This Insights Article is the second of four international case studies published to support the mHealth Solutions Insights Guide no. 2, Evaluating mHealth adoption barriers: Politics & Economics.
In February 2012 the Prime Minister of India, Manmohan Singh, held a press conference to address the issue of the health of the country’s children, in particular the estimated 160 million of them aged six years and under. “As I have said earlier and I repeat, the problem of malnutrition is a matter of national shame”, Singh said. “Despite impressive growth in our GDP, the level of under-nutrition in the country is unacceptably high.”
The trigger for the Prime Minister’s comments was the publication of the HUNGaMA (Hunger and Malnutrition) Survey, conducted by the Naandi Foundation across 112 rural districts of India in 2011. Among its findings, HUNGaMA discovered a reduction in the prevalence of child malnutrition from 53% to 42%. However while such progress is welcome, HUNGaMA found that child malnutrition is “widespread across states and districts and starts early in life”. Some 59% of all children in India aged five and under suffer impaired growth, a half of these severely.
Among his responses to this challenge, the Prime Minister committed the government to more resources for an updated Integrated Child Development Scheme (ICDS), which has grown to be a key policy tool for improving child health since its launch as a pilot project in 1975.
The primary aim of ICDS is to break inter-generational cycles of malnutrition and its consequences. The institution chiefly responsible for putting this into practice is the national government-funded network of around a million outreach centres known as Anganwadis – literally “courtyard shelters” – whose many vital services include supplementary nutrition; pre-school education; immunisation; health check-ups; referral services; and nutrition and health education.
The Anganwadi centre, located in both rural village and urban slum areas, typically operates daily for four hours except Sundays and holidays. The key personnel in its day to day operations are the Anganwadi worker (AWW) and her assistant, the Anganwadi helper (AWH). These are not regular government employees, but volunteers typically drawn from the local community and paid a monthly “honorarium”.
Maintaining records of the work carried out at the Anganwadi is an important responsibility of the AWW, and is essential for improving the implementation of the ICDS programme.
Registers maintained by the AWW include details of residents in the area covered by the Anganwadi, records of their attendance at the centre, provision of supplementary nutrition and pre-school education, a register of stock, and a daily diary. The AWW is also responsible for maintaining records of all immunisations carried out for children and pregnant women, a “growth card” for all children up to six years, and details of referral cases.
An evaluation of the effectiveness of ICDS, commissioned by the national government in March 2011, affirmed the crucial role played by Anganwadis and their staff. It also highlighted areas in need of improvement, including the need for a more consistent and accurate approach to record keeping.
Examples of disparity are provided by states such as Haryana, Punjab, Maharashtra and Tamil Nadu, where more than 70% of Anganwadis were found to maintain accurate registers, compared with those in Bihar, Chhattisgarh and Rajasthan, where just 10% do so. In addition, the survey found that generally, records of attendance at the centre were updated more diligently than records of children’s growth and referrals.
“Wide divergence between official statistics… and grassroots reality with regard to these indicators on the other has been observed in this study as well as in others. The existing monitoring system of ICDS needs to be strengthened and revamped,” the study concluded.
How will this be possible? The answer is likely to rest with mobile technology, to lift the bureaucratic burden.
India is home to many centres of IT research and expertise capable of developing tools that could be powerful weapons against deprivation and disease, including collecting health data with mobile devices.
The limitations of the long-established paper-based system can be exposed by fast-moving outbreaks of disease.
The limitations of the long-established paper-based system can be exposed by fast-moving outbreaks of disease. In rural areas these may take many weeks to be recorded at the state level because of delays in reporting, according to a team of researchers based at the Indian Institute of Technology Madras, Chennai, and in Sri Lanka.
Professor Ashok Jhunjhunwala and his team report that health workers in the field regularly have to carry 20 registers weighing almost 10kg to collate health information. They meet in primary health centres on a weekly basis to report health statistics gathered from the field and send the updated information to officials at the district level. These in turn prepare monthly reports for officials at state level.
Jhunjhunwala and his team recently tested the concept of equipping health workers in the field with smartphones to collect this data in a scenario that was deliberately chosen to be challenging: one of the most disadvantaged districts of rural Tamil Nadu.
The project required district health workers to learn to install and configure the software application mHealthSurvey on a Nokia handset – a type of task that was new to most – and use it in their daily work instead of pen and paper.
