Civil Society Magazine

At 18, Sonam Purti is a very young mother in the village of Bundu. Her baby girl is just a few months old and she is full of apprehensions. With every day of motherhood come challenges big and small. Not only does she have to overcome the rigours of childbirth and the changes in her body, but she also has to get used to meeting her baby’s needs.

Sonam had a serious scare in the first week after the delivery in December. The baby stopped suckling and her temperature dropped. In infants, these symptoms can be deadly. Immediate interventions are needed, but for mothers like Sonam in remote villages trained medical help is hard to find. The result is that each year in rural India a large number of infants die in the first few weeks after they are born for want of institutional care and timely interventions.

Sonam, however, was plain lucky that Priyanka Purti was on call. Priyanka could be just about any other woman in the villages of Jharkhand, but with this difference – she has been specially taught to identify and deal with the signs of ill health in a newborn.

Priyanka was quick to recognize what was happening to Sonam’s baby and did the few simple things needed like keeping the baby warm in a wrap and feeding her breastmilk from a bowl a little at a time. Very soon the baby was back to normal.

Priyanka is called a Sahiya in her village and she is part of the state of Jharkhand’s rural healthcare outreach. The interventions she used to save Sonam’s baby were learnt in two and a half years of training and intensive guidance under a project called MANSI or Maternal and Newborn Survival Initiative.

MANSI is the creation of Tata Steel, the American India Foundation (AIF) and SEARCH. The iconic Dr Abhay Bang and his wife, Rani, are the founders of SEARCH, which stands for Society for Education, Action and Research in Community Health and is located in Gadchiroli in Maharashtra.

In 2009 the three organisations came together for MANSI to strengthen the National Rural Health Mission (NRHM) in Jharkhand. It was decided that they would work with the Jharkhand government for four years till the end of 2013.

The idea was to design and implement management systems and training methods for improving home-based maternal and neonatal healthcare.

The Seraikela block, in the Seraikela Kharsawan district of Jharkhand, was chosen because it is one of the most backward in the country. Reducing infant and maternal mortality rates here would mean confronting the most difficult of challenges.

The Sahiya was crucial to this initiative. By keeping track of women through their pregnancies, the Sahiya could get them to hospital in time for deliveries.

Most newborn deaths happen in the first 28 days. Taking care of the mother and child during this period is the key to having better public health indicators. While Sahiya is the name used in Jharkhand, elsewhere in India under NRHM the woman performing this function is called an Asha.

There were four clear objectives for MANSI: To increase the knowledge and skills of Sahiyas and make them effective; to encourage the community to own and sustain public health initiatives; to increase access to healthcare providers; to influence state-level policy and take best practices under MANSI to other blocks.

MANSI will come to an end in November 2013 and the turbo-charged block-level system in Seraikela is to be handed over to the government once again. But so significant are the successes that MANSI is being seen as a model for driving up the efficiency of rural healthcare delivery across Jharkhand and perhaps the rest of India.

Infant and maternal mortality rates at the block level are not easily available. But information collected by the MANSI team for six months from July in 2010 showed 24 infant deaths in 390 live births. In 2012, from January to December these figures were 63 infant deaths in 1,594 live births.

Similarly, for maternal mortality there were two deaths in 390 live births over six months in 2010 and six deaths in 1,594 live births from January to December in 2012.

These figures are crude, but they indicate that much has been achieved in two years under MANSI – especially if the figures are read in the context of the efforts made on the ground in training people and spreading awareness.

Some 200 Sahiyas have been trained in 167 villages of the Seraikela block. The record of their interventions shows that they have been effective. They feel empowered and purposeful because they are embedded in structured field efforts.

Sahiyas keep track of women from the time they become pregnant. A ready reckoner helps them calculate the date of delivery. It is the Sahiya’s job to ensure that the woman eats well and stays healthy.

The Sahiya  prepares a woman and her family for a delivery in hospital. In the final hours as the woman goes into labour, it is she who calls the Mamata Van, an emergency vehicle, to take the woman to the hospital.

These days the Sahiya is allowed to go into the operation theatre for the delivery. It is a significant concession which raises the status of the Sahiya.

A Sahiya has been taught how to take care of premature babies whose weight is low. She can manage asphyxia and hypothermia. She knows to identify infections like sepsis. She provides treatment for diarrhoea and moves an infant to a doctor quickly in cases of pneumonia.

An important innovation under MANSI has been to give a kit to the Sahiya. The kit consists of a thermometer, weighing scale, mucous extractor, watch, warm wrap, blanket, flipcharts for nutrition and health education, checklists to record the health status of the child, Tetracycline eye ointment, Gentian Violet paint, soap and so on.

The government has also agreed to allow the Sahiya to administer cotrimoxazole syrup, which is used as a first line of treatment for sepsis and pneumonia.

Jharkhand is rich in minerals, but its social infrastructure is that of a very poor state. Its health indicators are among the worst in India. For instance its infant mortality rate is 42 per thousand live births and, assuming lapses in reporting, the figure would be higher. In the Seraikela Kharsawan district the infant mortality rate is 60.

