Health and Family Welfare Department, Government of Gujarat

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Complete, correct and timely information is a fundamental prerequisite towards better planning and better service delivery. National Health Mission (NHM) launched by Government of India (GOI) as a flagship program aimed at improving the health of our rural & urban population providing healthcare to each doorstep. Reduction of IMR, MMR and Total Fertility Rate (TFR) are specific outcomes envisaged by NHM. The major problems identified to improve health service coverage were rural and urban health challenges such as high dropout rates, high left out rates, quality of services, inability to track pregnant women and children leading to high MMR and IMR are well targeted through e-Mamta implementation. e-Mamta was Conceptualized by the State Rural Health Mission of the Health and Family Welfare Department of Gujarat, in January 2010. Purpose & Priorities of the initiative Before the roll out of e-Mamta in Gujarat, the planning for the Public health system was derived from the Health Management Information system (HMIS) which has following shortcomings: - Health Management Information Systems (HMIS) defines area/facility based monitoring numbers; no attention is given to individuals being left out of health care service delivery. - The gap between survey indicators (NFHS, DLHS etc) & official statistics i.e. State HMIS is over reported and not corrected as per actual status. 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. An online name based tracking system which aims at ensuring timely service delivery to every individual with special focus on mother & children and system which provides denominator based Work Plans to health workers was therefore, much needed. e-Mamta is a mother & child tracking web based application, exclusively designed management tool to address the gaps in ensuring comprehensive Maternal and child health services in rural as well as urban areas

B. Strategic Approach

 2. What was the solution?
1. It is a name based mother & child tracking software which enables health workers to utilize existing data efficiently and effectively to plan and deliver health care services to pregnant mother & Newborns. 2. It is information technology based enabled innovative management tool. 3. It monitors the performance of health services through autogenerated analytical reports.

 3. How did the initiative solve the problem and improve people’s lives?
The High Maternal Mortality Ratio (MMR) & Infant Mortality Rate (IMR) in Gujarat needed accelerated pace of reduction to attain MDGs. To overcome the health service coverage issue in Socio-Demographic challenged terrains of Gujarat as it has longest coastline, difficult and scattered desert areas, hilly and tribal areas where 15% Tribal population resides and Tracking of every individual beneficiaries which lacked earlier, e-Mamta has played important role as it is a Name based Tracking web application which covers more than 95 % of entire Gujarat population of 6.21 crores with special emphasis on rural, urban slum and slum like population. The problem of linking comprehensive maternal and child health information of individual beneficiaries for tracking of due health services and identifying high risk pregnant females for further referrals to higher health facilities was one of the large challenge faced by health workers. The logic of processed auto scheduled generated work plans in e-Mamta which addresses the list of names of beneficiaries (along with village location) to be targeted for respective service care such as Antenatal, Delivery, Postnatal, Immunization, Nutrition, other Child health services and tracking of high risk pregnant females for early intervention care has solved the issue of ensuring comprehensive Maternal & Child health service gap. The e-Mamta for the first time processes the available data to generate Denominator based work plans that determine the entire gamut of beneficiaries targeted during village level Mamta sessions (ANC clinics ), the workplan ensures that names along with village location and its respective due service information of every mother and child is provided to female health worker. Earlier, the traditional system of maintaining hard copies of large registers by Female health workers is observed to be time and energy consuming task and resulted in inadequate attention to drop out and left out beneficiaries for timely scheduled healthcare Service delivery, specifically service approach to migratory groups developed great difficulty. The improper reporting system where focus was more on number based area report resulted with no attention given to individuals, here, e-Mamta brought digitalized paperless reporting system and it provided the detailed schedule of beneficiaries to be targeted – name wise which further facilitates concentration on individual beneficiary and determines the left outs of service delivery during a certain period of time. Also, it aids in analysing the historical data to establish trends in policy making and planning process in public health system. e-Mamta has brought the concept of real time data entry of services provided to Beneficiaries which has helped the Medical officers to review the service coverage in their respective PHC areas and also monitor the performance of grassroot level health workers along with service utility trend among the targeted and vulnerable population. Similarly , the district and state office reviews the health program performance to monitor the important health indicators through e-Mamta database.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
e-Mamta is based on Principle of Name based tracking which ensures each family, pregnant woman and children are provided a unique identity number for tracking of essential RCH services. • 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. Following workplans are prepared: Work Plans for New registration, Ante Natal Care Delivery, Post Natal Care, Newborn care, Child services, Adolescents, Anemia, Family Planning services, Malnutrition, Institutional Delivery, Family planning services etc. Due to these beneficiary tracking has become more effective including tracking of migrant population. • Use of SMS Technology for Tracking beneficiaries: Customized vernacular language SMS and voice call jingles are sent as per predefined schedule to beneficiary and service providers from e-Mamta according to their due dates of services, which is a IEC based new paradigm in healthcare sector. SMS technology bridges communication gap between beneficiaries & service providers caused due to migration and disperse scattered population

