Digitised metrics for primary healthcare performance improve

Addressing the health needs of women and children has been one of the priority development agendas of all Five-year Development Plans in India. In the recent past, India recorded impressive economic growth but gains on the economic front do not appear to have been translated into hastening health transition and improvement in the health status of the population. Among the many reasons attributed to slower than expected transition in improving the health status, an important one is the performance of the health system in meeting the health needs of the people; especially for young children and women who are regarded as the most vulnerable population group. Perhaps, the most important obstacle in systematically measuring, monitoring and benchmarking the performance of the diverse health system in India, is the lack of necessary and even information at every tier of the health system and related to all aspects of health care ranging from inputs to the health system, health care service delivery institutions and infrastructure, facilities, and manpower available in these institutions and outputs, outcomes and impact of the health system on the health of the people. Similarly, there is virtually no information on the quality of health care being delivered through the system. Any effort to measure and benchmark the performance of the health system, therefore, is, at best, restricted, confined to selective dimensions of health care depending upon the availability of relevant data and information from a reliable source. Moreover, majority of these attempts have been confined to state-level analysis only. Assessment of performance of the health assessment at the district level, is more relevant in the context of the decentralised approach to planning and programming for health services delivery that has been emphasised and institutionalised under the National Rural Health Mission.

Terre des hommes (Tdh) in collaboration with a local NGO partner is currently working in Ranchi district of Jharkhand state in India, where we propose to scale up state-wide in the next 5 years. As per government of Jharkhand data source 2022, Jharkhand has an approximate rural population of 28 million (76% of the population); where Ranchi is the most populated among the 24 districts. While conducting a scoping exercise to understand the status of implementation of IMNCI services for U5 children, we found that people are not satisfied with the availability and quality of health services they receive from the government facilities. The factors that contribute to the problem are gaps in the availability of basic medicines, equipment and vaccines, lack of capacities of and availability of motivated, competent and equipped health service providers, lack of appropriate use of information systems for data management and tracking, lack of information with the community about the operational days and hours, and information on the functionality of the healthcare facilities especially when the location of the facilities are geographically inconvenient to access and Out of Pocket Expenditure( OoPE) is very high (non-affordable). COVID-19 further aggravated the problem where government medical supplies and human resources got diverted to manage the pandemic on ground, and the focus on monitoring healthcare performance was impacted. There is also use of information systems for reporting population health data to the next level from grassroots to the national level, however, there are gaps in the uniformity of the output indicators that are measured and reported monthly. Additionally, there are gaps in efficient team-based care (the village level health centres are either managed by single/two frontline healthcare workers where coordination at work is a challenge), supportive supervision and a lack of regular monitoring from the block and district levels to measure the quality improvement aspects.

Terre des hommes (Tdh) initiated the Integrated e-Diagnostic Approach (IeDA) programme in Burkina Faso in 2014, with the goal of reducing child mortality by enabling better quality of health services through mobile health tools, quality improvement processes and a data management strategy. IeDA helps the primary Health Care Workers (HCW) improve their level of adherence to the IMCI clinical guideline. The digital job aid of IeDA is an Android-based application that guides HCWs through the IMCI algorithm (Tdh contextualised IMCI as per the latest Indian National IMNCI Operational Guidelines) from the clinical assessment of the child to the classification, prescription, referral, and counselling. IeDA not only supports consultation of U5 children; but it also reduces classification and prescription errors, improves data quality, helps identify dysfunctional health facilities, measures individual performance, identifies training needs; and provides customised training and follow up of the users of the tool. The tool also contains tasking functionality features to generate a prioritized list of items for HCWs, to perform routine tasks such as follow-ups, referral, routine immunization, medicine pick up/ stock management, etc. The data driven tasking framework allows for effectiveness in service delivery and aims at measure bale performance improvements that would be relevant in responding to critical tasks and to enable the healthcare workers to provide precision care. The application is powered by Dimagi’s CommCare software platform and is designed for mobile devices (tablets or smartphones).

In the IeDA project, the data for U5 IMNCI consultations are collected by the frontline HCWs (Auxiliary Nurse Midwives and Medical Officers) who have been trained on the use of the IeDA application.  The software guides the HCWs throughout a consultation in a step-by-step process following the IMNCI algorithm, avoiding the problem of HCWs trying to memorize the IMNCI booklet and omitting key elements during the assessment. In addition to the e-consultations, there is an accompanying coaching application to support the quality improvement (QI) aspects during consultations.

