Background & Testing Assumptions

ICAAD has been working with Nazdeek, a legal empowerment organization committed to bringing access to justice closer to marginalized communities in India. Nazdeek shared with ICAAD the problems faced by women tea garden workers at health centers in Assam, such as: rejection of treatment at hospitals due to caste, tribal affiliation, or religion; being bribed while needing life-saving treatment; and a lack of doctors and medical supplies. Assam has some of the worst rates of maternal mortality in India. We wanted to find a way to prove the systemic nature of the problems leading to high rates of mortality to the government and healthcare providers.

We theorized that gathering data around women being denied service, their access to ambulances and transport, and if health centers had life-saving supplies like blood or medicines, would reveal the systemic nature of gaps in maternal healthcare.

We conducted an analysis of tools that could work given the resources of the population of tea garden workers in Assam — and found an example of a low tech solution that we thought could be adapted from a project in the Congo where they were tracking availability of medication at pharmacies.

To test these assumptions and leverage the power of community mobilization, we decided to pilot EndMMNow, a crowd-seeding model where community members would collect data and advocate for their rights.

Designing Approach

In designing our approach for EndMMNow, we shared our analysis and clarified our assumptions with local CSOs and experts. This ensured we had enough critical local input to help inform design decisions. We needed a reporting system that was easy enough for community paralegals to use where we could quickly record, verify, database, and map complaints. Tea garden workers in Assam don’t have access to smartphones or computers, and many families only have access to one basic phone. So we developed a SMS based solution. First, the participants would be trained on their basic legal rights and government entitlements, and trained to use a code-sheet to report violations. As violations were reported, they would be verified by local CSO staff, who would approve the reports on the EndMMNow platform, which automatically maps the violation. After collecting enough complaints, we would then analyze and use the data collected for advocacy.

Intervention

During the first months of implementing the pilot, we had to refine our approach. This meant having more regular trainings with the community paralegals to boost reporting. This connection is important, and having 1-2 engaged “connectors” (a person that knows many people in the community and can effectively spread information) can make all the difference. We also had to provide the data we were collecting to the community (and later policy-makers) in a digestible format, because while the paralegals themselves and CSOs find the data useful, community members don’t access it.

As the map above shows, in the first 9 months of the program, we had quite a number of complaints come in the with reports of maternal and infant deaths and the status of the health centers. 

The map below shows some of the systemic gaps uncovered, such as poor ambulance services and a broken referral system. In the case below, a pregnant woman who waited 4 hours for an ambulance was referred to four different health centers because she needed blood. The first three centers had no blood; she died before receiving treatment.