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Mobile Technology to Improve Maternal and Newborn Health Outcomes_Dennis Cherian_4.25.13
1. Mobile technology to improve maternal
and newborn health outcomes
Karuk district
Herat province, Afghanistan
Better Health for Afghan Mothers and Children
project
2008-2013
Dennis Cherian, BHMS, MHA, MS, Senior Director
Jahera Otieno, MPH, Program Management Officer, Health and
2. Introduction â Program Overview
⢠Project Goal: Achieve sustained improvements
in the survival and health of mothers, newborns
and children
⢠Partners: The DOPH
in Herat, MOPH, BDN,
USAID Mission in
Kabul and Dimagi
3. Introduction â Program Overview
⢠Location: 74 villages in Chisht-e-Sharif Karukh,
Kohsan, Zindajan districts of Herat province
4. Technical Interventions and LOE
⢠Maternal and newborn care, MNC (35%)
⢠Infant and Young Child Feeding (20%)
⢠Prevention and Control of Diarrhea (20%)
⢠Pneumonia Case Management (15%)
⢠Immunization (10%)
5. Overall strategies -Overview
⢠Home Based Life Saving Skills (HBLSS)
⢠Baby Friendly Hospital Initiative (BFHI)
⢠Positive Deviance (PD)-Hearth
⢠Timed and targeted counseling (TTC)
⢠Improve CHW capacity and outreach campaigns
6. Introduction â OR Objective and
Outcomes
To test if the use of CommCare can:
⢠Increase uptake of Healthy Actions by pregnant
women- Utilization
⢠Increase knowledge of Important Information
points-Knowledge
⢠Improve communication and coordination by
CHWs with higher-trained health workers- Access
⢠Improve pregnancy and newborn outcomes
through improved routine care- Access
⢠Document socio-cultural, gender, and community
factors influencing effective use of mphones apps
8. Research Design & Process
⢠Study Design: Case-Control
⢠5 remote village pairs in Karuk district
⢠Baseline and endline studies
⢠20 months of implementation
⢠Study population: CHWs, mothers of
children age 0-23 months, and health facility
staff in both intervention and control sites
9. Research Design & Process
⢠2009 Assessment trip with Dimagi
⢠2010 Baseline
Module Design & Refinement
⢠2011 CommCare Module
Training
⢠2012 Observation and field
support
⢠Jan 2013 Endline
12. Operational challenges
⢠CHW literacy
⢠Security in the province
⢠Cultural acceptability of using mobile phones for health
issues
⢠Understanding and use of the research tool by CHWs
⢠Healthcare worker capacity and knowledge
⢠Community access and use of health facilities
⢠Need additional manpower to support OR study
⢠Overall lengthy and labor intensive process
13. Lessons Learned
⢠Facilitated dialogue with families on the need for
facility births and helping them plan better for
births
⢠mHealth tool helped facilitate dialogue with families
and key community leaders
⢠Having flexibility in design and rollout of tool was
helpful
⢠Take time to find the most appropriate partner
⢠Tool was job aid, communication tool, and
monitoring systemâespecially in remote locations
14. Next Steps
⢠WV Afghanistan secured CIDA funding
⢠Scale up plans to additional locations
⢠Lessons learned applied within WV mHealth
interventions:
⢠Mozambique
⢠Motech
15. mHealth Theory of Change
Natl & Intl Goals
to
which project
contributes
Improved linkages
between facility and
community services
for quality
improvement
Improved linkages
between facility and
community services
for quality
improvement
Develop
Operating
Plan
Develop
Operating
Plan
Refine business
needs &
requirements
Refine business
needs &
requirements
CHW/V adherence to
behavior change
communications
protocols
CHW/V adherence to
behavior change
communications
protocols
CHW/V
adherence to
case
management
protocols*
CHW/V
adherence to
case
management
protocols*
Foundational
activities
immediate
outcomes
Outcomes to which
project primarily
contribute
Finalise M&E
plan and
conduct
baseline
Finalise M&E
plan and
conduct
baseline
Consolidate
sustainability
plan and
partner
relationships
Consolidate
sustainability
plan and
partner
relationships
Establish
programme
management
Establish
programme
management
Training,
curriculum and
partner
development
Training,
curriculum and
partner
development
Improved preventive
health behavior among
pregnant women and
caregivers at the
household level
Improved preventive
health behavior among
pregnant women and
caregivers at the
household level
Access to health
information and
complementary
social services
Access to health
information and
complementary
social services
Build and sustain
user capacity &
ownership
Build and sustain
user capacity &
ownership
Communicate
project- roadmap,
benefits, project
management
Communicate
project- roadmap,
benefits, project
management
More timely and effective
use of health services on
the part of pregnant
women and caregivers
More timely and effective
use of health services on
the part of pregnant
women and caregivers
Deployment
activities
Develop
solution based
on user needs
Develop
solution based
on user needs
Activity
tracking,
monitoring &
evaluation
Activity
tracking,
monitoring &
