The ‘lord’ of the slum-dwellers

Sumithra Sathyan | 01-March-2014

Detailed News

ARMMAN is a non-profit organisation committed to improve the wellbeing of pregnant women, infants and children in the first five years of their life. Its vision is to design and implement sustainable programmes to reduce maternal, neonatal and child mortality and morbidity in the underprivileged urban and rural communities in India. By identifying and addressing systemic gaps in health services, delivery and community healthcare practices and by adopting a multi sect oral evidence-based ‘community needs assessment’ approach, the organisation improves healthcare service in the most neglected section of our urban society       

By Sumithra Sathyan

RMMANs core programmes make innovative use of technology to develop viable interventions and maximise outreach. Its projects include mMitra, a free mobile voice call and animation film service providing timed and targeted preventive care information weekly/twice a week directly to pregnant women and women with children in the local dialect; HERO, which provides real time information regarding the availability of ICU beds, blood and also about blood banks in the city 24 x 7 through a website, phone number, SMS autoreply system and mobile app; Arogya Sakhi, a home-based care project which trains village women to become health assistants to provide home-based antenatal, postnatal and infancy care and mother and child healthcare tracking system using antenatal, infancy and childhood forms coded into mobile phones of the auxiliary nurse/midwives which enables early detection of high risk factors in the mother and child and prompt referral.

Mumbai slums

Armmans major initiative directed towards pregnant women and mothers with children in the slums of Mumbai is mMitra voice call service. mMitra will provide timed and targeted culturally appropriate comprehensive information on preventive care and simple interventions in case of emergencies directly to pregnant women and women with children under age one. The voice calls will be in the local dialect, specific to the womans gestational age or the age of the child and will be sent weekly/twice a week free of cost directly to the beneficiaries.

mMitra will use two key channels for enrolling women in the programme: through government municipal hospitals and approaching the community directly. In the first approach, health workers will be stationed in all antenatal clinics of all municipal hospitals and will enroll all the women attending the clinic. In the community approach, Sakhis of the community partners working in the slums of Mumbai will enroll women directly from the slums.

The voice calls can be accessed either through a mobile phone or a fixed land line. The women will be given a choice of one hour time slot every day when they can choose to receive the voice message. She will ensure that her phone or her husbands phone is accessible during that time slot every day, says Dr Aparna Hegde, founder, chairperson and managing trustee of ARMMAN.

Throughout pregnancy and the first three months of the childs life, the service will attempt to reach the enrolled woman through a phone call for the first message of the week thrice daily in her chosen one-hour time slot from Monday to Wednesday.

If the woman misses the voice messages on all three days, she can give a missed call to the system until Wednesday evening and the service will call her back immediately with the voice message. Similarly, an attempt will be made to send the second voice message of the week in the same time slot on Thursday, Friday and Saturday with the provision that if the woman misses the phone call again on all three days, then the enrolled woman can give a missed call to the system until Saturday evening and the service will call her back immediately.

We are also setting up a call centre that will enable the enrolled woman to inform the service regarding a change in her phone number, change in the preferred time slot, when she has delivered or if she has had an abortion/stillbirth, says Dr Aparna.

Experiences in slums of Mumbai

Due to heavy rush of patients at the antenatal clinic, Dr Aparna has  no time to counsel the patients regarding the need for the remaining antenatal visits, the danger signs and potential complications. Often the patients dont come back to access care during the antenatal period. Many amongst them come to the hospital only during labour with some major high risk factor that had not been picked up due to lack of appropriate antenatal care.

I can never forget this patient who visited a peripheral hospital in her third month but never came back and developed gestational diabetes in the fifth month that went undiagnosed. She only came back in labour. The labour resulted in shoulder dystocia and she was transferred to Sion Hospital (an hour and half journey) with the babys head sticking out of her vulva. She had to be operated upon to remove the baby and it was difficult to take the baby out from the abdomen during the cesarean section as it was jammed. We had to actually behead the baby on the operating table and because we could not give a beheaded dead baby to the relatives, we had to stitch the babys head to the body with a twine. The mother died three days later. This incident that occurred during my first post of residency will always stay with me,’’ says Dr Aparna.

It is tragic because she had visited the antenatal clinic in the third month. She had come to access care but because of lack of counseling and lack of access to information, she never came back for her remaining antenatal care. We cant afford to lose such patients. It is important to ensure they come back, that we counsel them, guide them gently through their pregnancy and infancy,’’ Dr Aparna adds.

Complex health issues among urban poor 

There is growing recognition of the urban health conundrum on the part of policy makers and the government is evident in the expansion of the mandate of the national rural health mission to include the urban poor. The health problems of the urban poor are complex and inextricably linked to the unique socioeconomic conditions  prevalent in the underserved slums. Hence, provision of primary healthcare for urban slum population cannot be compartmentalised and has to be improved as part of comprehensive urban slum development.There has always been an emphasis on curative services rather than preventive and promotive services .

Subhuman living conditions

 Majority of Indias population is currently living in slums. Every year, thousands of men, women, and children die around the world and India alone is responsible for 25% of the deaths. By 1980, slum-dwellers constituted half of Indias entire population. Slum-dwellers constantly deal with issues such as lack of clean water, constant migration at slums, no sewage or waste disposal facilities, pollution, and unsanitary living conditions. High levels of pollution, lack of basic amenities and room-crowding are some of the basic characteristics of slum housing. The Government of India has not been able to solve the problems so far, that are strangling the entire population of Indian slums.  

There are two kinds of slums: notified and non-notified. Areas notified as slums by the respective municipalities, corporations, local bodies or development authorities are treated as notified slums. A slum where only about 20 households live is considered as a non-notified slum.

Of the 19,749 non-notified slums estimated to exist in urban India, Maharashtra accounted for about 29% (5,769), West Bengal about 14% (2,684) and Gujarat about 10% (2,058). Of an estimated 13,761 notified slums in urban India, Andhra Pradesh has about 23%, Maharashtra about 14% and Madhya Pradesh, West Bengal and Tamil Nadu about 9% each.


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