Under MANSI the priority has been to work with the government and not override it. Many months were initially invested in convincing officials that the government would continue to have ownership of the healthcare system.

If MANSI could be successful within the limited geography of the Seraikela block with a population of 80,000, there was the prospect of it being tried elsewhere and scaled up. Only the government would be able to do this and so replacing it was never an option.

In fact, much effort has been made under MANSI to secure buy-ins from state officials, local government institutions and the community at every level. For healthcare programmes to be effective in the long term they have to involve people.

The project is unique because it has succeeded in building up and empowering the Sahiya as the first person the woman turns to for maternal and infant care services. The Sahiya will continue to remain within the community even after the project ends.

A functioning structure now exists in the Seraikela block. It looks like this: Sahiya, Sahiya Saathi, Maternal and Neonatal Health Mobiliser, Zonal Coordinator and Field Coordinator.

There are 14 Sahiya Saathis to oversee the work of the 200 Sahiyas. Then there are 22 Maternal and Neonatal Health Mobilisers (MNHMs) who handhold the Sahiyas in the field to ensure structured home visits, schedules, case management and maintenance of village-level records. The MNHMs ensure supplies and provide logistical support. There are also four zones with a coordinator each for roughly 38 villages. The coordinators keep the Sahiyas trained and up to date.

There are review meetings. Records are regularly maintained and checked at various stages. But at the same time MANSI has shown that the strength of a rural healthcare network is in the activities that take place at field level. A Sahiya is effective because she is next door. MNHMs, Sahiya Saathis and zone coordinators also work close to the ground so that they can spot problems even as they emerge.

Track is kept of women from before the time they become pregnant till 42 days after the time they deliver. What this means is that the health of the woman is taken care of during pregnancy, an institutional delivery is almost ensured and the infant and mother are closely monitored during the crucial month after the delivery.

In the case of Sonam, she had malaria during her pregnancy. If she hadn’t been at her mother’s home in Seraikela, her story might have been very different. Once again the problems her baby experienced received timely attention because Priyanka, as Sahiya, was present to attend on her.

Sonam’s mother, Laxmi, never knew such attention. She had eight children who were all born at home. Sonam is her eldest. Asked what she would have done to save Sonam’s baby in the past, Laxmi, says: “We would have used local herbs and medicinal plants. We would have prayed and gone to the witch doctor.”

Priyanka was chosen to be a Sahiya in 2008, two years before the MANSI initiative began. Ask her what difference MANSI has made and she says it is the training. Earlier she did receive training at the primary health centre. But under MANSI the training has been more rigorous.

“It is the systems, the knowledge about the newborn’s illnesses. We have also been given a kit with a thermometer and weighing machine. The warm wrap and blanket. The kit is very important,” she says.

Priyanka has clear leadership qualities. She is every bit a purposeful woman. She has two boys of her own.

Her name and mobile number are painted on huts in the village. A sketch of the Mamata Van is alongside together with a mobile number on which it can be summoned.

“We have charts with which we track women from the time they become pregnant. We educate them about the importance of having the delivery at the district hospital. I tell them to call me on my mobile at the onset of labour pains,” says Priyanka.

Asked how long the Mamata Van takes to arrive to take a woman to hospital, Priyanka says: “It comes in minutes. It is just a question of dialling the number.”

A call centre at the Seraikela District Hospital takes these calls. Two Sahiyas are on duty round the clock at a help desk at the hospital. The Sahiyas know the doctors and other hospital staff so when a woman turns up for a delivery she is readily admitted and the needful is done quickly.

The hospital is markedly clean and well administered. Dr Priya Ranjan, a paediatrician long in government service, is at the helm. A man of few words, he says: “ Where we find dirt we clean up.”

Basic blood tests, X-rays and ultrasounds are conducted at the hospital. As happens in rural health facilities run by the government, posts sometimes lie vacant. Doctors are transferred but replacements don’t arrive on time.

Despite such problems, women come to the hospital during their pregnancies and for their deliveries. The number of institutional births has risen sharply in Seraikela after MANSI.

At the village of Chorok Pathor, it is 12 days since Sumita Mardih returned home from the district hospital with her baby boy.

Sumitra Soren is the Sahiya who has been handling her case from when her pregnancy began.

“She would visit me from time to time to check on my health. She would caution me against doing hard manual work in the fields or from going into the forest to collect firewood,” says Sumita.

“She told me the importance of having the baby in hospital and prepared me for it. When the time came, it was late at night. We called her on her mobile phone and told her the pains had started. She summoned the Mamata Van. At the hospital there were doctors who took over and the baby was born,” Sumita says shyly, her words barely audible.

Over the 12 days that Sumita and the baby have been back home, Sumitra has come by thrice to check them out. These early days after the delivery are crucial for the mother and child.

Sumitra brings her Sahiya’s kit along for these check-ups and on this occasion we get to witness the drill.

