e-Mamta: Gujarat State Initiative of Mother and Child Tracking System
Commissionerate of Health, Family Welfare, Medical Services, Medical Education & Research

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
High rates of maternal and infant mortality are amongst the daunting challenges confronting public health in India. The High Maternal Mortality Ratio (MMR) and Infant Mortality Rate (IMR) need immediate reduction to attain the ambitious MDGs goals. The most common causes are hemorrhage (pre partum and post partum), hypertensive disorders, infections, obstructed labor and anemia. These causes could be attributed to three major delays: A woman’s inability to demand adequate care is amongst the first causes for delay. This can be attributed to socio-cultural restrictions in the form of barriers to her mobility, to demand resources, traditional beliefs and practices surrounding childbirth and poor educational status. Second, poor economic conditions and inability to access adequate healthcare facilities and third, delays in delivering appropriate care and services on time. Also, there was a peculiar challenge of declining Sex Ratio at Birth and hence Child Sex Ratio leading to gender imbalance, partly due to social importance given to male child, leading to Prenatal Sex Determination and termination of pregnancy of female fetus. This required continuous tracking of pregnancy from the day detected to pregnancy outcome. Major Groups affected were women and children, mainly in remote, hard-to-reach, underserved areas. Gujarat has a significant Tribal population with specific socio-demographic features. Migration of families for work left the women and children untracked and depriving them of continuity of care for basic Maternal and Child Health Services such as delivery registration, antenatal care, institutional delivery etc. Rural health challenges such as highdropout rates, high left out rates, quality f services, inability to track beneficiary pregnant women and childrenleading to high MMR and IMR were posing a threat to the wellbeing of the society. Situation before implementation of e-Mamta • Despite the availability of abundance of information in health sector, there was a need to build capacity to find, communicate or use the information effectively and link it to individual beneficiaries. Also, the traditional reporting system did not provide for “Left out” tracking which left a serious gap in complete and effective healthcare service delivery. The total time required for a complete report to reach the state center from the sub center used to take a minimum of 25-30 days. • Individual information about the beneficiaries, especially pregnant woman and children, regarding status of healthcare services and health status was not possible due to migration of the population. Real time information that could trace each and every person in the state to ensure complete health care delivery was not available. • No attention was given to individuals being left out of health care service delivery. Most of the analysis of data in the Public Health system as well as for establishing trends for policy analysis and planning till now concentrated on post mortem of the historical data. The gap between on ground surveys & official statistics was immense.

B. Strategic Approach

 2. What was the solution?
With a vision to improve Maternal and Child Health services delivery in rural as well as urban areas, the Health and Family Welfare Department of the Government of Gujarat, has introduced a Mother & Child name based tracking Information management system called “e-Mamta” in collaboration with National Informatics Centre (NIC), Gujarat, under the National Rural Health Mission (NRHM). Strategy To execute the initiative, a Family Health Survey was conducted in rural and urban areas by health workers, wherein individual records of around 52 million beneficiaries, covering almost 86% of population of Gujarat were entered in the Information Management System. The data was then validated by comparing with below poverty line list, voters list and ration card list. Secondly, a unique family healthcare ID was provided to capture migration details. After that, all pregnant women and children up to the age of six were registered and provided a Unique Mother and Child ID. The online software application was developed by NIC toregister the beneficiaries in rural, slum and semi slum areas of Gujarat. The application has enabled health service and health status real time information of each and every pregnant woman, children and adolescent through a unique Identification Number provided to them. Health data of 45 million individuals is available at the click of mouse, helpful in delivering health service to left outs by the unique ID. Real time information on individual basis is made available to the Primary health centres, Blocks, Districts and the State office to ensure complete service delivery. Individual based growth charts of the children, immunization details; ANC service details of each pregnant woman are now available for monitoring. The paperless system provides very reliable reports of health care management. Target Audience - Pregnant women and young children, as well the health services delivery workers in the State With the help of the e-Mamta initiative, 4.21 million pregnant women and 3.07 million children in the age group of zero to six have been tracked for essential Reproductive and Child Health (RCH) Services. Under the initiative, SMS alerts are sent to beneficiaries, health workers, and district and block level authorities to monitor due services. Customized and bilingual SMS are sent to target beneficiaries or their relatives in each group before their due dates. Automatic SMS are sent to beneficiaries to inform them about antenatal care and to inform about immunization for children under the initiative. Also, automatic messages are sent to officers to report maternal death and to report infant death. Apart from this manual messages have been sent for inter-departmental corporation and to mothers and families for the uptake of services. In addition, SMS have been delivered to all nurses and doctors of Gujarat within minutes of infant deaths reported due to measles vaccine. Post the introduction of the initiative, 24 graphs are available, location and period wise, which can be viewed in various permutations for quick analysis. Post implementation: • Individual based service and reliable report generation • Systematic Monthly Work Plans • Immunization Record of a child can be obtained at any age • Child Growth Record is stored and can be obtained at any age to analyze early growth • Paperless information management • Instantaneous compilation and reporting from a sub center to State level

 3. How did the initiative solve the problem and improve people’s lives?
Efficiency in administration encircles two chief prospects –no delay and complete reach, that are essentially targeted through mobile based technology by virtue of real time and individual based approach.SMS technology bridges the communication gap between beneficiaries and service providers caused due to migration and disperse scattered population. Bilingual (Gujarati and English) SMS on uptake of ANC & anemia management services, immunization, delivery, family planning, PNC are sent to beneficiaries before their due dates. SMS facility for intradepartmental coordination: The Chief district medical officer, block health officer and medical officers can communicate through SMS to the field workers. Developed for quick communication in times of disasters and medical emergencies in state, a record 16,000 SMS were delivered to all nurses and doctors of Gujarat within minutes of infant deaths reported due to measles vaccine. Concept of work plans: Concept of work plans (generated village-wise each month) has been introduced for the first ever time where beneficiary wise detailed schedule of due service is prepared for each grass root level worker. In addition, e-Mamta provides a Dashboard for quick analysis and action on important statistics like Deliveries, Immunization records, Maternal and Infant deaths, Child Growth Charts etc.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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
 6. How was the strategy implemented and what resources were mobilized?
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

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
• 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.

