Divya Datta's presentation on the findings of the Bihar Innovation Lab. At Health Public, CKS, New Delhi.

1. The First 1000 Days: Mother and Child in Rural Bihar

2. The Effort
5 Weeks
7 Innovation Specialists
3 Districts: Begusarai, Saharsa,Kishanganj
950 + hours of field interviews, observation,
photos, videos, audios
18 + hours expert and practitioner interviews

7. Human Experiences

8. Cultural Values of Health and Protection
A Lighter is kept near the
child to ward of evil eye
An Iron Kajrota, a holder of kajal,
to ward of evil eye.
Making children wear Tabeejs for protection
is a common practice
Worship areas outside homes as
women are not allowed to enter it
during gestation and periods
Palnas for the infant are
gifted by the maternal
household to new parents

9. Green Jhola
with medicines
Vitamin A syrup
New Syringes
Zinc Tablets
Ferro Tablets
Cotton Roll
Seeing like a Designer
Non-functional
hub-cutter
Purse
Bag with new syringes
Registers
& RI cards
Pen
Vaccine Vials
Registers

10. Mapping 1000 day Health Information Needs

11. Mapping ASHA’s Mobilization Interactions

12. Labor Journeys over Multiple Deliveries

13. Diurnal Mapping of a Pregnant Woman’s Nutrition

14. Building Divergent Ideation based on Failure Cases

15. A Convergent Approach to Prioritization

16. Public Health Delivery Systems Analysis
Tools
Players
Rules

17. Systems Challenge:
Unidirectional model of Care Provision

18. 18
Limited Interactions = Limited Scope for Impact
The focus of the healthcare
service and its (FLWs) on the
health and wellbeing of the
mother and child is limited to
these periodic and narrow
interactions
Largely influence of these
interactions are limited to
looking at health and wellbeing
through the lenses of
preventive medication and
vaccines.

19. The Circle of Influence and Decision Making around the Mother

20. Who is Responsible for the Health of Mothers and Children?
‘ASHA nahi aayi bulane toh hum nahi gayi injecsion lene – uska kaam hai na’

21. Systems Challenge 4:
Cookie Cutter Care and Counselling

22. Sulekha Devi | Health Vitals
HB: 5 gms | BP: 140/100
BMI:(Height: 5:2” Weight: 42 Kgs)
Severe Edema (Swollen Feet)
6th Pregnancy
2 Miscarriages in the Past
Rekha Devi | Health Vitals
HB: 9 gms | BP: 130/100
BMI:(Height: 5:4” Weight: 50 Kgs)
2nd Pregnancy
Standard Advice from Front-line Workers to Both These and all other
Pregnant Women:
‘IFA Tablet khao’ Eat Iron Tablets
‘TT Lagao’ Get TT
“Saag sabzi khao’ Eat green leafy vegetables

23. Missed Opportunities to Provide Relevant Care

24. Systems Challenge:
Uniform Service Delivery Across Socio- behavioral -
Geographical Contexts

25. 25
The Temporality of Health
Systems planning and emergency response is linear in structure and ignores
impact of temporal activities such as festivals, high volume, seasonality, etc.

26. Blanket Service Strategies
Existing systems aren’t designed to respond to variations
occurring due to:
- Seasonal factors
- Geographical challenges
- Attitudinal challenges
- Socio-Cultural resistance
- Local Healthcare Beliefs and Perceptions
- Infrastructure
- Political Events: Elections often result in total shutdown
in transportation. Ambulances and other key personnel are
redeployed during elections / political rallies impacting
access to public facilities

27. Systems Challenge:
Imbalanced Hierarchies Between The Service and
Beneficiaries

28. Service Provision Inequity
Inequity is rife in the system: Choosing whom to prioritize or whom to provide. “Hum hi bure bante hain.” – AWW worker.
Some FLWs show bias towards their own kin when itto distribution of resources and providing services.
Beneficiaries’ class & caste sometimes determines the attitude of FLWs, thereby affecting the quality of
service. Socially or financially influential beneficiaries may be givenpreferential treatment at the RI site.

29. Low Expectations

30. A Non-Participatory Environment

31. Systems Challenge:
Data Reporting over Care | Misplace Priorities

32. Only Measurable and Incentivized Services Provided

33. Who’s Interest is Priority?

34. Skewed Time-Spent on Data Reporting as opposed to Care Provision

35. In spite of there being no weighing machine at
the RI/VHSND a beneficiary’s MCH card had
mention of her weight recorded.
Data recording often takes precedence over
caring for the health of the mother and
reporting her actual status.
Data Reporting over Care

36. Systems Challenge 6:
Lack of Critical Infrastructure Required to
Operationalize Best Health Practices

39. A Woman Centric Approach:
The Layered 1000 Days

40. Key Innovation Directions
A ‘Mother and Child’ Centric Health and Well-being Ecosystem
Automating Patient Tailored Care Provision at Scale
A Self-Aware Healthcare Delivery System
Service Accountability towards Citizen Communities
Service Delivery Infrastructure for Best Practices
New Performance Evaluation Parameters and Differential
Incentive Structures