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How Auxillary Nurse Midwives (ANMs) in Remote Tribal Belts of Andhra Pradesh in India have brought down Maternal Deaths to Zero

With 4,000 employees in just its health vertical, Piramal Swasthya is prehaps the largest NGO in India, implementing 29 healthcare projects in 16 states.

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Akaru women, MATERNAL DEATHS
Midwifing change: How maternity deaths were reduced to zero in remote tribal hamlets. Flickr

The scenic beauty of Araku Valley in Andhra Pradesh is in stark contrast to the lives of indigenous tribespeople inhabiting the region. Living in virtual destitution, these tribals — like their counterparts scattered in remote locations across the rest of India — lack access to basic amenities like safe drinking water, healthcare and education. Till a few years ago, some of these habitations were not even covered in the national census and nobody knew they even existed.

But efforts of a leading NGO over the last seven years have yielded results in 181 habitations around Araku. This is testified by the fact that no maternal deaths have been reported here over the last two years — a giant step forward for a place where maternal mortality was double the national average.

Before emerging as a tourist destination about a decade ago, Araku, 100 km from the port city of Visakhapatnam, was an area that was the redoubt of Maoist extremists. Politicians and officials used to stay away from this forested area in the Eastern Ghats.

The population in scattered and inaccessible hamlets was suffering from malnutrition, leading to high maternal mortality and neonatal mortality rates. Some traditional practices of the tribals and deliveries at home were also contributing to this situation.

Araku, Maternal Deaths
Araku Valley is a hill station and valley region in the southeastern Indian state of Andhra Pradesh. Flickr

When the NGO Piramal Swasthya, the health vertical of Piramal Foundation, launched the Asara Tribal Health Programme in 2011, maternal mortality in this tribal area was over 400 per 100,000 live births as against the then national average of around 200.

No maternal deaths have been reported over the last two years while the percentage of institutional deliveries has risen from 18 per cent to 68 per cent. The neonatal mortality rate too has come down from 37 to 10 per 100,000 live births, say the officials of Piramal Swasthya.

The agents behind this change are Auxillary Nurse Midwives (ANMs) like P. Padma who toil selflessly to help the pregnant women in these remote hamlets. The 27-year-old has been working with the NGO for six years and has attended about 3,000 women. She has seen the transformation.

“The situation in the tribal hamlets was pathetic as women were reluctant to come to hospitals for delivery. A major reason for this was the superstition among tribals. Piramal Swasthya has removed the superstitions and motivated the women,” Padma told IANS.

Padma travels 12-13 km in a four-wheeler and, when the road ends, she goes on a bike driven by a “pilot”, covering another 11 km. When this narrow path also ends, she hikes across mountains and valleys for another 12-13 km to the last habitation of Araku.

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A Native Women From Araku. Flickr

This is what she does every day, explains Vishal Phanse, Chief Executive Officer, Piramal Swasthya.

Once in the habitation, the ANM identifies every pregnant woman, conducts basic tests, provides counselling on healthy practices and fixes an appointment for consultation with a specialist at the telemedicine centre. The next day, a four-wheeler is sent to pick up all pregnant women registered and get them to the telemedicine centre, where an expert gynaecologist sitting in Hyderabad provides the consultation through teleconferencing. Free medication, along with nutrition supplements, is also provided to the expectant mother and she is then dropped back to her habitation.

“If a woman can’t walk we arrange ‘palki’ (a kind of palanquin) to bring her till the four-wheeler to take her to the telemedicine centre,” Padma said. Last month, a woman delivered a baby on the palki in Colliguda village. She helped the woman and later safely transported her and the newborn to the hospital.

ANMs support the women and children through their pregnancy, child birth and neonatal period while keeping the government machinery in the loop.

Piramal Swasthya overcame all odds to achieve its goal of ending preventable deaths in 181 habitations, serving 49,000 pregnant women.

Adding some more interventions like training traditional birth attendants and health education of adolescent girls, it is now expanding the programme across 11 “mandals” or blocks comprising 1,179 habitations in the tribal belt of Visakhapatnam district to reach 2.5 lakh population.

It is currently running six telemedicine centres and plans to add five more. The NGO will also be opening two more community nutrition hubs in addition to existing one, where women are educated about a healthy and nutritious diet and trained in the use of traditional and locally available food items.

Araku ,women, maternal deaths
No maternal deaths have been reported over the last two years while the percentage of institutional deliveries has risen from 18 per cent to 68 per cent. Flickr

Based on the learning in Visakhapatnam, the NGO wants to create something which can be replicated in the entire tribal belt of India. More than 10 percent of India’s population is tribal and among them maternal mortality is two-and-a-half times the national average.

“If what works in Araku, works in Visakhapatnam, then we can replicate it in the entire tribal belt of the country,” said Phanse.

Niti Aayog, India’s policy think-tank, is looking at this model with key interest as to how they can scale it up.

“In fact, a lot of people including the United Nations, governments in states and at the Centre are looking at it. We had a lot of visitors trying to understand how we managed to do this. We ourselves are learning every day. Technology is a great enabler if you have to scale it up at the national level.”

Phanse believes that 80 percent of what worked in Araku can be replicated in tribal areas across the country and 20 percent could be local customisation that they have to work on.

What worked for Piramal Swasthya in Araku? “We have doctors, public health professionals and experts with the youngest aged 26 and the oldest 78. That’s the kind of expertise we have with actual feet on the ground. Our actuality to work with them, for them, staying with them and understanding them is what I think has worked best for us,” said Phanse.

Akaru women, maternal deaths
ANM’s support the women and children through their pregnancy, child birth and neonatal period while keeping the government machinery in the loop. Flickr

“If you want make anything sustainable in healthcare you have to create health seeking behaviour in the community. We were successful because we changed the community,” he added.

