mHealth: Strengthening Health Initiatives through the Use of Mobile Technologies in state of Bihar, India Dr. Hemant Shah, CARE AIDF Asia Summit
22nd June, 2016
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Bihar is one the most flood-prone states in India
Bihar is India's most flood-prone State, with 76% of the population in the north Bihar living under the recurring threat of
flood devastation
16.5% of the total flood affected area in India is located in Bihar while 22.1% of the flood affected population in India lives in
Bihar.
About 68,800 square kilometres out of total geographical area of 94,160 square kilometres comprising 73.06% is prone to
floods
There are 8 major rivers in Bihar which flow through Bihar and end up in Ganges
Ghaghra
Gandak
Budhi Gandak
Bagmati
Kamala
Bhutahi Balan
Kosi
Mahananda
An average of 21 of the 38 districts in Bihar are affected by floods every year
Source: http://disastermgmt.bih.nic.in/; http://fmis.bih.nic.in/history.html
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Bihar is among the frontrunners in the country when it
comes to penetration of cellphones in villages
82.16 per cent of the rural population in Bihar uses
cellphone, whereas the national average for the same
stands at 68.35 per cent
Such a high level of mobile phone penetration in
villages of Bihar is despite the fact that 43.85 per cent
of the total rural population in the state is illiterate
According to Telecom Regulatory Authority of India
(TRAI), Bihar had nearly 71.61 million wireless
subscribers and 347,309 wire-line subscribers as of
May 2015
At 71.61 million, Bihar had the fifth largest wireless
subscriber base among all the Indian states as of May
2015. As of 2014-15, the state had 1,238 telephone
exchanges.
Mobile and TV penetration in Bihar
Mobile Penetration
Source: TRAI, NSSO, WPWRF, Census 2011
TV Penetration
The television ownership % ( as per census 2011)
stands at 14.5% as compared to an all India average
of 47.2%.
Bihar has one of the lowest TV ownership % in India
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mHealth solution for Continuum of Care Services (CCS) was piloted as part of CARE’s work in Bihar, India
Background
Since 2010, CARE has been implementing a large project for reducing maternal and child mortality,
malnourishment and fertility rates in Bihar, India with financial support of Bill and Melinda Gates Foundation.
As a part of this project, CARE had conceptualized an mHealth innovation in 2012 to improve service delivery by
Community Health Workers (CHWs) to all pregnant women, mothers and newborns across ‘1000-day window of
opportunity’
Objective
“To transition from manual records kept by CHWs across several hand-written registers, to electronic formats,
thereby improving the frequency and quality of interactions between beneficiaries and Community Health Workers
(CHWs)”
Methodology and Assessment
Randomized Controlled Trial (RCT) was adopted to assess effect of the CCS mHealth innovation over and above
other interventions with CHW. The randomized control trial was designed (with help of an external evaluation
partner) and implemented, to assess whether the ICT tool would lead to improved outcomes. All CHWs, both in
treatment and control, received trainings on conducting home visits and on messages to communicate with
mothers.
For robust measurement, two-year implementation was done with large number of CHWs. Reported results are
from a two year follow-up.
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Geographical spread and scale of pilot
Sheohar
Sitamarhi East
Champaran
West
Champaran
Darbhanga
Gopalganj
Katihar
Madhubani
Muzaffarpur
Saran
Siwan
Vaishali
Aurangabad
Bhojpur
Gaya
Nalanda
Nawada
Patna
Rohtas Jehanabad Bhabua
Buxar
Lakhisarai Arwal
Samastipur
Khagaria Begusarai
Bhagalpur Munger
Banka Jamui
Araria Kishanganj
Saharsa
Supaul
Purnia
Saharsa Innovation Blocks
1. SONBARSA
2. SAUR BAZAR
3. KAHARA
4. SATTAR KATAYA
Saharsa district lies along the Koshi river belt, and is highly
susceptible to floods – is one of the more disaster-prone areas in
Bihar
Saharsa District Profile (all 4 blocks)
Total # of Subcentre 70
# Treatment Subcentre 35
# Population Covered 3,34,470
# ASHA 240
# AWW 272
# ANM 45
# Lady Supervisors 12
# CHWs, Supervisors 569
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At it’s core, this solution aimed at facilitating tracking of all events related to Maternal Health, Newborn Health, Child Health, Family planning and Nutrition
Areas of impact envisaged
Area Change envisaged
CHW-Beneficiary
interaction
Questionnaire based interaction
Timely contact with objectivity
Audio and video based content
Supervisory
Review
Supportive supervision
Availability of real time data
Job-aids and Tools Simplified tools with easy data entry
options
Counselling job-aids (context-specific
audio/ video clips)
Due list generator
Simple-to-use and saves time
Date arithmetic tools (EDD and Referral)
MIS & reporting Real time data visibility for decentralized
decision making
Continuum of Care Services (CCS) across the ‘1000 day window of opportunity’
Questions we wanted to address
Is mobile technology usable and effective in the hands of AWW
and ASHA during continuum of care?