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
e-Mamta is introduced in Gujarat by the collaborated efforts of the Health and Family Welfare Department of Government of Gujarat with technical support of National Informatics Centre (NIC) Gujarat team. The Government of India has appreciated the initiative of e-Mamta and announced Nation wide replication of the software as a step towards overall improvement in the public health of the entire country. e-Mamta database caters to more than 95% of entire Gujarat population focused on targeted segments of 14,52000 Pregnant women, 13,21000 Deliveries and 13,21000 Newborns across the state to provide effective and timely service delivery care. Beneficiary Coverage in e-Mamta • Families entered: 1.40 crores • Members entered: 6.18 Crores (More than 95% of Gujarat’s Population) Service Registered in Year 2015-16 • No. of PW reg. during the year (No. /% against Est.): 13, 25,224 (91.29%) • No. of Early ANC out of reg. PW (No. /% against reg.PW): 6, 83,000 (51.54%) • No. of Identification of High Risk PW: 1,49,328 (20 % ) • Identification of Eligible Couples: 69,93,433 • No. of Institutional Delivery (No./% against total delivery): 11, 73,103 (98.5%) • Total Children reg. (0-1 year) (No. / % against Est.): 12, 28,889 (93.03%) • BCG given: 11, 58,687(98.4%) • DPT-3/Penta-3: 11, 23, 723(95.4%) • Measles Dose: 10, 93,998(92.9%) • Fully immunized children: 10, 89,848(92.6%) • 0-5 years age group children screened across the state by FHW during Kuposhan Mukt Gujarat Mahaabhiyan to identify SAM child: 43,14,134
 6. How was the strategy implemented and what resources were mobilized?
• The e-Mamta system has passed on various critical benefits to the citizens of Gujarat. Through its ‘Complete Lifecycle Approach’, the system records the data from birth to death of an individual and addresses the gaps in ensuring comprehensive Maternal and child health services in rural as well as urban areas. It incorporates the concept of work plans at grass root level for clear understanding of targeted beneficiaries. The provision of Unique IDs (UID) to individuals has resolved the issues like migration / transfer in service delivery and duplication of registration of mothers. The system records every individual as one single unit, ruling out the possibilities of excluding even one person. • Rural health challenges such as high dropout rates, high left out rates, quality of services, inability to track beneficiary pregnant women and children leading to high MMR & IMR are targeted through e-Mamta. e-Mamta is accessed through user id and password for government department employees. • The state government has provided a computer with internet connectivity to each of its Primary Health Centres (PHC). The software for online tracking of mother and child has been developed by the National Informatics Centre (NIC) in consultation with the Ministry of Health & Family Welfare and State of Gujarat’s Family Welfare Division. The PHC is a referral unit for six sub centres consisting of 4 to 6 beds with a medical officer in charge and about 14 subordinate paramedical staff (7). The local health workers 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/children are then tracked through Work plans and followed for the outcomes mentioned below. 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. The information obtained and services provided during this day are as listed below: • Pregnant Females: o Antenatal Registration of Pregnancy o Measurement of weight, blood pressure and hemoglobin o Tetanus Toxoid Vaccination o Supplementation of Iron/Folic Acid/Calcium o Education and Counseling regarding childbirth and importance of institutional deliveries o Identification of high risk pregnancies and referral to tertiary centers for management • Children: o Vaccination Status o Monitoring of Growth o Vitamin A and Calcium Supplementation o Provide requisite nutritional supplementation • Lactating Females: Counselling regarding importance of breast feeding and methods of contraception and family planning The software will assess the gap for requisite service of individual beneficiary. If this service is not delivered, system immediately indicates this and a health worker is informed to correct the shortcoming. The year wise growth of eMamta is as enlisted below: • Jan 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 by GOI • August 2010: Training to state Nodal officers & State data entry Managers in four batches of all the states of India at Delhi & Gandhinagar. • December 2013: Presentation in Strengthening Civil Registration & Vital Statistics Systems Through Innovative Approaches In The Health Sector, Technical Meeting, Geneva, December 17-18 2013 Organised By The WHO In Collaboration With Canada, Unicef, USAID And The World Bank • Jan 2013 to Present status: Various modules of New programmes launched by GOI as per RMNCH+A guidelines has been in continuous development process to develop data entry screen, Workplans and Report modules • Aug-Sept 2016: Baseline data developed for identified Eligible couples

