1. Interoperability & Crowdsourcing :
Cantheseimprove themanagement of
ANCprograms?
Joy Kamunyori
MEASURE Evaluation, SIFSA
Rob Allen
MEASURE Evaluation, SIFSA
January 19, 2016
The MomConnect Project

2. Presentation
• Discuss how MomConnect is improving access,
coverage, and quality ofANC for women in
SouthAfrica.
• Discuss how data system interoperability and
crowdsourcing are improving information
systems and access to data for improved data-
informed decision making.

3. Key theme − interoperability
Integration of data systems: “. . the property that
allows for the unrestricted sharing of resources
between different systems. This can refer to the ability to
share data between different components or machines,
both via software and hardware, or it can be defined as the
exchange of information and resources between different
computers through local area networks (LANs) or wide
area networks (WANs). Broadly speaking, interoperability
is the ability of two or more components or systems to
exchange information and to use the information that has
been exchanged.”

4. Key theme − crowdsourcing
Crowdsourcing: “… an online, distributed problem-
solving and production model that leverages the
collective intelligence of online communities for
specific purposes.” “…an approach to accomplishing a
task by opening it up to broad sections of the public.
Innovation tournaments, paying online participants for
categorizing images and seeking feedback from a specific
target group are examples of crowdsourcing. What ties
these approaches together is that the task/request is
outsourced with little restriction on who might participate.”

5. MomConnect
• SouthAfrican National Department of
Health (NDOH) initiative
• To support maternal health through
the use of cell phone-based
technologies
• Overall aims:
1. Introducemechanismforrecording
allpregnanciesinthepublichealth
systemasearlyaspossible
2. Enablesendingoftargetedhealth
promotionmessagestopregnant
women
3. Providepregnantwomenwith
mechanismtoprovidefeedback–
Effectively crowdsourcing
information

6. Why cell phones?
• Successfully used to improve
MCH outcomes by multiple
projects in several countries
• High levels of cell phone access
• Potential to accelerate the
proven value

7. MomConnect
• Launched on 21stAugust, 2014
at KT Motubatse Clinic,
Soshanguve in the Tshwane
District of Gauteng Province
• Launched by Minister of Health
and partners, including the US
Ambassador representing the
President's Emergency Plan for
AIDS Relief (PEPFAR)
programme
• Over 500,000 women
registered in first year

8. MomConnect registration process

9. How does it work?

10. MomConnect registration information
• Data points collected:
o Phonenumber—automatically collectedifusingownphone;manuallyentered
ifusinghealthcareworker’sphone
o Preferredfacilitycode—nationally approved6digitcodethatisusedto
uniquelyidentifyahealthfacility
o Estimatedduedate
o IDnumber(orpassportnumber)—intheeventofnoIDorpassportbeing
available theusermustentertheirdateofbirth
o Preferredlanguage—outof11officiallanguages
Collected via USSD

11. What is USSD?
Unstructured Supplementary Service Data

12. Why USSD?

14. Interoperability
• Designed to be interoperable with other systems
o HasbeendesignedtobecompliantwiththeSouthAfricanHealthNormative
StandardsFrameworkforeHealth(HNSF)andthecountry’seHealth
architecture
• Information collected sent to a health information exchange and
stored
o Incomingmonthswill belinkedwiththeNationalPatientMasterIndex
o Linkageswithothersystemsbeingactivelyexplorede.g.,TIER.Net(HIV
informationdatabase),NationalHealthLaboratoriesSystem(NHLS)

15. Data use for MomConnect
• MomConnect data is already being used to
improve the health system
• There are also a number of potential uses of the
data and the system in the future
• Interoperability is key in increasing the potential
for effective data use

16. Current usage of data from MomConnect
• Setting targets for numbers of women registering
• Monitoring registrations by pregnant women
against targets and identifying at which clinics
and district improvements are needed
• Improving service delivery at facilities
• Individual client care

17. Helpdesk
• There is a helpdesk which handles compliments
and complaints as well as frequently asked
questions
• Registered MomConnect users can send a
compliment or a complaint about services they
have received directly to the national helpdesk via
SMS
• There have been approximately 6 times as many
compliments as complaints

18. Complaints
• Complaints are sent directly to MomConnect
focal points in each of the 52 districts in South
Africa. These people have the responsibility to
follow up and provide a response on how the
complaints will be resolved within 10 days
• If no response or resolution plan is received
within 10 days then there is a rapid escalation
procedure

19. Examples of complaints and resolutions
• Complaint: Lack of iron supplements in clinics was
reported by multiple users
o Resolution: The process for supply of iron tablets was
investigated and problems identified and resolved.
This can be verified by no new complaints
forthcoming about supply of iron tablets.
• Complaint: Long waiting times and lack of information on
when patient will be seen
o Resolution: The processes in the clinics was
investigated and commitments made to improve
processes communication to service users.

20. Service ratings survey
• After a pregnant woman is registered on MomConnect,
her information is securely stored on a central server. The
day after the registration, the woman is sent an SMS
which asks her to rate her service at the clinic by using
the service rating code of *134*550*4#.
• In the first six months of operation approx. 10 percent of
women registering at clinics filled in the service rating
survey.Asecond follow-up message was added and
now over 25 percent of women registering at clinics filled
in the service rating survey.
• 78,916 service ratings were received between 1 Oct
2014 and 30 Sept 2015.

21. Survey design
• The survey was based upon questions that it was felt that pregnant
women could reasonable answer about their experience at the
antenatal clinic and was aligned to the NDoH’s “Towards Quality
Care for Patients: FastTrack to Quality: The Six Most CriticalAreas
for Patient-Cantered Care” document. This covered whether:
o staff were friendly and helpful
o privacy was respected by staff
o waiting times were acceptable
o the facility was clean
• It was also determined that it would be useful to get a quantitative
indicator of actual waiting times.

