A mHealth Intervention “ImTeCHO” to Improve Delivery of Proven Maternal, Newborn and Child Care Interventions through Community Based Accredited Social Health Activists (ASHAs) by Enhancing Their Motivation and Strengthening Supervision in Tribal Areas of Gujarat, India A joint initiative of SEWA Rural and Department of Health and Family Welfare, Gujarat SEWA Rural

SEWA Rural: A Voluntary Service Organization Providing Medical, Health and Educational Services Rural, Poor and Tribal Community of Bharuch and Naramda Dists. in South Gujarat, India

About SEWA Rural A Voluntary Development Organization Established in 1980 200 beds General Hospital Comprehensive Eye Care Programme Out Reach Community Based Health and research Programme Health Training and Resource Center Vocational Technical Training Center for Rural Youth Promotion of Women Development and Empowerment

Initiative is in Partnership with Dept. Health, Govt. of Gujarat Intervention “ImTeCHO” (Innovative mobile-phone Technology for Community Health Operations) Initiative is in Partnership with Dept. Health, Govt. of Gujarat “ImTeCHO is a platform based on mobile phone technology… to improve coverage of proven MNCH interventions…… through improving performance of CHWs/ASHAs and PHC staff…… by ensuring effective support, supervision and motivation… Every ASHA will be given a low cost phone which will be General Packet Radio Service (GPRS) enabled and have multimedia feature available. Based on SEWA Rural’s and Argusoft India Ltd’s research, Nokia ASHA 3115 which costs Rs. 6,000 (Rs, 6,500 with all accessories) will be used for this study. Mobile phone application will have following features: Home visit forms, log cases details, work log, announcements, SMS information channel. Detailed description of these features will follow in next paragraph. ASHA will fill out forms on her mobile during home visits. Data will be sent using GPRS network to a server where data will be stored. In case GPRS is not available, data will be stored in mobile phone and it will be sent to server when GPRS becomes available; thus, data will not be lost even in absence of GPRS. Data entry time will be “time stamped”.

ImTeCHO: Conceptual framework and hypothesis ImTeCHO= Better support, motivation, supervision to ASHAs and ASHA program Better performance Increase in coverage of proven interventions SEWA Rural

ASHAs ASHAs/FHWs/ Helpline “ImTeCHO” (3 COMPONENTS) Mobile phone as job aid to…. ASHAs for ensuring her routine MCH services Mobile phone as a job aid to….. ASHAs/FHWs/ Helpline for better morbidity management Web interface at… PHC level to provide timely and accurate information for better Support to ASHAs From publication SEWA Rural 6 6

Data Flow across Network ImTECHO Program An interactive job aid to support and supervise efficiently Task Scheduling and Tracking PHC Dashboard provides an overview of ASHA performance data, calculation of incentives, tracking use of medical supplies Data Flow across Network Task completion rates, details of activities performed, health data Task scheduling, Tabulating ASHA incentives, tracking medical stock Behavior Change Communication Data collection and diagnostic tool to allow the ASHA to respond to the need of the beneficiary SEWA Rural Helpline Helpline staff provide ASHA with information in emergency cases and facilitates referrals to medical facilities. 7

Operational since May, 2013 Gradually Expanding in Bharuch, Valsad and Narmada districts, Gujarat (High Priority Blocks). >50,000 beneficiaries registered, >5,00,000 m-transactions, population: 8,00,000 May 2013 Initially we started Imtecho project in 2 phc of bharuch district than expanding in selected high priority blocks in valsad and Narmada district. September 2014 March 2014& Feb 2015 8

MONITORING TOOLS AND SYSTEMS

Input/output (Adherence to technology intervention) What do we monitor? Input/output (Adherence to technology intervention) Health outcomes Or…Both FINDING AND USING INNOVATIVE INPUT/OUTPUT/PROCESS INDICATORS WHICH ARE STRONGLY ASSOCIATED WITH OUTCOMES

Conceptual framework for monitoring tools ImTeCHO (Input) Better support, motivation, supervision to ASHAs and ASHA program (Output) Better performance (output) Increase in coverage of proven interventions (outcome) Better health outcomes (Impact) SEWA Rural

Monitoring tools- Example of NMR ImTeCHO (Input) Increase in Home-based Newborn Care (output) Increase in coverage of EBF, Hygiene, Mgmt of complications(outcome) 30-60% reduction in NMR (Impact) SEWA Rural

HOME BASED NEWBORN CARE REMINDER FOR HOME VISIT JOB-AID: VIDEOS, DECISION TREE HOME BASED NEWBORN CARE INNOVATIVE MONITORING TOOLS LINKED TO INCENTIVES

Innovative process/monitoring indicators Task completion rate= Proportion of assigned tasks completed by the ASHA/CHWs (n=299) Proportion of deliveries reported on the day of delivery (n=288)

Innovative process/monitoring indicators Mean duration of home visit suggestive of quality of home visit (n=288) Supervision by the medical officer in form of task completion rate SEWA Rural

Innovative process/monitoring indicators Digitized performance based incentives SEWA Rural

Monitoring “SYSTEM” Who is going to monitor whom? When? How? ISO 9001:2015 certification to ImTeCHO for its Quality management system SEWA Rural

EVALUATION/ RANDOMISED TRIAL SEWA Rural

Study overview Study areas: 6 tribal blocks Baseline household survey (4 months/2,000 respondents) Randomization with PHC as cluster Intervention area (11 PHCs/300 ASHAs) Control area (11 PHCs) Training (5 months) Delivery of intervention (18 months) 50,000 pregnant women & children End line house hold survey (5 months/7,000 respondents) Analysis and reporting writing (4 months) S U R V E I L A N C This will be a two arm, parallel, stratified cluster randomized trial in which unit of randomization will be a PHC. Stratification is required to ensure that prevalence of primary outcomes are similar in the intervention and control groups along with almost equal selection of PHCs from from the most backward Dediyapada block. Stratification will be also done to improve power and precision. The randomization will be done after baseline survey. Along with primary outcomes, randomization would help to balance cluster size across both groups. The allocation ratio will be 1:1. The allocation concealment will be done using sequentially numbered sealed, opaque envelopes. SEWA Rural

Lessons learned Finding and using tech-driven process indicators which are closely related to health outcomes Monitoring tools and user motivation Monitoring “Systems” is critical

Acknowledgements ASHAs, PHC staff, local health department staff Department of Health and Family Welfare Argusoft India Ltd ICMR, WHO, MacArthur Foundation, Jamsetji Tata Trust, Anupam Rasayan Pvt Ltd SEWA Rural

THANKS….SEE YOU AT THE “APPY HOUR” SEWA Rural