The proposed solution will integrate the primary healthcare performance management features with the IeDA application and performance management tool; to measure and compare the capacity of the HCWs to deliver the health services, the availability of basic equipment, vaccines, and essential drugs, location of the health facility, health facility infrastructure parameters like availability of basic WASH services, availability of functional android devices with HCWs, health facility opening hours, availability of healthcare service providers like Midwives, Nurses and Medical Officers during the Out Patient Department (OPD) hours, adherence to clinical guidelines and diagnostic accuracy by the service providers, and Out of Pocket Expenditure for accessing the health services. The IeDA application with IMNCI precision tasking and QI scores of HCWs will be extended to add the primary healthcare performance features to generate a composite score of performance for better measurement and knowledge sharing.

The priority targets of IeDA consist of the rural population, which includes the groups that are most vulnerable due to poverty and access to services, and thus present the worst health outcomes. The specific age-group that is addressed by IeDA consists of children under five years of age, whose vulnerability is attested by the high incidence of childhood illnesses and high mortality numbers.

The solution aims at “leaving no one behind”,and improving services and care at the point of contact of these groups with the health system. More broadly, since the solution is implemented in public healthcare facilities, the ill-effects of affordability of these services, which is a major cause of the further exclusion of already-marginalised groups, are effectively countered.

Based on our analysis, we have identified three inter-related pathways of change, involving three pillars: the Health System, the Communities, and the beneficiaries. All interventions are conceived to contribute to one or more of the changes illustrated in these pathways:

• Health systems, - we support health workers to continuously enhance their skills and abilities to provide high quality healthcare to reduce maternal, new-born and children morbidity and mortality. We support and work with governments to improve WASH conditions at primary health care facilities and strengthen their health information systems for evidence-based decision making and to deliver sustainable, resilient and low-carbon healthcare.
• Communities, - we partner, listen to, and work with Community Committees and groups to build up their capacity to promote healthy behaviours and manage, monitor, and improve their health, WASH, and nutrition services. We strengthen the collaboration between National Health System and Community Health System to ensure the continuum of care of children and pregnant women.
• Mothers, children, and their families, - we listen to, engage with, support, and work with them to improve their knowledge and raise awareness about good health practices. We empower them to make healthy choice for themselves and their children, encourage them to access health, WASH, and nutrition services, improve their resiliency, and create enabling mechanisms to sustain healthy environment.

Tdh is implementing IeDA in India from 2020 and has been working with the community and the health department of Jharkhand since then. The solution developed is based on Tdh’s long experience in Burkina Faso and thanks to strong support from international donors active in the health sector, and with the collaboration of partners and advanced research institutes, IeDA continues to expand. Digital health opens a lot of new opportunities. IeDA’s implementation for childhood illnesses was a success thanks to the close collaboration with the Ministry of Health to whom we will hand-over the project. We have additionally integrated functions to identify and treat malnutrition, pneumonia and to do maternity care for building a more holistic application as per the needs of the community and health system.

Tdh is implementing Integrated e-Diagnostic approach in Burkina, Niger and India in partnership with Dimagi and uses CommCare for designing robust technology solutions. Dimagi designs clinical interfaces, health information systems, and mobile technologies to perform clinical decision support, and health system monitoring. Dimagi specializes in adapting technologies to the local environment, enabling appropriate, scalable solutions to improve the lives of underserved communities.

For this project Tdh will play the lead in coordinating between the partners, ensuring community participation and engagement, engaging the government for building sustainability of the solution and be accountable for all deliverables. Dimagi will contribute on software development, user testing and building dashboards for analytics. The Local partner, Doctors For You (DFY) will be the implementing partner managing operations on ground.

The project will facilitate building of trust and accountability strengthening mechanisms between community and government systems. Inclusive stakeholder consultations will be conducted every month of the project to understand the challenges faced when seeking services from government facilities, to ensure support is contextualised to the voiced needs of the local communities. In addition, frontline workers will carry out home visits that will be monitored under the tasking framework. This would improve the community connection and support a greater number of beneficiaries to avail government services. A follow-up visit will provide information about the child’s status and the next steps a service provider is required to perform. Community and key stakeholders would be part of the design, evaluation process, and feedback process, where their active engagement and ownership will be encouraged. The performance indicator matrix will include ‘voice of the community’ as an important criterion to assess the quality of services provided at the health facility. 

