Triggering Synergies Between Demand & Supply in Government Health Systems in Uttarakhand

The burden of iron deficiency linked anaemia among women in India is well recognized, as is the importance of combating this, particularly among pregnant women. Prevalence of anaemia in pregnant women in India while on the decline, is still at an alarming 50.3% according to National Family Health Survey (NFHS-4). NFHS-4 data observes that nationally about 26% pregnant women consumed 100+ IFA tablets during their pregnancy, while in Uttarakhand 24% pregnant women consumed 100+ IFA tablets. Despite initiatives such as the National Iron Plus Initiative (NIPI) by the Government of India, uptake of IFA supplementation has not increased significantly.

Digital Green’s community-based video approach has been trying to ensure social behaviour change in the health and nutrition domain. A short video in the local language that dramatizes the best practices related to specific behaviours are more accessible to communities and These videos are created bearing in mind local taboos, myths and traditional practices that are contrary to scientifically proven best practices. The community videos are a blend of correct messaging coupled with examples of positive deviance from the community resulting in social behaviour change.

However, to ensure adoption we need to address gaps in both the demand as well as supply. There are several factors that need to come together in perfect synchronization for this. On the demand side, it is well documented that social taboos related to consumption of IFA tablets, augmented by the side-effects of consuming it (including nausea and vomiting) are most prominent. On the supply side, various studies have revealed bottlenecks including procurement, storage, and lack of personnel are a few.

Digital Green’s Project Samvad, funded by USAID, aims to improve family planning, maternal child health and nutritional outcomes in 6 states of India, namely, Bihar, Chhattisgarh, Jharkhand, Odisha, Assam and Uttarakhand.

In June 2018, Digital Green initiated a partnership with the National Health Mission Uttarakhand (NHMUK) to implement this project in the aspirational districts, Haridwar and Uddham Singh Nagar.

Project Samvad targets beneficiaries by exploring platforms that have a high proportion of women in the reproductive age group and 1000-days period. We found one such platform that is effective in reaching the target audience in Uttarakhand to be the Village Health Sanitation and Nutrition Day (VHSND) that is conducted at the local Anganwadi centre. It is an initiative by the Government of India – focusing on improving maternal and child health and nutrition outcomes. VHSNDs are observed once a month and attended by an Auxiliary Nurse Midwife (ANM) who administers a health check-up and appropriate vaccination to the children and pregnant women. The beneficiaries are also provided information and counselling about family planning and the commodities are also distributed here.

At one such VHSND on September 8th 2018, Devi, 26, pregnant for the first time was advised by the ANM to consume IFA supplements. However, the stocks with the ANM had expired and she had not received the new batch yet.

At the next video dissemination when the ASHA worker showed the beneficiaries a video on the importance of IFA tablets, Devi described her situation. We took note of this gap in supply and the importance of addressing it urgently to achieve impact through this project. To understand the bottlenecks on the supply side, we conducted a mapping exercise with the National Health Mission (NHM) officials. This exercise gave us a clearer picture of the supply of commodities such as IFA and calcium supplements, ORS and family planning methods in the area. Through this mapping, we discovered that the supply of IFA tablets in the area was truly dismal. This supply-side mapping also became a criterion for identifying the villages where we would implement the program.

We interacted with Government officials at the state, district and block level at every possible platform to discover a quick and sustainable solution. Based on our findings from the mapping exercise, we had a discussion with Mission Director, NHM who shared that they were already aware of the issue and were working on improving the supply. He shared that they had also already allocated funds for the block administration to buy some of the required stock from the market until the government supply was restored. We then discussed this with the Chief Medical Officers (CMOs) of Haridwar and Uddham Singh Nagar.

Our first breakthrough in this situation was when after multiple discussions with our team the Medical Officer of the Bahadarabad block in Haridwar, used their available budgets to get the supply of IFA tablets from the market, ensuring that appropriate stocks were maintained at the areas where our videos were shown. This ensured that we were able to build demand through our videos and our partners were supporting it by ensuring regular supply, thus ensuring sustainable behaviour change.