evaluation
Appropriate and
timely use of
program
monitoring
information
Appropriate and
timely use of
program
monitoring
information
Design
budget &
sustainable
financial
model
Design
budget &
sustainable
financial
model
Undertake user
acceptance
testing
Undertake user
acceptance
testing
Train users on
all aspects of
solution
Train users on
all aspects of
solution
⢠Lower maternal and child U5 mortality rates
⢠Lowered child U5 morbidity
⢠Improved maternal and child U5 nutritional status
⢠Lower maternal and child U5 mortality rates
⢠Lowered child U5 morbidity
⢠Improved maternal and child U5 nutritional status
Millenium
Development
Goals
mHealth Theory of Change
CHW/V
motivation &
retention
CHW/V
motivation &
retention
More sustainable
and effective
CHW/V workforce
More sustainable
and effective
CHW/V workforce
Referral
closure rates
between
CHW/V and
facilities
Referral
closure rates
between
CHW/V and
facilities
* i.e. ttC visit schedule or CCM clinical case management protocols
16. WV Program Coordination Unit
Structure: A small team of
dedicated professionals will
coordinate the mHealth
programming and work with
the Motech Suite Team. The
following Program
Coordination Unit (PCU) will
provide the management,
coordination, strategic and
technical support to existing
and future mHealth programs.
DM&E ExpertsDM&E Experts
Project ManagerProject Manager
Project SponsorProject Sponsor
Health ExpertsHealth Experts PPP ExpertsPPP Experts ICT ExpertsICT Experts
Technical Partner
Team
Technical Partner
Team
Business Advisory
Group
Business Advisory
Group
WV National Office Project
Structure & Management
Program/Project Governance Processes & Documentation:
â˘Program & project charters
â˘Annual planning process
â˘Communications plan
â˘Stakeholder management plan
17. WV Implementation Models
prioritized for Motech Suite
⢠CHW â Timed
and Targeted
Counseling (ttC)
⢠Community
Case
Management
(CCM)
⢠cPMTCT
⢠Community
Care
Coalitions
(CCC) / Village
Health
Committees
(VHC)
⢠Citizen Voice
& Action
(CVA)
Community Environment Yellow shading
-
Secondary
priority
Blue lettering
- specialized or
context-specific
adaptations of
models
18. Program Areas for mHealth
Solutions
Health System Strengthening
ďą Country Ownership
ďą Linkages to Health System & Services
Community
ďą Community Mobilization & Sensitization
ďą CHW Recruitment, Training, Supervision,
Incentives & Performance Evaluation
ďą CHW & Beneficiary Registration
Household/Individual
ďą Home-Based Care
ďą Referral System
ďą Counseling & Behavior Change Communication
ďą Response to Urgent Care Scenarios
ďą Monitoring & Evaluation Data Collection
ďą Provision of Health Commodities
ďą Household based diagnostics/screening/case
management tools
KEY SOLUTION FUNCTIONALITY
ďźRegistration
ďźReferral Process
ďźAlerts/Notifications
ďźReporting
ďźBehavior Change Messages
ďźIntegration with HMIS
ďźTesting/Rapid Diagnostics
ďźUrgent Response
ďźSupply Chain/Logistics
ďźCHW training, supervision,
performance evaluation
19. Phase II (Summer/Fall
2013)
ďStock Out Tracking*
ďUrgent Response*
ďCHW training, supervision,
performance evaluation*
ďIntegration with HMIS
ďTesting/RDT
Prioritized WV Functional Blocks
Phase I (Spring 2013)
1.Registration*
2.Referral Process*
3.Alerts/Notifications*
4.Reporting*
5.Behavior Change Messages*
WV Customization: White = live; Gold = Being finalized; Aqua= Initial preparation
* Functionality already exists in Motech Suite
20. Second Priority Functionality
Current Phasing
First Priority Functionality
Phase I Implementations
DATES: January - March 2013
PROJECTS: Sierra Leone - ttC
Uganda - ttC & CCM/malaria
Zambia - CCM/malaria & ttC
Tanzania - ttC
Phase III Implementations
DATES: TBD & Proposal Stage
PROJECTS: -Ghana - ttC
-Jerusalem/West Bank/Gaza â ttC
& PS
-Mozambique â CCM/Malaria &
RDT
-Haiti â HIV/AIDS
-Niger â CCM & Nutrition
-India â ttC/CCM & Advocacy
Phase II Implementations
DATES: April - September 2013
PROJECTS: India - MNCH
Afghanistan - MNCH & Nutrition
Sri Lanka â Nutrition
Mozambique - ttC
Malawi - ttC
Zimbabwe - ttC
Project Objectives: 1. Improved health status of vulnerable target populations: increased knowledge, practice and coverage of key interventions; improved access to services, and quality and equity in service delivery 2. Increased scale of interventions: improved partner capacity and improved systems and policies 3. Contribution to excellence in child survival nationally and globally The OR study within the BHAMC project aimed to test if the use of CommCare⢠increases utilization of maternal and newborn health services and knowledge of important information points and improves communication with higher trained health care workers. As a secondary objective, it aimed to explore cultural and technical barriers that exist in communities and health facilities that affect successful use of CommCare⢠or other mobile applications for health. This was the first time a mobile application was used in the country for a health intervention.  