Interactive and innovative mobile application for frontline health workers in Bihar, India – where accurate data collection became a byproduct of quality service provision

 “When we started this journey of developing a comprehensive mHealth platform for the frontline health workers in a district in Bihar, little did we realize that we would land up with a thriving system that has complex ramification more than just data capture and accuracy of reporting

The Integrated Family Health Initiative project of Care India Solution for Sustainable Development, Bihar had planned an Information Communication Technology based innovation component called the Continuum of Care Services (CCS). I joined the Care India team to lead this project from the technology perspective and I share some of my learnings and experiences in this work. 

Two of the biggest problems that were obstacles in Bihar’s achievement of the Millennium Development Goals (MDG) 4 and 5 were unmotivated front line workers and insufficient data for data driven public health action. Most technological solutions to this problem have addressed these two problems in parallel. On one hand there would be robust data capture techniques like the mHealth data capture systems, doing away with loads of paper work for the frontline workers as well as updating data on a real time basis. On the other hand there would be training, capacity building, motivation, supportive supervision of frontline workers like Accreditated Social Health Activists (ASHA) and Anganwadi Workers (workers in the government day care and Integrated Child Development centres). There have been problems with sustainability of motivation of the frontline workers. Moreover in other areas some of the frontline workers perceived the mHealth data capture technology as an additional burden on their work and showed little or no interest in it. 

We brought some very innovative minds together in our planning meetings and decided to bring these two approaches together. We decided to create a system where accurate data capture became a byproduct of quality service provision. We decided to introduce a simple mobile application which would be the frontline worker’s personal digital assistant. It would be her dynamic and interactive companion in her service delivery and help her deliver good quality services in the community. Even without her conscious efforts this simple mobile application would also automatically capture data effectively. The focus was removed from the conventional form filling methodologies and replaced into effective care delivery. 

We took a continuum of care approach for maternal and child health care. Starting from the first trimester of pregnancy to 6th year of a child’s life important events, treatments, preventive strategies like immunization, health promotion strategies, and monitoring activities were programmed into the mobile application. 

Each time a frontline worker registered a pregnant woman into the system, it would chart out a detailed plan of visits, contacts, immunizations, activities, monitoring sessions and milestones for that woman and her child. All the frontline worker had to do was register the woman, the application would do the scheduling of her entire work with this woman. It would also prioritize the various women that the particular frontline worker delivered services for and prepare job lists for her. It would prompt alerts to do her work effectively. 

It would also run her through the list of activities that she has to do during a home visit to a beneficiary. Interactive videos and job aids were also built into the application for her to use during her contact with the beneficiaries. It is like an assistant to her, a very intelligent assistant who not only scheduled and reminded her of her activities, but also validated her work and prevented misreporting and wrong reporting. Some of the unique features of this mobile application which distinguishes it from other available mobile applications are:

  • There is a possibility of case sharing and synchronization of activities of the two types of frontline workers, the ASHAs who do maternal and child health care activities and the Anganwadi workers who do nutrition, preschool education activities. This helped to share responsibilities and prevented duplication of efforts. For example, if there is a home visit to deliver key messages to mother near an Anganwadi worker’s home then she could complete the visit and it would get updated in the system. The ASHA need not visit her separately for this purpose. This brings convergence amongst the frontline workers to share the workload and complement each other in delivering services.  This was facilitated by the synchronization function in the mobile application. 
  • Mobile applications that are popularly used by frontline health workers for data capture are usually designed in several forms one each for maternal health, child health, nutrition, family planning, immunization etc. The workers have to open each form and feed the data. But, in this application, we removed the focus from data capture. The focus was placed on her day to day activities. We made the application into predominantly a scheduler and reminder driving activities to be performed by the frontline workers. Therefore data is being captured as a byproduct of her delivering services. Variables that were found in separate forms were all integrated based on the visit time and contact with the frontline workers. For example, during a routine post natal visit, the frontline worker would check for birth complications, child weight, child feeding, advice on breast feeding practices, counsel on family planning. Instead of having three different forms to capture this information, namely the birth form, the family planning form and the nutrition form, all information were integrated into the post natal visit schedule of the mobile application. 
  • Textual and numerical data entry was minimized. The frontline workers did not have to spend excessive time keying in data. Everything was converted to simple objective multiple choice responses. Navigation of the mobile panel was also simplified for use by the frontline workers by filtering relevant forms to the relevant case requirements. 
  • Validation and check points were introduced into the application so that only correct and valid information can be entered. For example, only if a frontline worker has entered the date of the first dose of Diphtheria Pertussis and Tetanus (DPT) vaccine can she enter the second and third, and if they are not appropriately spaced at 1 month each (with a limited flexible period) it would not be accepted. This ensured that vaccinations are given in time and reported immediately on giving them based on the immunization rule engine. 
  • The child’s growth could also be monitored and tracked on a ‘road to health’ WHO growth chart that was preloaded into the mobile application. Using the color codes of green, yellow and red, the frontline worker could identify children who needed special attention. 
  • If a particular activity was not performed by the frontline worker, she would be given three reminders (red exclamation marks would appear on her mobile application against the name of the beneficiary). Beyond that a notification would be sent to the supervisor of this frontline worker. This would ensure supportive supervision. 
  • The mobile application utilized the header space to display motivational tag line that made the frontline worker feel good about the good quality work that she is doing. 
  • The application also had options where the frontline worker could monitor her own activity of the past thirty days of her work

All the above innovations may seem like small tweaks in the existing mHealth applications. However in our experience these have drastically changed the health workers’ perceptions of their own work. By removing the focus from data capture and placing it on better quality of service delivery, the mHealth application removed the pressure and burden perceived by the frontline workers in using the application. She started seeing the application as her friend and assistant and this greatly improved the quality and efficiency of her work.

We at Care India, have evaluated the mobile application and the evaluation has shown some promising results. I have ensured that all these innovations and the improvements in the mHealth platform are open source. I will be more than happy to demonstrate the functioning of the mHealth application and also share it with those willing to join our journey. If you are interested and have queries please do not hesitate to write to me (Email:brkrishnan[at]careindia[dot]org). 

Ram Krishnan B.
Principal Consultant Information Communication Technology,
Care India Solution for Sustainable Development,
Patna, Bihar

Posted By : Ram Krishnan B.
Location : Patna, Bihar