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ORIGINAL ARTICLE
Year : 2016  |  Volume : 60  |  Issue : 4  |  Page : 329-333  

Computer tablet-based health technology for strengthening maternal and child tracking in Bihar


1 Associate Professor, Indian Institute of Public Health Delhi, Public Health Foundation of India, India
2 Project Associate, Indian Institute of Public Health Delhi, Public Health Foundation of India, India
3 Consultant, Indian Institute of Public Health Delhi, Public Health Foundation of India, India
4 Additional Professor, Indian Institute of Public Health Delhi, Public Health Foundation of India, India
5 Health Specialist, UNICEF, Bihar, India

Date of Web Publication15-Dec-2016

Correspondence Address:
Preeti Negandhi
Indian Institute of Public Health Delhi, Public Health Foundation of India, Plot 47, Sector 44, Institutional Area, Gurgaon - 122 002, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.195868

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   Abstract 


Background: UNICEF along with the State Government of Bihar launched a computer tablet-based Mother and Child Tracking System (MCTS) in 2014, to capture real-time data online and to minimize the challenges faced with the conventional MCTS. Objective: The article reports the process of implementation of tablet-based MCTS in Bihar. Methods: In-depth interviews with medical officers, program managers, data managers, auxiliary nurse midwives (ANMs), and a monitoring and evaluation specialist were conducted in October 2015 to understand the process of implementation, challenges and possibility for sustainability, and scale-up of the innovation. Results: MCTS innovation was introduced initially in one Primary Health Centre each in Gaya and Purnia districts. The device, supported with Android MCTS software and connected to a dummy server, was given to ANMs. ANMs were trained in its application. The innovation allows real-time data entry, instant uploading, and generation of day-to-day work plans for easy tracking of beneficiaries for providing in-time health-care services. The nonlinking of the dummy server to the national MCTS portal has not lessened the burden of data entry operators, who continue to enter data into the national portal as before. Conclusion: The innovation has been successfully implemented to meet its objective of tracking the beneficiaries. The national database should be linked to the dummy server or visible impact. The model is sustainable if the challenges can be met. Mobile technology offers a tremendous opportunity to strengthen the capacity of frontline workers and clinicians and increase the quality, completeness, and timeliness of delivery of critical health services.

Keywords: Computer tablet, health technology, innovation, m-health, tracking, Mother and Child Tracking System


How to cite this article:
Negandhi P, Chauhan M, Das AM, Sharma J, Neogi S, Sethy G. Computer tablet-based health technology for strengthening maternal and child tracking in Bihar. Indian J Public Health 2016;60:329-33

How to cite this URL:
Negandhi P, Chauhan M, Das AM, Sharma J, Neogi S, Sethy G. Computer tablet-based health technology for strengthening maternal and child tracking in Bihar. Indian J Public Health [serial online] 2016 [cited 2019 Dec 6];60:329-33. Available from: http://www.ijph.in/text.asp?2016/60/4/329/195868




   Introduction Top


A well-maintained Health Management Information System (HMIS) is one of the important building blocks of the health systems framework. It helps in collating timely and accurate information on health interventions' coverage, quality, and equity. It improves the ability to monitor progress at the ground level against the global, national, and subnational goals and forms the foundation for good public health practice.[1] With an intention to strengthen the existing HMIS system and accelerate the practice of providing well-timed essential services to pregnant women, newborn babies, and children, a web-based computer application called Mother and Child Tracking System (MCTS) was initiated by the National Rural Health Mission in 2009. It helps track the beneficiaries and provide information on health-care services including antenatal care, institutional delivery, postnatal care, and routine immunization and currently covers the entire country.[2],[3]

The MCTS data are updated on the server capturing the services provided to pregnant women and children. This is being done through the data entry operators on the basis of information received from auxiliary nurse midwives (ANMs). Every pregnant woman's contact number or that of her relative/neighbor is also noted for sending instant messages. The server generates SMS alerts from the database and sends automatically to both, pregnant woman and the area ANM about the due services, to ensure continued medical care. This system was introduced in Bihar in 2011 and has since demonstrated immense potential in tracking the beneficiaries for health-care service delivery. The existing health-care workforce has been trained and is being utilized for the operationalization of this system.

While MCTS is one of the most effective packages for strengthening the RCH program in Bihar, there have been some constraints, mostly related to data upload, completeness, timeliness, and feedback to the health-care workers. It was observed that if the data were entered into the system real-time in the field, the errors would be minimized and the system would become more effective. For this, UNICEF Bihar, in partnership with the State Health Society Bihar, launched a computer tablet-based MCTS in 2014 to minimize the challenges faced with the conventional MCTS and facilitate the provision of timely and appropriate health-care services. It does so by simplifying the process of providing on-time health services to all pregnant women, newborns, and children by generating work plans through the Android-based software that allows tracking and updating relevant information instantaneously. We report the implementation of this innovative practice, including its operational feasibility, challenges, and recommendations for further improvement and scale-up.