There were at least three facets to the intervention that was tested: one, the pregnancy and newborn care modules of CommCare⢠in written, pictorial and audio formats; two, airtime for CHWs to communicate with facility-based staff; and lastly the availability of real-time data to the project team. aths of women in reproductive age result from complications of pregnancy and childbirth World Vision worked with the software consultancy firm Dimagi in adapting the latterâs software application, CommCare⢠for CHWs in the OR intervention sites to develop two modules, one for antenatal care and another for postnatal care based on HBLSS. The modules were developed in Dari, the local language, in visual and audio formats. A database was also set up at the BHAMC office and at World Vision headquarters that can access data in real time. BHAMC trained five CHW couples in the use of these modules who were provided with mobile phones loaded with the application and with airtime to support them when they visited pregnant women at key times during pregnancy and postnatal and for making referral calls. The CHW couples visited pregnant women at specific times during pregnancy to discuss specific actions related to their health and to upload information related to their pregnancy on the mobiles. Key aspects discussed were: the need for antenatal care visits and delivering in a facility, planning and preparing for birth (transportation, saving money, coordination with health facility for delivery, essential newborn care items), danger signs during pregnancy, labor, delivery, and caring for a newborn. In particular, the CHWs discussed the need for facility birth with the family and facilitated related decisions. When the woman went into labor, the CHWs made a referral call and linked the womanâs family with a skilled provider at the nearest facility. In both intervention and comparison sites, as with the rest of BHAMCâs target communities, the HBLSS package was used to improve the same outcomes.
Project Objectives: 1. Improved health status of vulnerable target populations: increased knowledge, practice and coverage of key interventions; improved access to services, and quality and equity in service delivery 2. Increased scale of interventions: improved partner capacity and improved systems and policies 3. Contribution to excellence in child survival nationally and globally The OR study within the BHAMC project aimed to test if the use of CommCare⢠increases utilization of maternal and newborn health services and knowledge of important information points and improves communication with higher trained health care workers. As a secondary objective, it aimed to explore cultural and technical barriers that exist in communities and health facilities that affect successful use of CommCare⢠or other mobile applications for health. This was the first time a mobile application was used in the country for a health intervention.  There were at least three facets to the intervention that was tested: one, the pregnancy and newborn care modules of CommCare⢠in written, pictorial and audio formats; two, airtime for CHWs to communicate with facility-based staff; and lastly the availability of real-time data to the project team. aths of women in reproductive age result from complications of pregnancy and childbirth World Vision worked with the software consultancy firm Dimagi in adapting the latterâs software application, CommCare⢠for CHWs in the OR intervention sites to develop two modules, one for antenatal care and another for postnatal care based on HBLSS. The modules were developed in Dari, the local language, in visual and audio formats. A database was also set up at the BHAMC office and at World Vision headquarters that can access data in real time. BHAMC trained five CHW couples in the use of these modules who were provided with mobile phones loaded with the application and with airtime to support them when they visited pregnant women at key times during pregnancy and postnatal and for making referral calls. The CHW couples visited pregnant women at specific times during pregnancy to discuss specific actions related to their health and to upload information related to their pregnancy on the mobiles. Key aspects discussed were: the need for antenatal care visits and delivering in a facility, planning and preparing for birth (transportation, saving money, coordination with health facility for delivery, essential newborn care items), danger signs during pregnancy, labor, delivery, and caring for a newborn. In particular, the CHWs discussed the need for facility birth with the family and facilitated related decisions. When the woman went into labor, the CHWs made a referral call and linked the womanâs family with a skilled provider at the nearest facility. In both intervention and comparison sites, as with the rest of BHAMCâs target communities, the HBLSS package was used to improve the same outcomes.
