2. Project Duration: 4 Years (FY12 – FY15)
Partners: Vatsalya, Sarthi Development Foundation, Dimagi Inc. &
Government of Uttar Pradesh
Area of Intervention: 8 blocks of Kaushambi & 1 block on Lucknow
district
Beneficiaries: 13428 women & 12,308 children through 257 ASHAs
in two blocks
Total beneficiaries – around 1,42,000
Donors: CRS private fund, USAID small contribution DIV 2.0
Reducing Maternal & Newborn Deaths-ReMiND
4. ReMiND – What is it?
CommCare as a Job Aid for ASHA:
• Track and support woman through Pregnancy and
Postpartum periods
• Track and support baby from birth through first 2 years of life
• Localized and designed for ASHA use
Combines audio and still images for counseling and
assessment content based on ASHA Modules 2, 6 and 7
CommCare as a Decision Support tool:
• Helps the ASHA identify Danger Signs and make the
appropriate referral
CommCare as a supportive supervision tool
• Helps ASHA supervisors to manage ASHA performance
and provide constructive feedback.
4
6. REMIND APPLICATION SUMMARY:
Five Modules to Guide the ASHA Workflow:
1. Registration of Pregnant Mothers
2. Management of Pregnant Mothers
3. Management of Postpartum Mothers
4. Management of Newborns & Young Children
5. Referral Follow-Up
6
7. - Pregnancy Checklist
- Completion of ANC check-ups and Tetanus
Immunizations, Assess Use of Health Services,
Assess High Risks Signs in Pregnancy
- Pregnancy Counseling
- Information about High Risks and Pregnancy
Danger Signs, Antenatal Care, Nutrition, Rest and
IFA, Pregnancy Danger Signs, Birth Planning and
Preparedness, Essential Newborn Care
- Pregnancy Outcome
- Delivery information, Pregnancy outcome,
Newborn and mother’s health after delivery
- Modify Pregnant Woman Info
- Modify identification info for woman, and update
EDD/LMP information
PREGNANT MOTHERS:
7
8. - Mother Postpartum Visit
- Completion of Postpartum home visits,
Assessment of High Risks, Visit scheduling
- Postpartum Counseling
- Information about High Risks and Postpartum
Danger Signs
- High Risk Follow up
- Follow-up on high risks identified, Decision support
for assessing high risks
- Postpartum Review
- Review information about status and health of
postpartum mother, high risks identified, and next
scheduled home visit
- Close Postpartum
- To be filled 42 days post delivery once postpartum
phase is complete
POSTPARTUM MOTHERS:
8
9. - Home-based Newborn Care Visit
- Modify identification info for infant and mother, and
update DOB information
- Breastfeeding Assessment
- Additional follow-up for any mother/newborn with a
suspected feeding problem.
- Routine Immunization Tracking through 2 years
- BCG, OPV, DPT, Boosters, Polio, Measles, Vit A
- Routine Immunization Counsel
- Information about vaccines, benefits of
immunization, side effects, how/where to go
- Update Baby Info
- Update any details about the newborn case
- Close Baby
- To be filled to close the baby case after 2 years of
care and full immunization
YOUNG CHILD:
9
10. Supportive Supervision & Monitoring
Analysis &
use of
ASHAs’ real-
time data
Outcome:
Maternal, newborn & child
health outcomes
CommCare
HQ
Supportive
Supervision
Application
Quality:
IPC & counseling skills,
Mobile skills
Analysis &
use of real-
time
supervision
data
Active Data
Management
Reports
Output: Frequency &
timeliness of ASHA home
visits
SMS
reminders
& missed
visit alerts
10
13. Quality of counseling byASHAhas improved significantly
79%
100%
35%
77%
96%
94%
94%
100%
41%
50%
11%
24%
58%
59%
59%
85%
ASHA talked about her next home visit.
ASHA encouraged woman to use next
recommended health service.
Families who asked any questions.
Clients who asked any questions.
ASHA encouraged client to speak or ask
questions.
ASHA waited for client to respond before
moving to next audio message.
ASHA expanded on any of the CommCare
audio messages/questions.
ASHA greeted woman
Improvements in ASHA counseling tracked through facilitators’ observations
Sept-12 14-Sep
20. • Tailored handholding support to ASHAs
• Working with ASHAs who have no functional literacy
• Frequent change in the leadership in government at district
level
• Technology related issues
– GPRS problems
– Change in the settings in the hand set
• Engaging government in resolving tech issues
• Putting systems in place vis a vie leveraging technology
– Eg – ensuing ASHA visit & then making it ICT enabled
Challenges
21. • Make app more localized (such as voice of a local lady) and simple.
• With low-literate users, the mobile interface must ensure easy
navigation and training strategies must be adapted to maximize
learning.
• Immediate post training follow ups sustains interest and motivates
to practice.
• Need based supervision helpful in maximizing ASHA outputs.
• Strengthening local resources minimizes time in resolving
technology issues
• Understand the context well before launching the app
– Such as understanding capacities of ASHAs
Lessons Learned
22. • Success of a mobile app for ASHAs is dependent on having
sufficient supportive supervision for the ASHAs.
• Engagement of the government functionaries from the inception
enables easy uptake of intervention and increase their ownership
• Allow sufficient time at every stage – app development, training,
implementation and data analysis as well as its use
• Align with government programs and system
• Having tool is good. However, the purpose of using tool needs to
be given more importance than the tool itself.
