Medic Mobile Case Study by UNESCO-Pearson Initiative for Literacy

"....Medic Mobile was launched in Nepal in 2013 as a mobile phone-based health monitoring solution using a simple data capture interface appropriate for community health workers (CHWs) with low levels of literacy and technical skills."

Through the UNESCO-Pearson Initiative for Literacy: Improved Livelihoods in a Digital World, this case study is part of a series highlighting how inclusive digital solutions can help people with low skills or low literacy levels use technology in ways that support skills development and, ultimately, improve livelihoods - in contribution to achieving the Sustainable Development Goal on education. For more information on the initiative, click here. Recognising that the user-centered design process requires extensive collaboration with all types of users and key stakeholders, Medic Mobile developed a digital design to provide an mHealth solution to communities with low literacy, both traditional and technical, in order to address maternal mortality and infant mortality through connected and coordinated health access.

In 1997, Nepal instituted a Safe Motherhood programme and then added to its preventative practices the use of a skilled birth attendant (SAB) for all deliveries with a goal of 70% of deliveries at a medical facility or in the presence of an SBA by 2020. Constraints of moving towards the goal are: "inadequate referral mechanisms for receiving care, low coverage of ANC consultations, and lack of access to hospitals and health centres....In 2013, Medic Mobile partnered with the Ministry of Health in Nepal and One Heart World Wide2 to equip CHWs who conduct routine house visits for expectant mothers with basic mobile phones. The health workers receive reminders to follow up with mothers for ANC[antenatal] consultations, delivery procedures and postnatal care (PNC) visits. The primary objective of the programme was to increase rates of full ANC visits and institutional deliveries among expectant mothers. 

Medic Mobile invovled CHWs in human-centred design during two rounds of field testing. "Initial design activities included mapping current health-care system activities with CHWs and their supervisors to identify constraints and opportunities, and validating sketches of the proposed platform interface before developing a prototype for field testing. This process also involved individual interviews with staff at the government agency responsible for all public health programmes in the district." 

A pilot test followed with CHWs, a third of whom had little or no formal education. CHWs conducted home visits and registered maternal health information directly to their mobile devices. Feedback indicated that CHWs lacked motivation because they felt isolated form supervisors. A web-based digital dashboard allowed CHW supervisors to monitor CHW activity and schedule follow-up services for those with high-risk pregnancies. Through a personalised and automated SMS (text message) confirmation each time a report was submitted, including a warm greeting and salutation using the CHW’s name, CHW work was acknowledged and received more visibility.

Early feedback showed that CHWs preferred making phone calls for assistance in emergency situations rather than flagging them as high-risk pregnancies. Medic Mobile adapted workflow to redesign the phone call as the initial task and the reporting as the second task in the CHW workflow. Also, the size and nature of the mobile report was revised based upon pilot testing to be limited to essential data for primary objectives.

The programme was developed to run in feature phones rather than smart phones using a SIM card to hold the app. The menu-driven tools guided responses and increased accuracy data entry. CHWs  needed comprehensive digital literacy training on the phones to orient them to advanced features of the app. However, a subsequent adaptation replaced the menu with space-delineated lines of text to register data  reducing the number of key strokes needed to send an updated report. "A CHW might send a text message with content such as ‘P 8 Pabitra’, where ‘P’ indicates registering a new pregnancy, ‘8’ the number of weeks pregnant, followed by the patient’s name....Prioritizing the reporting items captured and streamlining the protocol allowed the team to revisit the topic of alternatives to SIM card apps. Further research revealed that text forms have two key usability advantages over SIM card apps. They reduce hardware procurement costs and improve routine software updates as an alternative to convening CHWs and updating cards one at a time."

Because supervisors indicated a need to have information available on their phones, not on computers, Medic Mobile updated the automated SMS schedules "to alert CHW supervisors each time a new pregnancy was registered. The alert was accompanied by a comprehensive report of delivery information related to the expectant mother, including anticipated delivery date, the assigned CHW and upcoming ANC consultations." The supervisors then integrated the mother's ID into her register at her local MNH clinic. Text is primarily numerical for easy use in low literacy settings; an exact syntax that is short and simple and standard was most successful for CHW reporting. The system makes possible remote registration and supports CHWs during the consultation through text alerts as reminders of care and ANC visits, visits can be confirmed, difficult pregnancies can be flagged and monitored, emergency alerts by phone can be followed by reports, delivery confirmation and monitoring can be reported as followup. District public health officers can monitor regions using web-based analytics dashboards.

CHW training involves 3 days of primarily case-based exercises beginning with a base-line questionnaire and pre-test and ending with a competency post-test. An illustrated manual and monthly meetings for feedback, with a refresher every three to six months completes the training. Benchmarking digital competences is an aid to developing appropriate solutions and tracking progress on digital skills. Development of the project was done in partnership with the Nepali Ministry of Health,and technical leads in Nepal maintain the platform, along with project managers and assistants, who work with training. 

Monitoring and evaluation is done through pre- and endline- training questionnaires and monthly meetings and reviews. Qualitative reports indicate that the training approach of pairing a high-literacy CHW with a low-literacy CHW is improving reading and writing and basic fluency with communication tools. Results from the 2015 year of full deployment in a pilot of four villages showed registry of 604 women, 215 births, 64% of which were in  official birthing centres. Focus group results suggested that increased CHW contact with mothers due to the use of Medic Mobile led to increased services, better management of complications, and more satisfaction of CHWs with their work. Testing of 500 CHWs on digital competencies showed a 40-45% increase. The CHW engagement rate with mothers is 60% and is above the target goals for the programme.

Medic Mobile is now deployed across 23 countries and continues to expand in each. The tools in some districts of Nepal are now used to track immunisations well. Since its launch, the programme has been scaled up in Nepal to over 2,500 CHWs. In Nepal, Medic Mobile aims to scale its model nationally in Nepal, with support from the national government and local buy-in and ownership from the district health office; it envisions   government staff deploying and managing these systems starting in 2018. Costs per CHW are estimated as $150-200 the first year and $10-15 in subsequent years. Future developments may include CHW educational messages to add support to the training.

Lessons learned and recommendations include the following:

• "Support scientific knowledge while respecting cultural beliefs."
• "User-centred design requires collaboration."
• "Leveraging expertise within the user base", as was done by pairing a literate CHW with a low-literacy CHW.
• "Leverage policy agendas for sustainable solutions."
• "Scalability does not always require iteration with the same technology." Pilot testing ,may result in changes in technology based on user feedback.