The catalytic role of the MIT BMGF funding will be to support IeDA in generating a strong evidence base on its ability to measure performance at the primary care level that has not been done in the previous impact evaluations carried out in Africa and Asia. The funding platform will provide IeDA a wider grant that will allow audiences to take notice of the results and value for money that IeDA brings. The evaluation study results coming out of the project will support Tdh’s advocacy efforts with government of India for replicating similar models in different divisions and states respectively. It will also support in including digital clinical decision support training in pre-deployment training for the frontline healthcare workers and as a national health strategy.

The inclusion of IeDA in the Jharkhand state budget for scale-up has given a strong reason for Tdh to believe that IeDA will have a wider influence on primary care in India. By inclusion of the performance measurement metrics in the model, IeDA will offer a platform that not only improves quality at the facility level but also at the health system level. The proposed funding will support in creating proof points for performance management and will position IeDA as a feasible tool that provides impact, is cost effective (evaluation for these 3 are available) and is also able to measure performance at the primary care level (present project funding will support this).

IeDA uses CommCare platform and is designed to ensure interoperability. IeDA has several unique features

• It is a single application that offers Clinical decision support, provides E-Learning content, collects, and synchronizes data real-time and supports quality improvement
• IeDA offers two-way communication to facilitate feedback from the users
• IeDA has an inbuilt tasking framework that improves accountability and connects with the community
• The proposed solution will integrate performance scores from the tasking framework and the performance improvement application thereby providing a composite score of performance that is trackable over a period of time
• Offers analytics for performance measurement, program management and policy decisions
• Has AI capability for predictive analytics that can be used for epidemic predictions
• Tdh has a collaboration with Cloudera, to include AI tools for assisting diagnosis and predicting coaching needs. In the proposed project
• The real-time scoring rubric and peer benchmarking will support the frontline healthcare workers to assess areas of improvement and design a pathway for performance improvement independently.

The impact goal for the next year:

•  Contribute towards improved IMNCI care for U5 children through integrated digital tools at the primary healthcare level

The impact goal for the next five years is:

• Contribute towards reduction in U5 mortality rate in the state of Jharkhand.

The impact goals would be achieved by ensuring that children under the age of five years have access to good quality diagnosis, treatment, and follow up of common illnesses, using the  innovative digital health tool. Primary healthcare performance will be evaluated

The performance management application capturing quantitative information on the functionality of supplementary parameters in the facility and its coverage will be integrated with the IeDA application and the Tasking framework to create a composite score of performance. Individual HCW performance scores on quality aspects of using the IeDA application, comparative data analysis among healthcare facilities and healthcare worker performance, explanation of gaps from the healthcare facilities, user feedback and suggestions for change will be considered in this model of primary care performance measurement.

An analysis of efficiency using a comparison between the base line and end ,line  evaluations on comparative analysis among HCFs, and the impact on the use of the application on clinical practices of the HCWs will be carried out to measure primary care performance.

From a performance measurement perspective, the digital solution will be used to

• Track key performance indicators for primary healthcare, identify which sections of the system are working well and which ones need  improvement
• Improve accountability of the health system and provide decision-makers with essential information to drive health system decision making
• Create a platform for the public health system to make data actionable and share lessons and best practices
• Connect the health system with community requirements through a digital platform that is transparent and participative.

Tdh wants to contribute to a significant and sustainable decrease in maternal, newborn, and child mortality and morbidity rates, and to the reduction of child malnutrition.

Through our projects’ monitoring and evaluation systems we will test our assumptions and gather evidence about our contribution to change. To this end, we have identified outcome indicators that focus on Tdh’s priorities of intervention:

Indicators at the Health System Level:

% of births attended by skilled birth attendants

% of women who attend 4 antenatal visits during pregnancy by a skilled personnel

% of women who receive postnatal care by skilled personnel within 48 hrs of childbirth

% of neonates who receive postnatal cae by skilled personnel within 48 hrs of birth

% of outpatient consultations conducted with support of  digital tools

% of healthcare facilities that routinely monitors performance through a digital application

% of primary care facilities that collect, monitor and analyze data and make them available to the district, state and national authorities through a digitized system

Indicators at the Community Level:

# of individuals benefitting from the capacity building and supportive supervision provided by the health programme

Proportion of communities who access improved health water and sanitation services offered at the primary care level

% Local communities who are satisfied by the quality of the health services and participate in the identification of needs and solutions on health for children under 5 years old

Indicators at the Family Level:

% of infants who are exclusively breastfed

% of births that happen in health facilities in the intervention area.

