Annual Report 2017-18
KHUSHI BABY 2017-18
Khushi Baby
KHUSHI BABY TABLE OF CONTENTS Message from the CEO
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About the Khushi Baby System
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Our Team
08
Our Growth
10
How the Platform works
12
Design and Strategy
14
Technology and Development
16
Research and Findings
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Our Engagements
20
“Who We Are”
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Our Impact
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Our Financial
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Our Vision
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Our Partners
30
Case Studies
34
Takeaway
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02
Dear Global Family This past year Khushi Baby has made great strides towards advancing our mission of monitoring and motivating health care of mothers and newborns to the last mile. In 2016, we made the bold decision to rebuild our entire technology platform from the ground up. We returned to square one to build something scalable, for over 250,000 government health workers in India to use for both maternal and child health tracking and for community engagement. On February 9th, 2017, we launched our KB 2.0 Platform in the Gogunda Block of Udaipur Rajasthan. Since then our platform has been used by over 90 front line health workers in over 350 villages to track the health of nearly 15,000 mothers and children across 33,000 checkups and for 80,000+ vaccination events. Our system has generated 75,000 patient-specific automated voice call reminders to the families. Every week, hundreds of messages are exchanged on our WhatsApp Groups to follow-up on high risk patients and health camp scheduling. Slowly but surely, we are understanding how our platform and our team can make an impact on the ground. The percentage of health camps held on time has doubled since our full roll-out in April from 40% to 80%. ASHAs (Accredited Social Health Activists) have told us about how mothers are coming to the village health camps on their own after receiving our automated voice calls, thereby allowing the ASHAs to optimize their schedule for door-to-door reminders. ANMs have showed us how they use our mobile app to plan their patient due list, and how they use our WhatsApp Channels to both report to and respond to high risk patients.
Still, the past year has not come without its challenges. From a technical perspective, we encountered hardware issues that led to a replacement of nearly 100 tablets. On the data side, we have exposed large gaps in important outcome and past illness records due to underreporting and data manipulation by ANMs within our current system. Finally, in the field, we were pained by the death of an 18 month old baby girl just days after she came to our health camp. This death may have been averted had she been brought by her parents to the District Hospital a day earlier as our field monitor and the ANM had recommended. Nevertheless, we firmly believe that together, our technology and team can be a vehicle for change. We are building better tools for our field champions - the ANMs, ASHAs, and local health officers. Our goal is to automate the routine tasks to make way for more time and resources to make an impact. And we hope to amplify such an impact through improved predictive models for high risk patients and enhanced voice call messaging campaigns to better engage our communities. Khushi Baby would not be able to do the work we do without a village of supporters. Our funders - 3ie, GAVI, Johnson and Johnson, and the Pierre Fabre Foundation, have given us an assured runway till early 2020 to grow our footprint on the ground. We are emboldened to dream big with the continued support from Dr. Sanjeev Tak, Chief Medical and Health Officer of Udaipur and the Udaipur District Health society. By end of 2019, we aim to track the health of over 100,000 beneficiaries by universally deploying our system across Udaipur in a Model District project for others across India and the world to scale and replicate. In order to achieve this vision, we will continue to grow as a team and family. With the support of newly-minted Design, Data Analyst, and Policy Leads, our core staff, field monitors, global team of volunteers, interns, and supporters from leading university groups such as MIT Sloan’s India Lab and now Yale’s Code4Good, we look forward to marching forward in our mission for maternal and child health.
RUCHIT NAGAR CEO & CO -FOUNDER
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Photo top left KB app with NFC screen used by ANM on the health camp day.
Photo bottom left KB Pendant with NFC chip as well as storage device stored in.
Photo bottom right Child’s Pendant scanning in Action at the Health camp conducted by ANM.
ABOUT KB Khushi Baby is an award winning maternal and child health platform which leverages Near Field Communication technology to provide beneficiaries with a decentralized, digital health record. Since winning the Wearables for Good Challenge, we at KB has been focusing on deployment of our system and field trials in the Udaipur district of Rajasthan, India, with the local District Government. In the last year, we have covered much ground thanks to the continued support from our partners, funders, and champion health workers in the field.
