Dr. Armida Fernandez reorients and reorganizes the limited resources of India’s public health system, crafting efficient programs to secure quality maternal and neonatal health care for low-income families.
The New Idea
The traditional explanation for India’s continuing failure to reduce urban infant mortality is that the country’s public health system is overburdened and the slum community is not educated and empowered enough to demand their rights for health. After years of experience as a practicing pediatrician and a senior administrator in an urban public health system, Armida Fernandez found that the real problem at the system level was a lack of efficient utilization of existing resources. Her programs focus on releasing the tremendous potential of the resources and infrastructure already available to the public health system, while simultaneously increasing the use of services at the community level. Armida proves that when the facilities and the community resources are used efficiently in a participatory manner, young lives can be saved.
Her work is centered in Asia’s largest slum, Dharavi, in the city of Mumbai. Her approach uses interconnected strategies to cover all aspects of maternal and neonatal health. The strategies are based on three core principles. First, ensure every level and unit of public health care provides quality services and is used appropriately and optimally. Second, transform clients into partners by equipping them to make decisions that use the system more efficiently. Third, use a behavior change methodology to influence attitudes of health care personnel towards their clients. The Municipal Corporation of Mumbai that is responsible for the public health of the city is a partner in her project.
Armida is confident that in 4 years, with viability of the pilot demonstrated and the model fine-tuned; other cities will be open to adopting it, recognizing its potential to solve the critical problem of neonatal mortality in a replicable, practical, cost-efficient way.
India’s goal is to decrease infant mortality to 30 per 1,000 by 2015, yet its infant mortality rate continues to be stagnant for the last 5 years. A staggering 60 percent of the country’s infant deaths occur in the neonatal period during the first 4 weeks of life. Heading the list of causes for neonatal mortality are birth asphyxia, low birth weight and sepsis—all of which are to some extent preventable. Even when these problems do not lead to death, they often result in disability and can seriously hamper the quality of life a child can expect to enjoy. Infant mortality is disproportionately high in poor sectors of society, which includes the urban poor.
Programs aimed at lowering neonatal mortality have been successful among isolated groups, but their benefits rarely reach poor urban mothers or their infants. Unlike the rural sector which has a well planned health infrastructure composed of a primary health center that provides basic health care and a planned system of referral, urban cities in India have no such infrastructure. The lack of quality programs in slums is particularly troubling when you consider the rapid growth of slum populations: recent surveys pin the slum population at 60 percent of total urban population in selected cities, and that proportion is quickly rising.
In cities where there is existing infrastructure, the lack of coordination between health facilities prevents the poor from accessing health care. The most vulnerable of these populations is the mother and her neonate. Mumbai, for instance, has a network of 150 dispensaries, 176 health posts, 26 maternity homes, 13 hospitals, and 3 medical colleges run by the public health system. However, because of the lack of coordination and the absence of a referral system, the smaller units are grossly underused or misused. Instead of providing needed health care, some facilities are converted into administrative centers for carrying out health campaigns. The result: almost all maternal and neonatal cases end up at the large government-run hospitals, regardless of how serious they are. These hospitals are in some cases well equipped, but the enormous burden placed on their resources inevitably causes ineffective treatment, which may result in death.
Mismanaged resources only compound the troubles of the already tenuous relationships between urban mothers and the health care system. Poor patients are often unwilling to access state health services because of the insensitive and apathetic treatment they tend to get from staff. Negative attitudes toward health care in general sometimes keep patients away from even the most worthy of programs: in many areas, regular check-ups through the course of a pregnancy have yet to become standard practice. Many expectant mothers seek health care only when a problem becomes severe. The same can be said for neonatal care: health care for poor babies becomes a priority only at the point of crisis.
Women in slums can rarely afford the conditions that keep their young children in good health. Most mothers are compelled to go back to work almost immediately after giving birth, leaving their babies virtually unsupervised for large chunks of the day. Slum living is a high-stress environment: accidents, violence, and natural disasters are factors that families have to address on a daily basis. With little backup for dealing with these crises, new mothers frequently cannot adequately cope with the demands of newborns; often with tragic results. Emergencies are common, and symptoms of sickness frequently go unnoticed until they reach dangerous levels, at which point children are rushed off to the nearest hospital and forced to wait while staff struggle to deal with the vast numbers of patients who are already there.
Armida works to make the most of the public health care system’s strengths, eliminate its gaps, and engage a wide circle of interested citizens so that all available resources function at optimum levels to protect and nurture young children.
One of her highest priorities is to build a crucial missing component of the current structure: a sound referral system that utilizes all facilities to their highest potential. She has gathered a broad coalition of health practitioners working within and outside public health to help create an efficient and practical system. The process starts with developing a stringent, well-organized set of referral protocols to guide the placement of patients. Then Armida coordinates an inventory of the country’s health facilities, assessing the resources and capacity of each hospital and health center. Based on this audit, she takes all steps necessary to ensure that each one gets the resources and assistance it needs to maintain an effective program.