Objectives and targeted changes

Tdh Health Programme directly contributes to SDG 2 “Zero hunger” namely 2.1: end hunger and ensure access to safe, nutritious and sufficient food all year round and 2.2: end all forms of malnutrition, SDG 3: “Good health and wellbeing” especially 3.1: reduce maternal mortality, 3.2: reduce new-born mortality and 3.8: achieve universal health coverage and SDG 6: “Clean water and sanitation” with regards to 6.1: universal and equitable access to safe and affordable drinking water for all, and 6.2: access to adequate and equitable sanitation and hygiene for all.

Based on our analysis, we have identified three inter-related pathways of change, involving three pillars: the Health System, the Communities, and the beneficiaries. All interventions are conceived to contribute to one or more of the changes illustrated in these pathways:

• Health systems, - we support health workers to continuously enhance their skills and abilities to provide high quality healthcare to reduce maternal, new-born and children morbidity and mortality. We support and work with governments to improve WASH conditions at primary health care facilities and strengthen their health information systems for evidence-based decision making and to deliver sustainable, resilient and low-carbon healthcare.
• Communities, - we partner, listen to, and work with Community Committees and groups to build up their capacity to promote healthy behaviours and manage, monitor, and improve their health, WASH, and nutrition services. We strengthen the collaboration between National Health System and Community Health System to ensure the continuum of care of children and pregnant women.
• Mothers, children, and their families, - we listen to, engage with, support, and work with them to improve their knowledge and raise awareness about good health practices. We empower them to make healthy choice for themselves and their children, encourage them to access health, WASH, and nutrition services, improve their resiliency, and create enabling mechanisms to sustain healthy environment.

The focus will be given to high-impact interventions such as, 1) perinatal care focusing on the before, during and after childbirth where the majority of mothers’ and babies’ deaths takes place; 2) Digital health, with an approach to integrating capacity building and data monitoring that helps health workers to improve their knowledge and skills and support clinical consultations of children < 5 and pregnant women, with the potential to reach millions of beneficiaries every year; and 3) health system strengthening, improving the quality of services at primary health care level to adequately respond to population’s demands during routine and crises periods alongside improving performance management of primary healthcare facilities.

The change pathways in our Theory of Change (ToC) are built over Tdh’s decades of experience and recognized evidence in Public Health Care. They are based on nine key assumptions about how we believe these changes are linked and might produce the intended effect on beneficiaries and systems:

Research/Publication links:

• https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-6692-6
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4973038/
• https://blogs.bmj.com/bmjgh/2019/05/17/can-digital-technology-help-reinvent-primary-healthcare-in-support-of-universal-health-coverage/
• https://www.sciencedirect.com/science/article/pii/S2211883720300691

Dimagi’s flagship technology product, CommCare, is an award-winning, open-source digital data collection and service delivery platform designed to improve data collection and the quality of frontline services in low-resource settings. CommCare is one of the most widely adopted and technically advanced digital platforms. CommCare provides a turn-key system that enables non-developers to quickly build mobile applications, web applications, and SMS interactions and workflows. This enables CommCare to meet aggressive timelines and provides the benefit of allowing very fast iteration on the user experience by allowing multiple rounds of user testing. The result is a product that is well matched to the expectations of the users. Furthermore, the fact that this system does not require software development expertise to make changes also means that an application built on CommCare can be easily handed off to a local team for maintenance without requiring staff with extensive technical skills. As such, the long-term sustainability of these applications is high as local staff can make changes to the system over time and can pass on responsibility over multiple staff changes without requiring external training.

The Commcare platform supports in developing digital tools such as mobile and web applications that can be used for last-mile delivery in a low-resource setting to:

• collect data for program and surveillance purposes,
• serve as a job-aid with an in-built decision and process logic,
• allow for individual case-level management,
• share counselling materials through multimedia,
• provide training for users in local language,
• provide monitoring and evaluation through surveys,
• create reports and data visualization,
• build the capacity of users and partners so they become self-reliant.