In the last year, we achieved the following milestones: • Launched KB 2.0 platform with 87 front line health workers to track the health of over 15,000 mothers and their babies across over 375 rural villages in Udaipur. In doing so, we monitored over 80,000 vaccination events and 33,000 maternal and child health checkups. • Completed over 70,000 voice calls to beneficiary families for appointment reminders and health education • Surveyed over 1100 Mothers for our Mid line Impact Evaluation exercise • Grew the KB Family to include 21 full-time and 14 part-time members between India and the U.S. • Raised over 750K USD in funding for the next two years.
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TEAM KB
Team Members Ruchit Nagar
Preethi Venkat
Tanooj Luthra
Founder , CEO
CRO
CTO
Mohammed Shahnawaz
Logan stone
Sukumar Salokhe
COO
Researcher
Delivery Manager
Pawan Singh
Ankit Tandon
Jitendra Kolate
Data Analyst
Tech (Mobile)
Jitendra Hayaran
Kyle Engel
Rishi Rawat
Research & Policy Manager
Data Analyst
Tech (Back-end)
Vijendra Banshiwal
Deepa Manjanatha
Bhupesh Nagar
Tech Program Manager
Researcher
Tech Manager
Hamid Abdullah
Sara Locke
Yehia Saleh
Implementation Manager
Researcher
Tech (Back-end)
Vaidehi Supatkar
Farhana Jamal
Yale Code4Good Team
Lead Designer
Comms Lead
Tech (Back-end)
Research & Data Manager
Md Sarfrazul Ambiya Lead Data Analyst
Dhanwant & Arjun Field Coordinators
Field Monitors
Advisors Zeena Johar
Joseph Zinter
Joe
Robert Hopkins
Shail Sinhasane
Dr Bhupendra Tripathi
Zeena
Joseph Zinter
Board member
Business development
Business development
Board member
Business development
Business development
Design
Research and policy
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Digital India Awards 2017: Innovation in E-health
Our Growth
Care Solutions
Awards and Recognition
Geneva Health Forum
Johnson and Johnson Gen H Grand Prize
Tech for Good Design Winner
NFC Forum
Pierre Fabre Foundation Laureate of the Global South E-Health Observatory
SpoIndia Emerging NGO Award 2017
Publications • Featured as part of the Digital India Heroes Series by Times Network • Published results of first trial in peer-reviewed journal: Vaccine • ISIF Asia Technical Scale-up Final Report • UNESCO Case Report: KHUSHI BABY • 3ie Thematic Window 10: Baseline Report
Conferences/Summits • Spark: Yale Social Impact Conference 2017 • SPO CSR Summit 2017 • Udaipur District Health Society meeting with demo for Primary Health Secretary Shrmt. Veenu Gupta,IAS • Khushi Baby Global Summit Udaipur 2017 • Pierre Fabre Foundation E Health Observatory Summit Lavaur 2017 • GAVI INFUSE Summit Barcelona 2017 • 3ie Learning and Synthesis Workshop New Delhi 2017 • Johnson and Johnson GenH Challenge Finals 2018 • Case Conference at Massachusetts General Hospital • FICCI CSR Summit: Sharing of Best Practices for Maternal, New Born, and Child Health 2018 • TITAN Design Impact Award Semifinalist pitch in Bangalore 2018 • Geneva Health Forum 2018 • Nasscomm Summit Bangalore 2017
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Photo top left KB app with NFC screen used by ANM on the health camp day.
Photo top left KB app used by the ANM while the beneficiary is sitting with the KB pendant
How System Works
Our mission is to monitor and motivate the health care of mothers and children to the last mile .Our goal is to provide a digital key to connect the last mile to health and social services.
We’ve integrated mobile health, wearable NFC technology and cloud computing to produce a complete platform to bridge world’s maternal and child health gap. By tying tradition with technology, we are putting the beneficiary back at the center of their care. Khushi Baby appreciates that technology cannot replace human effort. As such, our approach is not simply to provide a technology platform. Instead, Khushi Baby takes an end-to-end perspective from community engagement to design to development to capacity building to deployment to field research to analysis, stakeholder engagement, and partnership building.
