To my knowledge, the majority of Dimagi’s work in India has been in rural areas. Indeed, the part of our mission that is focused on “resource-poor” environments conjures the image of an isolated village. I’ve worked briefly on a couple of Dimagi’s deployments in rural India and on balance have spent more time in rural India. However, I have had the fortune to work on two very different yet very exciting projects in Mumbai, and its sister planned city, Navi Mumbai. Based on my admittedly limited experience over the past several months I thought I would share some observations from working on two urban CommCare deployments. Some of these may be things that I just think are specific to urban projects but are actually more general—or are actually specific to these projects. But here they are, for what they’re worth.
A Bit about Mumbai
In some ways Mumbai isn’t too different from any huge city in India. There are people everywhere and a large portion of the population has migrated from outside the state. The official state language here is Marathi, but on any given day I will easily hear Marathi, Hindi, Bhojpuri, Kannada, Gujarati, and of course English, all quite distinct languages. One thing that I think sets Mumbai apart is it is much more expensive to live here, relative to other Indian cities, and is much more densely populated. The first short-term available room I could find here cost more than I used to pay living in downtown Washington, DC. And this price bind affects everyone up and down the pay scale- which is why there are so many “slums” interspersed in this super-dense city. Some of them, such as Dharavi – one of the slums we’re working in—are in good locations and are a relatively affordable housing choice. “Slum” is a bit of a misleading term, because while some of these areas are in very bad shape, many others are pretty nice. I was talking with one CHW about all the satellite dishes visible on the roofs in the slum areas and she just smiled and said “TV is compulsory.” You don’t get much space, as most families have one small room, but people often have very clean, organized rooms and avoid hours of commuting every day. But these areas are definitely lacking in key infrastructure and resources like sanitation and clean water supply, which perpetuates the spread of diseases. For example in Dharavi, as of 2006 there was one toilet per 1,440 people, which leads to rapid spread of disease, particularly during the monsoon.
Migration is a Significant Issue
The summer months are difficult for a CHW in Mumbai. A large portion of the inhabitants in the areas we’re working are from rural Maharashtra, Uttar Pradesh, or Bihar and during the summer months they make their trek back to their home village. On some days I have been in the field upwards of a third of visits the CHW tries to make are fruitless because the houses are locked and the women they are looking to speak with are gone for the next two months. If you are trying to track “timely follow-up” then this is an added level of complexity. Do you allow a longer follow-up lag? Do you create a question that captures if the CHW went to visit the individual but they weren’t there? Besides just making data collection difficult, it also makes interventions a bit complex. Maybe a particular CHW has helped a family get a severely malnourished child extra sustenance and provided training such that the child has become normal. But they can be knocked back to malnourished status after a short visit to the village where they have different water, food, and lack of access to the same resources they were provided back in Mumbai under the intervention.
Besides these home visits back to the village, there is a lot of permanent migration. In one project we’re involved with, in some areas close to a third of cases have to be closed due to permanent migration. In that project the partner added additional forms to help keep track of all the migrating cases. The new CommCare capability to move cases around between users may become very useful for those families that migrate within the operational area of one organization. However that also requires a carefully planned workflow so that cases aren’t appearing and disappearing from phones without explanation.
Complexity in Diversity
The mixture of people from all over India makes for some unanticipated linguistic issues. While Dimagi has definitely done projects where a single CHW has to deal with a lot of languages, here a CHW has to deal with several languages in the course of a couple hours of work in one small cluster.
In one project we had originally decided to make audio counseling messages in Marathi, since this is the state “official language” and the CHWs were paid by the local government. In addition, Marathi was the primary language of all the CHWs. The partner was on board with this so we went ahead and made some nice audio messages to test. However, when we got to the field, it turned out a large portion of their beneficiaries do not speak or understand Marathi – they need counseling in Hindi (or some other language). So all of the beautiful Marathi audio recordings we made are only usable for at most half the population, whereas the rest of the clients, including Marathi speakers, would be able to understand Hindi. This still won’t help to reach the beneficiaries that don’t speak either Hindi or Marathi. I’ve heard of CHWs who visit women who are from Southern India and only speak Tamil or Malayalam. The strategy in such situations is to find an adolescent girl who speaks both languages and let her translate, though this is not always possible. Use of pictures and/or videos might be particularly beneficial in these situations.