Why Afghanistan: 2 nd worst maternal mortality rate and the highest infant mortality rate Only 24.3% of mothers receive skilled delivery assistance during delivery Only 20.8% mothers received post natal check by skilled health personnel after three days of delivery Almost half of all de Project Objectives: 1. Improved health status of vulnerable target populations: increased knowledge, practice and coverage of key interventions; improved access to services, and quality and equity in service delivery 2. Increased scale of interventions: improved partner capacity and improved systems and policies 3. Contribution to excellence in child survival nationally and globally The OR study within the BHAMC project aimed to test if the use of CommCare⢠increases utilization of maternal and newborn health services and knowledge of important information points and improves communication with higher trained health care workers. As a secondary objective, it aimed to explore cultural and technical barriers that exist in communities and health facilities that affect successful use of CommCare⢠or other mobile applications for health. This was the first time a mobile application was used in the country for a health intervention.  There were at least three facets to the intervention that was tested: one, the pregnancy and newborn care modules of CommCare⢠in written, pictorial and audio formats; two, airtime for CHWs to communicate with facility-based staff; and lastly the availability of real-time data to the project team. aths of women in reproductive age result from complications of pregnancy and childbirth World Vision worked with the software consultancy firm Dimagi in adapting the latterâs software application, CommCare⢠for CHWs in the OR intervention sites to develop two modules, one for antenatal care and another for postnatal care based on HBLSS. The modules were developed in Dari, the local language, in visual and audio formats. A database was also set up at the BHAMC office and at World Vision headquarters that can access data in real time. BHAMC trained five CHW couples in the use of these modules who were provided with mobile phones loaded with the application and with airtime to support them when they visited pregnant women at key times during pregnancy and postnatal and for making referral calls. The CHW couples visited pregnant women at specific times during pregnancy to discuss specific actions related to their health and to upload information related to their pregnancy on the mobiles. Key aspects discussed were: the need for antenatal care visits and delivering in a facility, planning and preparing for birth (transportation, saving money, coordination with health facility for delivery, essential newborn care items), danger signs during pregnancy, labor, delivery, and caring for a newborn. In particular, the CHWs discussed the need for facility birth with the family and facilitated related decisions. When the woman went into labor, the CHWs made a referral call and linked the womanâs family with a skilled provider at the nearest facility. In both intervention and comparison sites, as with the rest of BHAMCâs target communities, the HBLSS package was used to improve the same outcomes.
