The latest National Family Health Survey -5 presents sobering data on the health of India’s youngest. Eighty-nine percent of children aged six to 23 months (under two years) do not receive a “minimum acceptable diet”. In Maharashtra, the proportion is higher; only 8.9% of this age group receive adequate nutrition. Malnutrition is not a new problem for a country like ours, where dietary habits, access to basic foodstuffs and socio-economic vulnerability are problems for both rural and urban populations. Last year’s NFHS data for suburban Mumbai showed that 7.2% of children under five are severely wasted (weight-to-height ratio), 18% are wasted and 24.6% are underweight insufficient.
Since 2019, we have been working with the Foundation for Maternal and Child Health (FMCH), a non-governmental organization (NGO) that works with the poor in the cities of Mumbai and its suburbs, supporting over 50,000 beneficiaries . Field workers are trained to carry out door-to-door visits to provide the support that pregnant women, nursing mothers and children up to two years old need to stop malnutrition at its onset.
The objective of our foundation is to strengthen the capacities of NGOs. In this case, we found that the greatest support we could offer FMCH was to help them create a digital platform. Technology, we have found, can really help control widespread malnutrition in communities.
During each home visit, NGO teams should share relevant health content (e.g. good practices for maternal and child nutrition, breastfeeding guidelines, immunization schedules), as well as than conducting an anthropometry – measuring the child’s height and weight; the most important indicator of malnutrition – at specific intervals. So where does technology come in?
During series of discussions with the NGO, we helped create NuTree, a mobile application for the Android platform. The NuTree platform allows field workers to register beneficiaries and also register visits. We launched the first phase in 2020 in Bhiwandi, Kurla communities and Wadia hospital and to start with included a comprehensive decision tree for each type of visit which guided the field worker on the type of questions to ask, and also provided visual content like images and videos to help explain concepts better. For example, a pregnant woman is asked if she went for her prenatal visit (ANC). If she did, she is asked to provide more details – how many visits ended, when she went, etc. If she did not go for a check-up, she is counseled on its importance and given crucial information on where she might go. FLWs are also encouraged to ask about meal frequency and dietary diversity. They go through the NuTree questionnaire and enter data into the app, saving them valuable time.
In the second phase, launched last year, the app included decision trees for children with severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) after FMCH realized they were not had no standardized protocol for visiting and managing these cases, which was reducing the impact of their programs. As a result, they defined a protocol that ensured consistency between field workers and better quality of care: they standardized weekly visits for SAM cases and fortnightly visits for MAM cases, with detailed questions for each visit. Almost immediately, within 3-5 weeks, they were able to register improvements in the health of the recipients.
This phase also included a module allowing field workers to plan their day: everyone now had a list of visits due, by date and place, as well as late visits. Data after just four months of use showed the percentage of high-risk mothers who missed visits fell from 58% to 37%, pregnant mothers who missed anthropometric visits fell from 40% to 20% and children who missed anthropometric visits went down from 30% to 14%. FMCH found that the app enabled a field worker to manage an average of 100 additional families, a 50% increase in their productivity.
The government’s anganwadi system takes care of the health and nutrition of pregnant women, nursing mothers and children from zero to five years old in addition to several other aspects of health and education. While the system itself is vital for the long-term well-being of the community, the current structure has shortcomings, such as insufficient leadership and inadequate training of anganwadi workers to counsel mothers. Moreover, their visits require additional data entry, and tracking hundreds of mothers, children and visits adds to the burden of the anganwadi worker.
We found that implementing the right technology not only improved field worker efficiency by lightening a load, but also ensured consistency and accountability, as NGO leaders could monitor what was happening on field. While the adoption of technology cannot solve all problems, it clearly provides tools to equip our community workers and enable them to become more effective in addressing widespread malnutrition.
Rekha Koita is co-founder and director of the Koita Foundation, a philanthropic enterprise that works on the digital transformation of NGOs in the areas of livelihoods, education and health. The foundation is also working on the adoption of digital health in India and supporting the Indian government’s rollout of the Ayushman Bharat Digital Mission.