The primary health care data is collected by the facility level government workers mainly the Auxiliary Nurse Midwives (ANM) and the Medical Officers (MO) through the consultations.

IMNCI was introduced in India in 2003 and the implementation of IMNCI started by 2010. ANMs and MOs have been doing consultation of under 5 children by following IMNCI protocol since 2010; but there were several gaps in adhering to the protocol due to the robustness of the operational guidelines.  Hence, the digital aid of Integrated e-Diagnostic Approach (IeDA) helps and guides the ANMs and MOs through the IMNCI algorithm from clinical assessment of the child to their classification, prescription, referral in case a child is found to have any danger signs and counselling of mothers and caregivers.

The application helps the health care service providers to correctly diagnose and treat children, and the application acts as a job aid for the frontline healthcare workers. The ANMs also fill in the Quality Improvement (QI) indicators which are aimed to ensure environmentally conducive sanitation at the facilities and feed in information related to ensuring the availability of essential medicines and other supplies in the healthcare facilities.

To ensure the quality of services, it is essential to periodically assess the knowledge and skill of service providers. This is done through a supportive supervision tool in the IeDA application wherein the project supervisors and government functionaries observe and rate the ANMs live while they are doing a child consultation. The supportive supervision data is collected by the project staff as well as the supervisors from the government system. There is no incentive paid to the government functionaries nor to the healthcare workers for conducting supportive supervision while it is one of the job deliverables for project supported staff.      

The project is designed in a way that the data collection is not a separate activity except for Quality Improvement (QI) indicators which are currently done on a fortnightly basis and on an average require 5 to 10 minutes of ANM’s time. Though there is no financial incentive for doing so, since the ANMs work at the community level health centres, the quality of services enhances their social status within the community, and this works as a motivating factor for the frontline workers. The local administration does recognize the best performing ANMs and MOs based on the QI data and it has been observed that the winners of this recognition are not the same members every month, which points out to a healthy level of competition that encourages the ANMs/MOs to perform better. 

As a global leader in the promotion and protection of children’s rights working in over 30 countries, Tdh wants to ensure its programs proactively contribute to overcoming existing biases, prejudices, discrimination, and challenging inequalities in the distribution of power in any given context. All children are entitled to flourish and fully exercise their rights, and this requires a shift in how the concepts of gender & diversity is approached by Tdh.

Tdh has a Gender & Diversity Policy, which outlines Tdh’s commitments and guiding principles for gender and diversity across its operations and the inner functioning of the organization. It provides a clear framework for the organization to bring about a more inclusive working environment, and to systematically mainstream and monitor gender and diversity in Tdh operations. For its programs, Tdh is committed to applying a Gender & Diversity responsive approach and, where possible within specific projects, aim for a transformative approach.

Among its institutional commitments, Tdh seeks to “Put in place measures to enhance gender equity and diversity in Tdh teams and promote equal opportunities and inclusiveness in recruitment, orientation, promotion, retention, and duty of care”. Special attention will be given to balancing leadership and management positions. When recruiting all new staff, our advertisements mention that Tdh provides a safe working environment for all its employees; following the principle of equal opportunity for women, persons living with a disability, SC/ST/religious minorities, people living with HIV AIDS and candidates from the LGBTQ community, all who are encouraged to apply.

To establish its business model, Terre des hommes (Tdh) uses the BMC matrix - Business Model Canvas, modelled by Y. Pigneur and A. Osterwalder1. It is made up of 3 primary sets of elements: Value proposition, Value production and Budget equation.

We can summarize Tdh's current offer in two main categories: the global vision of child protection and implementing the mission through high-impact activities. These two offers are aimed at two types of client segments, namely donors and funders. In a business model, the notion of Client refers to those who pay for the Offer.

Donors - like the general public - contribute to the vision and support all of the Foundation's activities, mainly through donations of unrestricted funds (freely available).

Funders - such as a cooperation agency or a large foundation - commit to specific activities in defined programmatic and geographic contexts, often materialised by a contract. These funds are considered restricted.

