Assisting community health workers in India
Dimagi’s CommCare
Most of the world’s ‘bottom billion’ live in India, a ‘lower middle income’ country with a population of 1.24 billion (1,2). Global health experts have recognized the need for expanded and improved community health programming in order to reach these vulnerable people. But the shortage of qualified health workers in India, particularly in rural areas, means that the contributions of less-skilled health workers must be mobilized for these efforts. In India, accredited social health activists (ASHAs) are women selected and trained to work at the interface between members of their own communities and the public health system (3). Research indicates that ASHAs contribute to improvements in maternal, newborn and child health outcomes and reductions in associated mortality rates in India. But ASHAs face a number of challenges in performing their jobs, including high workloads, insufficient training, poor credibility in the community, difficulty addressing sensitive topics with families, poor support for home visits, and little or no feedback about performance (4,5,6).
INNOVATE EVALUATE SCALE UP IMPROVE HEALTH RESEARCH EVALUATE SCALE UP IMPROVE INNOVATE EVALUATE SCALE UP IMPROVE HEALTH
CommCare is an innovative mobile job aid that has been developed and pilot tested to assist ASHAs and other community health workers (CHWs) to reach more people more efficiently and effectively.
Developed in close partnership with on-the-ground organizations globally, CommCare is adaptable for a wide range of needs.
How CommCare works
CommCare operates through the use of locally available, inexpensive, Java-enabled phones or higher- end Android™ smartphones. It supports ASHAs by facilitating better data collection, decision support, communications with clients and health centres, and access to educational training materials. In particular, CommCare improves ASHAs’ performance by tracking case management data in real time – the households they visit, the duration of these visits, the services provided during each visit, the quality of their decision-making (based on adherence to checklists and protocols), and the health outcomes of the households they serve. The software includes registration forms, checklists, a tool for monitoring danger signs, and educational prompts with images and audio/video clips available in multiple languages. CommCare has also been shown to increase the retention of health-related knowledge among ASHAs and to help them keep up with their scheduled visits. Ultimately CommCare increases confidence among ASHAs and also improves engagement with clients (7,8). Dimagi, the United States- based software technology consultancy and software company that developed CommCare, provides an open-source online tool, CommCare HQ (www.commcarehq.org), which allows end users to design their own CommCare applications.
Supporting national public health programming
Since 2005, the Government of India has invested heavily in CHWs, training over 750 000 ASHAs and providing incentives that can amount to over US$ 1000 per ASHA per year. As the “first port of call for any health-related demands” at the village level (3), ASHAs are a crucial part of the Government’s push to increase access to primary health care and reduce maternal and child mortality. CommCare complements this community-based public health strategy by providing a mobile platform that can be used by CHWs and tailored to a diverse range of local needs and conditions. Development of CommCare involved conducting rapid prototyping with front-line health workers to ensure this versatility.
Partnerships for support and sustainability
CommCare is currently being used by over 50 organizations in 25 countries across the globe, to support projects that focus on health, agriculture, microfinance and supervision support. Dimagi contributes to the sustainability of these projects by providing user- friendly and versatile software for inexpensive mobile phones, in addition to an affordable model of long-term technical support and maintenance. Dimagi also contributes to strengthening programme management by staff at multiple levels of the health system by providing customized reporting and data for decision-making.
IWG catalytic grant for mHealth programme scale-up Dimagi was awarded a grant to scale up the use of CommCare in India by the United Nations Innovation Working Group’s (IWG’s) catalytic grant competition for maternal, newborn and child mobile health (mHealth), managed by the mHealth Alliance. CommCare was successful in the grant competition because it employs an effective delivery strategy for an evidence-based child health intervention, combined with creative financing strategies to promote sustainability – elements that are critical for mHealth tools to contribute to Millennium Development Goals 4 and 5.1 Through IWG, Dimagi is receiving specialized assistance from WHO RHR to optimize scale-up of CommCare while contributing to the mHealth evidence base and best practices on implementation and scale-up.
Assistance: The project receives a grant from the mHealth Alli- ance; and specialized research assistance from WHO’s Department of Reproductive Health and Research.
Partners: Catholic Relief Services, Save the Children, Real Medicine Foundation, Hewlett-Packard Company, World Vision, University of Washington, CORE Group, Maternal Concept Lab For more information please contact: Matt Theis, Country Director, Dimagi India (mtheis@dimagi.com), or Mohini Bhavsar, Senior Field Manager, Dimagi India (mbhavsar@dimagi.com)
1 MDG 4 is to reduce child mortality; MDG 5 is to improve maternal health (www.unmillenniumproject.org/goals/gti.htm)
References:
1. Keeley B. Where do the bottom billion live? OECD Insights – Debate the issues. 3 November 2010 (http://oecdinsights.org/2010/11/03/where-do-the-bottom-billion-live/).
2. Data: India. The World Bank, 2012 (http://data.worldbank.org/country/india).
3. National Rural Health Mission. ASHA – accredited social health activist. Ministry of Health and Family Welfare, Government of India, 2012 (www.mohfw.nic.in/NRHM/
asha.htm).
4. DeRenzi B et al. Improving community health worker performance through automated SMS. Proceedings of the 5th International Conference on Information and Communication Technologies and Development, 2012:25–34.
5. Baqui AH et al.; for the Projahnmo Study Group. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. The Lancet, 2008, 371:1936–1944.
6. Chittamuru D, Bhavsar M. CommCare: evaluation of a mobile application for maternal health in rural India. Presented at the International Association of Media and Communication Research, Durban, South Africa, 15–20 July 2012.
7. Bora G, Kumar A. mSAKHI: Putting technology into the hands of community health workers. Presented at the 13th World Congress on Public Health, Addis Ababa, Ethiopia, 23–27 April 2012.
8. Treatman D, Lesh N. Strengthening community health systems with localized multimedia. Presented at the 3rd International Conference on Mobile Technology for Development (M4D2012), New Delhi, India, February 2012.
Credits:
: Ben Rex Furneaux, from The Noun Project; all other icons adapted from The Noun Project Editing, design and layout: Green Ink (www.greenink.co.uk)
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Number of pregnant women reached*
India
Number of children reached*
Number of female community health workers (ASHAs)
Catholic Relief Service Uttar Pradesh
111 4000+
World Vision Maharashtra
40 2300+
Save the Children Rajasthan
70 4700+
CARE India Bihar
520 20 000+
Real Medicine Foundation Madhya Pradesh
61 9200+
* Up to beginning of November 2012 CommCare mobile phone software
supports ASHAs with: Education and training Communications with
clients and health facilities Forms, checklists, danger
signs, decision support Data collection, monitoring case
management
Resulting in confident ASHAs and satisfied clients
