The Village Health Sanitation and Nutrition Day (VHSND) is an intervention under the National Health Mission that attempts to improve access to a broad gamut of information and services related to health, nutrition, and sanitation. Organised once a month in each village with the Anganwadi Centre (AWC) acting as a hub, the District Administration brings together health personnel and village residents for the dissemination of information and services. The frontline workers such as Anganwadi workers, Accredited Social Health Activist (ASHA) workers, Panchayat Representatives, and Auxiliary Nurse Midwives (ANM) provide critical information and services with an aim to bring “ dramatic changes in the way that people perceive health and health care practices”.
In Bokaro, Jharkhand, one of India’s largest industrial districts, the District Administration was assisted by Aspirational District Fellows, Aditya Arun and Aaditya Mohan, in identifying and overcoming challenges faced in implementing VHSND.
Identifying an Intervention:
Upon a careful review of the program, it was found that two broad challenges exist. First, ANMs have a large volume of work. In addition to their multifaceted and broad role , it was found that ANMs also have to assist with surveys, upcoming COVID-19 vaccination drives, and other allied programmes. These additional responsibilities add to their work-volume, and eventually lead to missed targets and duplication of efforts.
Second, there exists a need for monitoring mechanisms and a robust reporting system to minimise errors. The District Officials overseeing health schemes and programs do not have a mechanism to monitor VHSNDs in near real-time. This results in an inability to view whether the targets set for the frontline workers are being met until the biannual review at the District Level. Not only does this cause delays and elongate processes, but also results in missed immunisations, which can be detrimental to the health of women and children.
Based on the two challenges which result in delayed implementation of programmes, gaps in data collection and assessment of programs, and prevent effective identification of implementation challenges due to an inability to review the programme on a near real-time basis, it was imperative to establish a unified technological solution. The existing pen-paper model created inefficiencies and delays, making it difficult to address the challenges with accuracy.
The e-ANM Application:
To overcome the challenges identified above, the e-ANM Application was created. The application functions through two platforms. First, where the ANMs can access a list of pregnant women, infants, and a platform to register both. Second, where the District Health Officials can access information about ANMs, details of their visits to intended beneficiaries, ANM attendance status, data on vaccination efforts, and a list of monetary dues in each VHSND site of the district.
Expected Impact of the Intervention:
Though the intervention is in an advanced stage of development, four broad impacts are anticipated after implementation. First, digitising records will help ANMs in the VHSND process by allowing them to keep track of their goals, accurately target women and children using the online registers, and meet the goals which have been missed. Second, effective migration of the reporting mechanism for VHSND services online. This will enable near real-time performance reports, which will be easily accessible to health officials at the District level, thus ensuring accountability of the ANM and the ability to make quick course corrections when required. Third, it will enable a culture of data-driven problem identification and focused interventions to increase efficiency and impact. Fourth, it will ultimately improve the various services provided at VHSND such as immunisation, linking benefits to beneficiaries, and providing nutritional information to beneficiaries.
Processes of Intervention:
In designing this intervention, a ten step process was followed by the Aspirational District Fellows to assist the Office of the District Deputy Commissioner (DC).
- Leveraging the experience of District Health Officials to assess and identify the challenges faced in implementing VHSND and the difficulties in monitoring the work of ANMs on a near real-time basis.>
- Randomised field visits to VHSND sites, to assess the processes in place to conduct the program.
- Garnering the opinions and views of ANMs for a holistic understanding of the challenges they face. It was found that their additional responsibilities prevent them from meeting targets.
iv) Post information collection, the findings were deliberated with the Office of the District Deputy Commissioner and relevant health officials.
- In the process of deliberation, the inadequacy of the existing pen-paper model was discussed, and it was decided that a technological solution would be ideal.
- On finalisation of the intervention, relevant approvals and authorisations were sought from the Deputy Commissioner.
- A Vendor was engaged to develop the software. The Vendor was chosen based on the price offered to develop the software and train Master Trainers.
- The Vendor was sensitised by the Aspirational District Fellows and District Data Managers on the context of the VHSND program and challenges faced.
- Regular meetings and feedback sessions were held with the Vendor to ensure an effective solution.
- There are some steps yet to be taken prior to roll-out such as: Establishing a training module (which is undertaken by the Vendor), and conducting training sessions.
The District Administration announced the intervention on January 26th, 2021, and seeks to finish the training module by February 15th, 2021.
Two types of resources are required to establish such a unified technological solution.
- A monetary fund to develop the software, train persons in using it, and recurring costs for software maintenance.
- Human resources in the form of technical inputs from health department officials, including on-field ANMs, and software developing agencies.
Given that the amount required was below Rs.1,50,000, a tender was not necessary. After reviewing the quotes received, the District Administration chose a local vendor for software development and training. The initial costs amount to Rs.1,45,000, and beginning next year (2022), it will attract a recurring cost of Rs. 24,000 per annum. The amount includes the costs needed by the vendor to train Master Trainers (District and Block Data Managers) at the District level, who in turn will train the 150 ANMs in Blocks.