For over three decades, Anjanabai Uikey, now around 60, and Kusumtai Gadpayle, also around the same age, have shared an impeccable bond, as community health workers, and friends. These women have a lot to do with the Indian story of a drastic reduction in its infant mortality rate between 2004 and 2014. They sowed a seed from which a national programme was born.

The former is an Arogya Doot, the latter works as a community health supervisor, in villages of north Gadchiroli region, in Maharashtra’s tribal hinterland. Both are drivers of a pathfinding social action research and study in health conducted in the 1990s by the Society for Education, Action and Research in Community Health (Search) founded by the Gandhian doctor couple Dr Abhay and Rani Bang.

It’s a model of home-based newborn care (HBNC) that helped drastically bring down the infant mortality rates not just in India but also across the developing world. Three decades ago, the two women, among the first batch of community health workers trained by a team of doctors as barefoot health worker.

Even today, Anjanabai does what she was long trained to do – visit households with newly born in her village of Bodli, a small hamlet of 650 people 40 km from Gadchiroli, and keep a tab on their growth. Kusumtai continues to do what she did years ago – supervise the works of health workers like Anjanabai and step in if needed to aide them with quick procedures to save lives.

“I go to the households visiting new mothers and newly born babies; weigh them, check their overall health and provide interventions if needed,” Anjanabai says, as she greets Astha Chinge at her new born baby Balya in Bodli, and then demonstrates what she must do in every such visit.

She empties her bag – full of medical instruments, weighing scale, thermometer etc, and then one by one carries out a number of procedures to measure the baby’s parameters.

After that, she instructs the mother and reminds her of the things she must strictly follow.

“That’s our daily schedule – visit the mothers, check the babies on how they are doing, and keep the record of parameters,” Kusumtai, the supervisor, tells us. On any day, Kusumtai visits two or three villages, meets the Arogya Doots, and checks their daily reports. At times, she personally visits the mothers and their babies to verify if the health worker is following her routine, keeping the records right. “There’s no margin for error here,” says Kusumtai. “If we don’t do our job accurately, there are consequences for these babies.”

Kusumtai is a divorcee – for no fault of hers she has faced up to the ignominy of being childless, for no fault of hers. So, she began saving the infants in her village as though they were her own. In the process, she revolted against the social ills and lent a support to the new mothers. She and Anjanabai are the saviours, who say they must have saved a lot of infants with their early interventions in the past three decades.

“The approach – HBNC – was born out of compulsion,” Dr Abhay Bang, founder of Search. “In the absence of formal healthcare, what were or are the options; we can’t allow the babies to die.” In 1990s, about two million infants died within a month of their birth in India; or over a hundred infants of the 1000 born would die within the first 28 days for a number of factors.

“The heart of this approach is women – ordinary women from among the communities.”

After the initial years of work, Search teams found in the data in 1992 that neonatal mortality rate contributed to 75 per cent of the infant mortality rate in the 47 control villages it had shortlisted for its work. Within that, infections – septicemia or pneumonia – were the major killer, apart from asphyxia or pre-birth complications. Doctors did not exist; not the hospitals.

Whatever had to be done had to be done at home, and with zero costs, says Dr Bang.

“Changes happen incrementally – that’s the Gandhian insight,” says Dr Bang. “We believed that Arogya Swaraj (health freedom) as a right is an idea rooted in the thought that village community should be autonomous and self-sufficient,” he says. Riding on this philosophy, Search developed and introduced between 1988 and 1998 in some 47 control villages of Gadchiroli of which it decided to test its interventions in 39, HBNC model. Who was to provide that care? And how? Answers emerged organically. Search teams asked village communities to nominate two women, preferably mothers or grand-mothers, who they thought would volunteer to train like nurses in the home-based newborn care and work in their own villages. From that emerged the first batch of 45 communty health workers like Anjanabai, women known as Arogya Doots.

An SOP was developed, ratified by top neonatologists of India, and chosen community women health workers were meticulously trained under guidance both in the hospital and actual field conditions and then sent back to work in their communities.

“They were trained in giving injections on brinjals and mangoes and other vegetables, to remove their fear,” informs Dr Sanjay Baitule, Head of Search’s HBNC programme. “If you watch them today, they are experts in giving injections – they are so deft,” he says.

Controlled trials of HBNC between 1992 and 1998 showed significant reduction in newborn and infant mortality rates in the poor, remote villages. “We had suffered the plight,” says Ashabai, “and during the training we realized what we had gone through – the confinement in a lightless room, a pit in the same room where we had to defecate until our umbilical cord had been severed, resistance to breastfeeding, and so on.”

Ashabai’s first delivery back in the late 1980s was a nightmare, but the subsequent two deliveries were after her training as the Arogya Doot when she followed the standard operating procedures and rebelled against the prevailing superstitions in the community to care for her infants.

“They naturally grew up healthier,” she says.

The HBNC in tribal areas also meant bringing in behavioural change, she says.

Once this model’s success was widely acknowledged and tested on all parameters, the model was first replicated at seven locations within Gadchiroli district with the help of NGOs. It worked as it had in the controlled trials. Then, it was tested across Maharashtra; it worked there too.

India’s federal health ministry stepped in to implement the model on a pilot in a few select states, and once encouraging results came in, this became a national programme in 2009 – the ASHA workers, or Accredited Social Health Activists, were trained in the HBNC at a mass scale.

The government trained the trainers at Search; they lived with health emissaries like Ashabai and Kusumtai; underwent intensive training in HBNC at Search campus; went back to the field and trained the other ASHAs – over a million of them, who now do HBNC across rural India.

“It’s very fulfilling to save the lives of infants,” says Kusumtai, of her most satisfying takeaway from her work. She once saved the life of an asphyxiated infant girl with her timely intervention. “She grew up well and is now a mother herself,” she says.