Objective="Using Innovative Technology for Effective Mechanism in public health facilities"
Details for Reform Option "Mera Swasthya Meri Aawaz- (MS,MA)"
The Mera Swasthya Meri Aawaz (MS, MA) project was designed to test whether an existing open-source software platform could be adapted and successfully used to increase the documenting of demands for informal fees for maternal health care services that, by law, should be free.
SAHAYOG has been mobilizing rural women to organize around their entitlements in health and related social determinants since 2006, through the Womens Health Rights Forum (MSAM). Following awareness-raising sessions, these community women for years have been highlighting incidents of informal fees being demanded and consequent denial of care, for which SAHAYOG in collaboration with AMDD set up a mechanism in 2012 to report this using interactive voice response (IVR) and mobile phones.
To serve the largely illiterate population in Uttar Pradesh, the system was adapted and integrated with an interactive voice response system. The project began in July 2011 in 2 district of UP (Azamgarh and Mirzapur) later it was up scaled in 5 more districts of Uttar Pradesh in September 2013 (Banda, Chitrakoot, Kushinagar, Gorakhpur and Chandauli).
1- Set-up Technology- The system works as follows: Users call a toll free number which is connected to a phone line. An ATA device transfers the calls received to Tropo which handles the IVR operation and sends the data to Ushahidi. The information collected is mapped in an Ushahidi installation and can be viewed at: http://meraswasthyameriaawaz.org/
2- District-level Campaigning- The first step in this pilot was to make communities aware about the free services they were entitled to, and the possibility of registering a complaint in case anyone asked them to make payments. For this a campaign was developed with many kinds of materials, using pictures and simple text. The content of the materials covered included:
Information about entitlements during pregnancy and in the postpartum period under the JSSK such as free medicines, tests, blood, caesarian sections, ultrasounds, ambulance services and food while in the facility.
Information about the Mera Swasthya Meri Aawaz helpline
Instructions on how to register a complaint on the helpline including the IVRS messages and codes of the health facilities.
In addition, the MS, MA sponsored wall writing promoting the campaign, street plays and community meetings. Letters were distributed to local decision makers and meetings with local government officials, health officials and frontline health workers were also conducted so that they were aware of the campaign and the helpline.
3- District-level Launch Workshops/Dialogues-Workshops/dialogues were organized in each district to familiarize the CBOs, local women groups (Mahila Swasthya Adhikar Manch), and other community members on the status of entitlements under the JSSK scheme and launch the website and campaign with and government health officials, while sharing women’s experiences on paying informal fees.
4- Government Engagement- Throughout the project, SAHAYOG and CBOs met with government officials from the block up to the state levels. The government was included in all MSMA workshops and dialogues. In addition, SAHAYOG and CBOs initiated individual meetings with key health officials and providers (such as the Additional Director, the Joint Director, the CMO, the Dy. CMO, the Medical Superintendent, the District Programme Manager, the Community Health Mobilizer, the Health Education Officer and the Medical Officer in Charge). The pilot phase results were shared on 4th June 2013 in Lucknow, before the Additional Mission Director (NRHM-UP), Director General of the Directorate of Health & Family Welfare, the General Manager of Community Processes and the General Manager of HMIS (NRHM-UP). Two members of the NRHM national Advisory Group on Community Action (AGCA) were also present in the sharing.
Additions in the up-scale phase:
5. Engagement with the Rogi Kalyan Samiti- Since the RKS is the mandated body for ensuring accountability of the public health providers towards the community, the Ushahidi data generated will be used to encourage them to perform this crucial role by enabling them to monitor in real time, the informal payments that women are forced to make. By making this data available and constantly advocating with the RKS to initiate remedial action, a culture of demanding informal fees for maternal health services will be discouraged thereby improving the quality of service provisioning.
6. Feeding back the data to the community- The Internet website was not referred to directly by the community women in the pilot phase; it was done periodically through workshops. In this phase, regular feedback of the data to the community women is planned through a publication in simple Hindi to motivate them to continuing reporting informal payments thereby promoting a call for improvement in the quality of services.
Based on the first year of its Pilot implementation in 2 districts-
Between January 24th 2012 and May 24th 2013, the helpline has recorded 873 reports of informal payments collected at 40 district hospitals, community health clinics (CHCs) and primary health clinics (PHCs) across Azamgarh and Mirzapur districts.
In the pilot period, 31 emergency calls were made through the helpline in these 2 districts. These calls were made for various reasons – denial of admission into the facilities, demands for money for obstetric treatment, ambulance payments or maternal examinations. The results of the emergency calls were that women received medical assistance and it also alerted health officials about the particular complaint.
The total cost of the pilot was Rs. 56,40,990 which included among other things:
1. Cost of the campaign activities in 2 districts -Rs. 6,01,253.
2. The adaptation and set-up of the helpline and platform cost - Rs. 5,33,489.
Source of funding- MacArthur Foundation
Currently the project is running in 7 districts of Uttar Pradesh, detail are given below-
1-Azamgarh- Gramin Punar Nirman Sanstha, Atraulia, Contact Person: Rajdev Chaturvedi, Contact No.-9451113651
2-Mirzapur- Shikha Prashikshan Sansthan, Chunar, Contact Person Sandhya Mishra, Contact No.-9450162867
3-Banda- Tarun Vikas Sansthan, Baduasa, Contact Person: Uma Kushwaha, Contact No.-8423283073
4-Chitrakoot- Ibtada Sansthan, Contact person: Urmila, Contact No.- 9450222821
5-Kushinagar- PGSS, Contact Person: Sudha, Contact No.-9450466951
6-Gorakhpur- Baba Ramkaran Das Gramin Vikas Samiti, Contact Person Awdesh Kumar, Contact No.-8858526664
7-Chandauli- Gramya Sansthan, Contact Person: Bindu, Contact No. 9415222597
During the pilot phase, it took 3 months to set up the IVRS system which included coding health centers in 2 districts.