Can we establish the use of mobile technology as job-aids for
AWW and ASHAs Frontline Workers (CHWs) and help improve
Service Delivery?
Can real-time data help effective Supportive Supervision?
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Key modules of mHealth solution
Name-based tracking
Registration (Pregnant Woman, Children upto 6 years)
Services (antenatal care, postnatal care, exclusive breast feeding and
initiation of complementary feeding, immunization, family planning)
Events (birth, death, migration)
Complications & High Risk Pregnancy Tracking
Growth Monitoring up to 6 years of child’s age as per WHO standards
Home visit scheduler with guided questions in a structural manner to
cover 19 necessary home visits in the continuum of care (-9 to +24
months)
Due List (on-demand mobile based)
Nutritional Components(THR, Spot Feeding & Preschool Activities)
Real-time supervisory review module
Application for ANM and LS
ANM Vaccination Planner for VHND
Drill down to case level, helps supervisors to monitor
Tools
Communication aids: context-specific audio/video clips
Date arithmetic tools (EDD and Referral)
Functionality features
Hindi, menu-driven, with audio prompt
Seamless integration of guided interactions and
recording of data
Synchronized between ASHA, AWW and ANM, LS
Convergence capability between MoHFW and MWCD
at gross root level
All data ‘uploaded’ when connected – sync with MCTS
feasible
Phones
Basic phones (J2ME)
Smart phones (Android)
Simple and easy to use interface design for low-literate frontline workers
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Results (1/3) Increase in home visits by CHWs
42% 39%
60%
36%
27%
52%
43%
73%
45%
29%
Atleast two home visits infinal trimester**
Home visit within 24 hoursof delivery
Home visit within 1 weekof delivery***
Complimentary feeinghome visit (child 5-11
months)**
Family planning home visit
Control Treatment (regression adjusted)
On average, treatment area beneficiaries were significantly more likely than those in control areas to
report receiving more home visit by CHWs during pregnancy and after child birth
Treatment means are adjusted using ordinary least squares regressions that control for study design effects, demographic characteristics, and subcenter-level
baseline means of the outcome (when available).
*/**/*** Significantly different from zero at the .10/.05/.01 level, two-tailed test, adjusting for clustering at the subcenter level.
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Results (2/3) Impact on quality of home visits by CHWs
Relative to beneficiaries living in control areas, those in treatment areas were significantly more likely to
receive advice from CHWs on topics related to breastfeeding and nutrition
Treatment means are adjusted using ordinary least squares regressions that control for study design effects, demographic characteristics, and subcenter-level
baseline means of the outcome (when available).
*/**/*** Significantly different from zero at the .10/.05/.01 level, two-tailed test, adjusting for clustering at the subcenter level.
Indicators Control mean Adj. treatment mean Adjusted difference p-Value
Advice provided by CHW
Advice on exclusive breastfeeding 48.4 55.3 6.9* 0.089
Advised to start feeding at age 6 months 33.2 24.4 8.9*** 0.005
Advice on types of food 25.6 34.2 8.6** 0.012
Advice on times to feed 24.1 33.9 9.8*** 0.008
Advised on quantity of food using katori 20.8 27.5 6.7* 0.065
Advised to feed from separate bowl 23.6 32.6 9.0** 0.017
Asha or AWW gave phone number of ambulance 22.9 29.1 6.2 0.104
Advice on skin-to-skin care 45.2 48.8 3.6 0.286
Home visit by ASHA/AWW about FP 26.9 29.3 2.4 0.537
Use of Mobile Kunji Card during home visit 21.8 39.3 17.6*** 0.000
Ever used Katori/Spoon during home visit 11.8 20.7 8.8*** 0.005
Mother’s knowledge
About Exclusive Breastfeeding 59.8 73.9 14.1*** 0.000
Initiating Complimentary feeding at age 6 mo. 55.0 60.2 5.2 0.268
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Results (3/3) Impact on quality of home visits by CHWs
Treatment means are adjusted using ordinary least squares regressions that control for study design effects, demographic characteristics, and subcenter-level
baseline means of the outcome (when available).
