Solving Maternal Health and Maternal Mortality Issues in Tribal Andhra Pradesh, India
HMRI’s Asara project envisions a future in which tribal women have access to high quality and affordable maternal healthcare, the ability to make informed decisions about their health, and do not die due to preventable or manageable causes. To achieve this goal, Asara deploys a comprehensive solution to health that provides women with culturally grounded and medically validated health information through IEC activities, first level care through the training of traditional birth attendants, and virtual access to specialist physicians through videoconferencing. HMRI achieves this cost-efficient, high impact solution by leveraging cutting-edge information and communications technologies and superior operations management.
About You
About You
First Name
Balaji
Last Name
Utla
Facebook Profile
About Your Organization
Organization Name
Health Management and Research Institute
Organization Website
Organization Phone
(+91) 40 2335 0480
Organization Address
8 – 2 – 248/A/5/16 Plot 717, Journalist Colony Rd. 3, Banjara Hills Hyderabad, Andhra Pradesh 500034 India
Organization Country
India, AP
Country where this project is creating social impact
India, AP
Is your organization a
Non‐profit/NGO/citizen sector organization
How long has your organization been operating?
1‐5 years
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Innovation
Entry Form title
Solving Maternal Health and Maternal Mortality Issues in Tribal Andhra Pradesh, India
What change do you want to bring to the world?
HMRI’s Asara project envisions a future in which tribal women have access to high quality and affordable maternal healthcare, the ability to make informed decisions about their health, and do not die due to preventable or manageable causes. To achieve this goal, Asara deploys a comprehensive solution to health that provides women with culturally grounded and medically validated health information through IEC activities, first level care through the training of traditional birth attendants, and virtual access to specialist physicians through videoconferencing. HMRI achieves this cost-efficient, high impact solution by leveraging cutting-edge information and communications technologies and superior operations management.
What are the primary activities of your project?
The primary goal of Asara is to reduce maternal mortality among tribal women. To achieve this goal, HMRI trains community health workers (CHWs) and traditional birth attendants (TBAs), conducts IEC activities, deploys a village health outreach program, and runs a telehealth center.
HMRI trains CHWs on pregnancy, risks and complications, delivery, infant care, and nutrition. Additionally, HMRI trains TBAs to conduct safe deliveries and provides them with delivery kits. Asara trainings transmit vital information and form a connection between Asara and villagers. After training, CHWs help to eliminate misconceptions regarding pregnancy through IEC activities and educate women about Asara. CHWs also track pregnancies.
CHWs and TBAs work closely with HMRI paramedics. Asara deploys one paramedic to each village on a fixed date once per month to conduct screenings and monitor pregnancies. If necessary, the paramedic will refer women to visit the telehealth center for virtual consultation with an OB/GYN.
The following day, a van transports women to the telehealth center where they undergo lab investigations and physical examination, consult with an OB/GYN via videoconferencing, and receive prescription medications or supplements if required. Asara ensures that all women receive a full antenatal checkup, including ultrasound, screening/diagnostics, and risk identification.
What is innovative about your initiative? How is it a new contribution to the field?
The traditional solution to maternal mortality is to build infrastructure and hire physicians. This solution results in poor reach, high cost, and low scalability. Asara’s chief innovation is HMRI’s state-of-the-art technologies, including two key medical technologies HMRI has developed for rural settings.
LOBSTER is a lightweight, portable device that performs over 200 lab tests for USD 1/capita. Dox-in-Box® is lightweight, portable, and integrated with HMRI’s patient service software. It is equipped with digital medical technology that captures vital signs and skin/ENT images, and performs ECGs and blood glucose tests. HMRI software automatically captures data, providing tremendous scope to eliminate data entry errors.
HMRI’s software stores all patient data in electronic medical records that are authenticated by biometric fingerprinting. Electronic medical records are visible to and can be updated both at patient and specialist ends. Physicians use this software and biometric fingerprinting to prescribe medication. Moreover, HMRI has built into its software evidence-triggered alerts that guide field paramedics to provide appropriate health advice, referral risky cases, and define follow-up actions for their next visit.
The combination of cutting-edge technologies and village-level outreach delivers efficient, high quality, and low cost healthcare at the doorsteps of people who need it the most.
What stage is your project in?
Operating for less than a year
Tell us about the community that you engage? eg. economic conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts.
Asara engages tribal women from Araku Valley, a mountainous region in eastern Andhra Pradesh, India. Tribal people are among the poorest and most marginalized populations in India. Tribal Araku Valley has very little infrastructure, including poor road connectivity and a lack of electricity and running water. Most tribal families generate a meager average income of USD 23/month through agricultural activities (ITDA, AP). Education facilities are unavailable or inadequate, resulting in a 22.70% female literacy rate, compared to India’s national average of 65.46% (ITDA, AP; Census 2011).
Health problems in the region are greatly influenced by these factors. There is a high prevalence of protein, iron, vitamin A, and iodine deficiency and malnutrition. People face illnesses caused by unsanitary living conditions. Moreover, the area’s MMR is 800 and IMR is 150. These ratios are roughly three times India’s national averages.
