID and Child ID. Status of various parameters regarding service delivery can be checked using these IDs. Each system 'transaction' uses these IDs
• Real time MIS reports from the system enable accurate and reliable analysis of data at State, District and Block levels. These reports were very helpful in monitoring the implementation of the project and taking corrective measures as required
• The real time tracking based on individual names, along with the unique ID provided, enabled the Department to track drop outs, left outs and migrating population.
• Monthly work plans were generated which gave a schedule of field visits and necessary actionable expected from the health workers. In turn, these plans enable m0nitoring of work on an individual worker basis. It also provided a clear picture of status of work and interventions required in order to expedite the functioning.
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| 9. What were the main obstacles encountered and how were they overcome?
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• Motivating the field health worker:
The role of a field health worker was crucial for the effective operation of the program. Resistance and lack of commitment towards their functions, apathy towards proper documentation and lack of adequate resources for data maintenance were identified as key constraints restricting active involvement of the community health workers.
However, continued efforts have been made to integrate the local health workers into the scheme. This was primarily ensured through regular training, sensitization programs and workshops and rewarding and acknowledging their contributions through incentives and awards.Resistance of outreach workers (FHW, ANM) towards filling and use of work plans was addressed though SATCOM trainings and regional workshops.
• Community ownership and participation
Several factors restricted community involvement in the initiative such as high level of unawareness, illiteracy and resistance to change. In most rural areas, women prefer to deliver at home using traditional practices. This has been a primary reason for high rate of maternal mortality. With help of ANM/ASHA workers, efforts are on-going to bridge these gaps and integrate more women from rural and urban (slum) areas into primary health care system.
• Hand holding and support
The responsibility of catering to the large scale demand for effective delivery of health services is dependent on continuous support and hand holding. The government was able to overcome this concern by putting in place a 24X7 help desk.
• Infrastructure issues
Restrictions in the form of connectivity and electricity supply in backward areas were major challenges. An offline mode was made available to enable working without connectivity. Another issue was that low end mobile phones could not support Gujarati language script. To overcome this, Guajarati messages were typed in English. Local health workers were trained in English to be able to comprehend the messages.
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