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: hshah@careindia.org