In addition to the dialogue with the Government partners, we continued working with the ASHAs to continue the dissemination of videos that emphasise the importance of consuming the IFA tablets and convincing the beneficiaries to buy the required stock of IFA tablet from local pharmacies as well. ASHAs also discussed alternative sources of iron supplementation through dietary intervention that are highlighted in the Samvad videos.

Manjeet Kour, an ASHA in Sitarganj block, of Udham Singh Nagar district shared, “A beneficiary shared with me how she bought the IFA tablets from the market following a video dissemination. She said that she had understood the importance and urgency of consuming IFA tablets.” Manjeet Kour disseminated the video and initiated discussions to make sure the women are convinced about consuming it.

“Many women had misconceptions and reservations about having the IFA tablets and even when they wanted to consume it they would not unless they were given the tablets by the ANMs or ASHAs. So I convinced them (beneficiaries) to buy it, when possible, from the market for the sake of their own and their babies’ health,” added Manjeet.

When we see such dedication to the overall objective of improving health outcomes we’re convinced that the impact is achievable. We see communities come together and discuss these issues in a group and they want to adopt these improved practices. This in itself is impact. The government partners too, are making an effort to bridge the obvious gaps in supply by collaborating with development partners to identify specific needs.

These may be only initial steps towards bridging the demand and supply gaps. But we feel that such efforts will go a long way to bring together the beneficiaries, the government and social organizations to make a lasting social behaviour change.

Natural Farming Yields a Debt-free Future

“It’s the end of the world,” said the caterpillar! 

“It’s just the beginning of the world,” said the butterfly!

– Author Unknown

I have seen that butterfly’s optimism in a farmer from a small village, Nandivelugu of Guntur district, Andhra Pradesh, India and it reaffirms my belief in the promise of natural farming and our farmers’ spirit and resilience!

There are many worlds within our world; for 30-year-old Arisetti Naga Malleshwari her world is 60 cents (0.6 acre) of her family-owned land and an additional 20 cents (0.2 acre) that is rented. Natural farming has made a world of difference to her small world.

Naga Malleshwari’sfather, Chandu Sambashiva Rao.

Mired in chronic debt over ten years of conventional farming, Naga Malleshswari and her husband Panduranga Rao decided to change the way they practised agriculture and adopted zero-budget natural farming(ZBNF) in the Kharif season of 2017. Inspired by her father, Chandu Sambasiva Rao who is growing five varieties of paddy landrace (native varieties) in Aathota village on a meagre 20 cents of rented land. He did this with support from the Andhra Pradesh Department of Agriculture and Cooperation (DoAC) & Rythu Saadhikaara Samstha (RySS)’s cluster activist, Ms Parishudda Kumari. After learning science and practices of natural farming by watching Digital Green community videos, Naga Malleshwari practised all important natural farming practices in Paddy, Jowar, and Colocasia.

Initially, Naga Malleshwari was filled with doubt due to the ridicule from her fellow farmers. But when she had harvested 18 bags of paddy from the 60 cents of land in November 2018, all her fellow farmers were convinced. The cost of cultivation in conventional farming (approx.. Rs. 10,000) was reduced (to Rs.4,000) in natural farming. Application of natural fertilizers and pesticides not only yielded a bumper crop, but it also ensured quality and healthy growth of crops. “I am yet to sell the paddy but the buyers are offering Rs.2,000 per bag; a profit of Rs. 200-400 per bag of the conventionally grown crop,” she shared with pride.

Naga Malleshwari follows all ZBNF practices meticulously.

After harvesting paddy, she sprayed cow dung-cow urine-asafoetida extract on the empty land as a precautionary practice to eliminate any residual fungi before planting Jowar (sorghum) in the Rabi season. She followed all ZBNF practices for the Rabi crop as well. Seed treatment with Beejamrutam, Ghanajeevamrutham application, spraying of Dravajeevamrutham and neem seed kernel extract and installed pheromone traps to monitor pests.

She shared that conventional methods of farming Jowar involve heavy usage of urea which results in higher levels of plant and weed growth during the grain formation stage, in turn resulting in lower yields. She is expecting higher yields and higher prices from the Jowar crop this time – (nearly 15 quintals that may fetch Rs.15,000) while the cost of cultivation was approx. Rs.1,000. On the 20-cents of rented land, Naga Malleshwari cultivated Colocasia using the ZBNF practices. Now, with reduced cultivation costs and higher yields, her net income was Rs.14,000, which is more than double the Rs.5,000 – 7,000 she used to receive.