   Materials and Methods Top


The implementation of this tablet-based innovation was described utilizing a qualitative study design for capturing relevant data. This process was carried out in October 2015, around a year after the commencement of implementation of the innovation. In-depth interviews were conducted with key stakeholders to understand the process of implementation of MCTS, challenges faced, and the lessons for its sustainability and scale-up. The interviewees included medical officers, program managers, data managers, ANMs, and a monitoring and evaluation specialist. All the interviews were carried out face to face and lasted for about 30 min each, after obtaining due informed consent from the respondents. The interviews were recorded and field notes were also taken. All the interviews were transcribed and translated appropriately after the data collection. Subsequently, detailed analysis was done manually with the qualitative data to arrive at the emerging themes, and field notes were also referred to draw valid inferences.

This process was part of the INAP project, which was approved by the Institutional Ethics Committee of Indian Institute of Public Health Delhi. The interviews did not include any of the beneficiaries or vulnerable persons. Written consent was obtained before each interview. We did not use any identifiable information in the analyses or results.


   Results Top


The responses of the interviewees were analyzed systematically to present the results. The tablet-based MCTS innovation was launched in Bihar by UNICEF in partnership with the Government of Bihar on April 1, 2014. Before the launch of the innovation, data entry operators were tremendously burdened with the large amount of data that were being provided to them by the ANMs for entering into the national MCTS portal. This system of data upload provided the scope for inconsistencies and fraudulent data entries, as well as incomplete entry of data, thus defeating the actual purpose of building a robust system. The data were not being uploaded timely, and the feedback mechanisms for the health-care workers to take appropriate action were not in place. Hence, there was a felt need to strengthen the existing system and accelerate the provision of well-timed health-care services to pregnant women, newborns, and children through a tablet-based MCTS.

The innovation was introduced initially in one Block Primary Health Centre each in Gaya and Purnia districts of Bihar. A total of 60 tablets along with 3G SIM cards were procured and distributed equally within the two districts. Each ANM received a device supported with Android MCTS software, which was connected to a dummy server for data entry and upload.

For designing the Android-based MCTS software, web management, and troubleshooting, an IT agency of repute was contracted by UNICEF. The components were entry and update of data within the software, work plan generation, information about provision of in-time health-care services such as prenatal and postnatal care, and immunization to women, newborns, and children. The MCTS software contained modules embedded within the tablet for entering data electronically. These data were preserved and managed on a dummy server and could be accessed real time. The webpage, which was developed and is currently being managed by the same IT agency, has date-wise information on mother and child health-care services. The software thus developed has been field-tested, and feedback of the ANMs and data entry operators was utilized to improve and make it more user-friendly.

Before initiating the pilot, advocacy was done by organizing a consultation meeting with key stakeholders of the two districts. The district magistrates, civil surgeons, and other health authorities were briefed about the conceptual framework of the pilot with a demonstration of the application of android MCTS software. The support of all key stakeholders and authorities from the government institutions was sought for coordinating and channelizing the administrative processes. Financial assistance was provided by UNICEF through SIHFW. Rigorous capacity building of ANMs was done to build their competence in the application of all steps, i.e., data entry, data upload, and generate work plans, via the devices. The capacity building was facilitated by stakeholders/partner institutions by way of work plan generation through classroom orientations, on-the-job hands-on training, weekly mentoring, and troubleshooting during weekly meetings. UNICEF, through its outreach services monitoring network, also appointed data consultants who were required to do regular monitoring and provide supportive supervision during the implementation of the intervention.

The introduction of this innovation using a computer tablet helped the ANMs enter data real-time and save it on a dummy server for uploading as soon as the internet connection was established. However, since this dummy server is not yet connected to the national portal, the data are being entered into the tablet as well as on the national MCTS portal.

Although a formal evaluation is awaited, it has already been expanded to two states in 2015 with minor improvements in the software to make the tablets more user-friendly. As mentioned by the respondents, the government has also planned to scale-up the innovation throughout the state of Bihar and update the platform by adding health videos, applications for capturing images (to support monitoring), and simplifying diagnosis by including tools to analyze clinical trends and data, and generating alerts to help ANMs make decision about appropriate actions. For example, ANMs could be alerted about abnormal blood pressure trends, hemoglobin results, or growth development of babies along with recommendation to the next steps, such as close observation or appropriate referral.

