Digital Health Obsession Has Compromised Care In Anganwadis

Anganwadis are childcare centers found predominantly in rural India. Anganwadi workers are one of the largest volunteer health workforce in India. There are 14 lakh Anganwadi workers in India, who are the backbone of Mission POSHAN, previously known as the Integrated Child Development Scheme (ICDS). ICDS has been in existence since 1975, and it is one of the largest programs in the world which focuses on early childhood nutrition, care, education, and development. While ICDS only focused on calorie deficiency, this updated program covers aspects like dietary diversity, the promotion of a balanced diet, and behavioral change communication.

Anganwadi workers are the people on the ground who deliver all these services to the beneficiaries. Previously, they used to maintain all the data in the physical registers. But now,  they have to compulsorily use a new mobile app called “Poshan Tracker” which is a digital data collection system linked with the Reproductive and Child Health portal of the Ministry of Health and Family Welfare. The government uses the data entered by workers for “real-time monitoring” of their work and the health status of the beneficiaries.  

The workers have been using the Poshan Tracker app on mobile phones, either given to them by the government or on their own. As per the author’s experience, the work for Anganwadi workers has increased and become difficult after the introduction of the app. The introduction of technology has brought a change in the nature of the job of workers, from being community care workers to data collection agents for the government.

Workers have to feed the data for over 150 metrics in the app. These metrics range from the weight and height of the children, and the weight of the pregnant mother, to the Aadhaar number of all the beneficiaries, the amount of food distributed, and the status of Anganwadi centers. Some of this data, like distribution of food, attendance of children, location of workers, and early childhood care and education (ECCE) activities conducted have to be entered every day, while some other like height and weight of the children, once a month. 

Since the data is constantly monitored and updated on the Poshan tracker dashboard, the workers have to update it regularly without fail or they lose the day’s incentives. However, workers face several socio-technical issues in this work. “We never get money for our phone and internet bills. We just got it once at the start. The phone was given to me by the government at the start, but it is not working properly,” told an Anganwadi worker. The author in her fieldwork recorded that 18 out of 21 Anganwadi workers had been using their personal phones to run the app.

Few were fortunate enough to receive a long-lasting phone. However, they faced different challenges. “I got this phone in 2019 and it is old now. My supervisor came a few days ago and looked at my phone and noticed that it was working. We are under pressure that if our phone has become old, if it is not working, or if it has been stolen, we have to give ₹10,000, and only then they will give us a new phone. It is sort of a fine for the workers. We are asked to pay from our own pockets to get a new phone (from the government). So we try to buy a personal phone and work on it on our own. This way we save money. A lot of workers have paid ₹10,000 for a new phone too.” 

The workers are under great pressure to upload data right at the demand, which, coupled with bad internet networks and devices, often leads to workers working late hours, sometimes at night, to upload data. This has led to increased work hours for the workers while being under-payed for the work they do. This also leads to a great amount of mental and emotional stress. “This phone is like a jhunjhuna (a toy for children that makes sounds all the time) forcibly given to us. It always keeps ringing, irritating us, and giving us work. We now have a 24-hour job because of this mobile phone. This jhunjhuna takes all our time,” said Worker R from Inderlok, Delhi.

The requirement of verification of Aadhaar and mobile numbers requires workers to put OTP in the app, and this OTP is received by the beneficiaries. Due to low digital literacy and ongoing scams, beneficiaries are reluctant to share OTP with the workers. “The cost of using this app is just not monetary. We have to call clients at night to send OTP, it feels bad and intrusive,” said Worker P. The Anganwadi workers reported that they face hostility from the community when they ask for OTP. This has soured their relationship and is creating distrust between them and the beneficiaries. 

The pressure to enter data on time has led workers to ignore their work in Anganwadi. Most workers reported that in Anganwadi centers, they are busy entering attendance and filling their physical registers, and they find no time in conducting activities with children and teaching them, which is their primary role. The workers the author met complained that the work of gathering data has made them secondary to the actual needs of the community. The usage of data to analyze the work of the Anganwadi workers thus obfuscates the actual care work they are supposed to do. Their performance is now being analyzed not by how effective they are in the community, but by how effectively they enter the data.

The irony is, whatever good work they might be doing on the ground, in the end, it will be assessed by the numbers that will be entered. It is imperative to ask here if the nature of the work of an Anganwadi worker can even be analyzed through the current mechanism imposed by the Poshan Tracker. Workers, under pressure to enter data, often enter fake data, and if they are not able to enter data, they suffer- because their job performance is being analyzed by this, and incentive is linked to this. This is what Solanki (2019) calls in his paper, a “performance of management” – when digital interventions like data collection are used to monitor work performances, as data is considered “objective.” Governments prefer dashboards because they can show “objective” proof that the work is happening. However, the practices on the ground and the actual problems faced by workers get pushed under the fancy carpet of technocratic glitz. 

Till now, 1053 crores rupees have been spent on ICDS-Common Application Software and Poshan Tracker. This shows the misplaced priorities of the government. On one hand, the program is not able to provide adequate nutrition to beneficiaries, and the workers are not left with any time to engage with them. On the other hand, digitalization and real-time monitoring have taken priority, while taking up important funds which can go towards basic requirements of the program. Workers in Delhi reported that the food quality is bad and often watery. As the children and parents often do not want low-quality food, a lot of it goes to waste. Meanwhile, the condition of the children fails to improve and sometimes even worsens due to lack of proper food.

The workers were used to the process of data collection in their registers. They still collect and maintain data in their physical registers. The collection of data was never the problem. However, the data collection was secondary to the work till their roles were changed by the government. The position of workers at the bottom of the hierarchy, and the volunteer nature of their work, leave them with no power to raise their concerns but to follow orders. 

Public health programs in India suffer from this digitalization and dashboard obsession. There has been an influx of an app or dashboard in every health-based scheme in India, be it Nikshay, Ayushman Bharat Health Mission, or Poshan Abhiyaan. However, the reality behind these tech-moderated glorified power points needs to be paid attention to. 

Edited by Parth Sharma.