“We have been debt-free since last two years,” shared Naga Malleshwari. “I am also growing several types of vegetables in my kitchen garden using the ZBNF method, which is sufficient for household consumption.” “I grew broad beans on paddy bunds during the last season,” she added. She was conscious of the health and nutrition benefits of consuming natural farming produce for her family of five members.

When almost all curry-leaf plants in her neighbourhood were affected with powdery mildew disease last summer she convinced all her neighbours to spray sour buttermilk on the plants –  the practice was effective, and this marked Naga Malleshwari’s first step in spreading ZBNF practices among her fellow farmers. As a Community Resource Person (CRP), she supported many paddy farmers in her village in the adoption and practice of natural farming in the Kharif season of 2018.

“I have attended several video disseminations on ZBNF and I interact regularly with resource persons to further build my understanding of natural farming,” she shared.

Change is slowly coming full circle in Naga Malleshwari’s natural farming journey. She began as a farmer merely practising natural farming, and is now playing a leadership role in supporting and encouraging her fellow farmers to adopt and practice natural farming. I am sure that Naga Malleshwari will continue to create many more circles of inspiration in her farming community!

How Samvad Project’s Video-based Intervention in Jharkhand is Addressing Supply Side Gaps

30th October 2018 remains a memorable day for the men and women of a small village barely 100 kms from the capital of Jharkhand, Ranchi. On that day, armed with new knowledge they sat across the table with the Block Medical Officer to demand healthcare services particularly for 4 pregnant women, 10 lactating mothers and 10 children below 3 years of age.

“We gained knowledge about the health services provided by the government health system from videos shown by Parvati Devi (Community Mobilizer) in the anganwadi centre,” shared Dulari Devi, who has just delivered a child. She was able to get 2 Antenatal Check-ups (ANC) since the Anganwadi Nurse Midwife (ANM) resumed the services in Shijhua village, Tatijharia block of Hazaribagh district in Jharkhand.

The village now has regular Village Health & Nutrition Days (VHNDs) with an ANM in attendance, 2 beneficiaries have registered, services like scheduled check-ups during pregnancy, TT vaccine and distribution of IFA is now regular. The village has had 2 cases of Institutional delivery and 10 children have received immunization during the last quarter.

Digital Green’s Project Samvad, funded by USAID seeks to improve knowledge and awareness about health and nutrition among pregnant and lactating women and children under 2 years of age as well as the full range of family planning methods among the rural agrarian communities of 6 states in India, including Jharkhand.

Digital Green is working with MKSP PIA-Srijan , a local NGO in the Hazaribagh district of Jharkhand, that has been supporting the implementation of the Samvad project on the ground since July 2018.

The project blends health and nutrition messages with agriculture messages through community videos. For example, the nutri-garden intervention which is promoted to ensure the community is growing their own fruits and vegetables in their backyard using the wastewater and other materials to irrigate and create compost. This ensures they get the necessary nutrition through a diverse diet.

The community is also shown videos about services that the government health systems provide and the importance of availing those services, thus motivating them to further demand those services.

This project is being implemented in 35 villages of Ichak and Tatijharia Block of Hazaribagh district in Jharkhand.

In the neighbouring Shayalkala village of Ichak block, a hamlet, named Mammarak had never been visited by an ANM or received any government health services. The community lacked awareness on health issues. When videos of Project Samvad were disseminated in the hamlet community members started paying closer attention to the information shared.

“Very recently a family in our village had lost a mother and child immediately after delivery. After watching the videos, we understood that this had happened due to lack of proper care during pregnancy,” shared Baby Devi, who has watched all videos shown in the hamlet since the project intervention began.

The Community Mobilizer (CM), Chanda Devi, who mediates the video dissemination encourages a diverse and healthy discussion at the end of the video to gauge the grasp of the video among the community members and motivates them to identify any gaps in the supply of service and demand for it.