Upon initially entering Araku Valley’s tribal areas, Asara faced challenges attracting pregnant women to its services as many tribal people believe it is bad luck for women to cross their villages when they are pregnant. Working with CHWs and TBAs was vital in gaining the trust of local communities. Currently, the care provided and pregnancy outcomes speak for themselves.
Share the story of the founder and what inspired the founder to start this project
Dr. Mastan Rao Govada is the founder of Asara. He has over 40 years of experience in medicine and public health. Dr. Mastan Rao has served as Additional Director of Health Services, Additional Director of Health Planning, and Director of Health for Andhra Pradesh.
Dr. Mastan Rao grew up as a member of a marginalized community. Throughout his youth he could see the inequality and disparity and feel the pain of deprived sections of society. Although he felt he was unable to effect change when he was young, Dr. Mastan Rao decided to commit himself to social service and therefore became a doctor. As a doctor, he witnessed malaria, hunger, malnutrition, and preventable death and observed gross disparities between tribal and state health indicators. He recalls, “”Walking through [tribal] areas you can feel the smell of it [the disparity].”
Once the issue of maternal mortality began to garner attention from the international health community and India’s National Rural Health Mission, Dr. Mastan Rao saw an opportunity to transform society through programmatic innovation. He pioneered HMRI’s Asara program to solve the health inequalities he experienced as a child and witnessed as a medical professional.
Social Impact
This Entry is about (Issues)
Please describe how your project has been successful and how that success is measured
HMRI describes Asara’s success along a variety of metrics. The primary metric for Asara is maternal deaths. Asara has identified and referred 279 women with risky pregnancies (39% of total registered pregnant women) for specialist care. Consequently, only one maternal death has been recorded, compared to 7 expected maternal deaths per the region’s MMR.
Pregnancy outcome is another key factor. Among Asara’s 596 deliveries, there have been 550 live births, nine stillbirths, eight abortions, and 28 neonatal deaths. The number of stillbirths and abortions is five times lower than prior to Asara’s intervention. These outcomes are due, in part, to the fact that nearly 80% of deliveries were attended by a skilled health professional.
Also important is the number of beneficiaries registered with Asara. Asara has registered 1,586 beneficiaries, including 100% of the service area’s total expected pregnancies. The number of registrations during the first and second trimesters has risen from 11-30% and 36-48%, respectively. This demonstrates the less measurable yet equally important factor of changing perceptions of maternal health among tribal people.
*All data is as of 31 August 2011
*HMRI recorded one additional maternal death during September 2011
How many people have been impacted by your project?
1,001- 10,000
How many people could be impacted by your project in the next three years?
More than 10,000
Winning entries present a strong plan for how they will achieve growth. Identify your six-month milestone for growing your impact
HMRI aims to change the behavior of pregnant women so that they actively seek healthcare.
Task 1
Empower local resource persons to undergo home-based neonatal training to identify neonatal risks early and motivate parents to bring their child to the hospital.
Task 2
Form clinical risk committees of OB/GYNs and pediatricians to review every risky case on a weekly basis to ensure they do not degenerate into morbidity/mortality.
Task 3
Ensure key village influencers are aware of risks related to pregnancy and neonatal care and ensure that they become part of the change process.
Identify your 12-month impact milestone
Ensure that no deliveries will occur without the presence of a doctor or trained traditional birth attendant.
Task 1
Train and conduct refresher trainings for all traditional birth attendants in the project area.
Task 2
Establish an early risk identification and management program so that pregnant women and traditional birth attendants can take necessary precautions.
Task 3
Establish an effective referral system such that risky patients travel to Community Health Centres with test results from Asara and can undergo care/treatment immediately.
How will your project evolve over the next three years?
HMRI plans two key evolutions over the next three years. The first is that HMRI will reduce the maternal mortality ratio among tribal populations under its service areas by 50%. The second is that HMRI will expand its telemedicine services in tribal areas beyond maternal and infant care to include illnesses that debilitate tribal communities. These illnesses will include, but are not limited to, malaria, vector-borne diseases, anemia, goiter, arthritis, and malnutrition, etc.
Sustainability
What barriers might hinder the success of your project and how do you plan to overcome them?
HMRI anticipates two major barriers to the success of Asara. The first is resistance from tribal populations. Many tribal populations believe that illness and death are God’s will and therefore do not seek care from allopathic doctors. In Araku Valley, the tribal population believes that women should not cross their villages during pregnancy. Consequently, potential beneficiaries resist outside interventions that seemingly contradict these beliefs. By working closely with CHWs and TBAs and conducting village outreach, Asara staff have been able to develop relationships and build trust with communities. HMRI plans to continue this practice to address any beliefs that may prevent tribal women from seeking external healthcare.
