Bringing the three frontline workers in each village on one common platform to synchronize data, review each other’s work, micro-plan activities, and share learnings
Three government women health-workers are responsible for delivering health and nutrition services in India’s villages. Each village has an Auxiliary Nurse Midwife (ANM), the ASHA (Accredited Social Health Activist) and Anganwadi worker (AWW). Each of these frontline health workers has distinct, but related roles, and they work in the same villages. All too often, they do not collaborate enough. The AAA (ANM-ASHA-AWW) Platform brings them together.
There are some fundamental issues:
There is no village map, so workers are often unfamiliar with the geographical area and location of households
Frontline workers have different methods for identification and tracking of beneficiaries
Households are approached in a prescribed linear sequence and not prioritised in terms of case urgency
Workers are not equipped to handle community resistance
There are few opportunities to share information and learn from each other
The AAA Way
1. Establishing a common database
AWWs organise people by families, ASHAs use households and ANMs work on a record of eligible couples (married couples in the age group 15-49).
AAA work together to create a village map, synchronising household and family coverage. On these maps, they number houses and affix coloured bindis to denote various categories of beneficiaries and dynamically track them, prioritising those at highest risk.
Now, village health and nutrition information is available at a glance. AAA also involve the community in validating the maps. This raises community's interest in village health issues and the AAA's standing in society.
ASHA workers visit ten houses every day. Previously, they did it in a linear manner (House one to ten on day one, eleven to twenty on day two and so on). AAA enables them to plan visits based on beneficiary needs using a simple algorithm. This enables them to deliver care when and where it is most required.
One specific day every month (varies state-wise), a Village Health and Nutrition Day (VHND) is organised in every village. Through the AAA platform, the three workers have a formal meeting. Here, they review each other's work and data, plan for the next month and close with a peer learning session where they educate each other on technical and administrative matters.
Know more about village mapping in the video below
"This is a good platform, where we can review our day to day work, and discuss and finalise the activities of upcoming month in the meeting. We review the status of ANC, PNC, High Risk Pregnant Women, Immunisation, New Born care and malnourished children in accordance with the Anganwadi Centre. This review helps us to identify the women who are not coming for their first and second ANC, children left out from immunization and also the status of women with high risk pregnancies"
Munni Devi, ANM - Kamkheda, Jhalawar
The AAA Platform has had a significant impact on the identification of high-risk cases in Rajasthan. Outcomes are based on internal monitoring
The AAA platform was initially piloted in 2,700 villages (3 million population) across two districts in Rajasthan. The mapping of villages was done entirely by the AAA workers together with local communities. In December 2017, the then Hon. Chief Minister of Rajasthan Vasundhara Raje announced that the AAA platform would be introduced to every village in the state (over 45,000) under the name 'Rajsangam'. 140,000 frontline workers and supervisors were trained, reached through transmission to over 250 regional video-centers.
Rajsangam has been embedded within the state government's health system and is being managed by the government. The government also developed a system to monitor the scale-up of the program across the state, hence allowing us to withdraw our support smoothly.
Build, operate and transfer!
Our monitoring data from 80 anganwadi centers showed a strong increase in identification of various critical beneficiary groups, due to the AAA Platform. These high-risk beneficiaries are most vulnerable, and contribute the largest towards morbidity and mortality. Timely identification is crucial to ensure prioritization and focused service delivery, thereby improving health outcomes.
The AAA Platform enabled this through a combination of factors:
Data sharing and synchronization of records increased enumeration quality, by inclusion of missed beneficiaries and higher data accuracy
Joint accountability with regular AAA review meetings ensured increased adherence to job responsibilities (e.g., weighing of children, screening for malnourished children)
Peer learning sessions on various topics improved AAA’s knowledge and skills (e.g., proper weighing of children, accurate detection of malnourishment)
Below are three metrics that recorded a significant rise:
Identification of malnourished children below age-five went up by over three times. Rise in malnourishment screening from 20% to 76% was a key contributor.
Identification of underweight children below age-five increased by 117%, contributed by an increase in number of children weighed from 70% to 97%.
Identification of high-risk pregnancies increased by over 60%. Better knowledge among AAA about classifying pregnancies as high-risk was an important factor (AAA knowledge scores rose from 43% to 67%)
A key factor driving increased identification across categories was a sharp rise in overall data integration among the AAA, from 57% to 94%. Data integration measures the degree of synchronization of AAA records for crucial information such as number of households, number of pregnant women registered, number of infants, etc. Higher data integration reduces chances of beneficiaries being left out, and increases accuracy of captured beneficiary details.
This increased identification has been ensuring provision of proper service delivery for each beneficiary type. For example – extra supplementary nutrition provided to severely underweight children, referral of severely malnourished children to nutritional rehabilitation centres, and special counselling to high-risk pregnant women including referral to a medical officer.
Stories from the field: AAA in Action
Watch the AAA Platform's impact along its theory of change: enhancing enumeration, enabling prioritisation, improving knowledge and ensuring joint-work