Strengths

Supported by UNICEF and the Government of Bihar, this innovation for improving maternal and child tracking and service delivery is helpful in addressing a critical component of health care. It allows tracking and update of relevant information and, thus, identifies services already given versus pending services. The software is available in two languages: Hindi and English. Given their limited literacy in the use of tablets, ANMs were initially skeptical about using them, but its easy language and easy-to-use interface, together with training, motivation, and support from UNICEF, helped them establish a considerable level of confidence to use the tablets. The user interface was so simple that the ANMs have begun using the English forms for entering data. The success of this innovation is further built on its ability to allow instant data uploading and generation of day-to-day work plans for easy tracking of beneficiaries. The software is self-sustaining and cost-effective as it can be easily downloaded multiple times and can be directly installed into an android mobile or computer tablet. In addition, there will be no further cost during subsequent scale-up.

Challenges

Despite many strengths of the innovation, there were some challenges as well, as mentioned by the key informants. The tablet was primarily designed to feed data directly into it and reform the traditional paper-based registers. One of the major challenges in achieving this objective continues to be the linking of the dummy server to the national MCTS portal. Unless that happens, the data entry operators would remain equally burdened, as they were before. As a result, ANMs are still entering data primarily into the maternal and child health (MCH) registers, and the information is later updated in the tablet. It was perceived that some amount of paperwork is required for supporting smooth functioning of the systems. Huge workload deters the ANMs from entering complete data into the tablet. As a result, the work plans are not generated properly. Software corruption was also another issue faced during the initial implementation. Up-gradation was done four times until a quality variant was developed, which is being used now. Frequent breakdown of the tablets was another limiting factor. In addition, the internet connectivity in the blocks was poor (2G) resulting in slow, delayed data upload. Limited or erratic power supply was also a setback as restricted battery capacity of the tablet required frequent charging. Besides, electronic illiteracy of the ANMs with poor educational qualifications was problematic which, initially, made it difficult for them to operate the tablets.


   Discussion Top


The tablet-based MCTS is a workable innovation aiming at tracking services related to mothers and children. It has positively impacted the way ANMs do their work and has incorporated in them a higher sense of confidence and accountability.

It is well known that electronic medical record systems including mobile phones/tablets improve the efficiency of health-care service delivery. Further, it is observed that providing mobile phones to pregnant women increases their visits to health facilities, thus reducing maternal fatalities.[4] It can also help track and map diseases and drugs and logistics stock levels through mobile networks. An in-depth assessment of the MCTS in Rajasthan and Uttar Pradesh documented that a well-conceptualized and well-implemented information and communication technology has the potential to ease the workload of the frontline workers, thereby increasing the efficiency of health-care delivery.[3] Moreover, mobile phones/tablets can improve the completeness of data that might improve accuracy in the long run. The Bihar tablet MCTS was designed for the same purpose.

There are examples from across the globe on the use of technology for improvement in health service delivery. For instance, m-health innovations utilize mobile and wireless technologies to support the achievement of health objectives as can be seen in this innovative model for improving mother and child tracking. Their objective is to modernize, yet simplify the processes for better outcomes with the help of appropriate technology.[5] A resembling model, the mobile-Solutions Aiding Knowledge for Health Improvement project, launched in 2013 by Lata Medical Research Foundation, adopted the CommCare platform to help frontline workers in tracking pregnant women for public health awareness to improve health-seeking behavior and subsequently maternal and child health outcomes. The project has shown significant improvement in timely seeking of health-care services by pregnant women, reduced rates of newborn resuscitation, and improved breastfeeding practices.[6] Another analogous model, a collaborative program between Qualcomm's Wireless Reach Initiative and stakeholders including the National Primary Health Care Development Agency, the mobile operator Etisalat Nigeria, Evidence for Action, Vecna Technologies, and InStrat Global Health Solutions for capturing patients' information at the point of care and assistance in the analysis and diagnosis of clinical conditions, is an example of the positive impact mobile technology that can bring to health care.[7] There are other global examples of the use of similar technology with a focus on improving maternal and child health services among pregnant women, strengthening human resource capacity, and developing health system capacity.[8],[9],[10]

Several other models focusing on improving demand for have been implemented across the globe. One such example is Mobile Technology for Community Health in Ghana, which utilizes two applications: mobile midwife and nurses' application. It integrates community-based electronic records of care with the delivery of SMS or prerecorded voice messages to pregnant women and their families to remind them that they are due for or are nonadherent to the scheduled care.[8] Mobile Alliance for Maternal Action implemented in Bangladesh, India, South Africa,[9] and an SMS appointment reminder system of Philippines are models innovated for the same purpose.[10]

In case of Bihar, the computer tablet-based MCTS innovation has been successfully implemented to meet its objective of tracking the beneficiaries. However, the other significant objective of entering data directly into the tablet, thereby reducing paperwork altogether, could not be achieved. It still relies upon receiving paper forms for entering data into the national database due to the nonlinking of the dummy and national database servers, so that regular SMS and workplans can be generated. This is a challenge that still needs to be worked on.

