The Unsung Heroes of Healthcare and Nutrition

“When my first child was born in 2014, he weighed just around 1.25 kgs,” recalls Ruby Devi, a homemaker in Ratni village of Jehanabad district in the eastern Indian state of Bihar. “He would fall sick often and grew up to be a slow learner.” However, everything changed after 2016 when Ruby Devi learned about the importance of proper nutrition during pregnancy, the ideal spacing between pregnancies, and how to feed her baby correctly. Her second child was born healthier at 3.5 kgs, and is now ready to start second grade, while the elder one remains in the first grade.

Ruby Devi is one of the beneficiaries of the World Bank-supported JEEViKA program, which has significantly improved awareness about nutrition among millions of women members of self-help groups across the state. This is a remarkable achievement, considering Bihar's high percentage of poor people, who face challenges in health, education, and overall standard of living.

Vinita, 29, from Muzaffarnagar, Bihar, is a “Poshan Sakhi” – nutrition friend – under the JEEViKA program. Speaking about the challenges she faced when she first joined the program in 2019, Vinita recalls, "Many women in the village would hastily retreat at the mere mention of nutrition during pregnancy or the importance of regular check-ups." Bihar, at that time, was steeped in old beliefs regarding childbirth, and old mothers argued that what worked for previous generations would suffice for today's young expectant mothers.

Today, Vinita is welcomed with open arms as she visits five to seven households daily, engaging in conversation with pregnant women and their families about proper nutrition, routine health check-ups, and even suggesting meals that can be prepared using ingredients readily available in their homes. To indicate progress, she places a red dot – ‘bindi’ in the homes where she feels there is room for improvement and a green one where she is confident that her advice is being followed. Over the years, Vinita is delighted to see the once red bindis gradually turning into vibrant greens.

Friends Who Ensure Pregnant Women Adopt Healthy Practices

Bihar boasts a dedicated force of some 7,500 Poshan Sakhis, who operate within the government’s JEEViKA program for poverty alleviation. These women are selected based on their interest and knowledge about health and nutrition and receive a 7-day training by Master Resource Persons under the program. They earn about Rs 160 a day and serve as the community nutrition resource person for the gram panchayats, offering crucial guidance to pregnant and lactating women in dispelling myths related to pregnancy and jointly supporting the state in bringing down maternal mortality rates and improve adoption of good dietary practices.

Bihar has made impressive strides in nutrition. Today, half of the state's young children, under 5-years of age, are eating a more diverse diet, compared to just 2 out of 10 before 2018. According to 2018-2022 data, 6 out of 10 women of reproductive age are eating better, compared to just 2 out of 10 before (project data). This is particularly noteworthy given Bihar's high rate of child undernutrition, where 41 percent children below 5-years of age are underweight and 69 percent anaemic. Global studies have shown how nutritional deficiencies in the first 1,000 days of life lead to slow physical development and cognitive impairment, with corresponding poor educational outcomes.

Friends Who Guide at Hospitals

Almost 250 kilometers away in Bihar’s Bhagalpur district, 27-year-old Shalini wakes up at 4 am, readies her 7-year-old son for school, prepares food for the family, before setting off for her 6 am shift at the medical college, some 15 kilometres away, changing three auto-rickshaws on the way.

Shalini has been working as a Swasthya Mitra – health friend – at the Bhagalpur Medical College since the past 10 months guiding and assisting patients about the right doctors to meet, facilities at the hospital, and medical tests.  She says, “The medical college gets about 30-40 patients each day and most of them are poor and unfamiliar with hospital procedures. Sometimes, for example, they must undergo surgery immediately. It is my job to guide them and to connect them with the right departments.”

Under the JEEViKA program, the Swasthya Mitras are selected based on their interest in health and they must have completed at least grade 12 in school. They receive a two-day training at the All India Institute of Medical Sciences at Patna, the state’s capital city. Shalini acknowledges the steep learning curve she faced initially at the medical college. “It took time to navigate interactions with medical staff, grasp the intricacies of medical terminology, and understand hospital procedures. Today, my proudest achievement is being able to assist underprivileged individuals who journey from distant villages, laden with uncertainty and fear of being misled.”

Forty-six-year-old Taimul Haque, an HIV patient from Purnia in Bihar, shares his experience, saying he had never visited Bhagalpur before and did not know where to go and what to expect at the hospital. “Shalini was like a real sister to me and my family as she guided us patiently through the complicated hospital procedures and kept track of follow-up checks for us.”

There are 135 Swasthya Mitras working in 35 district hospitals and 10 medical colleges  throughout Bihar under the JEEViKa program.

Twenty-nine-year-old Rinju has a Bachelor of Business Administration degree from Haryana and works at the Sadar Hospital in Jamui district and earns a daily wage of Rs 491. Her husband is unemployed, and she remembers a time when her family of four was going through financial difficulties. “I had to ask my parents and in-laws for money. With the income I earn as a Swasthya Mitra, I can afford to send my children to school without relying on others,” she beams.

According to JEEViKA officials, a distressing trend prevailed earlier, where several expectant mothers failed to reach the Sadar Hospital for timely treatment. Instead, they were hastily directed to private clinics, where they had to pay a premium on tests and diagnosis.  “Middlemen, motivated by incentives from private clinics, used to threaten us if we tried to intervene with the patients,” says Rinju.

Efforts by the district administration and improved services in Sadar hospitals with the help of the Swasthya Sakhis have borne fruit. Since October 2022, the Sadar Hospital at Jamui has conducted 57 c-sections and more than 600 tests, ultrasounds, and x-rays.

Nourishing the Future

In a parallel endeavor to enhance nutritional outcomes among children between six months and six years of age, Bihar has embraced the Balahar collective enterprise. Supported by the Pusa Agricultural University in the state, Balahar or baby food is a nutrient-packed dry meal comprising wheat, moong daal (lentils), milk powder, sugar and ghee or clarified butter and has received quality certification from the Food Authority of India.  It is packed with 370 calories per 100 gram serving and available for purchase at Rs 12 for a 50-gram pack.

Madhu, a 27-year-old mother of two, has been feeding Balahar to her two-and-a-half-year-old daughter since April and plans to continue this practice with her baby boy once he turns six months.  Madhu finds that Balahar is an affordable alternative to other supplementary foods available in the market and is packed with essential nutrients necessary for her daughter’s growth. “My little girl has gained weight and height and I will continue to use it for my second child as well.”

Two Balahar units have been operating in the state’s Samastipur district with World Bank support since December 2022, while another is scheduled to start in Bhagalpur from November 2023. Some 40 women under JEEViKA who had an interest in setting up a small-scale industry were selected and trained by Pusa University in the production, procurement, cleaning, and packaging of Balahar meals.

This multifaceted approach in Bihar showcases a collective determination to empower communities, dispel myths, improve healthcare access, and enhance nutrition, ultimately driving positive change for individuals and families. Given the program’s significant impact, JEEViKA has been recognized as a national resource organization for health and nutrition in India.