Why Afghanistan: 2 nd worst maternal mortality rate and the highest infant mortality rate Only 24.3% of mothers receive skilled delivery assistance during delivery Only 20.8% mothers received post natal check by skilled health personnel after three days of delivery Almost half of all de Project Objectives: 1. Improved health status of vulnerable target populations: increased knowledge, practice and coverage of key interventions; improved access to services, and quality and equity in service delivery 2. Increased scale of interventions: improved partner capacity and improved systems and policies 3. Contribution to excellence in child survival nationally and globally The OR study within the BHAMC project aimed to test if the use of CommCare⢠increases utilization of maternal and newborn health services and knowledge of important information points and improves communication with higher trained health care workers. As a secondary objective, it aimed to explore cultural and technical barriers that exist in communities and health facilities that affect successful use of CommCare⢠or other mobile applications for health. This was the first time a mobile application was used in the country for a health intervention.  There were at least three facets to the intervention that was tested: one, the pregnancy and newborn care modules of CommCare⢠in written, pictorial and audio formats; two, airtime for CHWs to communicate with facility-based staff; and lastly the availability of real-time data to the project team. aths of women in reproductive age result from complications of pregnancy and childbirth World Vision worked with the software consultancy firm Dimagi in adapting the latterâs software application, CommCare⢠for CHWs in the OR intervention sites to develop two modules, one for antenatal care and another for postnatal care based on HBLSS. The modules were developed in Dari, the local language, in visual and audio formats. A database was also set up at the BHAMC office and at World Vision headquarters that can access data in real time. BHAMC trained five CHW couples in the use of these modules who were provided with mobile phones loaded with the application and with airtime to support them when they visited pregnant women at key times during pregnancy and postnatal and for making referral calls. The CHW couples visited pregnant women at specific times during pregnancy to discuss specific actions related to their health and to upload information related to their pregnancy on the mobiles. Key aspects discussed were: the need for antenatal care visits and delivering in a facility, planning and preparing for birth (transportation, saving money, coordination with health facility for delivery, essential newborn care items), danger signs during pregnancy, labor, delivery, and caring for a newborn. In particular, the CHWs discussed the need for facility birth with the family and facilitated related decisions. When the woman went into labor, the CHWs made a referral call and linked the womanâs family with a skilled provider at the nearest facility. In both intervention and comparison sites, as with the rest of BHAMCâs target communities, the HBLSS package was used to improve the same outcomes.
Improve pregnancy and newborn outcomes in remote villages of Herat province through improved routine care and practice of pregnancy, and better access to higher-trained health workers
The OR study used a pretest-post test design with baseline and end line household surveys carried out in intervention and comparison sites. The sample size of each of the 4 surveys was 103 mothers with children less than 24 months of age. Four surveys with sample size - 103 mothers with children under 24 months old
The intervention area had 20% point improvement in women receiving at least one ANC (p=0.006), 12% more in having a birth plan (p=0.03) and 22% more facility births over the intervention period (p=1.06), than in the comparison sites
The OR study showed that the addition of the mobile phone application to ongoing HBLSS intervention leads to further increase in utilization of MNC services. The intervention area significantly greater improvement over time than the comparison sites in ANC visits, birth planning and facility births. The mobile application served as a job aid in user-friendly formats, and helped CHWs communicate directly with facility staff and provided real-time data to the project team. Â
Referral and follow up services - Continue to be poor with out ICT OR Identification of danger signs during pregnancy and intervention of skilled health personnel â remains a challenge Emergency care during pregnancy- in the absence of an ambulance Post natal visits â continue to be a challenge Basic information of newborn care and breastfeeding issues
mHealth increased community and household dialogue with mothers and their household members leading to a significant increase in facility based births. This is especially important since f acility birth is a critical measure for the health and survival of newborns in a setting such as Herat where moving an asphyxiated newborn to a facility in time might be next to impossible.
KEY POINTS: The goals are tied most closely to MDGs 4 and 5 but also contribute to some aspects of MDGs 1 (particularly nutritional status of pregnant women and children U5) and 6 (particularly HIV and malaria). At the outcome level, we expect the âvalue addâ of mHealth to be reflected in these 4 areas. These metrics would only be gathered periodically with the purpose of documenting quantifiable change at the population, CHW workforce or community level. Immediate outcomes that would be tracked on an ongoing basis to both refine the application itself and document how the mHealth application has directly effected program beneficiaries. The information would either be sourced from standard M&E data tracked by the mobile application itself or by CHW supervisor records and the records kept by community-based structures that support the CHW program, for example, community health committees or advocacy groups. Strengthening community level structures is a central aspect of WVâs Maternal and Child Health and Nutrition strategy. NOTE that adherence to case management protocols can contribute to both the first and second outcome listed here â adherence to the ttC visit schedule for example, would also strongly affect the first outcome. Similarly, appropriate and timely use of program monitoring information can reinforce CHW supportive supervision systems and thus support both the 3 rd and final outcome listed here. We are in the process of developing an illustrative logical framework to propose appropriate indicators at both the output and outcome level.
World Vision has piloted the first four mhealth functionalities in Afghanistan, Mozambique and Zambia, and is now moving forward on implementations with additional functionality and scope for ttC/CCM in another 4-6 countries, utilizing the Motech Suite, in collaboration with Gates Foundation, Grameen Foundation and Dimagi.