We are empowered to see the complete process by bringing a multidisciplinary team of public health practitioners, designers, engineers, analysts, social workers, field researchers, physicians in training, and policy analysts - all working together around the same table along with a village of world class partners.
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Design at KB DISCOVER
Immersion Empathy mapping Interviews(participatory) Heuristic reviews Usability Test
DEFINE
Interpret findings Identifying themes Define Insights Frame opportunities Set Design Challenge
DEVELOP
Brainstorm Ideate Wire frame(low fidelity) Test Iterate
DELIVER
Hi-fid wire frames Visual Design Prototype Get Feedback Capture learnings
EVOLVE
Benchmark Deepen roots Scale up Track learnings Re-iterate
Khushi Baby Redesign process In order to redesign the Khushi Baby application, we endeavored to gain a better understanding of how the system currently stands. We did this through field visits, interviews with ANM’S, observations in the field about how the ANMs use the app as well as their routines during camp sessions. These observations essentially gave us insight into the user experience of the application. Use the app on a daily basis enables us to create an application which caters to their exact needs and enhances the overall experience of the application by enabling us to see the world through the eyes of the people we study. Various participatory design tools were used to break the ice with users in order to get qualitative feedback such as heuristics and usability reviews to understand where problems lay in the following categories: Technology, Behavior and Design. From the feedback we received, we mapped out a “problem wall”.
The usability reviews also gave us quantifiable data in the areas of the application that need more focus on than the others. Which was then mapped on a graph for better communication and understanding Post the problems through participatory sessions with a multidisciplinary team ideation was done and ideas discussed. Post which use cases and scenarios were jotted down and wire frames both low and hi-fidelity were made and tested on field. With a constant user feedback we keep iterating the modules till it is both field ready and user friendly for the ANM(community health worker/front line health worker).New section that we are currently working on include: personalizing the application for the ANMs by making the language more personalized and colloquial rather than overly technical,adding modules that ease the workload for the health worker such as Eligible couple module,automating Form 6 etc.
Insights By gathering insights through participative methods we are designing with the user not for the user. Designing for behavior change can often be tricky the key lies in understanding various behavior,discovering the right behavior -designing it, refining in based on feedback , feasibility and desirability. Which results in the ultimate uplifter of the end user through ease of operation, comfort and joy.
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Card Sorting
Participatory Empathy Mapping Exercise
User understanding (card-sorting) Empathy map canvas
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Usability test sessions with ANM
Problem mapping
Heuristic analysis
Success metric Graph
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Information architecture
TECH At KB Tech team at Pune
Application training of the Front line Health workers
Yale code for good team
New Dashboard Prototype
Data Analytics at Udaipur
Daily Tech call at the HQ
KB consists of : • KB App • KB Dashboard • KB Pendant • KB WhatsApp Groups Technologies • GPS • NFC • Mobile • Biometrics • Off line/Online • Android • Ruby on Rails • Heroku • Twilio •R • Python • Artificial Intelligence Core Tech Able to summarize and encrypt 100+ columns Of data into 868 bytes on an NFC tag Method For verification of records owner by storing Digital biometric template and applying matching Algorithm against live thumb. Key Metrics Till date will have tested 150+ builds (Figure as on 8 May is 160). 4 Deployed Production Builds: Feb 2017, April 2017, Nov 2017, December 2017 In last 90 days 95.83% Crash Free Sessions. Next on Deck • ANM Data Quality Scorecard • Text to speech integration • Infant Facial Biometrics with IDEMIA • Full Immunization Predictive Modeling • Stillbirth and Early Infant Death Machine Learning • Voice Call Machine Learning • Block-chain applications as a “health wallet”
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Research At KB Mid line Analysis We analyzed data from over 1100 household interviews of mothers in our research cohort to assess the head-to-head comparison between the Khushi Baby system and the existing paper-based system. We found improvements in Data Quality Retention: 82% (with KB) vs. 76% with MAMTA Card Completeness on minimum Mandatory Fields: 96% with KB, 58% with MAMTA Card Consistency between Patient and Back-end Data: 95% for KB vs. 71% with PCTS Sync time: 4 Hours (2.1-15.9 IQR) with KB vs. 10-40 Days with PCTS We saw improvements in program deployment Camps held on time doubled from 40 to 80% Equipment related Denials for antenatal care check ups fell by over 50% across the board Patients receiving KB Voice Calls were 16% more likely to finish vaccinations through their third Pentavalent shot than those who didn’t receive any call.
