Good morning, it is a pleasure to be here and share with you Pathfinder’s work using mobile technology to strengthen the work of CHWs. I will be presenting on behalf of my colleague Marion McNabb who was not able to attend. As is the case in many countries and contexts, CHWs are often the backbone of service delivery projects and most of the organizations that are here at this meeting are engaged in finding ways to enhance and support their performance. Increasingly organizations are turning to mHealth as an innovative solution to improving the quality of CHW service delivery as well as improving data collection by CHWs. Today I will be talking briefly about Pathfinder’s approach to incorporating the use of mobile technology, specifically an application called CommCare, within several of our projects to support various cadres of CHWs.
Briefly, Pathfinder is a sexual and reproductive health organization whose mission is to ensure that people everywhere have the right and opportunity to live a healthy sexual and reproductive life. Our work is focused on 6 core areas listed on the slide and 3 strategic initiatives one of which is mHealth. These core areas and strategic initiatives are supported by 4 cross cutting strategies, behavior change, gender equality, capacity building, and systems strengthening. mHealth is a strategic initiative because we recognize that it is a powerful tool that can be leveraged to enhance our work in all of the six core areas.
Phone picture: http://erictula.wordpress.com/tulasalud/technology/CommCare is a is a case management solution for CHWs. It is a mobile phone application that uses open source software and runs on low cost mobile phones such as java-enabled phone such as a Nokia phone or higher end Andorid phones. CommCare contains registration forms, checklists, algorithms or job aids that can help monitor danger signs, and educational prompts. It helps manage enrollment, support, and tracking of all of the CHW’s clients and activities. It allows the CHW to captures data from each home visit and sends the data to a central location for program improvement, health surveillance, and workflow interventions. It can be used even when there is no network available and then transmit data at a later point when the network is available. CommCare is easily customizable for widely different environments; houses select client data on the phone and uses skip logic to support client interaction that is customized to that particular client. For example if a woman is coming in for a 2nd ANC visit, it would have recorded that she has already had one does of TT and therefore the CHW would be prompted to offer a 2nd dose of TT. It also can handle multiple languages and incorporates multimedia elements for low-literate users.
Pathfinder has used CommCare in three of its projects. Our first initiative was in Tanzania in 2008 through a partenrship with D-Tree. We used CommCare to support provision of community home-based care using relevant health protocols, such as home-based care, home counseling and testing, TB and malaria screenings, as well as supporting referrals. CommCare has been designed in alignment with national HMIS for community care and supports data collection and collation as well as the use of that data by CHWs and their supervisors. We are also engaged in a study with FHI 360 where we have loaded the Balanced Counseling Plus tools on CHWs mobile phones to support provision of FP to CHBC clients (20 CHWs)In Nigeria we started a project in 2012 with private funds based in 20 facilities in Abuja and Nasarawa using CommCare to support improved quality of care in terms of maternal health. The facilities range from ones that are primarily staffed by community health extension workers (CHEWs) to those that alos have midwives. Similar to Tanzania, CommCare has been adapted to track clients over time as well as to provide various prompts and algortihms that the CHEws can use to enhance service provisiopn. Counseling messages are incorporatedthat prompt the CHEW to have further discussions with clients and we are also using counseling messages during group health talks over a phone and have plans to attach speakers to these phones in the near future so that large groups of clients can hear well. At baseline we conducted a study to examines the feasiblity and acceptability of using CommCare with CHEws in this setting. We are currently engaged in a study look at the impact that the use of CommCare has on QoC and at endline we will also assess provider perspectives on the benefits of using mobile phones and CommCare.In Kenya we developed an application for MNCH Health as well an application to support tracking of OVCs and what services they have received. We are currently rolling this out with 300 CHWs that are part of our APHIAPlus program in Nairobi and Coast provinces with the potential of scaling this up to 3,000 CHWs.
In all three of our projects Pathfinder has followed the same process in terms of program design and implementation. The first step is to define the problem. This takes about 3 months and involves discussions with CHWs as well as shadowing them to see what they really do, what their needs are and how will mobile technology fit. We explore perceptions in terms of how the CHW sees mobile technology helping and how will the clients interact with the CHW when they use a mobile phone. At this stage is very important to involve the government in terms of having them review and be on board with the mHealth project as well as integrating data collected into national HMIS systems. Also it is important to be a part of national working groups that aim to develop guidelines and coordinate with other partners who are implementing mHealth projects. It is critical to design the initiative from the beginning with scale up in mind. In terms of developing the solution : In partnership with D-Tree or Dimaggi, we have developed the prototype app with input from CHWs and then tested it live with CHWs and obtained their feedback, this takes sometimes up to 6 months. The goal is to ensure that the application meets the need of the CHW and make it useful for them. We have used pictures and audio for CHWs who are illiterate. We then field test the app – mapping the workflows of the CHWs. How and when CHWs ask certain questions without the use of mobile phone should also be taken into consideration when you develop the app. In every country – we aim to seek out others who are doing mHealth work to make sure we are coordinated through participation in working groups and other venues. And lastly Iterations and monitoring: It is imperative to build into your process continual refinement of the app over time, making sure that data elements captured in app also match to HMIS as well as to otherdata standards for future integration. We are looking to find ways to improve data use in supervision by developing reports to share with stakeholders that look at individual clinic performance as well as aggregate performance. In terms of integrating mobile into the workflow of CHWs, we really try and understand how they are currently working and for the phone to be a minimal burden – and more of a help. This is not that easy all the time, and it is something we are learning day by day.
