How community health volunteers are using mobile technology to provide better care in remote areas of Madagascar
By Samy Rakotoniaina
In remote villages of Madagascar, people who live miles away from a health center largely depend on community health volunteers for basic health care, such as family planning services, or the diagnosis and treatment of simple childhood infections. These volunteers are identified and elected by the community, and are then trained and supervised by the head of the nearest health center. The country’s national Community Health Policy places them at the foundation of the health pyramid, as they are serving the most isolated communities. However, ensuring the quality care provided by these volunteers can be challenging: one study reported that only 49% of health volunteers offer family planning in accordance with national standards, and only 53% of children under the age of five are correctly treated for diarrhea, malaria, and pneumonia by health volunteers.
Being a community health volunteer is a tricky job. Among the many difficulties they already face, they are expected to report their activities by completing paper registers on a daily basis. But these paper tools, which are long and time-consuming, often result in delays and errors in the reporting process.
The USAID Mikolo Project, which is led by Management Sciences for Health, along with the Ministry of Public Health and other partners, has developed a mobile health (mHealth) application to improve the quality of healthcare services provided by community health volunteers through standardizing care delivery, as well as the quality of and access to data emerging from their health activities.
The process is smart and simple. For example, if a woman visits a community health volunteer for family planning services, the application will guide the volunteer through a standard set of questions that will help ensure that the required information is collected, limiting the possibility of errors in the counseling service. The process integrates step-by-step instructions, validation checks and job aids to ensure that key health messages are delivered. As some family planning clients also need to return for the next dose of contraceptive, the application will prompt a reminder on the appointment date so that the health volunteer can seek out the client to make sure she doesn’t miss her scheduled visit.
The application can also help detect cases of serious illness. For instance, a red notification pops up when a child’s weight indicates severe malnutrition during a growth monitoring session. Parents tend to pay greater attention to the advice and recommendations of a community health volunteer when supported by the mobile application.
During a recent field evaluation, one of the volunteers stated that in the past people didn’t care much when he referred them to the health center for advanced treatment. Apparently, a notification on the smartphone is viewed as more “reliable” for clients, which spurs them to follow the instructions, particularly when it comes to referrals to health centers.
The application significantly saves time. Previously, the health volunteers were required to follow a paper-based job aid during case management appointments, and often instantly filled in their forms, which slowed down the service time. With the smartphone, beneficiaries confirmed that they were satisfied with the new system, which has become faster and more accurate, saving time for everyone involved.
Finally, the smartphone enhances the communication between heads of health centers and community health volunteers; they can easily get in touch by telephone to ask specific questions or to share important health information. Health volunteers can also check whether referred patients actually went to the health center, which reinforces follow-up and the continuum of care.
This mobile health application has proved successful in its pilot phase at the community level, despite initial challenges in introducing community health volunteers to the use of the touchscreen devices. Training and practice helped users quickly master the smartphone and its components within a few days. The application has also been designed to run offline, in order to mitigate any potential problems due to limited internet coverage throughout rural Madagascar. Additionally, community health volunteers sync their database when they visit the nearest town with internet coverage at least once a month. However, the pilot project also revealed challenges, such as phone battery life, which must be addressed to improve the application for scale-up. More reliable solar chargers and powerbanks will ensure the functionality of the electronic devices in off grid locations.
Ultimately, the introduction of mobile technology to improve the quality of care remains a real innovation in community health, as the application generates a diagnosis and recommendations for treatment and follow-up, thereby offering standardized, evidence-based care. The preliminary results of the pilot project suggest that the mobile application has the potential to generate significant positive impacts on health service delivery and data collection at the community-level. Following this successful pilot phase, the Ministry of Public Health and the USAID Mikolo project, decided to scale-up the use of smartphones at the community level to strengthen the country’s health system and to improve health outcomes in remote villages.