Digital alone does not transform

In 1990, Michael Hammer wrote an article in the Harvard Business Review with a blunt title, “Reengineering Work: Don’t Automate, Obliterate”. His argument was that companies were spending heavily on putting computers on top of old processes and getting old results faster. The real gains came when they rethought the work itself.

Public health often meets a version of that lesson. We talk about digital transformation, and we often mean deploying technology. But a digital system records the work that is done. If the work around it does not change, the system can only record what it is given. This is the story of one indicator, in a few districts, that made the point clear to me.

A portal for every pregnancy

India took an ambitious step more than a decade ago, tracking pregnant women and children by name rather than only counting them. The Ministry of Health and Family Welfare describes its Mother and Child Tracking System as built on name-based tracking of each beneficiary, and the RCH (Reproductive and Child Health) portal that succeeded it as designed for early identification and tracking of individuals across the reproductive life cycle.

The portal had the capability that mattered here. If good data went into it, high-risk pregnancies could be identified, reported and followed up. In the districts where I worked in Chhattisgarh under USAID’s Saksham project, including Kanker, registration of pregnant women was already an established part of routine work. That depends on many frontline workers doing careful, repetitive work every day, and it deserves to be said plainly.

The next problem

Once registration was in place, a different number stood out. Very few pregnancies were being recorded as high risk. Planning guidance on emergency obstetric care has long assumed that a sizeable share of pregnant women will develop complications. That is not the same measure as pregnancies recorded as high risk, but against it the recorded share looked low enough to examine. The likelier explanation was under-identification or under-recording, not a population that was unusually safe.

The portal could hold the information. The question was why so little of it was reaching the portal.

What was really needed

Identifying a high-risk pregnancy means checking a consistent set of signs, history and measurements with every woman, and then recording the result. In the settings we worked in, the existing routine did not make that assessment systematic or easy to record. The opportunity was to strengthen the support around frontline workers, rather than to rely on individual memory alone.

Saksham worked with core groups of frontline workers, the ASHAs, ANMs and other health workers who knew their communities best, to identify high-risk pregnancies and plan follow-up for each woman.

The changes

Three practical changes helped strengthen identification and recording.

Training and support. ASHAs and ANMs were supported on how a high-risk pregnancy is identified, including which signs, history and measurements matter, and why.

A simple tool. A clear list of high-risk signs gave every worker the same reference, so identification did not depend on who happened to be doing the visit.

A paper register, entered into the portal. This was the decision I learned most from. One possible response would have been to build a new app. But frontline workers were familiar with paper registers, which fitted their routine visits and needed no phone or network. So high-risk information was recorded first in a register. The register was then sent to the data entry operator, who entered it into the portal, so that district and state teams could see high-risk pregnancies and follow them up.

Over time, the share of pregnancies recorded as high risk rose substantially, from a very low level to one much closer to what planning guidance would suggest, according to programme monitoring in the intervention areas. This is consistent with better identification and recording, although the figures alone cannot show how much each change contributed. More women being flagged is also not the same as better outcomes. Whether flagged women were referred in time and received the right care needs its own evidence.

The point

No new feature was added to the portal and no new app was deployed. What changed was the work around the system, including what frontline workers were supported to look for, the tool they used, and the way information travelled from a woman’s home to the portal and on to a district review.

For me, this is what re-engineering the work means in practice. Technology and process are not alternatives. A digital system can make something possible, and the processes around it decide whether it happens. Sometimes that means building something new. Sometimes, as here, it means using a paper register because that is what fits the work.

It is also a continuous process. You find a problem, you deploy technology to address it, and then you re-engineer the processes around that technology. Once registration was in place, the gap in high-risk recording became visible. Once high-risk pregnancies were being recorded, the next questions came into view. Were those women followed up, referred in time and supported to deliver in the right facility? Addressing one gap tends to reveal the next. A digital system does not end that cycle. At its best, it helps the next problem become visible sooner.

Views are my own.

Sources

• Hammer M. Reengineering Work: Don’t Automate, Obliterate. Harvard Business Review, July–August 1990.
• Ministry of Health and Family Welfare, Existing technology platforms for health schemes (2018)
• PATH, Advancing maternal, newborn, and child health in tea plantation and tribal communities in India (2023)
• WHO, UNFPA, UNICEF, AMDD. Monitoring emergency obstetric care: a handbook. WHO, 2009.