Phanse feels that the community engagement and participation in the programme is key to its success.

For Piramal, winning the trust of the local community was the key challenge. As Araku was an extremist stronghold, gaining the trust of locals took time.

Most of the 38 people that work for the organisation are from the local community who are wedded to the cause. Forging the local partnership by using the services of dedicated individuals who can speak the language of the community ensured smooth implementation.

Also Read: The Plight of India’s Homeless Women Increases As Cities Expand

With 4,000 employees in just its health vertical, Piramal Swasthya is prehaps the largest NGO in India, implementing 29 healthcare projects in 16 states.

India ranks 131 among 188 countries on the Human Development Index (HDI) 2016 released by the United Nations Development Programme (UNDP). India was placed behind countries like Gabon (109), Egypt (111), Indonesia (113), South Africa (119) and Iraq (121), among others. The government is working towards improving this rating by creating competition between states to perform better on key social indicators like infant mortality rate, maternal mortality rate and life expectancy. (IANS)

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To Catch Up With China, India Needs To Focus on Improving Its Educational Outcomes

China reached a 100 percent gross enrollment rate (GER) in its primary education in 1985, whereas, India attained that level only in 2000.

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Children learning in a classroom, pixabay

By Amit Kapoor

Both China and India started building their national education systems under comparable conditions in the late 1940s. Different policies and historical circumstances have, however, led them to different educational outcomes, with China outperforming India not just in terms of its percentage of literate population and enrollment rates at all levels of education, but also in terms of number of world-class institutions in higher education, and greater research output.

The roots of China’s successful education system date back to the Cultural Revolution (1966-1976), which unintentionally expanded access to the primary education through democratising the schooling system, which was previously elitist in character, thus addressing the problem of mass illiteracy.

In contrast, India continued to focus on its higher education system since independence and only realised the importance of basic education in 1986, keeping it behind China and many other countries in Asia in educational development. In terms of enrollment, China reached a 100 percent gross enrollment rate (GER) in its primary education in 1985, whereas, India attained that level only in 2000.

In terms of secondary school enrollment, India and China both started at the similar rates in 1985, with about 40 percent of their population enrolled in secondary schools. However, due to a wider base of primary school students, the rate of increase in China has been much faster than in India, with 99 percent secondary enrollment rate in China and 79 percent in India in 2017.

Happy kids in School Uniform
China reached a 100 percent gross enrollment rate (GER) in its primary education in 1985, whereas, India attained that level only in 2000.

India is closing in on the Chinese rate in terms of access to education, but on the literacy level front, there is a huge gap in the percentage of literate populations in the two countries. In the age group of 15-24 years, India scores 104th rank on literacy and numeracy indicator, compared to China’s 40th rank.

The OECD Programme for International Student Assessment (PISA), which assesses after every three years the domain knowledge of 15-year-old students in reading, mathematics, science and finance, revealed that students in China performed above the OECD average in 2015. Moreover, one in four students in China are top performers in mathematics, having an ability to formulate complex situations mathematically. Further, China outperforms all the other participating countries in financial literacy, by having a high ability to analyse complex finance products. For India, the comparable data is not available as it was not a participating country in PISA 2015.

However, in India, the Annual Status of Education Report (ASER) 2017 provides data for rural youth, aged 14-18, with respect to their abilities to lead productive lives as adults. According to this survey, only about half of the 14-year-old children in the sample could read English sentences, and more than half of the students surveyed could not do basic arithmetic operations, like division. For basic financial calculations, such as managing a budget or making a purchase decision, less than two-thirds could do the correct calculations.

India
Schools in India

With regard to the higher education system, both India and China dominate the number of tertiary degree holders because of their large population size, but when it comes to the percentage of the population holding tertiary degrees, only about 10 per cent and 8 per cent of the population possess university degrees in China and India, respectively. By contrast, in Japan, almost 50 per cent of the population holds a tertiary degree, and in the United States, 31 per cent of the population hold a tertiary degree.

In terms of the international recognition of universities, the Times Higher Education (THE) World University Ranking for 2019 places seven of the China’s universities in the top 200, compared to none for India. The global university rankings, which are based on various performance metrices, pertaining to teaching, research, citations, international outlook and industrial income, shows progress for several of China’s low-ranked universities, largely driven by improvements in its citations.

In fact, the Tsinghua University has overtaken the National University of Singapore (NUS) to become the best university in Asia due to improvements in its citations, institutional income and increased share of international staff, students and co-authored publications.

While India has progressed in terms of massification of education, there is still a lot which needs to be done when it comes to catching up with the China’s educational outcomes. China’s early start in strengthening its primary and secondary education systems has given it an edge over India in terms of higher education. Moreover, Chinese government strategies are designed in line with the criterion used in major world university rankings, especially emphasis is on the two factors which weigh heavily in the rankings — publications and international students.

Also Read- The Government Shutdown in Washington D.C

The relentless publications drive, which is very evident in China, is weak in India and has led to a growing gap in the number of publications contributed by the two countries. Further, China enrolled about 292,611 foreign students in 2011 from 194 countries, while India currently only has 46,144 foreign students enrolled in its higher education institutions, coming from 166 countries. The large number of international enrollments in China is a reflection of its state policies granting high scholarships to foreign students.

To catch up with China, India needs to lay emphasis on improving its educational outcomes. Massification drive for education has helped India raise its student enrollments, but a lot needs to be done when it comes to global recognition for its universities. Further, it needs to focus on building the foundation skills which are acquired by students at the school age, poor fundamental skills flow through the student life, affecting adversely the quality of education system. (IANS)