1. With the use of this technology, there has been a shift from anecdotal narration to systematically recorded evidence that informal payments are being demanded for free maternal health services. This has increased the value of the data as health officials in the districts and the state perceive it as being authentic. Health officials at all levels found the platform useful for supervision of health facilities
2. This technology could be used to monitor incidents where location is important but witness protection is ensured, such as incidence of violence against women or incidence of maternal deaths by frontline workers and community members.
1- In cases where redress is not immediate, the complainant does not know the
impact of their making complaints.
2- In some cases, when the people realize that their money would not be returned
even if they complain, their interest in the helpline reduces.
3- There is a fear in the community that if they complain, there will be a
backlash and so they are afraid to use their own mobile phones.
4- Some local health officials and elected council members have not taken the
helpline seriously even though they were informed about the real-time data on
5- One phone line was often busy when women were making reports. Multiple
calls at the same time, would lead to a busy signal. Women would get
discouraged from making reports if they had to make repeated calls to get
through to the helpline.
6- Too many options in IVRS were confusing. However, another option to test in
the future would be to have women leave a voice message which then could be
manually fed into the Ushahidi. The problem with this option might be that there
is no certainty that all the detail about the incident such as location, amount of
payment, reason for payment, etc would be provided by the complainant.
7- Lack of good internet connection effected the reporting.
8- Given the fact that a large proportion of the rural population do not have
access to computers, they could view the maps only when someone showed it to
1.Technology and Hardware Requirements:
The reporting system is built around Ushahidi, an open source tool used to
crowd source information from multiple sources (e.g., phone calls, SMS,
Twitter, etc.) and display the results on an interactive map. The system also
uses Tropo, an application programming interface (API) used to integrate an
interactive voice response (IVR) system with Ushahidi to collect the
information from users. The IVR component is essential to the success of the
project because many users of the system are unable to read or write.
The system works as follows: Users call a toll free number which isconnected to one phone line. An ATA device transfers the calls received to Tropo which handles the IVR operation and sends the data to Ushahidi. The information collected is mapped in an Ushahidi installation and can be viewed at: http://meraswasthyameriaawaz.org/
2.Importance of Active Citizen Engagement: It requires a level of ‘active citizen engagement’ to take the trouble to report informal payments. The mere provision of a free reporting help-line does not ensure that grievances are reported (especially since money paid out is not recovered). The presence of a rights-based organization like the Mahila Swasthya Adhikar Manch ensures that women invest in making complaints to improve and strengthen the health system, even if they do not personally benefit in any way.
3.Importance of health officials engagement:
Involving of state and district-level government officials is needed for instant responses to save lives. Merely generating data is not enough, it needs strong follow-up action by the health authorities involved. There has to be an institutional mechanism of reviewing the complaints and taking action with the staff of the concerned health centres.
4.Importance the role of CBOs: Presence strong rights-based community based organizations in the project areas is crucial. CBOs need to be involved in the project who have a strong record of working with the community and have engaged in advocacy with district level officials by providing them with evidence from the ground
Who needs to be consulted
PraveshVerma- 9235888222, firstname.lastname@example.org
Dr. Shishir Chandra-9451507178, email@example.com
Dr.YK Sandhya-09868839789, firstname.lastname@example.org
Technological innovations in the field of grievance redress alone are not
Sufficient to promote greater accountability. As experience has shown, the
presence of motivated individuals like local CBO partners in districts and an
empowered citizens group like MSAM are critical to such innovations being
used for its sustainability.
Chances of Replication
The technical parts of the project can be replicated anywhere. However for the
project to be successful it is necessary to invest in building peoples knowledge
about health entitlements, and mobilizing citizens to claim them by engaging in
regular monitoring of services and seeking redress for their grievances.
The MS,MA proved that with assistance and training, poor, rural women were
able to use mobile phones to make confidential complaints about informal
payments thus exploding the myth that illiterate women could not use modern
technology. It enabled community women to call for accountability withoutbeing victimized or punished for reporting, as it provided anonymity.
The MS,MA experience also showed that technological innovations in the field of grievance redress alone are not sufficient to promote greater accountability. The presence of motivated individuals (CBO partners) and an empowered citizens group (Mahila Swasthya Adhikar Manch) are critical for such innovations being used.
While using IT to generate data which is accepted by health providers is important, none-the-less unless we build pressure on officials (through various advocacy strategies using this data), improvements and greater accountability will not result automatically. Thus the MS,MA shows that while the generation of data on informal payments is essential, but without related official action to improve accountability, the practice of informal payments will not be stopped.
Dr. Shishir Chandra (Programme Manager) and Pravesh Verma (Advocacy andICT Officer) at SAHAYOG