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mHEALTH: DANDORA Utilizing Mobile Technology to Improve Maternal and Child Healthcare in Dandora, Kenya

mHEALTH: DANDORA Utilizing Mobile Technology to Improve Maternal and Child Healthcare in Dandora, Kenya 08Fall

Fall 2013Client Contact: Dennis HaraszkoInternational Development in PracticeFord Family Program Development Advisory TeamDougie Barnard, Ali Searle, Katie Suarez, and Sally Xie Table of ContentsExecutive Summary3Context and Goals5Key Objectives6Project Evaluations7TABLE 1: Evaluation of mHealth Projects8Mobile Alliance for Maternal Action (MAMA)8Wazazi Nipendeni10FrontlineSMS12Uganda Health Information Network (UHIN)13CommCare15Recommendation17Budget19Timeline21Future Directions23Conclusion24Appendices25Appendix A: How MAMA Messages Work25Appendix B: Comparison of the Five Projects on Cost Effectiveness25Appendix C: Comparison of the Five Projects on Ease of Implementation26Appendix D: Comparison of the Five Projects on Proven Benefit and Impact26Appendix E: Comparison of the Five Projects on Ease of Scalability27Appendix F: Comparison of the Five Projects on Relevance to Local Context27Appendix G: Sample Timeline for the Implementation of CommCare28Development Advisory Team29References30

