Labour Managment Tool June 2015

D E S I G N I N G F O R A N E F F I C I E N T A N D E F F E C T I V E M O B I L I Z AT I O N

12.06.2015

VILLAGE HEALTH SANITATION AND NURITION DAYThe Bihar Innovation Lab conceives, builds and implements high impact solutions for the public health sector to save more lives and improve the health of women and children. It is supported by the Bill and Melinda Gates Foundation and the Government of Bihar..

The VHSND Product development team is aiming at transforming the VHSND from a day that was previously devoted solely to routine immunization, to a community run health festival with new standards of care and user experience.

Labour Managment Tool June 2015

CHALLENGES OF MOBILIZATION

Seema, an Accredited Social Health Activist (ASHA) in a village in Kishanganj, leaves in the morning of the Village Health, Sanitation and Nutrition Day (VHSND), to mobilize people due for vaccination. She visits the prospective households to inform people that there is a VHSND (referred to as tikakaran) happening at the Anganwadi (child day care centers). She simply asks them to come to the site, ‘...aaj tikakaran hain, bachein ko lekar anganwadi ajana’. That is all she says, no details are given on why they need to come to the site, what all services are provided there and why is it critical for them to come. That’s the usual way the ASHA mobilizes people for VHSND. Let us list down the problems that this way of mobilization leads to:

1. The ASHAs mobilization efforts are not tailored according to the profile of the beneficiary. ASHAs communication remains the same be it for a pregnant woman or a child due for vaccination- there is anyways no protocol to mobilize people outside of these two profiles be it for counselling on Family planning or nutrition or danger signs. People have therefore come to perceive VHSND as a platform for ‘just vaccination’. 2. The ASHA furthers the perception of VHSND as a platform for only vaccinations, people are thus left unaware of the range of services they can avail at the site. In many cases the ASHA mobilizes people unaware whether they are due for vaccine or not, in which case the beneficiaries on reaching the site are told to return, ‘…kitne baar jatein hain wahan aur didi bolti hain ki agle baar ana, aaj tika nahi lagega.’

3. The informal and impersonal process of mobilization does not provide for required amount of motivation to push people to visit VHSND- apparent from the fact that they put their household chores, work in the farms, and visit to a relatives above getting their child immunized or the pregnant women checked.

4. No proper understanding of ‘why’ (visiting VHSND is important, immunization is critical, ANC is instrumental) makes way for many myths and misconceptions- ‘...vaccinations lead to impotency, IFA is responsible for dark skinned babies, contraceptive methods are non-reversible, etc.’

5. The referral process for complicated cases never gets initiated. While mobilizing the ASHA comes across many cases where the beneficiaries report of some complications, ‘child is down with diarrhoea, pregnant woman has body ache or fever or some other complications’ which they give as the reason for not being able to come to the site. ‘…kitne baar log boltein hain ki bachein ko bukhar hain to nahi a payenge, hum unhe boltein hi ki aspatal chalejana ya’.

6. Many families are not mobilized as ASHA tends to skip on families that she does not share a good relationship with or those who pose difficulty or simply because the ASHAs coverage ares is large and she skips on far away households.‘…ASHA yahan nahi atin, hum chotin jaat ke hai na.’, ‘…humara ghar anganwadi se bahut door hain to yahan humein koi bulane nahi ata.’

ASHA on her mobilization round. ‘..itna bada gaon hain ki akele karna bada mushkil ho jatan hain’

The ASHA informing the beneficiary of the VHSND, ‘tikakaran hain, bahu ko bhej dena’

Labour Managment Tool June 2015

MOBILIZATION TOKENS: DESIGNING A FORMAL INVITATION TO THE SITE

Having identified the challenges the team underwent rounds of brainstorming and concepting exercises to either develop suite of solutions to target the problems that mobilization acts as an advent to or create one holistic solution that can cater to all. From a mobile app to a loudspeaker announcement to an ASHA script the team thought of various ways to approach these challenges. However the concept that drew everyone’s attention was a single word – ‘An invitation’. This single word opened up a range of possibilities that could be explored. It could:

- Create a seriousness around VHSND

- Put pressure on the ASHA to mobilize all

- Obligate the beneficiaries to come to site

- Create awareness on what all VHSND as a platform has in offer

- Determine the different profile of beneficiaries who need be mobilized

- Create a perception that ASHA is professional healthcare service provider

- Aid the ANM and ASHA track the missing families

- Define a protocolwherein complicated cases can be identified, screened and referred to higher facility

- Get profiles outside of just children and pregnant women to come to site.

Madhubani stylized visual language, selected after rounds of field testing and creative workshops.

Icons to inform the beneficiaries of the services they can avail at the site.

