The main objective was to facilitate innovation in the delivery of maternal and child healthcare services in Bihar and other rural parts of India through design solutions that not only address challenges in the vaccine delivery mechanism, but also cater to related services within the broader ecology of maternal and child health care. The intent was to understand the barriers to the routine immunization from the perspective of the users – namely, front line health workers, recipient families, In addition to the innovative solutions that account for user preferences and helps them to overcome everyday day challenges.
Understanding Framework
In the National Health Mission program undertaken by the government, each district in the state has a PHC (Public Health Clinic) and under each PHC there are a number of villages under its monitoring. The PHC then appoints a ANM (Auxiliary Nurse Midwifery) for a number of villages and a ASHA for each village. Primarily there are three main stakeholders in the system, the beneficiary i.e. the maternal women, the ASHA and the ANM.
Stakeholder Study
Role of ANM
The ANM are the health workers appointed by the PHC, they play a very important role in improving the Immunization coverage of mothers & children. They expected to immunize all children and pregnant women. Their responsibilities are
• Planning for Immunization
• Maintaining Cold chain at immunization site
• Conducting the immunization session
• Recording, Reporting and tracking of drop outs
Role of Asha
The responsibilities of the ASHA is to mobilize pregnant women/ mothers /children during the immunization session. She has to help the ANM during the immunization in terms of setting up the center, help her keep and track record of the beneficiaries. etc.
Mapping a day of a ASHA
Journey Mapping, for ANM, ASHA and Anganwadi worker
Research
Research was conducted in various districts of Bihar. Our focus was mostly on rural locations, where migration rates, lack of access to private services etc. The choice of locations offered maximum diversity in terms of key variables, including robustness of the public health infrastructure, caste, cultural and ethnic diversity, socioeconomic status, education, geography, political and administrative factors, and others. We used methods such as one to one interviews, shadowing and focus groups for research.
Some of the pain points of the beneficiaries
Three injections have been given. Why do we need more?” - Beneficiary on lack of information about vaccination
"This is my first child. I do not know when he is due for vaccine. I am not aware that ANM comes to my village."
When I do not get payments on time, I lose determination. If I do not have money to eat properly how will I find energy to roam around in the field? - ASHA
Research Analysis
An intensive analysis phase followed the culmination of the research phase. The enormous amount of data collected during the research was broken down and represented through various data models. This helped in organizing the insights, making challenges and potential interventions more evident. The various breakdowns identified were clustered into larger sets of challenge areas, and prioritized by analyzing its gravity and the potential scale of impact on improving RI coverage by solving the given problem.
The challenges
Six key challenge areas emerged out of this exercise. This helped in focusing our brainstorming for solutions around these challenge areas.
The key challenges are:
Inadequate Understanding of How Immunization works for Protection
Low Recall of RI Session Dates amongst Beneficiaries
No Conceptual Framework of a Healthy 1000 Days
Absence of Targeted Mobilization Efforts
Failure to Link Beneficiary Identity and Health Services Received
Broken Interactions at the RI
Ideation & Brainstorming
There are a number of touch points in this system where this breakdown is evident and there are multiple dimensions to the challenge. While some challenges lead to a broken bond, some are a result of it. We used various methods like card sorting, analyzing the broken bonds and brainstorming solutions around it.
Generating Concept Cards
We generated concept cards around each challenge by using various methods such as card sorting and exercises such as Round Robin.
Prototyping Concept Ideas
These are some of the concepts to help the ANM's better maintain, track and record the beneficiary details for vaccination.
1. Arm band
The armband will be worn by the beneficiary or the child. The arm will have the information of the beneficiary which will help the ANM to track the identify the beneficiary information and give vaccination accordingly. The ANM will have a smart device through which the ANM will access the information. She will manage and update the information with the help of the smart device.
2. Due List Register
The ANM has to fill and record lot of register, while giving vaccination to the beneficiary. A lot of her crucial time is consumed while managing all the folders, registers and beneficiary cards. A due list folder will help her better organize the her documents and register saving her time while giving vaccination to the pregnant women and children.
3. Taveez Stickers
The ANM has to fill and record lot of register, while giving vaccination to the beneficiary. A lot of her crucial time is consumed while managing all the folders, registers and beneficiary cards. A due list folder will help her better organize the her documents and register saving her time while giving vaccination to the pregnant women and children.
ANM monitoring the track records
Of the many problems in the NHM program, I focused on the problem of the ANM tracking and maintaining the health records.
Tracking recipients due for immunization is a fundamental activity of the FHWs on the day of immunization. In order to identify which recipient is due for what vaccine type and dose, the ANM generally refers to her MCH register. However, there are many challenges that have been observed with respect to the utility of the register for efficient tracking of recipient information.
The registers are too large and ANMs often find it difficult to locate specific recipients in her register, as the search criteria is sometimes inadequate or wrong. The health card also fails to assist the ANM in tracking relevant recipient information, as the serial number on the card is often not filled or does not have any correlation with the entry in the register. Name of the recipient and the father’s name are commonly used as the search criteria. However, recipient names are sometimes observed to change from the name they have been registered with, in which scenario the ANM is unable to track the right information from her register. Sometimes both recipient names and the father’s names are found to overlap, as a result of which the ANM finds it difficult to distinguish and assess the right dose due for individual recipients.
Challenges ANM face for monitoring records
It has been observed that the task of record keeping is perceived as burdensome and time-consuming by the ANMs, due to the multiple registers they are required to update, and innumerable and redundant data fields within each.
Sometimes when there are many recipients waiting at the site, the ANM does not update her records immediately after administering vaccine to each recipient, but carries out all record keeping tasks at the end of the session. This may lead to her making wrong entries and mixing up information of different recipients.
It is difficult to travel to villages with the vaccinations as they are remotely accessible.
A Mobile Application for the ANMs
The most tedious and the challenging job for the ANM is the maintain the records of the beneficiaries. Hence an application for the ANM which will help to maintain patient records.
Information Architecture
Prototype Link
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About MCTS
Mother & Child Tracking System (MCTS) is a centralized web based application for improving delivery of health care services to pregnant women and children up to five years of age through name based tracking of each beneficiary and monitoring service delivery.
