Using GSM-based GIS tracking to improve workforce monitoring for improved geographic coverage of immunization services Subhash Chandir, PhD Director, Maternal & Child Health Program Dec 13, 2016 @ PHCA Conference

The Problems 1 2 3 Despite having multiple mass immunization campaigns, Government fails to achieve optimum immunization coverage for polio and/or measles

Fatigue among health workers The Problems 1 2 3 Fatigue among health workers

Resistance to repeated and now routine immunizations among parents The Problems 1 2 3 Resistance to repeated and now routine immunizations among parents

Immunization Services in Pakistan Public sector Expanded Program on Immunization (EPI) Routine immunizations centers Door-to-door supplemental immunization activities Majority of vaccination events Essential for finding ‘missing’ children

Constraints of Supplemental Immunization Activities Inability to track SIA teams in field Repeatedly missed households Administrative Lack of accountability Inaccurate, hand-drawn maps of SIA site Monitoring Icons: treasure map by Lloyd Humphreys, Track by Akhil Komath All icons were downloaded from The Noun Project at thenounproject.com

Solution - I GSM based GIS tracking of healthcare staff No additional infrastructure required Better mapping of target areas Highly scalable

Solution - II + = + GSM based GIS tracking Real-time monitoring Mobile Phone SIM + = + Online tracking

What is GSM? Global System for Mobile Communications Geospatial positional system that utilizes cell towers for triangulation Accurate from 50m (urban) to 100m (rural) Compatible with all mobile phone devices 1 Rasouli S, Timmermans HJP, editors. Mobile technologies for activity-travel data collection and analysis. Hershey (PA): IGI Publishers; 2014.

What is GPS? Global Positioning System Geospatial positional system that utilizes satellite signals Requires GPS device Accuracy of up to <10m

GSM vs GPS tracking GPS GSM Universal Compatibility Requires GPS-enabled smartphones No battery drain GPS feature drains battery rapidly No activation required Tracking disabled if GPS turned off No internet required Requires internet data package

Objectives Pilot test the use of Global System for Mobile Communications (GSM) based GIS tracking for vaccinators during polio SIAs. Assess vaccinator and supervisor attendance/performance Identify & cover missed areas Create cost-projection for district-wide scale-up Icons: calendar by anbo, Find missing piece by Chris Homan, graph projection by Bezier master All icons were downloaded from The Noun Project at thenounproject.com

Methodology - Setting Shikarpur District 242,000 U5 Children 523 active SIA Teams Shikarpur District 242,000 U5 Children 523 active SIA Teams Sukkur District 262,412 U5 Children 586 active SIA Teams

Methodology - Participants Sukkur Shikarpur 1 Medical Officer 6 Area In-Charges 3 Vaccinators

Methodology – Tracking Enrollment Verbal Consent Collection of names and phone numbers Affirmative response to tracking confirmation Automatic tracking every 15 minutes Monitoring on web portal

Methodology – Tracking of Field Workers Real-time monitoring through web portal Automatic location reporting at 15 min intervals Report generation Field sites visited Time spent in the field

Tracking Map Types Team Tracking Member Route Tracking

Tracking of 500 individuals Tracking Costs 130 USD Tracking of 500 individuals

Results - Team attendance & performance Team and individual tracking allowed detection of personnel: Starting work 2-3 hours after 8am (reporting time) Visiting sites for 30 minutes in the afternoon Going out of town during SIA Failing to visit assigned SIA site Identification of missed areas

Results – Cost Projection USD 695,448 Annual cost of district-wide SIAs Projected additional cost of adding GSM to district SIA budget USD 6,960 (1%)

Limitations Technological limitations Ethics/privacy issues GSM may not pinpoint household-level location in dense urban areas Tracking may be inaccurate in rural areas with few cell- towers Ethics/privacy issues Tracking of personal devices Possibility of tracking outside work hours

Conclusion Highly cost effective Low initial investment/operational cost Generates real-time actionable data Improved geographic coverage of SIAs Improved accountability of vaccinators High degree of interest shown by District Health officials

Thank you