22. Service rating survey example questions
• Afive-question service rating survey was programmed and linked to
the service rating code. When a woman dials the service rating
code, these questions are asked in sequence:
• Example questions
o Q2. How do you feel about the time you had to wait at the
facility?
 Very Satisfied |Satisfied |Not Satisfied |Very Unsatisfied
o Q3. How long did you wait to be helped at the clinic?
 Less than an hour |Between 1 and 3 hours | More than 4
hours |Allday

23. Reporting on service ratings
• The collected data is automatically uploaded to a reporting system
(DHIS 2).This allows for real time data and dashboards
• Standard service rating reports have been developed for calendar
months and calendar years for provinces, districts, subdistricts, and
facilities. These reports attach the following data to service ratings for
the purpose of comparison:
o First antenatal visits asper the SouthAfrican DHIS data set for the
previous year
o Aggregated MomConnect registrations during the time period
specified
o Aggregated number of service ratings for the time period
o Rating response rate (a percentage based upon the formula:
number service ratings / number of MomConnect registrations)

24. Reporting (2)
• The total number of survey
responses per answer are
given inadditional columns
together with percentages
• This allows for comparison
between facilities (and
provinces and districts)
regardless of the total number
of service ratings received
Facility X
Aformulaisusedtoprovideascoreoutof100.If
everyoneisveryunsatisfiedthenthescorewillbe0–If
everyoneisverysatisfiedthenthescorewillbe100

25. Service rating data: Upward
trend (Hawthorne Effect?)
65.00
70.00
75.00
80.00
85.00
90.00
Jan-00 Jan-00 Jan-00 Jan-00 Jan-00 Jan-00 Jan-00 Jan-00 Jan-00 Jan-00 Jan-00 Jan-00
Cleanliness Rating
Friendliness
Rating
Privacy Rating

26. Opportunities for improved feedback to
districts and facilities
• All service ratings can potentially be given to
districts and facilities to enable management to
address reported issues.
• It may even be appropriate for any “Very
Unsatisfied” response to be treated as a
complaint about the services at the specific facility
and followed up accordingly.
• The actual scores may give an impression that all
is well if a facility has an overall score of 65 out of
100. However, this is much lower than average
and can be highlighted as such.

27. Service rating survey challenges
• Theservice ratingcomponentofMomConnectis affectedbythe same
issuesaffectingregistrationofwomenon MomConnect– networkand
languageissue.
• As ofAugust2015,only78.4percentofuserswhostarted thesurvey
ratingssurvey completedit.
• It tookan averageof 1.6 usersessionsto completethe survey.This
impliesthatmanyusersexperiencetime outsduringthesurvey.
• Anotherissue isthatthere maybe somebiasin the responsesdueto
self-selectionbysurveyparticipantsandnonresponse.It maybethat
womenwith a strong positive or negativeviews aremorelikelyto
completethe survey thanthose with nostrongopinion.
• Thepositioningof theanswersmayalsoaffect theratingsin thatsurvey,
asrespondentsmayjustchosethe first optionor maynotsee the last
option.Both of theseissueswarrantfurtherstudyastheymayaffectthe
qualityof the surveydata.

28. Possible future uses of the current data
collected through the MomConnect System
• Data about the length of pregnancy at first visit
can be used to identify where interventions are
required to get women intoANC before 20
weeks.
• The data around the pregnant women’s ages and
estimated due date can be used to provide
information for policy makers.
• The data around language choice per district can
be used to inform health promotion programmes
per district.

29. Possible future uses of the system
• The service rating survey model can be used at other times – for
example getting feedback from women about their experiences
during labour or main problems faced during the first few months of
motherhood.
• The compliments and complaints model can be used throughout the
health system (not just antenatal clinics) to provide a means of
providing a voice to citizens.
• The system can become the backbone of a longitude record of care
for the child (an enhancement of the Road to Health card given to
each child) which could record information such as vaccinations,
PCR test information, illnesses, allergies, etc.This could feed into a
standardised electronic patient record.

30. Final points
• Crowdsourcingdatafrom service beneficiariescan bean effective tool to
generatedatato supportthe implementationofpatient-orientedservices.
• UsingUSSD andSMStechnologiesfor datacollectionhasadvantages
over traditionaldatacollectionmethodsbecauseit enablestheDoHto
collectdataon a nationalscale.
• Theimmediatevisual displayofdata into dashboardshelpsmanagerto
quicklyidentifyandsolve problemsto improveservices.
• It is possiblethat theact ofmonitoringishaving a positive impacton
services asratingshave increasedover the first yearof the MomConnect
implement.However,thereareotherfactors whichmayhave hadan
impact.
• By makingdata systemsinteroperable,standardizingmaster facility lists,
andstrengtheningthe nationalpatientmasterindex,the nationalhealth
informationsystem is beingstrengthened.Thisresultsin greateraccessto
dataandimproveddata-informeddecisionmaking.

31. MEASURE Evaluation SIFSA is implemented by the Carolina
Population Center at the University of North Carolina at Chapel Hill in
partnership with John Snow, Inc., ICF International, Management
Sciences for Health, Palladium, and Tulane University. For more
information, visit https://www.cpc.unc.edu/measure/sifsa and
www.measureevaluation.org
This presentation has been supported by the United States
Agency for International Development (USAID) under the terms
of MEASURE Evaluation – Strategic Information for South Africa
associate award AID-674-LA-13-00005. Views expressed are not
necessarily those of USAID or the United States government.