“The best feature in the Khushi baby App is the checkup summary. Sometimes we are in a rush filling the details of the ANC. But the checkup summary shows me all the high risk conditions and the action steps I need to take in one place,so I find this very helpful” Rekha Garg, ANM,Ruao Sub Center, Salumbar Block,Udaipur
“I used to walk 5km to inform mothers to come to camps. Now because of the Khushi Baby voice calls,mothers themselves will call me and tell me that they were informed about the camp. Now I don’t have to travel to the houses which are further away. I only walk 2 km, and I save my mobile balance” Pepu Kuwar, ASHA ,Ruao Sub Center, Salumbar Block,Udaipur
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Engagement At KB International level engagement
National & State level engagement
District level engagement
Block level engagement
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Where We are
Travels Deployments Team members
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Our Impact
75000 Voice Calls To Mothers & Fathers.
87 Nurses 375 Villages.
RCT with 3200 Mothers.
4 hrs data sync Vs. 30 Days.
82% Retention Vs. 76% For card.
96% Data covered Vs. 58% On card.
40% Point increase In Health Camps Held On Time.
15000 + Mothers & Children Tracked.
Baby Prince Before Follow up
Addressing Severe Acute Malnutrition
“Baby Prince was found to weigh 3.5kg at 13 months of age, down from 4.1kg at 9 months and 4.5kg at 8 months,with a hemoglobin of 3.0. KB Field Monitors reported this patient on the appropriate KB WhatsApp Group. Health officials mobilized an ambulance to take the mother and child to the Malnutrition Treatment Center. After a week of stay, the child’s oral intake has improved and hemoglobin has increased from 3.0 to 6.0 g/dL”.
Baby Prince After Follow up
Mother Valu with Baby prince meena at PHC Seriya Salumbar Block,Udaipur
Building a Platform for Infant Vigilance
Front line nurses used the Khushi Baby WhatsApp Groups to report cases like that of Baby Komal, who was found to have a large Ventral Septal Defect of the heart. The Khushi Baby Team is meeting with local health officials to coordinate in-time, cost-free, surgery, scheduled to take place this next quarter.
Mother Many with Baby Komal at her home Jhadol Block,Udaipur
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Financial At KB
Khushi Baby took a significant leap forward towards financial sustainability this past year. Most revenue was grant based, generated from ISIF Asia, 3ie, ARM, and GAVI. New grants from GAVI and Johnson and Johnson establish runway till beyond 2019. Despite a limited budget we are proud to have supported the full-time salary of over 20 team members in the past year. Our largest sources for expenditures included tech development expenses, core team salary, and for subcontractors for our field survey exercises.
Photo on the left Financial Position & Projections till now.
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Our Vision for The coming year With the new year already well underway, we are happy to share some exciting developments to look forward to in the coming months. • Our Impact Evaluation Final Report We will be wrapping up our research study with a cohort of over 3,200 mothers which began in Fall of 2016 and sharing the results of the value-add and opportunities that lie ahead • KB 3.0 We will be expanding our application to include family planning tracking, repeat pregnancy tracking, and high risk patient tracking (a module built for referral centers) to cover all sections of the National Health Mission’s Reproductive Child Register and to allow for better impact tracing from village to referral center and back. This application will include major user interface/experience improvements, spearheaded by our Design Lead. We will further spin off new apps for new users such as apps targeting the role of the Asha and mobile friendly dashboards for supervisory staff to increase engagement.” • Our back end Will include automated forms generation for each health worker and official, automated data quality checks on over 30 column-specific rules to quantify probability data loss and manipulation. We hope to also see improved voice call targeting after we train our models on our growing data set, NLP used to better quantify the data-driven engagements on our WhatsApp channels, infant Facial Biometrics, and Government Back end Integrations.
