Making it sustainable: Investing in developing skilled maternal health women entrepreneurs.

Background

The idea is to deliver the maternal health care in an innovative and holistic manner which is sustainable. The Drishtee's Maternal Health care project in Guwahati started with the main aim of reducing the incidence of maternal mortality by educating community about the causes of maternal mortality and to meet the demand created by facilitating access to maternal health care services. The uniqueness of the model lies in the fact that the flagholders of project are the Drishtee trained women health entrepreneurs, unlike incentive based health workers in most of the community based health projects or interventions.

Why do we require a better maternal health intervention?

Efforts are being made globally for the improvement of maternal health as a part of the Millennium Development Goal 5. These ongoing efforts have surely made us informed about the state of maternal health all over the world and the challenges faced by various maternal health interventions. There is no doubt that the improved maternal and new born health can only be achieved by delivering the essential services at the critical times and in the key locations in such a manner that they can be easily accessed by the women.

We have clear goals, transparent data and defined requirements. And at this point of time, when we all stand only five years away from the expected achievement of the the millennium development goals, world calls for concerted actions that are truly effective, practical, equitable and sustainable. In simpler words, we all need a template for sustainable delivery of maternal health for the under privileged sections of the community.

The government led maternal health-care programs are based on performance based incentives for the health workers which require massive funds to sustain the program over a longer period. And, the major challenge is the high dependency of donor funding to sustain the program. Moreover, the required financial resources might not be affordable by every country. Secondly, the health workers are seen to loose motivation to maintain the quality of the services after sometime. The perceived reason is the lack of ownership towards the services and often start malpractices as their focus lies on the incentives.

Either the services are free or incentives are given to the pregnant women. For example a pregnant woman delivering at a healthcare institute will receive certain incentive for the institutional delivery. This can prove to be a negative reinforcement of the character as the pregnant females are delivering at the institute for the incentives. The proposed system should incorporate the necessary behavioral changes in the service user and the service provider establishing a programmatic dynamics between the both.

How the model works?

Drishtee is a social enterprise which works towards creating an impact on rural lives by building an eco-system of Drishtee trained women entrepreneurs. Drishtee's health model engages and trains women health entrepreneurs to work in a cluster of villages on defined routes based on predefined criteria. The selection is done carefully in the regions where the government facilities are absent or non-functional to avoid duplication.

In addition to basic maternal care, these women are also trained by Drishtee for non-invasive diagnostic and pathological tests (BP, Glucose estimation, pregnancy test and temperature). These Drishtee Health Franchisee (DHF) are owners of the Drishtee Health Kiosk (DHK) and owns all the maternal services.

The DHK is equipped with the digital thermometer, blood pressure monitor, digital blood glucose monitor, weighing scales, pregnancy test strips, etc. The amount to set-up a DHK is financed by Drishtee and is re- paid by the DHF in the form of easy monthly installments (EMI).

At the backend, this health franchisee is linked with a qualified Auxiliary Nurse Midwife (ANM), with an estimated ratio of 1:10 of ANM to DHF. Drishtee selects the ANM, partner and link them to the DHF. Similarly a gynecologist is also linked to the DHFs. Gynecologist holds a maternal health camp once in a month at the particular kiosk to screen the complicated pregnancy and refer them for timely management at the health care facility. A schedule is set for the visits of the ANM and gynecologist at various kiosk. For the rest of the month both ANM and gynecologist are available for the tele phonic consultations.

The pregnant women are charged a small and reasonable user fee for the registration. The ANM, gynecologist, Drishtee and the DHF share the revenue generated by the registration of the pregnant females. The higher involvement and the motivation of the DHF towards the maternal services positively impacts her revenue. As she experiences higher revenue from the services the motivation level and involvement are boosted. This ensure quality and regular services available to the pregnant women in the community.

Ironically, the pregnant women who were registered on the program by paying a reasonable amount of the user fee demonstrated higher level of ownership towards the maternal check-ups and services. A small amount paid by the females made them more responsible in attending the ANC clinics at the scheduled time.

DHF works as a community mobilizer and contact point for the pregnant females to avail maternal care. Her role and responsibilities can be summarized as follows:

1)Registration of the pregnant women in the region and maintain the maternal record of the women.
2)Hold community meetings and women discussions for educating the villagers about the need of maternal care and its role in preventing maternal deaths
3)Educate the pregnant females and their families about the maternal care, birth preparedness, complication readiness, institutional delivery, hygiene, nutrition and breast feeding. She also informs about the benefits under government schemes and methods to avail them.
4)Hold once weekly ANC clinic at DHK with the support of ANM. Ensure that pregnant women attends the check-up.
5)Track the drop out cases and counsel them and their families about the need for timely check-up.
6)Hold once monthly gynecologist check-up at DHK and to ensure all the pregnant women are screened for complication of pregnancy.
7)Interacting with pregnant women to ensure that the advise or treatment is followed for example Iron Folic Acid tablets etc.
8)Visit the pregnant woman, prior to the due date of delivery and ensure that she has all the information about place of delivery,time for travel, contact of ambulance, blood bank etc.
9)Visit the pregnant female for Post Natal Check-up (PNC)

While the project will preliminarily focus on a limited population, it is our objective to bring this program to a much wider scope, impacting the lives of not only the women in rural Indian villages but also their families whose livelihoods rest upon them.

This project looks at sustainability from two different perspective. The first sustainability is on project sustainability and the second one is on the institutional sustainability.

Project sustainability
The basic objective of this project is to create a team of health-care entrepreneurs, who will be skilled to mobilize the community on maternal health care and continue to provide these services on a long-term basis. The Drishtee Health Franchisee (DHF) are trained as business entrepreneurs. This approach enables them to generate the revenue for sustaining the health kiosk and related activities by charging a small user fee. The approach fosters a long-term presence in the villages and supports:

1. The sustained presence of a trusted, credible health-care provider who can meet several health-care requirements of the village long-term, in addition to the scoped intervention.

2. A small user fee for the registration of the pregnant women helps the DHF to understand the process of sustaining the business for a long-term. The revenue generated will keep DHF motivated to mobilize more females for the screening afterwards

Institutional sustainability
The most important aspect of any development project is to make the institution sustainable and motivated to carry-on facilitating the intervention. In this project, DHF shares a small margin of the profit with Drishtee to keep it engaged with the project and continue to provide the support in the form of health-care workforce and other facilities.

Problema

1)Most of the maternal health programs are donor-driven and short-lived 2)Lack of motivation among the maternal health workforce on the poor health service delivery field. Often malpractices like over reporting are observed among the health workers for more incentives 3)Poor health seeking behaviour of the community