This week, I had the pleasure of meeting a matrone in Senegal (women in villages who provide pregnancy counseling to younger women) as part of a field visit with the local NGO, Africare. She was one of 30 matrones my Dimagi West Africa colleagues Carla Legros and Patrick Keating trained in Ziguinchor, Senegal for Africare’s CCHT project.
As part of the project, our team developed two CommCare applications. The first application is used by matrones to monitor completion of antenatal care check-ups, help identify pregnancy danger signs, and trigger referrals. The second application is by nurses, who see referral cases created by the matrones, as long as there their phones have synced via an Internet connection. After the training, the matrones had gone out to the market to buy themselves a beautiful blue and white patterned local fabrique to… wait for it… make themselves dresses with blue and white patterns that resemble the CommCare logo. The matrone I met even modeled her CommCare dress for me!
After having worked with Dimagi in India for over three years, I moved overseas to Senegal last July to oversee our work in West Africa. I’m learning a lot about the differences among community health actors, how the systems are set up, and which services they deliver in Senegal and India. In some ways one can say they are vastly different. This of course means, designing for both systems is different.
While in Senegal, community health workers are volunteers, in India they are incentivized for the services they provide or receive a salary. There are between 4-6 different health workers at the community level from the Relais Communitaire, Matrone, Bajnegok, Marraine, and ASC…. All of the workers in this health unit work together, many of the roles are complementary and sometimes overlapping. It takes some work really mapping out which workflows are owned by which health workers in Senegal. One of my colleagues, Claire Cravero, described that a group of health workers laughed as we tried to define each person’s role and figure out what form is filled by who and why, saying that’s not how it works here! We all work together. Designing ICT for a highly collaborative process can be hard, but the way to do it is to stick to flexible systems.
In India, the community health unit is made up of two health workers, ASHAs and Anganwadi workers, who have very clear and different responsibilities. In Senegal, since populations are so dispersed there isn’t a defined population a health unit serves. In India, a health unit serves a population of 1000. Given this, it is easier to estimate the case load health workers will be dealing with when scaling a mhealth project in India than it is in Senegal.
As I stepped outside of my India biases like I often have to do, I realized that in fact, there are many parallels here too:
- Women believe that the audio messages in CommCare come from the Ministry of Health.
- Health workers were really engaged during our trainings.
- We need to spend more time on how to search and filter the case lists to avoid double registrations in the applications.
- Health workers want a way to correct spelling mistakes of women they have registered.
- Immediately after training, health workers here also continue to register some test practice cases which then need to be closed out.
- Project staff had doubts about health workers being able to type in the phone or use the touch screen but were surprised to find that people learn with time
- Project staff learned that they need to emphasize how to improve interpersonal communication now that we’ve introduced a phone into the provider-patient interaction.
Later that week, we went to a facility to speak to some nurses who use the second application to manage referrals. We couldn’t find the nurses as they were at a training elsewhere, but we cross paths with another person who also happened to be using CommCare, but on a tablet!
In Senegal, Dimagi has also worked with Intrahealth’s Informed Push Model project to develop an application to help track and deliver family planning commodities nationally. The users of the application are operateurs who deliver the commodities to all facilities in Senegal. There are just over 25 operateurs across the country using their CommCare application to calculate stock that needs to pushed to facilities.
The two teams exchanged their experiences managing CommCare, any technical issues they’ve been experiencing and how they managed them, described what stage of scale they were at and generally shared their enthusiasm about the systems they were planning to scale or was already operational at scale. I’m excited about our work in Senegal and the rest of the region because of the potential for different organizations and teams to work together to understand, deploy and maintain these systems together, even if they are running different programs. The barriers of maintaining ICT may significantly go down as more people understand the platform and collaborate. I would like to imagine a future where the nurses using CommCare for managing antenatal care visits and counter referrals partner with another organization to have a new health service module installed on the same phone. I’d like to imagine a future where technology creates synergies among programs, while adding more value for the end users. A future where we begin leveraging a system that is well known at the community level already instead of putting in place something new each time we want to deploy a new mHealth service.
At the end of our visit, the project team on site had an epiphany and understood how much effort it is to actually launch and scale an mHealth program at the community level. Eight months ago, they had thought there was a pre-existing application and that it would be available instantly. That we could easily install it on phones and deploy it to hundreds of users in no time. I never really understood this misconception, until this field trip. In this age in time, when mobile apps can be so easily downloaded and go viral by night, it is no surprise that partners new to mHealth for community health workers believe the same can be done for health care workers. In reality, what we’re actually doing is deploying and scaling an enterprise mHealth solution.
Our work is serious business. It is integrating an ICT system at the bottom of the health system pyramid, influencing how an entire frontline workforce delivers services to their community members, how supervisors then monitor their dispersed team and close the feedback loop, how management begins to gain visibility in real-time about programmatic indicators collected vis-à-vis the application. Once the mHealth application is actually launched for the health workers, the work is not done. It has only just begun.
I love the moment when partners new to mHealth realize this. This is why we encourage deployments to crawl first, then walk and then run. Technology automates and amplifies and we want to be super sure what we’re automating and amplifying are the right things.