This work included entering patient details such as case date and time, village name, symptoms, gender and age group, and over the course of fourteen months some 91,000 records were created in this way. Although the health workers typically needed a significant amount of technical help, mobile scored well in terms of the business case, with low handset and monthly connection charges and a cost per 100 completed records of just $0.09. These costs compare favourably with the current paper based system, say the researchers: “Based on our findings, we would conclude that mobile phone based patient data collection is feasible on a large scale.”
This work indicates that mobile phones could play an important role in collecting health data, but the project brought to light some drawbacks with a text-based approach: many of the health workers had never used a phone for text messaging, and some had limited experience even with voice services. In training workshops many said they turn to their children or young neighbours for help with using a mobile phone.
The project brought to light some drawbacks with a text-based approach: many of the health workers had never used a phone for text messaging, and some had limited experience even with voice services.
In addition, many found it difficult to enter data while they worked with visitors: they tended to do it at the end of the day. This brings with it the risk of forgetting to upload new data, or putting it off and undermining the benefits of having real-time information, which can be vital in responding to a fast-moving disease outbreak.
A promising alternative is a system using Interactive Voice Response (IVR) technology. This has been tested by Jhunjhunwala and his team in Madhya Pradesh, a state where an estimated 60% of children aged three years and under are malnourished. “The reasons postulated by experts point to poor health care reforms, lack of transparency, low health literacy and most importantly [a] slow reporting system,” says the team.
They have run tests in Anganwadi centres of Voice Net, a technology designed to support voice-based data collection in multiple languages and dialects, and viewing of real time data on a remote web portal. Importantly, it enables visitors to the centre to create their own records and submit data for themselves and their children. In the tests, some users forgot their pass phrase, which resulted in the system failing to authenticate them, and occasionally there were other reasons for failure such as loud background noise, faulty handsets or bad network coverage.
Despite such problems this approach shows promise, the team says. “The supervisor would be there to guide them but the data entry and authentication was entirely done by the users and the entire phone call would only take about two minutes.”
India set out a vision of online public services for all citizens with the launch of the National e-Governance Plan (NeGP) in May 2006. A massive infrastructure project, it aims to reach out to all parts of a country that includes an estimated 650,000 villages along with some of the largest cities in the world.
The plan took an important and innovative step in January 2012 with the unveiling of the Framework for Mobile Governance by the country’s Ministry of Communications & Information Technology. In broad terms it commits India to making online public services as accessible by phone as through internet-enabled PCs, tablets, or other devices.
The move was prompted by recognition that millions of less-privileged individuals without internet access have no realistic chance of accessing online public services. By contrast, with a subscriber base of 870 million and rising, mobile phone use reaches out to even the remote rural areas of the country.
“Given the fact that the majority of Indian citizens reside in rural areas, mobile devices are ideally suited as alternative access and delivery channels for public services,” says the ministry.
One example of a regional mHealth project that is already being scaled up to the national level is e-Mamta, a web-based system for creating and managing health records for mothers and their children launched in 2010 by the Indian state government of Gujarat.
The system holds the details of individual pregnant mothers, individual children and adolescents. It enables Gujarati healthcare workers to improve delivery of services for ante natal care, childbirth, post natal care, immunisation, nutrition and advice for adolescents.
It can help to identify those mothers and children who are entitled to health services but are not receiving them, and will be a powerful tool for planning the future provision of health services, and for reporting and monitoring health-related issues.
The system enables patients and healthcare workers to receive reminders by text message, alerting them to make an appointment, or sending brief health-related messages.
Mobile phones were part of e-Mamta from the start. The system enables patients and healthcare workers to receive reminders by text message, alerting them to make an appointment, or sending brief health-related messages. This will also help the Gujarati health services to identify those geographical areas where services are not being taken up, and find out why not. In future, the government of Gujarat intends to expand these mobile services to include smartphone applications.
Progress has been rapid: within a year of its launch in January 2010, e-Mamta had registered roughly 80% of the individuals it is designed to serve, the state government says. The government of India was impressed enough to fund a national program that will see a version of the e-Mamta system implemented in all states, work which began in 2011.
By its own admission, however, e-Mamta has been a “mammoth” task for Gujarat, requiring the creation of more than 40 million individual records, and ways of making this process quick, simple and accurate will be a key requirement for success at a national level.
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