What We Learned Deploying 1 mHealth App Across 4 Countries in Africa

Starting mid-2014, Dimagi implemented mobile health tools for malnutrition screening in four countries in partnership with one of our biggest clients, World Vision International. The work involved Dimagi executives, project managers, and field implementers across all five of our company’s country offices.

Whether circumstantial or not, Niger turned out to be a good place to launch the first malnutrition screening application for Community Management of Acute Malnutrition (CMAM), given the level of need in the country. Niger is a country in West Africa that regularly makes the news for its food shortage challenges. Landlocked, and with more than 80 percent of its surface as desert or savannah, Niger has inherent challenges feeding its 17 million inhabitants. Yet, because it is more politically stable than a few of its neighbors, Niger occasionally serves as a receiving place for refugees fleeing insecurity in the region. For example, since the Boko Haram insurgency began escalating in neighboring Nigeria (situated right below Niger), thousands of Nigerians have crossed the border into the southern cities of Niger—cities already strapped for resources for their own citizens.

What the CMAM application is designed to do:
The World Vision CMAM application provides decision-support, multimedia and checklists to help nurses and community health workers diagnose cases of malnutrition among children aged 6-59 months and among pregnant and lactating women.

The application then tracks each beneficiary throughout his/her continuum of care, recommending dosages of supplemental food or medicine this person should receive, providing audio-supported counseling, or referring to a health center when appropriate.

This is all the user-facing end. On the back/ World Vision-facing end, the application provides regular reports on the level of activity at each clinic, as well as indicator reports.

The deployment and its impact: 

With the guidance of World Vision, Dimagi iterated over several weeks on the design of the CMAM application to reproduce and, especially, reinforce the global protocol established by the World Health Organization (WHO) while still upholding, as much as possible, the subtleties of the local cultural context.
In December 2014, we deployed the first CMAM application in eight clinics with 16 users after the requisite training of trainers and of users. In the past 10 months, despite not at full utilization, these eight clinics have screened over 6,000 women and babies.

The grant that facilitated World Vision’s first launch also funded deployments in three subsequent countries: Mali, Chad and Kenya. Mali launched in April 2015, northern Kenya in June, and Chad in July 2015. By the end of all deployments, the application will be operational in 49 clinics.

Two notable challenges in user-centered design:

1. Fragmented, fluid workflow, both at clinic and national levels: At the clinic-level, a beneficiary (child, especially) might interact with several actors owning different aspects of the multi-point care circuit. And this differs not only among countries but also among clinics in a single country. With this fragmented, fluid set-up, there is an increased risk for data entry and classification error. As such, we have had to think where best to place the application along the care circuit. Careful observation of the clinical workflow and consideration of which activities would yield the highest impact on the beneficiary helped us to determine at what points the users should interact with the application.
2. Varying levels of comfort with the protocol: Actors in the care circuit hold various levels of education, literacy levels and training, yet all must accurately do their part to reduce malnutrition rates in the regions of intervention. While the program has been implemented too recently for us to draw any definitive conclusions, some early evidence that the application makes big difference for decision support, improving the continuum of care for the target beneficiaries. While our statement does not purport to be scientific, it was interesting to note the significant increase in average scores on pre- and post-tests for protocol knowledge. For the users in one country, pre-test average was 45 percent while post-test average was 76 percent.

Look for our next blog post, where we will share tips for designing programs for multi-country scale. Have questions about our work in West Africa? Reach out by clicking the button below!