The success of the innovation can be noted in terms of its adoption by two more states and its state-wide expansion in Bihar. In the meanwhile, the challenges are being monitored, and continuous planning is being done by the UNICEF to overcome them. During scale up, continuous monitoring is needed at each stage to enable quality check leading to significant neutralization of the barriers. The software needs to be upgraded from time to time and the tablet's quality in terms of its physical capacity needs to be improved, so that it can support data entry and once charged can operate for a longer duration.


   Conclusion Top


Mobile technology offers a tremendous opportunity to strengthen the capacity of frontline workers and clinicians and increase the quality, completeness, and timeliness of delivery of critical maternal, neonatal, and child health services. This requires a high level of motivation and commitment from the service providers. If used appropriately, the tablet may be used not only for quick data entry and tracking of beneficiaries for service delivery but also for stimulating demand for essential services, strengthening human resource capacity, and transforming health system capacity, thus leading to greater efficiencies in the delivery and management practices.

Acknowledgments

We would like to acknowledge the funding support provided by the UNICEF team for the INAP project. Our special thanks goes to Dr. Siddharth Reddy, Mr. Rajendra Kumar Bastiroy, and Dr. Syed Hubbe Ali for their technical inputs during the study and also during the preparation of this manuscript.

Financial support and sponsorship

Dr. Ghanshyam Sethy is affiliated to UNICEF (Sponsor of the study and supplement).

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
United States Agency for International Development. Strengthening Health Management Information System for Maternal and Child Health: Documenting MCHIP's Contribution; December, 2013. Available from: http://www.mchip.net/sites/default/files/Strengthening%20Health%20Management%20Information%20Systems.pdf. [Last accessed on 2016 Sep 20].  Back to cited text no. 1
    
2.
Ministry of Health and Family Welfare. Maternal and Child Tracking System – Operational Manual. Available from: https://www.nrhmmis.nic.in/Home%20MCH%20Tracking%20System/User%20manual%20for%20MCH%20Tracking%20by%20NIC%20-%20PDF%20format.pdf. [Last accessed on 2015 Nov 13].  Back to cited text no. 2
    
3.
Gera R, Muthusamy N, Bahulekar A, Sharma A, Singh P, Sekhar A, et al. An in-depth assessment of India's Mother and Child Tracking System (MCTS) in Rajasthan and Uttar Pradesh. BMC Health Serv Res 2015;15:315.  Back to cited text no. 3
    
4.
Oyeyemi SO, Wynn R. Giving cell phones to pregnant women and improving services may increase primary health facility utilization: A case-control study of a Nigerian project. Reprod Health 2014;11:8.  Back to cited text no. 4
    
5.
mHealth Alliance. Leveraging Mobile Technologies to Promote Maternal and Newborn Health. The Centre for Innovation and Technology in Public Health, Public Health Institute, Oakland, California. The Current Landscape and Opportunities for Advancement in Low Resource Setting. Available from: http://www.mhealthknowledge.org/sites/default/files/17_leveraging_mobile_technologies_to_promote_maternal_newborn_health.pdf. [Last accessed on 2016 Sep 13].  Back to cited text no. 5
    
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Lata Medical Research Foundation. Mobile SAKHI Project: CommCare for Improving Maternal and Child Health. Available from: http://www.dimagi.com/wp-content/uploads/2015/01/LMRF-Case-Study.pdf. [Last accessed on 2016 Sep 27].  Back to cited text no. 6
    
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Centre for Technology Innovations at Brookings. Using Mobile Technology to Improve Maternal Health and Fight Ebola: A Case Study of Mobile Innovations in Nigeria; March, 2015. Available from: http://www.brookings.edu/~/media/research/files/papers/2015/03/11-mobile-technology-nigeria-west/ctinigeria.pdf. [Last accessed on 2016 Oct 04].  Back to cited text no. 7
    
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Grameen Foundation. Mobile Technology for Community Health in Ghana – What it is and What Grameen Foundation has Learnt so far; March, 2011. Available from: http://www.courses.cs.washington.edu/courses/cse490d/12sp/docs/MOTECH.pdf. [Last accessed on 2016 Oct 05].  Back to cited text no. 8
    
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MAMA (Mobile Alliance for Maternal Action). Research Agenda; 2015. Available from: http://www.unfoundation.org/what-we-do/issues/global-health/mobile-health-for-development/mama-research-agenda.pdf. [Last accessed on 2016 Oct 04].  Back to cited text no. 9
    
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Sarmiento RF, Fernandez RJ, Bañez RJ, Marcelo P, Lee A, Sy MI, et al. Design and Implementation of SMS-Based Enhancements to a Community-Based Health Information Management System. Final Technical Report; 11 January, 2011. Available from: https://www.researchgate.net/publication/276837374_Design_and_Implementation_of_SMS-based_Enhancements_to_a_Community-based_Health_Information_Management_System. [Last accessed on 2016 Oct 05].  Back to cited text no. 10
    



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