Executive SummaryThe Ford Family Program, in conjunction with the Holy Cross Parish, established the Brother Andre Dispensary in 2011 to meet the medical needs of the people of Dandora, a large slum outside of Nairobi, and the primary dump site for the capitals waste. The Brother Andre Dispensary is currently an outpatient facility, which consults with 70 to 100 individuals a day. In 2013 the Ford Program conducted a maternal health assessment, in which it analyzed the existing maternal health care services available in Dandora. This assessment exposed, among the few health centers in Dandora currently providing maternal health care, a lack of community outreach and a corresponding lack of accessibility and knowledge of care options by women and children. While the existing maternal health facilities provided basic brochures on issues around pregnancy, such as breastfeeding; this was generally the extent of community outreach. Few pregnant women and mothers turned to the centers for care by an educated medical professional (Scott 2013).In order to address the exposed gap in the provided maternal health services, and combat the high rate of maternal and infant mortality, the Ford Program is in the process of adding a maternal ward to the Brother Andre Dispensary. Acknowledging the power of technology as a means to interact with women at a distance and low cost, the Ford Program is interested in adopting a mHealth platform. Our team was solicited to (1) Research; (2) Evaluate; (3) Identify; and, (4) Develop a recommendation for an mHealth strategy for the Ford Programs efforts in Dandora. We first conducted comprehensive research of various mHealth projects, ultimately focusing on five that we found to be the most successful and applicable to the Brother Andre Dispensary. These were divided into two comprehensive groups, (1) direct SMS messaging platforms for mothers; and, (2) mobile health tools for community health workers (CHWs). Specifically, we evaluated three direct messaging platforms - Mobile Alliance for Maternal Action (MAMA), Wazazi Nipendeni, and FrontlineSMS; and two mobile technology tools for CHWs - Uganda Health Information Network (UHIN) and CommCare. Each of these projects was evaluated relatively by five considerations provided by the Ford Program - (1) cost effectiveness; (2) ease of implementation; (3) proven benefit and impact; (4) ease of scalability; and, (5) relevance to local context, which were then analyzed as a whole. Based on previous assessments highlighting the need for community outreach and increased knowledge of and access to services, as well as these individual evaluations, our team concluded that focusing first on a CHW-centric project would enable the Ford Program to most effectively address the immediate needs in Dandora and improve maternal health outcomes. The successful implementation of such will ideally result in a network of mothers that can support additional implementation in the future of a direct message campaign for new and expectant mothers. Our analysis identified two platforms, CommCare and MAMA, capable of most effectively and efficiently addressing the maternal health issues in Dandora. We recommend that the Ford Program first utilize CommCare to strengthen the services provided by CHWs, namely data collection, case and CHW management, and the improvement of care. CommCare was found by numerous studies (Svoronos 2010, Mitchel 2012, Mohamed 2013) to effectively standardize support and improve the ease of data collection. The recent implementation of CommCare by Pathfinder in Nairobi under the mHMtaani campaign, primarily concerned with HIV/AIDS, provides evidence of the platforms success in a context similar to that of the Brother Andre Dispensary.CommCare also excels in regard to cost effectiveness. The Ford Program, with less than 50 CHWs (potential mobile users) would fall within the Community package, thus the required software, as well as technical and developmental staff support for the first year, would be provided free of charge. If in the future, the Dispensary grows beyond the scope of the basic package, it has flexibility to expand at little cost. A final benefit to CommCare, which concerns both cost and ease of implementation, is that CommCare does not require the use of smart phones. The platform has the flexibility to be run on any java-enabled phone, which are available at very low cost and are already familiar technology to many potential users. In summary, we primarily recommend the implementation of CommCare, a mobile technology for CHWs, which has been shown to be cost effective, easy to implement, impactful, scalable, and relevant to local context.Evidence suggests that only upon the successful establishment of a network of mothers and awareness of available maternal health services, possible via implementation of CommCare, would the Ford Program benefit from pursuing a direct mobile messaging campaign for mothers. Based primarily on relevance to local context, ease of implementation, and cost effectiveness, we recommend that if such a stage is reached, MAMA may be an ideal mobile platform for the Ford Program to additionally implement. MAMA provides new and expectant mothers with two messages per week, from their fifth week of pregnancy through their childs first year, covering topics such as breastfeeding, appointment reminders, postpartum family planning and tips to avoid mother-to-child HIV transmission.In conclusion, based on the overarching need for community outreach and provision of services, we recommend the Ford Program first implement CommCare, a relevant and evidence-supported tool providing CHWs with easier data collection, better management, and improved care. Upon successful implementation of CommCare, we suggest the Ford Program then consider adopting MAMA, which would build on the established network with the community to directly provide new and expectant mothers with encouragement and information. Through the adoption of this collaborative mHealth strategy, the Ford Family Program can meet needs and improve provision of maternal services in Dandora, ultimately improving health outcomes. Context and GoalsThe Ford Programs request that we research mobile health technology strategies adaptable for maternal healthcare in Dandora reflects new trends in global health. The twenty-first century saw an enormous rise in mobile subscriptions in the developing world. In 2000, 5.5 per hundred people had a mobile subscription; but by 2009, 67.6 per hundred people had mobile subscriptions in developing countries. In conjunction with an increase in mobile subscriptions, interest in utilizing mobile technology to inform and distribute health care services has grown. Innovative and dedicated global health organizations such as Care International, the Rockefeller Foundation, the mHealth Alliance, and the United Nations Foundation have created a multitude of projects exploring the potential of mobile health (mHealth) technology in a variety of settings. The Ford Programs recent needs assessment indicated that community health care has much to gain from harnessing mobile phone technology (Scott 2013).Dandora, an Eastern suburb of Nairobi, Kenya, has an estimated population of 200,000 people. A large slum area, and Nairobis principal dumping site, Dandora is host to a multitude of health issues. The dumpsite deposits over 2,000 tons of waste daily, exposing nearby residents, criminals, and scavenging children to a myriad of health ailments. According to a report from the United Nations Environmental Program, 50% of children living in the areas surrounding the dumpsite have respiratory ailments and toxic blood lead levels. Additionally, reports from Community Health Workers (CHWs) include elevated cases of cancer, anemia, hypertension, frailty, kidney problems, nervous system disorders, and miscarriages (Africa Science News). It is within this context of structural issues that the Ford Program established the Brother Andre Medical Dispensary to provide medical treatment for the poor and most in need in Dandora. The Ford Program believes that the community health issue of paramount concern, that must be addressed, is the issue of maternal and infant health. In response to the findings by the Dandora Law and Human Development Project, which used organizational mapping to conduct a baseline survey of social, economic, and political conditions in Dandora, the Ford Program is planning to soon erect a new maternity ward. The greatest contributing factor in the decision to build a new maternity ward is the lack of maternal health services at public hospitals in Dandora. This