Case: Tackling the Root Causes of Child Health, Mortality and Abuse.

Armida Fernandez started as a young pediatrician in a municipal hospital that treated Mumbai’s poor, following the trail of mortality of infants and young children, and later also domestic violence, to improve health, nutrition, and safety among slum communities. SNEHA, the non-profit she later founded, is an enabling partner to municipal services that supports and coordinates better delivery of government services, empowerment of communities to gain agency and using data and evidence to develop public health interventions that work.

This is the blog version of Cities and Social Entrepreneurs: A Playbook for Catalytic Change that I wrote in collaboration with Manmeet Mehta and David Lubell, published by Ashoka and Catalyst 2030.

Here is how it happened. A story in two Acts.

Act I — If that is the truth, then do something

Studying neonatal mortality rates as a young lecturer, Armida uncovered practical issues that caused an unacceptably high rate of death among newborn babies. She became India’s first neonatologist and built a world-class unit in her municipal hospital.

In the late 1970’s, Armida was a young pediatrician and lecturer at the Municipal Sion Hospital in Mumbai when she began to analyze the hospital’s post-natal mortality rate. Shocked by her findings and ridiculed by the medical research conference she presented the results to, her supervisor told her “If that was the truth, and if it felt bad, do something”. Sion Hospital, at the time was understaffed and under-resourced by about 75%, meaning that generally doctors and nurses were unable to keep up with demand. But she began to track down the causes of the high mortality rate among newborns. Incubators donated by UNICEF proved too hard to clean, so they were hotbeds for infections. She removed them and developed an effective work-around instead: heaters and the warmth emitted by desk lamps did the trick and made a first dent in numbers. And Armida became the first neonatologist in India. Her pursuit to lower mortality brought her to ban problematic milk powder and formula from the ward that caused diarrhoea and institute breast feeding, and later Asia’s first breast milk bank inspired by work at Oxford University Hospital. To overcome shortages, she trained new mothers to become wet nurses providing milk for their own, and the ward’s other children.

Mortality rates kept dropping, and the neonatal department grew under Armida’s leadership, including an intensive care unit. By the late 80’s, it was a world-class unit, saving thousands of lives. The team was proud about the results.

Act I — Take Aways

“Recognizing unacceptable outcomes around you and asking ‘why’, are the foundations for the kind of improvements that will change outcomes and systems.”

“Harness the power of good diagnostics, of finding the root cause of problems that, with some creativity, can then be solved with relatively simple interventions.”

“Develop your own, resilient art of problem-solving. One of Armida’s achievements was to develop a science-based problem-solving practice that was effective to change multiple systems, even in the high-stress context of an understaffed hospital.”

Act II — Follow the problem

The clinical success led Armida to the next problem. To help poor parents care for sick children and prevent violence against women and children she started SNEHA, an NGO to complement the municipal government.

As the hospital department became ever more robust as a healthcare provider, Armida found a new disturbing truth. Children kept dying, either at home, by not returning to the hospital or coming back in bad shape. Parents, the majority living in slum areas, were unable to look after children with complications or complicated care requirements. This was a particularly challenging finding since it undermined the great improvements in the hospital that saved children’s lives, only to then expose them to dangerous conditions on release. And it was outside her official remit to provide care in communities, where assistance was needed. She decided to follow the evidence and go where the families are.

She began to take hospital staff to the slums. Whilst they had experience treating slum residents, experiencing their lives provided many new insights and built their resolve. In 1999, she and her team founded Society for Nutrition, Education and Health Action (SNEHA), an NGO. After seeing evidence of violence against children and women at her hospital, where a whole ward was dedicated to female burn victims, they expanded their mission to decrease death and violence of babies and mothers. At first, her team at the hospital, including students, provided much of the backbone of SNEHA, employing a single social worker. Their weekly visits to the slum did more than inspire research, it revealed the dignity and humanity of children and families living under severe circumstances. Children were often happy, families invited the team into their homes.

SNEHA began to provide support to health workers at health posts, strengthening their skills and showing appreciation for their work. They offered training to professionals and communities. From the outset, all programs were based on research and included randomized control trials — best practices in medical research — to find interventions that work. Armida eventually moved from the hospital to SNEHA, creating programs around what needed to be done, like setting up the centre for violence against women and children. The approach caught on, but Armida also realized soon that she didn’t have the skills to run the organization in a way that would achieve the best results from people and fundraising. Vanessa D’Souza succeeded her as CEO, professionalizing and growing the organization to a team of almost 500 staff running programs that cover maternal and newborn health; child health and nutrition; empowerment, health and sexuality of adolescents; and prevention of violence against women and children. Armida’s evidence-based approach has evolved into a continuum of care approach, that intervenes at critical points so that women and children have continuous access and are aware of health services they need to live healthy and safe lives. SNEHA serves tens of thousands of vulnerable families, women and children through direct services and trainings, and by supporting municipal staff like health post staff, outreach workers and training the police force on gender violence and paralegal volunteers among many other groups.

SNEHA has a clear part to scale its models and solutions. One example is the maternity referral system, which saves the lives of women and babies in high-risk pregnancies. The interventions were developed using SNEHA’s principles of evidence-based work, scaling through partnerships and sustainability. To date, 43,000 pregnant women with potential complications have been referred through the system, which relies on 1,300 health post staff and outreach workers that have been trained by SNEHA. The model, developed in Mumbai, has been documented and replicated through partnerships in seven other municipalities since 2013.

Armida explains that the success of SNEHA has been possible because of a highly productive partnership with the Municipality of Mumbai. She had the great advantage of coming from within the system, one of the city’s leading hospitals, and knew the system’s strengths and weaknesses. But just as importantly, she says that the system knew and trusted her. SNEHA was started with partnership baked into its DNA. There was no way in which SNEHA on its own could serve a slum population of more than five million people. Instead, they became a trusted supporter to the government, with its mandates and significant resources.

One guiding principle for her work has been to never tell anyone in government what to do, but instead let officials and workers lead, and offer help to them.

Data and evidence help guide that relationship toward a common goal, leading to internal improvements as well as providing feedback to the government. Over time, this made SNEHA quite unique: where other NGOs stood out through complaints and critiques, SNEHA focused on improvements and celebrating the efforts of front-line workers. Armida says she also went to great lengths to not criticize the government in the media, and instead focus on what they are doing right.

Financially, SNEHA operates programs that are funded by both government and philanthropy. Having a business relationship with government provides both access to significant funding and resources, but also is in line with the organization’s strategy in which innovations developed through SNEHA are institutionalized in government, like the gender violence training SNEHA is providing to Mumbai’s police force or by being appointed the implementing agency for Mumbai’s first one stop shop centre for women and children survivors of domestic violence.

Act II — Take Aways

“Keep following the problem. Armida’s method of diagnosing and solving the causes for unacceptable health outcomes led her from the hospital ward into the homes of the poor, and even into the policing practices. It also led her to take on the problem of widespread violence and abuse.”

“Trust is essential in collaborating with government. Consider Armida’s advice on how to become a partner that is, over time, being seen as being ever more reliable, supportive, and trustworthy.”

“How will you divide your roles and responsibility between the government and NGOs? A clear understanding will help you make the most of your resources. SNEHA, for example, developed human-centred and creative problem-solving capabilities that developed interventions that could be delivered at scale by the municipality, with all its human and financial resources.”