How the Akshada Program in Rajasthan is creating ‘Silent Health Revolution’

Three women forces of Rajasthan join hands and strengths to work towards one common cause – the health of mothers and their children

Rajasthan Government had signed a very important Memorandum of Understanding, in March 2015, with the Tata Trust and Antara Foundation for a special program called ‘Akshada’ (meaning: God’s blessings) in the presence of Chief Minister Smt. Vasundhara Raje and Shri Ratan Tata, Chairman of Tata Trusts.

Chief Minister, Smt. Vasundhara Raje had said on the occasion, “there is plenty of scope to improve the health status of women and young children in State. We believe that private partnership in the programme for improving maternal and child health and bettering the nutrition status will take Rajasthan a long away in emerging as a State with health indicators at par with India’s best.”

She had also laid stress on active participation of ASHA workers with this programme. Flagship program for the state of Rajasthan, Akshada aims to transform the state’s outcomes on nutrition, maternal and child health.

The story of Akshada

The ‘Akshada’ program focuses on the crucial ‘1000 days’ between conception and till completion two years’ age of a child and incorporates the most critical aspects like maternal anaemia, neonatal mortality and improvisation of immunization. The programme also involves deploying interventions that could greatly reduce the levels of malnutrition amongst children under five.

Currently, Akshada is being implemented intensively in Jhalawar and Sirohi districts. The innovations once successful in these districts, will be replicated, amplified and rolled out across the state.

An innovative initiative, addressing the problem of malnutrition amongst mothers and infant children, Akshada will have a positive impact on millions of children in terms of their improved health and resistance to illness and physical and mental deformity at birth and make a difference in the health of the future generation.

Empowering Frontline Health Workers

In reference to the health sector, three frontline health workers at the ground level aid every village in India.

ANM (Auxiliary Nurse Midwife): It is through their activities that people perceive health policies and strategies. Planners at the upper level gain insights into health problems and needs of the rural people via ANMs. Considering their status as grass-root level workers in the health organizational hierarchy, a heavy responsibility rests on them.

Accredited social health activists (ASHAs): Health activists in the community who create awareness on health and its social determinants and mobilize the community towards local health planning and increased utilization and accountability of the existing health services.

Anganwadi Workers (AWW): The workers at the Anganwadi centres provide supplementary nutrition, non-formal pre-school education, nutrition and health education, immunization, health check-up and referral services of which later three services are provided in convergence with public health systems.

With Akshada’s intervention, all 3 A’s – ANMs, ASHAs, AWWs, came together as a team to create a Triple A platform in each village. The purpose of the AAA platform is to bring the three health workers together in each village so that they do not work in silos. Regardless of their education or literacy levels, the idea is to create a common ownership, better coordination and accountability for the lives of women and children in their villages.

The Story of AAAs

As they kick-started their program in Rajasthan, the Akshada team activated several committed health workers. These are some stories of their experiences:

Ramjanki Nagar

Ramjanki often walks several kilometers in scorching heat to a village where she goes door to door to attend to new mothers, pregnant women and newborn children. She is an ASHA health worker and is responsible to visit every home to identify pregnant women, check on nutrition, immunization status and health of children under the age of 2 years and ensure that they receive health services at the weekly Village Health Nutrition Day – which is observed in a village every month to provide essential health services to women, adolescents and children.

She says, “Before the organization of AAA, I used to survey any 10 houses randomly without any goal that often meant that services could not reach the needy on time. Now with the help of Village Mapping technique, I have a home-visit calendar that sets my goals right. For example, my due list enables me to contact those eligible two days before the vaccination day. Previously, we used to identify high risk pregnancies only on the basis of hemoglobin, now we ascertain several more factors like previous pregnancies, aches and pains etc. Many instruments provided under the Akshada programme have benefitted us greatly!”

“The AAA meeting has given us a common platform to work together in identifying and conducting regular and timely home visits,” said Ramjanki who will now co-ordinate with the Anganwadi worker in identifying malnourished children. “It is also very motivating when we work together and learn from each other rather than working alone,”.

Josh Maria

Another health worker, Josh Maria is an ANM in Soomer. She says, “With the AAA platform, all three health workers have developed a sense of coordination and are now working together towards a common goal. Our modus operandi has improved significantly and so has our knowledge. Identification of sensitive and risk prone mothers has become easier with enhanced capacities and planning. Involvement of adolescent girls and public representatives has created more awareness in the communities. This harmony between health workers, community and public representatives shall surely bring bright results!”

Mini Mol

As an auxiliary nurse midwife (ANM), trained in nursing, Mini Mol of Sojpur village has been providing primary health care services at her sub center in the village for past 20 years. Convincing women to have institutional delivery, conducting regular health check- ups and practicing safe deliveries, she has ensured a 100 per cent institutional delivery in her village.

She says, “ In the past, Anganwadi workers rarely used to go out in the field marking it as a job for ASHAs. Now all of us are out there in the field that has lead to better identification, better services and higher productivity. With such added capabilities, we shall soon see a great difference in maternal mortality ratios”.

Anju Kumari

Anju Kumari, Sarpanch, Sojpur says that AAA is worthy of praise because it helps maintaining the functioning of the health care plan and beneficiaries receive health services timely and properly. She says, “our home visit schedule calendar based on village mapping where coloured dots are used to represent pregnant, high risk pregnancies, newborn and undernourished children has made it easier for us to help the needy and also increased our confidence”.

Ramjanki, Josh, Anju and Mini Mol are amongst lakhs of frontline health workers who serve communities in villages and provide families with a range of proven, life-saving services including maternal and newborn care. These communities typically lack access to mainstream medical services making this team of 3 women the backbone of a health system in the rural India. In the past, the 3 of them would have worked in silos despite catering to the same base of pregnant women, young children and their mothers.

Under the Akshada program, a range of initiatives are being rolled out to facilitate collaboration, planning and coordinated service delivery amongst the 3 women who can transform the state of maternal and child health in Rajasthan’s villages.

Various meetings are being organized at the village level to bring together representatives of Panchayati Raj, adolescent girls and communities. Several training sessions are also being conducted to introduce innovative tools such as village mapping and micro-planning that would help the AAAs in identifying pregnant women, new born children, malnutrition hot spots and unaddressed households. Based on their shared inputs and insights, it is encouraging to see how the health workers quickly identified ways in which they could work together.

The Difference

It is too early to say that the program has made vital difference but the numbers suggest that significant improvement has been made.

Improvement in Identification of High Risk Pregnancies:

Block Manoharthana

Block Khanpur

Improvement in Identification of malnutrition in children:

Block Khanpur

Block Jhalarapatan

Akshada Programme: Before And After

The success of Akshada has motivated the Government of Rajasthan and shall be soon extended across the state. The simple acts of simplifying the planning process for frontline workers, improve motivation among the community workers and increase of accountability through community involvement has worked like magic in these areas. The potential impact of such a powerful village level platform has given great impetus to the Mission of CM Vasundhara Raje in creating a ‘Swasthya Rajasthan’.