The link between the Offer and the Donors is made through salesforce channels (national actions, etc.) and communication channels (magazine, website, etc.). The Offer to Donors is mainly made in response to funding proposals, but they are also approached within the thematic networks. The relationship between Tdh and donors is based on the publication of information reports on activities, the creation of personalized or even individual relationships, or participation in events. Tdh relies internally on teams dedicated to client relations and externally on groups of volunteers in the Swiss cantons and ambassadors of public renown. At the level of the Funders, the essential link is the production of contractual reports on financial and operational aspects, but it can also include the production of technical documentation.

Tdh has key resources at its disposal to produce this Offer: the most important is human resources. Next, material, and financial resources and finally intangible and intellectual resources. Externally, Tdh collaborates with implementation partners who constitute an essential resource for the deployment of operations. All these resources contribute to the implementation of the organization's essential activities. This includes fundraising to ensure financial coverage.

Next, come the activities that are essential to the production of the Offer. These include operational deployment, including program management and support, and global coordination activities.

The proper functioning of the model depends on the involvement of key partners. First, institutional partners, such as the Swiss Confederation, and the strategic alliances, which are more political within the Tdh Federation. At the operational level are the academic and technological entities, essential to constructing and valorising high-impact activities. Working on a systemic approach, local governments and field operators are indispensable partners. At all levels, suppliers are key for information systems, communication, fundraising, and treasury.

Tdh Business Model Canvas, detailed version

Jharkhand is the first state in India where the IeDA initiative is being implemented. The project was initiated in the year 2020 which was by way of an Innovation Grant through the USAID supported “Vriddhi” project. Sustainability is the key to any initiative and with IeDA, sustainability is inbuilt into the project design itself. The project from its first day of implementation had the Government’s health care workers as the service providers including supportive supervision and help desk arrangements. The training, meetings and consultations all taken at the government health facilities ensuring ownership of the project. ANMs are using the android devices that are provided by the government for using the ANMOL (ANM Online) application, to run the IeDA application, thereby leveraging available government procured hardware.

There are separate review meetings for the IeDA project conducted by the Medical Officer in-charge of the project intervention areas wherein emphasis is on reaching out to U5 children currently not enrolled in the application. The review meetings are conducted at the District and State level as well, the focus in the state level meetings is on integrating the IeDA data with the government Health Management Information System (HMIS) for a more comprehensive decision support system. The project is currently in the implementation phase in three areas of Ranchi district. While the implementation cost is being covered with donor support, almost 4/5th of the project cost is being set off as it is being implemented leveraging government health machinery, thereby reducing the donor dependency right from the project inception. The project outcomes and continuous advocacy by Tdh has helped the state secure funding from the Government of India for upscaling this initiative to newer geography’s in the state, though this would only cover the cost of training of healthcare workers and supportive supervision for the scale-up, however, even while major costs will be met through the government funding until the state has been saturated with the IeDA project the technical support will have to be provided by Tdh for which there will be dependence on donor support.

As of now, the project has a funding commitment from Horace W. Goldsmith Foundation until 2023, there is interest expressed by other donor agencies as well and discussions are ongoing with these agencies for future scope.

The project objective is to save the lives of the U5 children in the state.  As per the government census 2011 data, 76% of the population in the state lives in rural areas, where limited primary level healthcare services are available. A large section of this population is tribal with traditional practices still in practice. Under the circumstances and to address the infant and U5 mortality in the region, it is important to provide quality health care services with robust referral linkages and a dashboard to monitor disease outbreaks and disease prevalence which will enable the public health system to equip itself to provide quality and timely services.

The government finds IeDA as the solution to address the above issue.

The project is designed to be implemented through the government health machinery where a large part of the cost is set off already.

The project team works closely with the government officials at each – Block, District and State level to keep the officials posted on the progress and developments. This has resulted in the state government requesting Government of India for funds to scale up the initiative in newer geographies. The Government of India has allocated funds for the scaleup in a phased manner wherein the state would utilize this fund to cover select districts in its first phase.

Training of the ANMs, MOs and other Supportive Supervision staff was a major cost for Tdh in its initial phase which is now being absorbed by the state government budget. Also important to note that the hardware for the application was procured by the government and the same is being used for IeDA.

Tdh has secured grants from Goldsmith Foundation and that supports the core technical and management team to be maintained. With a wide array of previous funders for the project eg: USAID and Zusage Bank Julius Baer, Tdh is confident to continue the current project growth phase in Jharkhand and beyond.