Digitising healthcare at grassroots
The science fiction author William Gibson famously quipped the future is here, it’s just not evenly distributed. There is arguably no greater manifestation of our uneven world than that of healthcare,” says the noted technology writer Richard Hartley. “In the wealthiest countries, thousands of people in their 60s and 70s are kept alive with cardiac pacemakers that are remotely monitored over the internet, and adjusted by algorithms with no human intervention. In poorer states, three-quarters of a million children under five are dying each year because of shit in their water,” he adds.
Inequity in healthcare distribution holds true for India as well—in comparison to South Asian and Sub-Saharan African countries and also among its states. As per Credit Suisse First Boston’s latest wealth-data book, the inequality in India has sharpened, with the top 1 per cent possessing 58.4 per cent of the national wealth in the country.
Healthcare indicators in Uttar Pradesh, home to over 200 million people, are abysmal. In a study by the Rajiv Gandhi Institute for Contemporary Studies, public health centres (PHCs)—the frontline of government’s healthcare system—decreased by 8 per cent over 15 years till 2015, with the state’s population increasing by more than 25 per cent in the same period. Uttar Pradesh has India’s second highest maternal mortality rate—285 maternal deaths for every 100,000 live births. The state also performs poorly in child mortality indicators with 64 deaths in children below five years of age per 1,000 live births, as per pan-India Rural Health Statistics 2015.
Healthcare innovation of Uttar Pradesh, thus, deserves attention. The state’s government, in collaboration with the non-profit IntraHealth International and the tech major Qualcomm, has been running a mobile app-based programme “mSakhi” in Jhansi since 2013. The programme enables community health workers, who are at the forefront of India's National Health Mission, to help women and their families recognise maternal and neonatal danger signs and promptly seek care.
These community health workers comprise of accredited social health activists (ASHAs) in the lowest rung of the healthcare vertical, anganwadi workers (AWWs) at the bottom of the nutrition-cum-child development vertical and auxiliary nurse midwife (ANMs) at the frontline of the professional healthcare workforce.
However, a majority of ASHAs and AWWs are village women with low literacy skills, and they face operational challenges in conducting routine maternal, newborn and child health activities and in keeping their skills updated. They lack access to healthcare information, refresher training, meaningful supervision, and user-friendly job aids, which compromise their ability to contribute to improved maternal and newborn health outcomes.
mSakhi (where m stands for mobile and Sakhi for a friend) is an interactive regional language (available in Hindi currently) audio/video-guided mobile application that supports health workers in conducting routine activities across the continuum of mother and child care. The application’s content is based on the guidelines and formats laid out in the National Health Mission and the Integrated Child Development Scheme.
Health workers register pregnant women and newborns by entering necessary information into mSakhi app during home. Upon registration, mSakhi generates a home visit schedule for each beneficiary and provides a set of audio-video guided instructions for counselling, assessment, and referral specific to each mother and child, in each visit. Auxiliary nurse midwives, the de-facto supervisors can track ASHAs and beneficiaries in real-time as data is stored on mSakhi’s central database. A similar approach is worked for the Anganwadi workers and their respective supervisors, the Child Development Programme Officers at the block level.
The app is compatible with any Android smartphone and can be downloaded for free.
Amod Kumar, the original architect of the programme, currently posted at the Chief Minister’s office, states that unburdening the Anganwadi workers, ASHAs, ANMs from the kilograms and kilograms of registers and flip charts (which restricts their mobility) to do their core job of tracking of mother and child and counselling them was the primary aim. Bringing comfort and efficiency to their jobs were the thought behind this app.
The app also simplifies public administration, eliminating the need for data-entry operators. mSakhi manages to convert the data into digital format right from the point of entry, to be used, analysed, accessed, and processed across the health system by all relevant staff members.
This was the systems’ approach needed in a country where various departments think in silos, rarely collaborate and duplicate efforts. Qualcomm partnership in this initiative stems from that systems approach worldview, points out Anirban Mukerjee, manager at Qualcomm Wireless OutReach, working on the intersection of development, mobile phones and internet access.
Hence investment in tools which gives them an on-going, on-job training, reduces their burden of carrying registers and reduces the task of compilation by compiling and processing data automatically, seems a worthwhile effort. mSakhi is one such. Though Meenakshi Jain, country director IntraHealth India, has a word of caution—apps can only increase efficiency but staffing inadequacy, human resource challenges, systems’ inefficiencies still need to be tackled to counter the morbidity and mortality problem comprehensively.
The app has the added benefit of improving the social status of women health workers since they were some of the first ones to get smartphones in their villages and blocks. Unlike the standard criticism of online courses and digital applications, that doesn’t recognise deprivation, class and dehumanises every interaction, this is one app that actually enhances humanised interaction by guiding the service providers (ASHAs and AWWS, in this case) to have structured interpersonal conversations with the mother and her family members to counsel and care for them better.
This is one innovation that deserves our attention. Not just for clinical and public health reasons but social, anthropological reasons. And the fact that this app puts health workers front and centre, who are the backbone of effective health systems, is as good a reason as any to demand our attention.
(The author is researching the potential and limits of mobile health apps in low-cost settings where mSakhi is a case study. The author works on Poverty, Public Policy and Governance in South Asia and Horn East and Central Africa, Adjunct Faculty at Pondicherry Central University, SLU-Uppsala, UNESCO-MISARC. Views expressed are strictly personal.)