“After watching the videos under project Samvad, the community members understood the importance of the best practices promoted including Diet Diversity During Pregnancy, Importance of ANC checkups, Danger Signs During Pregnancy, IFA tablet etc. and met with the Mukhiya (village head) to discuss the gaps they had identified,” shared Chanda Devi. The Mukhiya further wrote to the Block Medical Officer requesting that the Village Health and Nutrition Days (VHNDs) be started and held regularly in their hamlet too. “The Mukhiya too started attending every video dissemination along with the Ward Member (local elected representative) and motivates the community to avail the facility being rendered during the VHNDs,” adds Chanda Devi.

Breaking barriers around IFA supplementation for pregnant women through videos


Sohini Banjare, a Mitanin Trainer in Ambargarh Chowki block, Rajnandgaon, Chhattisgarh has been advocating regular consumption of Iron Folic Acid (IFA) tablets by pregnant women for years. “The side-effects of the iron supplement and the stigma related to having any medicine during pregnancy has been a big barrier to my work,” shared Sohini.


She recalls one particular case from 2017 to demonstrate this. “Sangeeta Mandavi belonged to a loving and supportive family in Thetwar Lanjhiya and was expecting her first child. When I came to know about Sangeeta’s pregnancy, I visited Sangeeta’s house,” recalled Sohini.


A Mitanin’s visit to a pregnant woman typically involves counselling the woman about her health, update her on the government schemes and entitlements and remind her of the check-ups she must get. These visits are also meant to keep a check if everything is alright in this delicate stage; ensure she is getting adequate rest and optimum diet but most importantly, to ensure she is consuming the IFA tablet regularly, which goes a long way in ensuring the health of the mother and her child.

Sangeeta’s husband and in-laws were very supportive and assured that they would take good care of her and Sangeeta herself assured Sohini that she’s taking the IFA tablets regularly.


“One tends to think that it’s easy to pop a pill which ensures good health for the mother and child. However, women often discontinue it due to the side effects such as vomiting which accompany it in the initial days until the body gets used to it,” shared Sohini.



“Closer to her baby’s delivery, a neighbour’s child playing in Sangeeta’s room was seen with some tablets. Soon her family discovered a heap of IFA tablets discarded under her bed,” shared Sohini. “It turned out that Sangeeta had been throwing away the tablets under her bed as she could not bear the side effects when she initially started taking the tablets,” she added. Sangeeta had hidden this from her family fearing that they may insist on her having the medicine. A week later, Sangeeta delivered a low birth weight baby (2 Kgs) and faced a lot of weakness herself.


In January 2018, Digital Green entered into a partnership with the State Health Mission in Chhattisgarh under its USAID funded Samvad project. The project seeks to address Family Planning, Maternal Child Health and Nutritional goals through a participatory approach, using locally relevant content created by, of and for the communities. The program is being implemented on a pilot basis across 2 districts of Chhattisgarh, namely Rajnandgaon and Kawardha, through the State Health Resource Centre. Digital Green trained Mitanin Trainers (MTs) to produce and disseminate the videos using pico projectors. These MTs have reached nearly 41,000 women (up till Dec 2018) with community videos on themes such as IFA supplementation, Complementary feeding, Diarrhea management and Family planning messages.



In March 2018 Sohini received training on video-based approach from Digital Green. The Mitanin Trainers were also given a pico projector to disseminate videos on various health topics to improve awareness of the community. The Mitanin Trainers would use these new tools to bring all pregnant women and new mothers together to disseminate these videos.


In April 2018, Sangeeta was pregnant the second time and Sohini made it point to invite her to the dissemination of video titled – Importance of IFA tablet. The video illustrated in great detail a woman’s hesitation in eating the supplementary iron tablets due to the side effects in a dramatic and emotional manner. After the video was shown, Sohini invited Sangeeta to talk about her experience of taking the tablet and then discontinuing it. Sangeeta shared her struggle with the side effects and hesitation in taking the medicine and the consequent problems of having a low birth weight baby. Sangeeta resolved, “I will not make the same mistake again with my second pregnancy. I will follow all the suggestions as shown in the video to combat the side effects.” Sangeeta’s second child was born a healthy baby of 3 kgs.