“Of course households do not want to share their health problems with me. But they can only shoo me away the first two times. When I knock the third time, they invite me in,” says Vaishali Tarade, a volunteer working in Dharavi.
Dharavi is widely believed to be Asia’s largest slum – it is home to more than a million people. Some might describe it as an eyesore and the stench from its open sewers is certainly overwhelming. But Dharavi’s thriving businesses and resilient inhabitants offset the grave public health concerns posed by its open drains.
Vaishali is one of 700 volunteers from Aahar, the flagship nutrition program at the Society for Nutrition, Education and Health Action (SNEHA). SNEHA is a Mumbai-based non-profit that works on maternal, new born and child health and nutrition in Mumbai’s urban slums and low-income communities.
Aahar, which translates to food in English, began in 2009 with just two-day care centres with 20 children each. Today, the program works with the Integrated Child Development Services (ICDS)which runs 150 anganwadisor child care centres in Dharavi and Wadala. ICDS is a government run program that provides food, preschool education and primary healthcare to children between 0-6 years and their mothers.
Every fourth child in the 10 most populous Indian cities has stunted growth. Malnutrition often manifests through three conditions – underweight (low weight-for-age), stunting (low height-for-age) and wasting (low weight-for-height). All three conditions have a lasting impact on a child’s health, stifling their ability to live healthy and productive lives. According to SNEHA’s survey in Dharavi in 2016, the prevalence of wasting was 18% and stunting, 24% amongst 0-3 year olds.
Mumbai continues to face daunting challenges to overcome these issues. The sprawling city is acutely short of space and its poor are often crammed into dingy homes in crowded neighbourhoods. There are fewer primary health centres and hospitals than they need; and there are more delays in funding than the malnutrition schemes can withstand. The system of supply-and-demand that sustains healthcare in India is skewed. Historically, successive governments have invested too little in healthcare. Coupled with that is poverty – people cannot demand healthcare that they cannot afford. This is why we need a complex yet innovative solution – one that involves public-private-partnerships between the government, the private sector, local communities and NGOs. But neither the government nor the private sector can simply inject money for building better public health infrastructure. Rather communities must demand quality healthcare.
There is a need to drive “systems change” – a social development approach that seeks to fix broken systems at scale by bringing relevant stakeholders – local communities, non-profits, governments, corporates and donors, together. In 2017, the Rockefeller Foundation launched Co-Impact, a $500 million global collaborative fund to invest in “systems change”.
Steve Waddell, a researcher who has worked for over 30 years on systems change and transformation recently introduced a frameworkin the Stanford Social Innovation Review that discusses the different strategies prompting “systems change”. According to the framework, the four basic approaches – “Doing Change”, “Co-creating Change”, “Forcing Change” and “Directing Change” are often adopted by organizations as they evolve.
The Evolution of Aahar
During its initial years, Aaharfocused on early screening, treatment, home-based care and behaviour change communication to increase the awareness of healthy practices for pregnant mothers and new-borns. The program was delivered through Community Organizers (COs) – SNEHA’s field staff. The COsplayed a critical role in ensuring ante-natal and post-natal care for pregnant and nursing mothers, immunization of new-borns and distribution of supplements to reduce maternal and child mortality.
The program model mirrors the work of the ICDS – its own frontline workers, the sevikas, also work to reduce malnutrition in Dharavi. Aaharinvolves government field staff in its own activities and even trains the sevikas to build critical response skills for healthcare delivery. COs and sevikasvisit children with symptoms of malnutrition and conduct follow up visits to educate mothers on hygiene and nutrition. Mothers are urged to take children to aanganwadis every monthto have them weighed.
SNEHA exhibits Waddell’s “doing change” and “co-creating” approaches through its program which seeks to bridge gaps between the government, public healthcare system and civil society. This approach to tackle healthcare challenges echoes the non-profit’s goal to create better referrals between aanganwadis, urban public health centres, community health centres and tertiary hospitals to enable quality care.
Referrals are critical as they are a step towards the institutionalization of a cohesive healthcare model in India – a woman who approaches an aanganwadi in her slumshould be able to approach the right doctor at a tertiary hospital close to her to receive the care she needs. The program focuses on not just actively implementing an intervention to reduce malnutrition but also on collaborating with the government to instil the willingness to work together to achieve a goal. Sustainability lies at the heart of it.
“This support from SNEHA has led to a strong relationship between the community andsevikas. Today, the mothers in Dharavi and Wadala are aware of the closest aanganwadi center and the dietary precautions to take during pregnancy”, said Rajesh, SNEHA’s community organizer.