As a result of her efforts, many more women can enjoy routine consultation at health facilities near their home, and only high-risk or complicated cases are referred to larger hospitals. For doctors and staff at the larger facilities, this means they can give full attention to the neediest cases rather than rushing to serve long lines of patients whose needs are uncertain.
Armida leverages the coalitions she builds to accomplish far more than the creation of a referral system. Health practitioners work with her to develop protocols in the key areas of administration, hospital upgrading, training, and intensive emergency care. They spread awareness and advocate for more resources to be allocated to maternal and neonatal health care. Coalitions of doctors, friends, and ordinary citizens work to persuade corporations and civic clubs to support health care facilities with training and equipment.
To keep these facilities working at optimal capacity, Armida takes measures to heighten the morale and commitment of hospital staff. Working with the Indian Society for Applied Behavioral Scientists, she has devised a people-centered staff program. Using psychoanalytical tools like appreciative inquiry that build on the vision and positive practices of an organization, she works to improve the overall outlook and performance of each staff member. She has so far tested this approach with extraordinary results in six maternity homes, and plans to spread the program far and wide.
As these efforts to reform and support the public health care system proceed, Armida works to ensure that poor mothers are willing and able to use this system to its fullest. To make these women and their families active partners in the health care process, she has created programs to educate them about best practices during and after pregnancy. Following her slogan to “make every mother a nurse,” she enables women to become informed and responsible caregivers for their babies. She also trains families to seek out local health care facilities, use the referral system, and identify maternal and newborn health problems before they reach the point of crisis.
Training alone cannot help mothers overcome the stresses and demands that so often prevent them from giving the supervised care their babies require. To address this gap, Armida has set up support services for mothers that help them care for their children safely while continuing to work. Her organization runs a crèche in the Dharavi slum where working mothers can safely leave their babies while on the job. She also founded a crisis center which provides counseling and referral services to guide mothers through the difficult situations they face.
As her programs encourage poor families to work with the public health care system—and as the system learns to work with them—Armida helps them come to the realization that access to proper health care is a basic right. Communities gradually shift out of their roles as passive recipients of health care, becoming active participants who understand and demand their rights. To support rigorous research for community participation, Armida has partnered with the International Perinatal Unit from University College of London, adapting their model of community organizing to the needs of urban India.
In all of her efforts, Armida integrates research and data collection to refine her strategies and provide the hard evidence she needs to advocate for policy changes. To successfully integrate her programs into a public hospital system suspicious of outside programs, Armida has from the start used participatory research that encourages staff and patients to explore and solve their own problems. Armed with hard data and a successful model for action research, she can attract the support of a wide range of donors and gain the funding she needs to rapidly replicate her programs.
These programs are expanding through a partnership with the Municipal Corporation of Mumbai, which helps spread her referral system through the city. To replicate her community education work and staff behavior interventions, Armida carefully pilots programs in vulnerable populations and recalibrates before spreading further. Working step by step, she plans for her programs to cover the entire city of Mumbai within four years. As she demonstrates the power of her model in a densely populated city like Mumbai, she builds the capacity to export the model to cities across India.
Armida Fernandez was born to a Goan family in a small town in the state of Karnatak. Her father was a professor of English literature and fought for Indian independence. Her brother was active in Goa’s struggle against Portuguese occupation. Drawing from these brave spirits, Armida had a deep passion for protecting children from an early age. This passion, matched with her deep need to convert ideals into actions, drove her to become a pediatrician.
She spent most of her working life in Sion, one of Mumbai’s largest municipal hospitals. As a pediatrician in this bustling hospital, she encountered disturbingly high rates of infant death among the poorer patients. Investigating the causes of these deaths led her to study neonatology, a virtually unknown field at the time. She immediately saw the potential of this field to save young lives, and in 1977 she launched a department of neonatology in her hospital—only the second in the country. Simultaneously, she introduced a series of measures in her ward, including a neonatal intensive care system, that reduced mortality rates in preterm babies in her hospital from 74 percent to 12 percent. She used low cost technologies and strategies for the survival of babies in a hospital which are now followed by neonatologists all over the country.
Her next major initiative focused on breastfeeding as an underused guardian of children’s health. She set up India’s first human milk bank while relentlessly campaigning to popularize breastfeeding and expose the harmful effects of formula. Once the project was stable, Armida convinced the Mumbai Municipal Corporation to take it on as a high-priority project.
Outreach work in the Dharavi slums was at first one of many projects for Armida, but it quickly planted the seeds that would grow into her life’s work. Convinced that the basic health care needs of the slum women and children were not being met, she started an organization based in an unused health center to meet these needs. Her project soon evolved into the Integrated Center for Women and Children, gathering a coalition of citizen organizations under one roof to serve the urban poor. This center met with great success, but it could not alone serve the thousands of mothers who lacked proper care. Not satisfied with partial success, Armida made up her mind to address the problems of the entire public health care system.
Armida recently retired from L.T.M.G. Hospital, Sion, after 28 years of service. Applying her intimate knowledge of the public health system full-time to the development of her model for improving maternal and neonatal health care. Her efforts are driven by an ambitious but unshakable belief: “As far as possible babies must never die.”