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
• 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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
• Increase in institutional deliveries and lowered MMR and IMR Probably the biggest benefit toward lowering the MMR and IMRs is the increase in institutional deliveries post e-Mamta implementation. 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. The percentage of home deliveries has reduced from 10.6% in 2009-10 to 4.9% in 2012-13; at the same time, the institutional deliveries have gone up from 89.4% to 95.1% in the same time period. The IMR per 1000 live births was 44 in 2009-2010, and has come down to 38 in 2012-13, showing a downwards trend. • Increased efficiency of outputs/processes and effectiveness of outcomes The system enables the health care providers to devote their time in health care delivery,freeing them from keeping bulky records and preparing reports, which is handled through e-Mamta. The man-hours saved of this highly skilled human resource are now being utilized effectively for service delivery only. Analysis in form of graphs, reports such as Hemoglobin, Weight chart, growth and immunization charts are effective tools for Medical Officers to review the beneficiary-wise health status of the population in their command area. • Use of SMS Technology for Tracking beneficiaries & better intradepartmental coordination: Evaluation implies use and communication of information from the data collected. Cutting on the effort of health manpower for evaluation activity and continuous effective reminders, a SMS interface with e-Mamta is developed. Customized SMS for each beneficiary according to their due dates of services is a new paradigm in Information, Education and Communication (IEC) in the healthcare sector. SMS alerts facilitate the intradepartmental coordination through e-Mamta. Plans are in place for including additional features of sending voice messages/ alerts to beneficiaries and service providers for due services. • Financial & Logistic Monitoring Through incentive details entry at each Primary Health Centre and inventory details of in and out logistics, a better and non-manipulated monitoring of ASHA incentives, drugs and vaccines at each PHC is done at District and State level. • Graphical Analysis Before e-Mamta, there was no tool to visually analyze the health care services status below District level. Now, there are 24 types of graphs available, with location and time period specific filters for accelerated analysis.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Sustainability of the initiativeamounts from: • Program developed by Gujarat State Government and NIC, Gujarat and supported for life. The source code of the IT application is freely transferable to other states, and replication is already underway. • Dedicated funding is assured through NRHM and State funds, at the same time, the recurring expenses are not significant and hence the initiative is light on use of funds. • The initiative has been well integrated and institutionalized within the State health system • Minimal infrastructure and familiar and easy-to-use software for grass root workers • Involvement of regular staff from State, district, block and PHC • Time, cost and effort saved through the use of the e-Mamta software application is visible • The initiative has changed the mindset of the rural and semi urban population about institutional child births. This social change has sustained since the launch of e-Mamta and almost 95% births are happening at hospitals and not at homes. This in turn has given boost to the e-Mamta project • One time data entry of the basic details (Family Health Survey)and then just updating it through the regular field level work. • ASHA incentives, incentives through AADHAR enabled Direct Benefit Transfer for Janani SurakshaYojana (JSY) etc are implemented through e-Mamta platform • The achievements of the program have also been recognized by other states. Several measures have been adopted to replicate the model and intensify its impact. • The Government of India has recognized the initiative of e-Mamta and replicated it at National level with some selective indicators from e-Mamta as MCTS, the Mother and Child Tracking System. • As a step towards overall improvement in the public health of the entire country, the Government of Gujarat has trained senior state level health and NIC officers of 26 States and all Union Territories of India

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
• The key lesson learnt was that a change in public mindset was critical to ensure adoption of healthier and safer pre and post natal care practices. Often, this became a secondary criterion as many citizen groups were faced with survival choices first - migrating between cities for livelihoods and lack of education and basic healthcare knowhow. The field workers mobilized through e-Mamta is bridging this gap and the indicators till now have been positive. • Government of Gujarat is planning to expand the scope of e-Mamta within the state. It aims at integrating the system with a mobile based technology (m-Health ), combine the program with other national policies and initiatives such as ICDS (Integrated Child Development Services), primary education and school health, evolve a supply chain management of vaccines and drugs, generate complete health records and integrate private sector providers and institutions at the village level including e-Gram and e-Sewa. • The public health facilities such as Primary Health Centers (PHCs) shall be the registration points for e-Mamta. The beneficiaries shall be linked to their UID (Unique ID) or 'Aadhar' number so that they received direct benefits such as any cash subsidies or disbursals, in their bank accounts • The e-Mamta system may be integrated with BADEA (Birth & Death Data Entry System) • In conceptualization and development process is integration of voice calling (automated voice calling) with in E-Mamta to send Information, education and communication messages to pregnant woman in events of Ante natal care due services, delivery due services, Post Natal Care due services, anemia, malnutrition, complications such as high BP.

Contact Information

Institution Name:   Commissionerate of Health, Family Welfare, Medical Services, Medical Education & Research
Institution Type:   Government Department  
Contact Person:   Prem Kumar Taneja
Title:   Principal Secretary (Public Health & Welfare)  
Telephone/ Fax:   079-23253299/079-23253401
Institution's / Project's Website:  
E-mail:   cohealth@gujarat.gov.in  
Address:   Commissionerate of Health & Family Welfare Department, Block no 5, Dr. Jivraj Mehta Bhavan
Postal Code:   382010
City:   Gandhinagar
State/Province:   Gujarat

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