This transformation came with its own challenges. There was a time when aanganwadi sevikasand Community Organizers (COs) disagreed over something as innocuous as who should carry the weighing scales. Since SNEHA painstakingly developed a strong relationship with the community on its own, the sevikaswere unsure of their role. But SNEHA anticipated this challenge and overcame it by training its own staff. “We had several vision building workshops through SNEHA that helped us collaborate with the sevikas.We were always urged to think bigger and envision what a successful handover of the intervention to the government would mean to our communities”, added Rajesh.
SNEHA also facilitates monthly knowledge sessions on Dharavi’s most crippling challenges – tuberculosis, malnutrition and cancer. This helps inform the conversations that community organizers, sevikas, and volunteers have with the community.
SNEHA was able to do this through a two-pronged strategy – it worked with communities to increase “health-seeking behaviour” which in turn increased the demand for the access to healthcare and strengthened healthcare delivery by engaging local government stakeholders such as aanganwadiworkers.
Aahar directly served 37,480 children and pregnant women, trained 300 aanganwadi sevikas,30 ICDS supervisors and Child Development Project Officers through 100 training sessions. It led to a 23% reduction in wasting and a 31% increase in the use of services offered by ICDS in 4 years.
Although SNEHA planned to roll out Aahar simultaneously across 10 beats* of Dharavi, it was done so in phases during its first year – three beats in the first quarter, two in the second and the rest followed gradually. This allowed SNEHA to learn from each phase, work through challenges and reinvent the wheel. The model was improved and adapted to serve the needs of the community.
Aahar demonstrated that a deeper integration of the community with the ICDS and Municipal Corporation of Greater Mumbai’s public health care services can reduce malnutrition. It strengthened referral systems and bridged the gap between healthcare supply and demand in Dharavi. Supporting government systems and training frontline workers is the most critical element of this intervention – it points to SNEHA’s commitment to a lasting “systems change”.
SNEHA has been able to “force change” by Waddell’s logic as it worked to influence the stakeholders by advocating for better quality of healthcare. It worked with the government to ensure that its intervention was a success on the ground and built the capacity of government staff – a win-win for both.
SNEHA also recognized the importance of creating a model that is self-sustainable – the ICDS and Municipal Corporation of Greater Mumbai (MCGM) are better equipped to take the model forward. Aaharwas also resource heavy as SNEHA’s field staff were implementing the program on the ground. There was the need to gradually move away from implementing to supporting the government to do so.
A step towards sustainability
In April 2016, SNEHA, ICDS and MCGM formally agreed to tackle malnutrition in Dharavi together. Aaharbegan to move away from direct implementation to an indirect intervention– a model that focuses on leveraging the relationships built over the last four years coupled with building community ownership to hold the government responsible. The indirect intervention, Aahar 2.0,is mobilizing communities in Dharavi to demand these services and constantly improve them through building a strong volunteer force. Volunteers like Vaishali are knocking on doors every week to share their knowledge from training sessions offered by SNEHA.
“While the first phase of Aahar focused on Dharavi, Aahar 2.0will use the learnings from Aahar in Dharavi and Wadala, a neighbouring community with malnutrition levels comparable to Dharavi. SNEHA’s focus will move from implementation to sustainability – the community needs to demand that the ICDS and MCGM deliver”, said Anagha Waingankar, the Associate Program Director of Aahar.
“We want our community to benefit from ICDS services. We want more aanganwadisin our communities. Pregnant and nursing mothers hesitated to visit hospitals because the referral systems were weak – they often commuted for hours and ended up in hospitals with no doctors”, an Aahar volunteer.
Tabassum said home visits by Community Organizers and follow-up visits from volunteers like her helped Dharavi’s women learn about nutrition requirements during pregnancy – such as what rations to take home and how to keep iron and vitamin levels in check.
“SNEHA has given us a voice in our community, added Vaishali. “Our lives were confined to the four walls of our home in Dharavi. Today, we have the opportunity to learn about nutrition and health and educate our community to demand these services. I used to be very shy when I first joined but as a volunteer, I am more confident and outgoing”, she added.
Aahar 2.0 also plans to create “Community Action Groups” that will advocate for specific health issues. Today, SNEHA is “forcing change” by gathering communities to express their demands for healthcare publicly.
SNEHA’s success can be attributed to its strong community mobilization and the passion and dedication exhibited by its volunteers and staff. Volunteers like Vaishali are dedicating time to families in urban communities to discuss healthcare needs – their energy, enthusiasm and persistence to serve their community is “directing change”.
Waddell states that these strategies often guide the development of resilient societies, paving the way for “systems change”. This is evident in SNEHA’s intervention as its vision is instilled in everybody from its senior leadership to its volunteers, and finally within the community as well – people’s homes are often converted to aanganwadisto ensure that healthcare needs are not compromised.
After all, space is not sacred in Dharavi.
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