First of all a Sahiya washes her hands thoroughly with soap all the way to elbow before touching the baby. She does not use a towel and instead holds up her hands till they are dry.

After this she examines the baby. She has been taught that a bloated stomach or a sunken chest are signs that the child is not well and needs to see a doctor. She checks for eruptions and rashes. She takes the baby’s temperature with a digital thermometer. She also weighs the baby using a handheld scale.

Sumitra has a checklist of questions she must go through when she visits Sumita. For instance, how many meals does Sumita have in a day? Does the baby cry a lot and pass urine less then six times in a day? How many times in a day does Sumita breastfeed the baby? Is the baby wrapped up and kept warm and does Sumita hold the baby close to her?

These and other questions provide telling information on the health of mother and child. All the information is recorded on worksheets where current findings can be compared with those from previous visits.

Since reviews are regular, if a Sahiya has been negligent it will show up. If she has overlooked warning signs, others in the system will notice.

A Sahiya addresses the needs of a single village. A Sahiya Saathi supervises all the Sahiyas under a panchayat.

The government selected Bharati Mandal to be a Sahiya in 2006. Then came MANSI in 2009 and somewhere in 2010 she was chosen to be a Sahiya Saathi.

Bharati has seen the NRHM at work before MANSI and after. She says there is a world of difference.

“Earlier we saw ourselves in a clerical role – taking down information, telling the women they must go to hospital and so on,” she explains. “But under MANSI we feel that we are part of a healthcare system and can save the life of a child. It is a big thing. After this training we have a sense of responsibility. After all someone’s life is in our hands.”

A Sahiya Saathi gets Rs 1,500 a month for 15 days work. Bharati says she knows what is expected of her. For seven days in a month she visits homes. Six days are spent in gram sabha or village level meetings to discuss health and cleanliness. One day is for a block level meeting and one day for a cluster meeting with seven Sahiyas representing seven villages. The cluster meetings discuss the problems the Sahiyas may be facing. The talk is about expecting mothers and the condition of newborns. If there are deaths they are discussed in an attempt to understand and record the reasons.

MANSI’s success has been in engendering aspirations and delivering empowerment. It succeeds in giving women in a village a sense of importance they have long been denied. Expecting mothers, who are visited by Sahiyas and know they can go to hospital for their deliveries, have never had so much attention or felt so good about themselves.

The Sahiyas, too, have a status they never dreamed of. They get very little money, but their names and mobile numbers are up on village walls.

“People look up to us. They give us respect. It feels good to know that we make a difference,” says Priyanka. She is eloquent and self-assured ­– a thin, matured woman who likes what she is doing because it gives her a sense of purpose. She is brisk and businesslike in the way she puts out two plastic chairs at her homestead. When she talks, it is one to one.

Sumitra is less articulate. She is camera shy. She doesn’t know what to say into a microphone. But she likes being a Sahiya because it gives her a position.

Sahiyas earn just Rs 350 per delivery. It adds up to very little. Sahiya Saathis get an assured Rs 1,500 a month. A Sahiya can aspire to be a Sahiya Saathi, but money is evidently not the motivating factor here.

These are women who have experienced a change of status under MANSI. They can save lives because they have acquired knowledge and skills through formal training. A Sahiya basks in her newfound identity. She is no longer just a housewife in the village.

Sahiyas have been going to training camps which keep them away from home for four or five days a stretch. They had never enjoyed such freedom before. It took a lot of persuasion to get their in-laws and husbands to allow them to go.

“Money is not everything, “ says Bharati. “It is the sense of achievement. The satisfaction of being able to save a life is much bigger than money.”

THE PROJECT: AIF was looking for a partner for a project in maternal and neonatal care. It chose Tata Steel because of the company’s involvement in social programmes. The district of Seraikela Kharsawan falls in the hinterland of Jamshedpur where Tata Steel was founded.

Says Anupam Sarkar, AIF’s project advisor: “Our partnership with Tata Steel has been very successful and we have gone about it very purposefully. Tata is very highly regarded in the community, not just in health care but in livelihoods and education as well.”

“We had a partnership with SEARCH to bring in technology and skill, but we wanted a partner who would actually deliver. So looking at the strength of the organisation and its values, we thought it would be best to do a pilot project with Tata Steel and then look at its replication.”

Says Dr P. Mohapatra, a paediatrician and a veteran of social initiatives at Tata Steel, “When they came to us with the idea, we thought, in terms of the millennium development goals, this was the perfect project for showcasing Tata Steel’s contribution to public health care which has been taking place over the past 100 years.”

“We had already been making some of the interventions AIF wanted, but by focusing on a community in the context of a project we would be able to show the impact much better,” says Dr Mohapatra.

An important feature of MANSI has been the partnership between a company, the government and the voluntary sector. Each has had its own strengths.

Dr Mohapatra sums its up when he says: “ If you want to produce sustainable results within a timeframe you have to work with the government and the community. There is no alternative. Knowledge has to be passed on to the community and it is important to draw on the vast infrastructure of the government.”

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