*/**/*** Significantly different from zero at the .10/.05/.01 level, two-tailed test, adjusting for clustering at the subcenter level.
58% 55%
32%
77%
55% 65% 64%
41%
78%
59%
Skin-to-skin care * Child (6-11 months) eatssolid or semi-solid food *
Child (6-11 months) beganeating solid food by age of 6
months **
Child (6-11 months)received DPT3 vaccines
Child (6-11 months) fullyimmunized (excep measles)
18% 22%
32% 29% 24%
29%
43% 36%
Use of permanent methods ofcontraception **
Use of temporary method ofcontraception (ever) **
Use of any modern method ofcontraception (ever) ***
Use of any modern method ofcontraception (current) **
Control Treatment (regression adjusted)
The study found that children 6–11 months old in treatment areas were 9 percentage points more likely
to eat solid or semisolid food compared to those in control areas
There was also a significant impact on the timely introduction of complementary feeding (at six months)
Also, Current use of modern contraceptive methods was 7 percentage points higher
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Stories of success Continuum of Care Services (CCS) – Working together (AWW & ASHA)
Ms. Seema Kumari, AWW, Nariyar, Kahra, Saharsa - received a new pregnancy information
from her catchment. She pre-registered the beneficiary details by looking from her Register-1
into CCS. The pre-registered beneficiary details reflected in her counter part Ms. Lalita Devi,
ASHA, Nariyar, Kahra, Saharsa ’s phone. Ms. Lalita Devi went to beneficiary house and
completed the registrations with necessary LMP details Ms. Seema Kumari & Ms. Lalita Devi
Ms. Lucy Kumari, AWW, Khojraha, Sonbarsa, Saharsa completed the home visit which is nearer to
her house and in the Ms. Sabnam Kumari, Khojraha, Sonbarsa, Saharsa ’s phone the visit has been
marked as done automatically. Ms. Sabnam Kumari went to the other due for that day’s home visit
Ms. Lucy Kumari
On Village Health Nutrition Day(VHND), Ms. Munni Kumari, AWW and Ms. Neetu Devi, ASHA Baijnathpur,
Saurbazar, Saharsa has the same immunization due list generated automatically in their phones. Ms. Neetu
Devi used for mobilizing the beneficiaries from the catchment to VHND site and Ms. Munni Kumari used for
punching the data as soon as the service delivery happened on that day Ms. Neetu Devi
Ms. Sabnam Kumari
Verbatim:
“CCS is helping us to work together in the catchment to bring progress in our community” ~ Sabnam
Kumari, ASHA, Khojraha, Sonbarsa, Saharsa
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Lessons learnt (1/2)
Despite limited initial familiarity with technology, CHWs were able to learn to use many of the CCS features
effectively
CHWs experienced some technical and logistical challenges in using the CCS tool, in particular due to
limited internet connectivity, which limited synchronization of records
CHWs used some features of the ICT-CCS tool more often than others. Tools to register beneficiaries and
manage visits were commonly used; videos, checklists, and supervisory tools were less commonly used
After 2 years of implementation, CCS led to substantial improvements in CHW-beneficiary interactions
Impact observed in the antenatal care domain, some newborn care practices, child nutrition and use of
contraception; No impact on other newborn care practices, facility delivery, or immunizations
Impact observed despite the fact that some features of the CCS tools were under-utilized
In scaling up, focus will be on improving use of all features of the tool, resolving technical issues, and
providing sufficient training
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Lessons learnt (2/2)
What has perhaps been the most noteworthy learning from this pilot, is the fact that over 50% of the CHWs and
supervisors who were part of this pilot, are still using the ICT-CCS tool today (currently in its fourth year of
operation), without any supervisory push to do so.
The CHWs have seen value in monitoring and scheduling aspects of the tool, which helps make their day-to-day
operations efficient (i.e. by replacing tedious, manual registers and cumbersome process of individual follow-ups),
and hence continue to use this tool of their own accord.
Ms. Bharathi Kumari, AWW, Mokama, Sonbarsa, Saharsa - used the same phone to alert the department about waterlogging areas after the floods and used a नाव (hand made boat) and mobile application to deliver post-disaster services.
Ms. Bharathi Kumari
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For any further information, please feel free to contact us!
Dr. Hemant Shah,
Chief of Party, Bihar Technical Support Program,
Care India, Bihar
Email: [email protected]