The First 1000 Days: Mother and Child in Rural Bihar

5 Weeks

7 Innovation Specialists

3 Districts: Begusarai, Saharsa,Kishanganj

950 + hours of field interviews, observation,

photos, videos, audios

18 + hours expert and practitioner interviews

The Effort

Human Experiences

Cultural Values of Health and Protection

A Lighter is kept near the

child to ward of evil eye

An Iron Kajrota, a holder of kajal,

to ward of evil eye.

Making children wear Tabeejs for protection

is a common practice

Worship areas outside homes as

women are not allowed to enter it

during gestation and periods

Palnas for the infant are

gifted by the maternal

household to new parents

New Syringes

Ferro Tablets

Zinc Tablets

Vitamin A syrup

Green Jhola

with medicines

Cotton Roll

Non-functional

hub-cutter

Bag with new syringes

Registers

& RI cards

Vaccine Vials

Pen

Registers

Purse

Seeing like a Designer

Mapping 1000 day Health Information Needs

Mapping ASHA’s Mobilization Interactions

Labor Journeys over Multiple Deliveries

Diurnal Mapping of a Pregnant Woman’s Nutrition

Building Divergent Ideation based on Failure Cases

A Convergent Approach to Prioritization

Public Health Delivery Systems Analysis

Tools

Players

Rules

Systems Challenge:

Unidirectional model of Care Provision

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The focus of the healthcare service and its (FLWs) on the health and wellbeing of the mother and child is limited to these periodic and narrow interactions

Largely influence of these interactions are limited to looking at health and wellbeing through the lenses of preventive medication and vaccines.

Limited Interactions = Limited Scope for Impact

The Circle of Influence and Decision Making around the Mother

‘ASHA nahi aayi bulane toh hum nahi gayi injecsion lene – uska kaam hai na’

Who is Responsible for the Health of Mothers and Children?

Systems Challenge 4:

Cookie Cutter Care and Counselling

Sulekha Devi | Health Vitals

HB: 5 gms | BP: 140/100

BMI:(Height: 5:2” Weight: 42 Kgs)

Severe Edema (Swollen Feet)

6th Pregnancy

2 Miscarriages in the Past

Rekha Devi | Health Vitals

HB: 9 gms | BP: 130/100

BMI:(Height: 5:4” Weight: 50 Kgs)

2nd Pregnancy

Standard Advice from Front-line Workers to Both These and all other

Pregnant Women:

‘IFA Tablet khao’ Eat Iron Tablets

‘TT Lagao’ Get TT

“Saag sabzi khao’ Eat green leafy vegetables

Missed Opportunities to Provide Relevant Care

Systems Challenge:

Uniform Service Delivery Across Socio- behavioral -

Geographical Contexts

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Systems planning and emergency response is linear in structure and ignores impact of temporal activities such as festivals, high volume, seasonality, etc.

The Temporality of Health

Existing systems aren’t designed to respond to variations occurring due to:

- Seasonal factors

- Geographical challenges

- Attitudinal challenges

- Socio-Cultural resistance

- Local Healthcare Beliefs and Perceptions

- Infrastructure

- Political Events: Elections often result in total shutdown in transportation. Ambulances and other key personnel are redeployed during elections / political rallies impacting access to public facilities

Blanket Service Strategies

Systems Challenge:

Imbalanced Hierarchies Between The Service and

Beneficiaries

Inequity is rife in the system: Choosing whom to prioritize or whom to provide. “Hum hi bure bante hain.” – AWW worker.

Some FLWs show bias towards their own kin when itto distribution of resources and providing services.

Beneficiaries’ class & caste sometimes determines the attitude of FLWs, thereby affecting the quality of service. Socially or financially influential beneficiaries may be givenpreferential treatment at the RI site.

Service Provision Inequity

Low Expectations

A Non-Participatory Environment

Systems Challenge:

Data Reporting over Care | Misplace Priorities

Only Measurable and Incentivized Services Provided

Who’s Interest is Priority?

Skewed Time-Spent on Data Reporting as opposed to Care Provision

In spite of there being no weighing machine at

the RI/VHSND a beneficiary’s MCH card had

mention of her weight recorded.

Data recording often takes precedence over

caring for the health of the mother and

reporting her actual status.

Data Reporting over Care

Systems Challenge 6:

Lack of Critical Infrastructure Required to

Operationalize Best Health Practices

A Woman Centric Approach:

The Layered 1000 Days

A ‘Mother and Child’ Centric Health and Well-being Ecosystem

Automating Patient Tailored Care Provision at Scale

A Self-Aware Healthcare Delivery System

Service Accountability towards Citizen Communities

Service Delivery Infrastructure for Best Practices

New Performance Evaluation Parameters and Differential Incentive Structures

Key Innovation Directions