M&E: In all three of these initiatives we have developed a rigorous M&E plan that allow us to measure the impact that CommCare is having in our CHW programs. For the Nigeria project, we have developed performance indicators that will allow us to measure the effect of using Comm Care on quality of care. And as I mentioned earlier wewill also measure user satisfaction with CommCare in supporting quality service delivery.In terms of integration with existing systems, we have developed reports (pulling data from CommCare directly into our online data system) to mimic the Nigerian HMIS registers and reports to facilitate monthly and quarterly reporting by facilities. We are moving onto integration with DHIS2 now in both Nigeria and Kenya and cultivating a culture of data use by both CHWs and their supervisors.In 2010 in Tanzania, a pilot study followed by two larger studies were conducted to evaluate the impact of SMS reminders to improve the promptness of routine CHW visits. An escalating reminder system that first sent SMS reminders directly to the CHW before notifying the CHW’s supervisor after several overdue days. The reminders resulted in an 86% reduction in the average number of days the CHW’s clients were overdue (9.7 days versus 1.4 days) with only a small number of cases ever escalating to the supervisor. However when the supervisor was removed from the reminder loop in the second study, supervisor performance significantly decreased.
With regards to challenges, many are the ones you would expectCHW familiarity with and comfort using technologyBurden of double reporting both in terms of using CommCare as well as paper formats. This is why we are doing things like creating reports that replicate the HMIS reporting formats to help encourage providers and supervisors to only use CommCare and do away with paper data collection and reportingAnd lastly, the beauty of CommCare is that it generates real time data that can be used by both CHWs and their supervisors. The challenge comes in when they don’t use this data because there is no culture of using data for targeted supervision. CommCare generates a plethora of data so this requires a culture of data use as well as the capacity of supervisors to decide which data is most useful to their needs. We are developing automated solutions whereby certain key data is automatically fed to supervisors in easy to use formats to help address this challenge (e.g., the work that was done in Tanzania using SMS alerts)Lessons LearnedDefine the benefits for the CHW to maximize use in terms of being able to track clients over time, improved and standardized counseling, and not having to drag around heavy log books that in some cases such as our Tanzania CHBC program carrying around CHBC logbooks can create stigma as the community associates this with HIV and AIDS. By not carrying anything the CHW appears more to just be making a regular visit to a neighbor or friend. Actively engage governments from the beginning to create ownership and pave the way for scale up through integration with existing systemsShow the benefits of using data to improve quality of services both to the CHWs, the supervisors and other managers at district or higher levels.
Leveraging Mobile Technology to Strengthen the Work of Community Health Workers_Gwyn Hainsworth
Leveraging Mobile Technology to Strengthen the Work of CommunityHealth WorkersSpring CORE Group MeetingApril 25, 2013Gwyn HainsworthSenior Advisor, Adolescent Sexual and Reproductive Health
ContraceptionMaternal &Newborn HealthHIV and AIDSAdolescentsAbortion &Postabortion CareAdvocacyCore areasPeople everywhere havethe right and opportunityto live a healthy sexualand reproductive lifeOutcomeCapacity BuildingGender EqualityBehavior ChangeCross Cutting StrategiesStrategic InitiativesmHealthPopulation Healthand theEnvironment (PHE)Cervical CancerSystemsStrengthening
CommCare – Case ManagementIt’s a mobile phone appthat can:• Document questionsand answers• Transmit data whenmobile network isavailable• Use multimedia• Use logic to stepthrough a processdynamically
Pathfinder CommCare ProjectsTanzania• D-Tree, start 2008• 300 CHWs in Dar• Focus on HIV/AIDS• Study with FHI360,CommCare forFP/HIV IntegrationNigeria• Start in 2012• 20 facilities, 150CHEWs• Focus on ANC• Study looking atquality of careKenya• Start in 2012• Aiming for 300CHWs in Nairobi andCoast• Focus on OVCs andMNCH
The Design and Implementation Process• Identify challengesat point of care• Shadow CHWs• Discuss perceptionsand needs with end-users• Design with scale upand sustainability inmind• Engage governmentin the designDefining theproblem• Design app with theend user• Field test app;mapping workflows• Developingcounseling andaudiovisual tools• Partnerships forcoordination andownershipDeveloping thesolution• Refining the app tofit the needs of theCHW• Integration ofmobile into CHWworkflow androutine• Using data toimprove supervision• Engaginggovernment inmonitoring and datauseIterations andmonitoring
Supervision, Monitoring and EvaluationRigorous M&E Plan• Performance indicators• User satisfactionIntegration and use of data• Data standards matchedto reporting requirements• Data integration withnational HMIS• Cultivating a culture of data useDeRenzi, et al 2012
Challenges and Lessons LearnedChallenges• CHW familiarity with technology• Burden of double reporting• Culture of using data for targetedsupervisionLessons Learned• Define the benefits for the CHW to maximize use• Actively engage governments from the beginning• Show the benefits of using data to improve quality of services