The Good and Bad of Neighbors
When people live in such high-density environments it is difficult to keep too much private. This can sometimes be very helpful if a CHW is looking for a family as in many cases the neighbors will know if they’ve gone temporarily out of the city or have moved away permanently. People often also know if someone has become pregnant or a child is ill and will tell the CHW of the new development while they are wandering in the winding alleyways trying to find their clients.
But just as frequently there are families that move in, don’t talk to anyone, won’t allow the CHWs to talk to them or enter their house, and then disappear without anyone knowing where they’ve gone. Even if a family has moved to an area monitored by another CHW in the same program, it can be very difficult to know that without a careful inspection of the data.
While I’m sure all of the users we work with have their own sets of biases, in as dense an environment as Mumbai there are lots of different people in close proximity to people of different religions, that speak different languages, or have different traditions/practices. I’ve frequently heard the CHWs make generalizations about how group X will react to advice about family planning, how group Y won’t want them to come into the house, and how group Z already knows to go to the hospital for delivery. I guess this is a combination of stereotypes and direct experience but it speaks to the challenges of dealing with such a densely diverse group of beneficiaries.
One unexpected issue we had was with SIM card activation. After the terror attacks here in 2008 regulations on issuing SIM cards got strict across India, but particularly in Mumbai. In one project almost all of the SIM cards were deactivated due to “documentation issues” within one week of deployment. It is a big burden to get the CHWs to take time and money to travel to a provider outlet to discuss documentation. Plus, many people do not have “proper” addresses which makes presenting proper documentation even more difficult. In the end we developed a system of SIM sharing. Each CHW whose SIM doesn’t work has a “partner” CHW with a working card, and they switch the SIM periodically to send unsent forms.
Things I Forget to Think About
Having spent so much time in the big city, when I recently went to a rural site I found I had forgotten about some considerations in project design that are quite significant in rural settings:
- Electricity: While having access to electricity to charge phones is a real consideration in a lot of our projects, in our experience even people who live in what would be considered “slums” generally have ample access to electricity. In most of Mumbai power cuts are relatively rare.
- Network Coverage: While not universal, coverage by almost every network in and around Mumbai is not a huge concern.
- Transportation: An ASHA in rural India could have a catchment area that is very spread out and visiting a particular beneficiary could be logistically or physically very demanding. Here, a “beat” is usually pretty small and dense and most CHWs have pretty good access to all the houses they need to visit once they get to the general area.
- Literacy/Education of CHWs: Not that this is a non-issue in Mumbai but there is a big pool of people to draw upon to fill CHW positions so organizations and governments can be a bit picky. The Mumbai area has higher than average literacy. So most of the CHWs I’ve gotten to work with are sharp, relatively educated, and at least bilingual.
- Time: People in rural areas have a lot of work/things to attend to, but our partner organizations here in the city can be particularly busy- they’re involved in lots of projects, travel a lot, and operate at a bit city speed. The CHWs’ clients are also very busy as many of them may have jobs that take them away for the house for at least part of the day.
The CHW programs here are a bit different as well. There are no ASHAs so Link Workers, various NGO-supported CHWs, Anganwadi workers, and ANMs are all working in the same areas, sometimes with different requirements, overlapping roles, and different incentives. In the coming years we may see the creation of a National Urban Health Mission (NUHM) to complement the existing National Rural Health Mission (NRHM). This could include a new CHW, the Urban Social Health Activist (USHA), as the urban counterpart to the ASHA. To some extent, both of the projects we’re involved with here are helping to characterize what the role of the USHA should be.
Overall it’s been really interesting to see how these projects shape up in Mumbai, and fun to get a taste of the big city. The country is rapidly urbanizing so hopefully we will learn a lot from our big-city experiences and gear up for more urban projects going forward.
Jeremy is a Dimagi Field Manager based in Mumbai. His work includes design, development, testing, training, and evaluation of CommCare mobile applications for use by community health workers in urban India, often in slum areas. To learn more about CommCare, please visit www.commcarehq.org