Motivational message to reinforce the benefits of visiting the site

Brainstorming over the design of the mobilisation token

Creative workshops with FLWs on deciding the content on the token

Post-it exercises with FLWs and beneficiaries

Labour Managment Tool June 2015

THE NEW MOBILIZATION PROCESS: HOW WOULD MOBILIZATION CHANGE WITH THE TOKENS?

On the morning of the VHSND or a day prior, the ASHA will distribute Green tokens to pregnant women, yellow ones to guardians of children who are to be immunized, blue ones to couples who need to be counselled on family planning (delayed childbearing, birth spacing or sterilization) and red ones to people who show signs of complications (danger signs in pregnant women, fever, diarrhoea). While distributing these tokens the ASHA will be required to explain what VHSND is and what all services they can avail there. The visual cue on the tokens would: one aid the ASHA to better explain the services available there, two create awareness among beneficiaries on what all services they can avail and third act as a reminder for them to demand services in case they do not receive any at the site.

These tokens act as an invitation to the VHSND. The beneficiary will be expected to return to the site with the token. Our design hypothesis says that a physical token will, at a subconscious level, obligate the beneficiary to come to the site of service to return it to the FLW. They are also numbered in each color set. In this way, the ANM and ASHA can keep track of how many of each category of beneficiaries have been called and how many finally turned up. Thus it is not just the tokens but the protocol or the process these tokens kick start, that targets these multiple set of problems

Labour Managment Tool June 2015

The ASHA gives out the respective token to the beneficiary and explains the range of services they can avail at the site. She hands out the token to the beneficiary asking her to come to site and return it to the ANM.

The beneficiaries come to the site with their respective tokens. Anyone carrying red token gets to meet the ANM first, while others wait for their chance.

Towards the end of the day the ANM along with the ASHA checks the mobilization register to see which all tokens have not returned.

The ASHA goes for her second round of mobilization to call the missing families. In case she is unable to convince, the ANM either calls them or visits them to reinforce the importance of VHSND.

She then notes down the details of the beneficiary against the token number given in her register.She notes down her name, husbands name and mobile number in order to track the missing tokens

The ANM on the basis of the token color picks respectiveflash card which lists out the services she needs to give. It simply acts as a check-list for the ANM to ensure that she does not miss out on any service.

Labour Managment Tool June 2015

ASSESSING IMPACT: THE INTERIM FINDINGS FROM THE IMPACT EVALUATION STUDIES CONDUCTED

Even though the VHSND team tested every aspect of the token with both beneficiaries and FLWs, the real test of any product can only be determined by positioning it in reality. We selected three sites one each in Patna, Vaishali and Muzzafarpur, conducted a brief baseline to understand the current state of affairs around mobilization process followed, perceptions around what VHSND is and what all services can be availed therenumber and reasons for drop outs, conversion rate- number of people mobilized to number of people who turned up at the site, amongst others. The baseline was followed by piloting the tokens at the three sites and doing observations and in-depth interviews with FLWs and beneficiaries to understand the impact of the innovation. Some initial insights and responses on the tokens:

• Vaishali saw 4 blue family planning tokens and couples coming to site which was a first. ‘Pehle keval parivar niyojan ke liyein koi nahi atan tha. Iss baar pehli bar 4 parivar ayein hain. Humne unhe arein tariko main salah bhi di aur condon OCP bhi batein’, the ANM reported.

• Muzzafarpur, saw an increase of 12 beneficiaries to the site compared to the baseline data ASHA reported that with tokens people took her invitation more seriously. ‘…Sab pooch rahein the kya karna hain iska, lekar ana hain kya. Badi utsukta thi logon main.’

• The beneficiaries responded well to the red tokens across all three locations. The ASHA reported that the women who otherwise would not have come to the site due to some complication or due to their child being down with fever or diarrhoea came when told that they will get to skip the line and meet the ANM directly. ‘…didi ne lal token diya aur bola ki wahan akar jaldi ANM didi ko milo, who dawan dengi, aur iss lal token se wahan intezaar bhi nahi karna padega.’

• People reported that they came to know about some services that they did not know they can get at the site, more so in Muzzafarpur as not many services are given beyond immunization. A beneficiary reported ‘…humein nahi patan tha ki yahan ORS bhi milta hain. Hum to dukaan se kharidh kar laye the jab bachein ko daast lagein the.’

• The ANM reported that having token number against the name of the beneficiary called to the site made it easier for her to track the people who did not turn up at the site. ‘…asani se patan chala ki kaun nahi ayan hain, to phir ASHA unhe phir bulanein gayi.’

A beneficiary at the site with the yellow token. ‘...Achan lagan jab didi ne yeh token diya, bola isko lekar ana.’

The ASHA making note of which all tokens have not returned - ‘...Isse yeh patan chal jatan hain ki ab kisko bulana hain.’