Lessons Learned
23. Keep it simple
Test, Test, Test & Then Scale
Invest in building local capacities
It takes a team
Share & learn…learn & share
Summary and Close
Part of the rational for choosing to work in Kaushambi was that is was a GoI high-priority district & CRS was already working there. In an effort to increase access to health services the ReMiND program equipped ASHA with mobile job aids and monitoring tools.
In 2011, the district level authorities requested that ASHAs from Manjhanpur be selected for the initial piloting of the MNCH app. As the district seat, Manjhanpur allowed for closer participation and follow-up with district health authorities. When it was then finally time to go to scale in the first block, it made sense to stay in Manjhanpur because that is where the pilot had been and we already had 10 very experienced ASHAs to build from. The subsequent scale-up to Mooratganj was also strongly influenced by district health authorities’ preferences/recommendations. Network coverage and geographic access/proximity for Manjhanpur-based staff were also considerations in the decision to scale-up to Mooratganj.
ReMiND equips and trains ASHA on mobile-phone based tool to improve home visit counseling, assessment and referrals during the first 1,000 days of life (pregnancy, postpartum/newborn through first 2 years). ASHAs use basic feature phones (Nokia C2-01) operating Dimagi’s open-source CommCare software
Key Milestones- could also speak to when each app was designed and rolled out, and the various iterations.
March-October 2011: First version of MNCH app, showing enough promise for CRS to earmark funds. 10 pilot ASHAs
July 2012
Sector Facilitators are trained on ReMiND's monitoring and supportive supervision tools for scale-up of the pregnancy module to ASHAs
August 2012: Training 111 ASHAs (100%) in Manjhanpur block of Kaushambi on a CommCare-based pregnancy application.
March 2013:
USAID DIV 2.0 funding for an additional 149 ASHAs (100%) from Mooratganj
September 2013:
ASHAs are trained on the pregnancy referral and routine immunization modules of MNCH application
September 2014:
Roll-out of CommCare-based supportive supervision application to a new government cadre of ASHA supervisors across all 8 blocks of Kaushambi district and in partnership and in one block of the state capital of Lucknow.
Postpartum and baby modules of the MNCH ASHA application to be rolled-out in March 2015
Highlight the use of labels and color-coding (pregnancy = yellow, postpartum mother = green, baby = blue) to help low literate ASHAs more easily navigate the application.
Trained on Maternal & Newborn Child Health Care based on the GOI’s guidelines.
Hands-on training on using customized mobile application on java enabled phones.
On job support in conducting home visits and counseling of beneficiaries
Feedback from the blocks on performance application.
ReMiND is exploring ways to leverage mobile technology to strengthen ASHA supportive supervision and monitoring. This is currently done at 3 levels:
Output level monitoring and support focuses on tracking and improving the frequency and timeliness of ASHA home visits. This is done through weekly and monthly Active Data Management Reports. With the planned roll-out of the postpartum & infant applications, a system will be introduced that includes SMS reminders to ASHA to conduct home visits with missed visit alerts to ASHA supervisors if the visits are not conducted on time.
ReMiND is also using a CommCare-based mobile application for supportive supervision that includes tools for monitoring the quality of ASHA’s interpersonal communication and counseling skills during home visits, as well as their mobile use skills. This application is currently used by ReMiND Project staff, but is easily transferrable to ASHA Facilitators once that cadre is in place and to other ASHA supervisors. Real-time data generated from the use of the supportive supervision data can then be used to target support low performing ASHA and recognize those who are high performing.
At the highest level, ASHAs’ use of their CommCare-based job aids (mobile application) generates real-time health outcome data for every pregnant woman, newborn and infant they have registered. The project is currently doing quarterly analysis of health outcome data, but via CommCare HQ (Dimagi’s cloud-based server) the data can be accessed and analyzed at any time.
The supportive supervision and monitoring tool application that ReMiND is using allows supervisors to first register each ASHA in her area and then to individual follow-up and monitoring of each. The application contains the following forms/tools:
ASHA Follow up Form : Reports details of follow up visits with ASHA
Home Visit Observation Form : Tracks quality of ASHAs interpersonal communication and counseling skills with clients based on an observation checklist that the supervisor uses while accompanying ASHAs on home visits.
Mobile Experience survey: Assesses ASHAs’ skills at using the mobile application on her phone and other mobile use skills.
Technology Issue form : Gives picture of reported and resolved technological issues of ASHA’s phones
From the Technology Issue form is a Tech Issue Follow-up form that can be filled to report the status and resolution of the tech issues.
Meeting Form: Captures information about the type, time, place, participants and decisions made in different meetings attended (e.g., ASHA monthly meeting, ANM meetings, etc.)
All of the data the supervisors collect using this supportive supervision application is uploaded onto CommCare HQ where it can be regularly analyzed to track the quality of ASHA performance (home visit observation) and identify areas for strengthening.
This data is used in:
Discussion with ASHAs by HEO during meetings
Planning of SFs – to prioritize support to poor performing ASHAs)
Project Reporting
good to explain what we mean by high and low coverage when you speak to this slide also number of women who were never-visited by an ASHA from 39% to 24% of the sample population 39% to 24% would mean that 1881 fewer women did not receive a home visit (moving from 4890 to 3009 who did not get a home visit)
Counselling by ASHA, mobile phone is just to ensure the critical points are covered