• Roll-out We will be graduating from 375 villages to over 1,000 villages to universally cover 5 administrative blocks with a team of over 250 health workers. By the end of this year we are looking at tracking the health of over 40,000 beneficiaries. This will involve a bigger team (close to 30 on the ground) and improved community mobilization efforts, including meetings with local Panchayats, educational skits, and awareness campaigns. • Revenue from sources other than grant funding including the following channels 1. Health Insights as a Service 2. Solutions that use Core NFC Tech for other MCH Applications. 3. Solutions that use Core NFC Tech for Generalized Health Cards. 4. Cost sharing with the government for our existing system, under a Platform as a Service Model. • Opportunity to Scale Beyond: We have the approval of the District of Udaipur, Chief Medical and Health Officer to universally roll-out our platform across the District to cover 150,000 annual beneficiaries. This widespread roll-out will serve as a Model District Project for Districts across Rajasthan State and India as a whole, to replicate, adopt, and scale. We target 80% revenue from sales of our platform alone by 2021, with a major Ministry of Health partner on board.
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Partners
GAVI has provided critical financial support towards the forthcoming KB expansion to 1000 villages. They also have helped introduce KB to networks of private players looking to amplify impact. GAVI too has supported KB, with UNICEF Innovation at the World Economic Forum, showcasing the innovation to a multitude of affiliated country Ministries of Health.
UNICEF Innovation provided key incubation early on as part of the Wearables for Good Challenge and continues to support KB by facilitating partnerships with the global UNICEF network, including with Ministries of Health, to expand KB’s footprint.
ARM has been another key partner in the Wearables for Good Challenge initiative and has provided key technical and financial support for the ongoing development of the KB platform
FROG has been a key partner in the Wearables for Good Challenge and has provided KB with frameworks for design thinking to improve the product and user experience of the platform
MOBISOFT has been KB’s lead technical partner for over a year and a half, supporting KB with development services
Johnson and Johnson has provided critical financial support towards the forthcoming KB expansion and is further providing strategic mentorship for business development. JNJ is further expanding global networks of partners, particularly in pharma.
Harvard Medical School has provided KB with mentorship in public health, organizational strategy, and stakeholder engagement
Yale has supported KB since 2014 with mentorship on strategy and design and specific collaborations with students for platform development. Yale School of Public Health also has collaborators working with KB for forthcoming projects on immunization efficacy tracking.
GATES India has provided KB with strategic mentorship on product and research objectives
Our platform is modeled off all requirements outlined by the National Health Mission Reproductive Child Health Register.
Udaipur District Health Department Is the first Government partner to launch the Khushi Baby platform.
KB was awarded the National Digital India Trailblazer Award by Hon RS Prasad.
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Partners
An industry leader in biometrics and major player in the AADHAAR roll-out, has been KB’s lead hardware partner, providing KB with tablets being used in the field, supporting KB with technical expertise for biometric integration, and working with KB to jointly pitch the platform for State and Central stakeholders
BCG India is working with KB as a policy partner to advocate for solutions to better monitor data quality with the State of Rajasthan’s maternal and child health back end database and to build solutions to drive data-driven engagements at the local Block level.
Has supported KB as a Global South e-Health Observatory Laureate to develop new high risk modules for the KB platform.
PCH International provided Pro-bono consultation on manufacturing and scale-up during the UNICEF Incubation period.
Twilio.org powers our automated voice calls to families for antenatal and infant care checkups.
Fenton is providing KB with mentorship on marketing strategy for individual donors as part of the JNJ GenH Challenge Award.
Cooley has provided pro bono legal support to KB for the past two years.
Spark Philanthropy LLC Spark Philanthropy LLC is providing KB with mentorship on fundraising With a focus on building philanthropic Networks.
ISIF ASIA has provided KB with key financial support and expanded access to philanthropic networks in the South Asia region.
Go2Tags has been the preferred NFC tag provider for the Khushi Baby wearable.
