Micro data can help make public health delivery systems better
India ranks 154 out of 195 countries in terms of health performance, says the Global Burden of Disease Study.
But one should not blame the design of the health system for this adverse report card. The main problems lie in
the dearth of efficiently deployed micro-data and the lack of a co-ordinated approach on the issue of last-mile health care delivery.
The health system provides for three kinds of frontline workers for every 1,000 people. These workers are: the Auxiliary Nurse Midwife (ANM), who provides basic health services; the anganwadi worker (AWW), who is responsible for the monitoring of child nutrition, and the Accredited Social Health Activist (ASHA), who mobilises the community. Together, these workers (AAA) could be a powerful force, if they can focus their efforts first on the most at-risk cases within a village.
But this is not happening because of various reasons. First, as per today’s protocol, an ASHA worker is required to visit houses 1-10 on the first day, 11-20 on the next and so on. This means there is no prioritisation or urgency, focused on the critical cases. Indeed, she may miss households. Second, an anganwadi worker has to spot malnourished children under the age of six. But the cases she has to find are often buried deep in ill-maintained registers. The data the ANM receives from these workers often does not arrive at all or is too late. Another problem is the absence of micro-data, which can be efficiently shared by the AAA workers.
Good micro data – well envisaged, efficiently captured and smartly used ---- is arguably one of the biggest needs in health care delivery in India. Currently, an AWW maintains 11 registers, the ANM five, and the ASHA one. Information on a single beneficiary can be spread over multiple registers. That there are two ministries — health and women and child development — involved in the process only adds to the problem.
It is important to understand what kind of data AAA workers need in order to be more efficient. For example, she may need to know how many pregnant women are there in a particular village; of these, how many are in the high-risk category; how many new-borns are particularly vulnerable; what is the number of children under the age of two; and how many children are malnourished.
The AAA also need a simple system to monitor health performance of beneficiaries in her village. She needs to
be able to look at trends, recognise patterns and ask relevant questions in order to become an effective front line problem solver. This requires an efficient mechanism to share data among the AAA workers.
Some interesting innovations are being tested in states such as Rajasthan, Bihar and Gujarat to enable better data use by frontline health workers. Rajasthan has simplified the registers that an AAA use. An original system of village mapping is being rolled out in which the AAA meet, share information and place bindis of different colours on those houses with the most urgent cases. They develop a household to-visit calendar to prioritise service delivery, rather than go the sequential way. Women come in to the anganwadi centre where the maps are mounted to ask what they have to do to get the red bindi removed from their house. The panchayat takes notice, and monitors progress.
Ashok Alexander is founder-director of Antara Foundation
The views expressed are personal