The second is funding to run the project long term. Current funding for Asara stems from MacArthur Foundation. In the long term, this is not financially sustainable. Since tribal populations are too poor to pay any fee for medical care, HMRI plans to diversify its funding base by building relationships with other multilateral aid organizations, government organizations, and wealthy individual donors.
Tell us about your partnerships
HMRI partners with MacArthur Foundation, Centre for Policy Research, Avantor Performance Materials, and Zolt Info Solutions for Asara. In addition to providing funding for the entire project, MacArthur Foundation provides critical clinical feedback and advises on components that can be added to Asara to strengthen the project. Centre for Policy Research conducts independent, third party monitoring and evaluation of Asara and other HMRI projects. Avantor Performance Materials supplies Asara’s laboratory equipment. HMRI purchases Chem master – Semi Automated Biochemistry Analyser and Noble III which are integrated with HMRI’s telemedicine software. HMRI also uses Avantor Performance Material’s SEDY – 12 and ER – 2007. HMRI works closely with Zolt Info Solutions to develop HMRI’s patient service software and LOBSTER and Dox-in-Box® technologies.
Current annual budget of project, in US dollars
$250,001‐500,000
Explain your selections
MacArthur Foundation funds Asara in its entirety. This includes capital expenditures such as equipment, vehicles, and technology, and operational expenditures such as salaries, rent, and utilities. The public health system, under the Government of Andhra Pradesh and Andhra Pradesh’s National Rural Health Mission (NRHM), also provide valuable support to Asara. Asara works closely with NRHM’s Accredited Social Health Activists (ASHAs, community health workers) to deliver IEC activities and monitor pregnancies. Moreover, Asara works closely with NRHM’s Community Health Centres and District Hospitals to refer risky pregnancies for care, treatment, and deliveries.
How do you plan to strengthen your project in the next three years?
HMRI plans a phased approach to expanding tribal maternal health telemedicine centers. The first phase will involve launching seven new telehealth centers throughout Paderu Division, an administrative division in Andhra Pradesh. These telehealth centers plus the current telehealth centers will reach a population of roughly 596,000.
Phase two involves expanding tribal maternal health telemedicine centers throughout the entire state of Andhra Pradesh. These telehealth centers will reach the state’s entire tribal population, roughly 5,600,000, through 52 telehealth centers with each center catering roughly to a population of 75,000.
In Phase three, HMRI will expand tribal maternal health telemedicine centers throughout India. HMRI currently runs two successful projects in Assam, a state with a high percentage of tribal people and therefore tremendous scope for expansion.
To conduct such a vast expansion, HMRI must diversify its revenue base. Consequently, HMRI plans to approach various state governments in India, multilateral aid organizations, and wealthy individual donors to ensure the future of Asara.
Challenges
Which barriers to health and well-being does your innovation address?
Please select up to three in order of relevancy to your project.
PRIMARY
Lack of physical access to care/lack of facilities
SECONDARY
Limited human capital (trained physicians, nurses, etc.)
TERTIARY
Health behavior change
Please describe how your innovation specifically tackles the barriers listed above.
Asara addresses its primary barrier by training TBAs to attend deliveries; deploying paramedics to each village once per month to monitor pregnancies, conduct screenings, provide advice, and make referrals; and transporting women to the telehealth center where they undergo testing, collect prescriptions, and virtually consult an OB/GYN.
Asara addresses its secondary barrier by training local TBAs, training paramedics to rely on disease summary and algorithm software, and connecting tribal women to skilled OB/GYNs through videoconferencing.
Asara addresses its tertiary barrier by training CHWs and TBAs to conduct IEC activities that provide culturally sensitive, medically relevant information in an accessible format.
How are you growing the impact of your organization or initiative?
Please select up to three potential pathways in order of relevancy to you.
PRIMARY
Grown geographic reach: Within host country
SECONDARY
Enhanced existing impact through addition of complementary services
TERTIARY
Leveraged technology
Please describe which of your growth activities are current or planned for the immediate future.
In the immediate future, HMRI plans to expand Asara through the addition of seven maternal telehealth centers throughout Paderu Division, Andhra Pradesh. These centers will serve a total population of 596,000. HMRI is also making improvements to Dox-in-Box® so that full service delivery happens through the device. This will make Dox-in-Box® a much more user-friendly technology. HMRI also plans to build into Dox-in-Box® an evidence-based alert system so that immediate measures can be taken to resolve potentially risky cases.
Do you collaborate with any of the following: (Check all that apply)
Technology providers, NGOs/Nonprofits, For profit companies.
If yes, how have these collaborations helped your innovation to succeed?
HMRI’s primary collaborator is MacArthur Foundation which funds Asara in its entirety. HMRI collaborates with the local government by leveraging and training CHWs to liaise with local populations and conduct IEC activities. HMRI also collaborates with government-run hospitals for referral of high risk cases and institutional deliveries. HMRI collaborates with technology providers/for profit companies to innovate new software and technologies such as HMRI’s patient service software and Dox-in-Box® which decrease cost and error and increase efficiency and quality of care.
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