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
State Health officials • Conceptualization and Implementation across the state, facilitated National Roll out Upgradation of various modules in alignment to Newer National guidelines • Develop database modules as per State’s priorities and campaigns launched • Impart training to District officials • Resolve technical queries of Districts incoordination with NIC team • Conduct the reviews of District’s performance and identify the Gaps • Coordinate with MCTS team based at Government of India for updation of e-Mamta data in central server. • Technical support of other UN agency such as UNICEF for upgradation of Nutrition module in e-Mamta. State National Informatics Centre Officials • Technical development of Web based software application • Training to Government of India’s NIC team for national roll out of the software District Level Officials • Overall implementation of program across District • Solve issues: HR, Technical and Other as per guidance of the state • Training and guidance to Taluka and PHC • Timely feedback to state for improvement, Data monitoring & review, cross verification/Validation Block Level Health Officers • Ensure avaibility of network connection, hardware, operator for data entry • Ensure correct facility mapping in e-Mamta • Performance review PHC wise • Ensure updated information/Cross Verification Medical Officers/FHS • Family Health Survey: Ensure completeness and verification every year • Registration: Ensure completeness for ANC and Child services • Coordination between staff for data entry and workplan content • Validation/Verification: e-Mamta Vs HMIS • Migration: Updated information of services data entry • Performance review: Subcentrewise • Ensure updated information • Cross verification of sample Data Entry operators • Timely completion of correct data entry from Workplans • Generate Workplans and provide to Female Health Workers Female Health Worker (FHW) • Family Health Survey Updation/Verification every year • Work plan receive in timely manner and submit duly filled • Record: e-Mamta generated unique ID to be noted in RCH register and Mamta Card • Provide e-Mamta generated ID to beneficiaries • Counselling to keep Mamta Card and ID when attended facilities

 8. What were the most successful outputs and why was the initiative effective?
1. Identifies high risk pregnant females for timely service delivery and increases the number of deliveries occurring under the guidance of appropriately trained individuals, both in institutions and the community along with stringent monitoring of pregnancy outcomes assists in preventing adverse conditions along with distribution of vaccines based off the database to PHCs serving the most unvaccinated population to take advantage of economies of scale 2. Eligible couples for family planning services improves access and provision of basket of family planning services 3. Detailed Nutrition module provides opportunity for real time identification and management of Severe Acute malnutrition children and appropriate treatment facilitation 4. Instantaneous deployment of personnel based upon unmet needs leads to a more effective use of existing workforce and rapid correction of any service shortcoming as indicated by the computer generated report. 5. Improved data analysis to create improved Block/District health action plans based on accurate denominators in addition to Information which can be readily accessed through any remote location and transferred rapidly.

