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.