Georgetown & University of Miami provide KB members with research and public health mentor ship
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Case Studies Persistence in the Pursuit of Care
On the first of February 2018, a two-month-old baby girl was brought by her mother, a 22-year-old housewife and caretaker of two older daughters, to the monthly government health camp for maternal and child health in the village of Nichli Sigri, Jhadol Block, Udaipur. As the health worker-in-charge of the camp, Auxiliary Nurse Midwife (ANM) Indra Parmar identified that the child (born preterm at 7 months weighing 1.5kg) was suffering from severe acute malnourishment and that the mother also looked weak. Khushi Baby (KB) Field Manager Hamid Abdullah and Field Monitor Bhavishya Purabia were present at the camp and observed this case. Together, Team KB and ANM Indra strongly recommended that the baby’s mother take her child to a doctor at the village’s Primary Health Center (PHC). The mother said at the time that she would not be able to take that decision. She told Indra, Hamid, and Bhavishya to speak to her husband (and the father of the baby) if they were truly concerned. Team KB then called the father and he came to the camp about fifteen minutes later. Even though the father is a well aware of the child’s health conditions he agreed to go at that moment but did not really make the effort to take the child to the hospital. The next day Bhavishya(field monitor) followed up with ANM Indra to check on the baby girl’s status.
ANM Indra informed her that she had visited the house where she encountered the father in an entirely new disposition. He told Indra that his daughter was fine and that he would not be taking her to the health center. Hamid, Vaidehi (our new design lead), and Bhavishya were not discouraged by the sudden turn of events and traveled 80km to return to Nichli Sigri, to follow-up with the family at their house. The team was joined by the ASHA (the locally based “Accredited Social Health Activist”). At the house Team KB met the resistant father. Hamid attempted to explain that the child was malnourished and in dire need of treatment,and he offered to call the ambulance. But the father did not yield. He showed no sense of urgency, in his tone nor body language, to treat the child. In fact, he was skeptical of the PHC. He was skeptical not in spite of his profession but rather because of his profession. He told the KB field monitor that he had prior negative experience with the government rural health center .He believed because of what he perceived as their lack of urgency and sensitivity to their patients.
Nevertheless, the PHC level doctor strongly felt that the child’s condition merited a higher level of treatment and referred her to a pediatrician at the District Hospital. After the PHC doctor visited the home. This hiatus was due to two factors: we cannot usurp the responsibility of local government officials even when we are leading by example for community-based follow-up; second, there were other children, who were also high risk and in need of follow-up. Currently, the baby girl weighs kg at 3 months of age (1 month gestational age). She remains severely acutely malnourished, and her father never took her to the hospital. She also remains at risk for infection, developmental delay, and early death. Team KB went with the family to the PHC, they were informed that no doctor was present that day. “I told you there would be no doctor here,” the father said frustrated. It was clear that his lack of trust in the government health facilities had only deepened. Hamid called the Block Medical Officer of Jhadol and told him about the situation. The Block Medical Officer also expressed his frustration and connected Hamid with the doctor. Hamid spoke with the doctor, who promised to visit the family’s home and examine the baby the next day. Meanwhile, the family was still at the hospital and a nurse on duty gave them some basic medicines without conducting any tests, nor a proper examination of the child. The following day, as promised, the doctor went and treated the baby. He asked the parents to follow up with a doctor at the District Hospital due to her extreme case of malnourishment. The parents refused to take the baby to the District Hospital, as the father repeated that he did not want to lose wages or days of work.
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Takeaway This account from the field was not intended to give the audience a sense of closure. Its purpose was to create a sense of the opposite - the fact that much more change is needed. To make such change we must think deeply about the underlying issues at the heart of this story. We can take away several key themes: the multiple stakeholders involved in care delivery success, the deficit in trust between communities and local health care providers, the lack of access to health providers, the lack of action towards unwanted girl children, and above all, the persistence which is needed to change the landscape of rural health care at the grassroots level.
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KHUSHI BABY 2017-18
Annual Report 2017-18
123 Kharol Colony,Fatehpura,Udaipur 313001,Rajasthan,India 107 Avenue Loius Pasteur,Vanderbilt Hall Room 135,Boston MA,02115750 USA Phone:+1 281 725 8062,+91 9001469934 Email: engage@khushibaby.org