 9. What were the main obstacles encountered and how were they overcome?
• Need of orientation/Training to implement e-Mamta application: Orientation/Training was arranged at all level: District/other state Official’s training conducted at State office, Taluka level health officers along with PHC/UHC Medical officer’s training conducted at District office, Health facility based Data entry operators and field level health worker’s orientation was conducted at PHCs/UHCs. Gujarati and English language Guidelines developed and uploaded online • Vacancy of Human Resource and unavailable Logistics:Ensured the HR at all level through regular recruitment and monitored/reviewed the supply of logistics • Data (Collection, Data entry): Workplan generation: Work plan is conceptualized to process the available online registered data to generate & provide denominators that determine the entire gamut of beneficiaries and provides the detailed service schedule to be targeted – name wise. This further facilitates concentration on individual beneficiaries and determining the left outs of service delivery during a certain period of time. Work plans are generated village wise assumed on Mondays at PHC/UHC level and handed to ANMs so that beneficiaries are tracked in advance by ASHAs prior to Mamta session planned on Wednesdays. Direct data entry from workplan is facilitated for ease of DEOs to understand the indicators and search beneficiaries. • Poor data entry Issue: Regular review at all level : State/District/Taluka/Health facility • Verification/Validation of data Issue: Family Health Survey verification conducted annual basis • Duplication of Data Issue: Report for duplicate data, entry generated and verified. SEARCH module is developed to track any registered beneficiary on basis of parameters such as Aadhar UID, Ration card no, BPL no, DOB, Name, Village location, Health id. Helpdesk callcentre to answer queries related to health id search in online database • Technical issues: Helpdesk at State level to solve queries in coordination with NIC team under support of Demography & Evaluation team • Communication Issue: Regular feedback from field through email and improvement

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Improved Service Delivery: This program is novel in its approach to reduce MMR/IMR as it uses technology and broadband connectivity to organize for detailed organization and rapid dissemination of healthcare information. It has tremendous potential to revolutionize healthcare of pregnant women and children residing in impoverished settings in a relatively cost-effective manner. • Complete service delivery of essential RCH services: 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 service provider and auto SMS for due services to pregnant woman and families of children, besides analytical reports, computerized Hb./weight chart, immunization cards. • Service Impact & tracking: Coverage of 13, 25,224 (91.29%) Pregnant Women, 12, 28,889 (93.03%) Children (0-1 years age group), 11,73000 (98.5%) Institutional Delivery recorded and 10, 89,848 (92.6%) of Full immunization for year 2015-16 Permutation and combination of data available on SEARCH module in e-Mamta of Family Health Survey module which serves as important base for various program implementation, example adolescent married out of school girls- village wise, name of infants non-immunized for measles/polio round-village wise etc. Effective Use of Data for Decision making and Service provision Potiential Benefits:  Alerts appropriate health authorities to be activated to care for pregnant females optimizing delivery of fetus and timely service tracking of High risk pregnant females  Information can be readily accessed through any remote location and transferred rapidly.  Improved data analysis to create improved Block/District health action plans based on accurate denominators. IMR of Gujarat has come down to 35/1000 (SRS 2014) live births from 48/1000 live births (SRS 2009). Rate of decline has further increased in last three years at average decline of 7.5% per year, one among the highest in the Country. Gujarat’s MMR has reduced from 148 in the year 2007-09 to 112 in year 2011-13 (SRS), registering 26 points decline. Rate of decline has drastically accelerated to 8.6% annual decline, which is 2 ½ time faster decline compared to previous estimate. Reducing physical reporting & increase efficiency: Time saved is resources saved. e-Mamta through implication of IT has cut on time used in compilation of reports from subcentre to block to district to state. The time of health staff particularly FHW used in manual reporting is saved. Accurate, Self Generated , Valid reports: HMIS forms, Growth chart, Immunization records, HB & Weight chart, Maternal & Child health registers Before e-Mamta: Manually compiled (4-5 days), errors of duplication, time consuming, non accurate & operationally difficult to store & maintain hard copies After e-Mamta: Instantaneous, accurate & easy to operate

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
• Accountability in health service delivery enhances through real time service delivery monitoring. Due to online system, real time continuous evaluation right from Subcentre to State/district level is possible. Real time monitoring of incentive and validating service delivery performance through stocks of medicines and supplies distributed reflects improved integrity in public health service. • The online system generated unique Health IDs, which have been provided to individual Pregnant mothers, individual children within the age group 0-6 years and adolescents, this assures that complete services of Ante Natal Care, Child birth, Post Natal Care, Immunization, Nutrition and adolescent services are extended to target segment and resolves the issues like migration / transfer in service delivery and duplication of registration of mothers. The system records every individual as one single unit, ruling out the possibilities of excluding even one person. • The comprehensive Work Plans are versatile tools to the service providers at the grass root level to determine the latent recipients of the services along with their details. It becomes the mandatory task for FHW to locate the recipient for timely service provision. • Through e-Mamta, accurate reports to review provided service performance (State/District to village level) and various analysis are segregated for further increasing the efficiency and utility for optimal public welfare through reports, health cards, nutrition chart, immunization cards, pregnant woman Hb/wt chart and graphical analysis of various indicators. • e-Mamta application is implemented in four steps namely Family Health Survey, Pregnant women and Child registration, Workplans to track due beneficiaries, Service deliver and tracking of left outs/dropouts. Workplans shows detailed schedule of DUE RCH/other health service which is prepared for each grass root level workers. Use of workplans ensures that Maternal and Child health service reaches each pregnant woman and children in time, which in turn is critical in reduction of Infant and maternal mortality. The system also enables member SEARCH of beneficiary on several parameters like name, name of village, ration card number, mobile number, health ID, family ID, Bank account details, Rashtriya Swasthaya Bima Yojna card number, Below Poverty Line card number and Aadhar number to track the recipient and provide complete services.

 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)
To witness the significant reduction in the quantum of maternal and child deaths, Gujarat state has developed individual mother and child based service tracking application tool named ‘e-Mamta’ which bridges the gap for grassroot level health workers in relocating and identifying the Pregnant women and newborns for providing RMNCH services based on lifecycle approach. Rural health challenges such as high dropout rates, high left out rates, quality of services and inability to track pregnant women and children leading to high MMR & IMR are well targeted through e-Mamta. o The impact and attainment of the ‘e-Mamta’ inventiveness has been significant which accelerates the process of effective and efficient delivery of health services to the grass roots. o Institutional delivery rate in the state has been increase from 77.8 in 2007-08 to 98.5 % in 2015-16 o IMR in the state decreased from 50 in 2008 to 35 in 2014 (As per SRS) per 1000 live births o MMR of the state decreased from 148 (2007-09) to 112 in 2011-13 (As per SRS) per one lakh live births o In the improvement of IMR, MMR and Institutional Deliveries rate in the state, e-Mamta had played critical role through tracking of Services

Contact Information

Institution Name:   Health and Family Welfare Department, Government of Gujarat
Institution Type:   Government Department  
Contact Person:   Dr.Prakash Vaghela
Title:   Additional Director-Family Welfare  
Telephone/ Fax:   00917923253211
Institution's / Project's Website:  
E-mail:   addir.health.fw@gmail.com  
Address:   Commissionerate of Health, Block 5/2, Dr.Jivraj Mehta Bhavan, Gandhinagar , Gujarat
Postal Code:   382011
City:   Gandhinagar
State/Province:   Gujarat

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