In mobile health – ‘health’ should come first

Ours is a small niche in the development sector, with less than a decade of experimentation, and minimal evidence of impact behind the claims that are made.

The development sector, on the  other hand, is built on decades of experience documenting best practices, effecting policy change, recommending strategies for implementation (some effective and others not), lessons learned, not to mention there are on-going debates on in all of these areas . I wonder if in its beginnings, mHealth was more about development and health rather than the technology?

More than just a technology vendor, or technical support team, we have to remember that we’re working in the development space and there’s a lot of responsibility that comes with implementing development projects. This reflection is a gentle reminder to me and my fellow implementers in our work with mobiles, that the ‘health’ part should come first.  It’s pretty easy to get cornered in the world of forms, constraints, and skip logic and lose track of the health impact questions.

To stay focused, I’m trying to learn more about development best practices, debates and failed experiments – especially failed experiments. I recommend that our in-country field-based implementers invest some time to browse through government documentation, and academic literature to understand the background and history for the national community health programs we are affecting along with me. And we should start a dialogue about these things.

If we’re trying to change systems, shouldn’t we understand them first? At minimum, this due diligence should be something our field team should commit to, especially since many of us are coming from another country. This could mean understanding the political context, learning of previous interventions, exploring knowledge repositories and processes of our partners and their local implementers and improving the way we share our knowledge and experiences with each other.

Pick up the local newspaper, ask questions to fellow passengers on your next train ride, jump in on a political discussion at the corner tea stall.

There’s a time when you realize you just cannot avoid the fact that our work is political. It was only post Anna Hazare’s campaign, I started to make the effort to follow Indian politics. While I’m no expert, I do know that current events affect all the people we work with in the chain in some way or the other: government priorities, funders, NGOs small and big, and our health workers.

For example, in the worst managed districts of Bihar, CHWs have not been paid their monthly incentives for three years.  A local implementer who was facilitating my work showed me the article in the morning paper. He recited many stories of CHWs who rally at government offices and demand their payments. Why do they keep working? They are waiting patiently for some day the government to do a lump-sum payout. How does this affect my work as an implementer?

• It affects the sensitivity I display when I am training CHWs. I am emphatic  about the upstream battle CHWs face to stay motivated while struggling to feed their children and justifying their unpaid jobs.

• It affects what expectation I have of them for their work output and quality. This informs my recommendations for setting reasonable targets for performance monitoring.

•  It influences the evaluation questions I ask during one-on-one interviews with CHWs so I can gain more context about their daily challenges.

• It affects the way I design applications for them. Starting with a simple basic application has a higher guarantee of usage for overburdened and less motivated users. If they use the application, only then will they be able to fairly assess the value-add and implementers to achieve buy-in. My approach would be different for highly motivated and supported CHWs, who would quickly consume the product.

• It changes the way I talk about potential benefits that we envision this program could have in the future for them. (I.e. If you try to use this program, the work you do will be recorded and could serve as evidence for the hard work you are doing).

I had just returned from a series of CommCare trainings and a highly enthusiastic batch of CHWs when a friend forwarded a short local newspaper clipping.  A couple of political leaders were found guilty of mismanaging the NHRM funds in Uttar Pradesh. Stolen money from community health programs, training programs for CHWs, incentives for CHWs, monetary assistance to women for institutional delivery, and projects directly affecting women and children.

An ASHA I’ve worked with in Rajasthan was notorious for leading rallies to demand payments from government officials. In a three-day training, I would have never have thought this young woman could have led a health official to lock himself in his office for an entire day, fearing getting beaten with sticks.

These discoveries coupled with growing frustration, simply push people over the edge. When I learn about the political context in any region we are starting a new deployment, I gain a better sensitivity  for the big picture. Development is not mutually exclusive from political contexts, and neither is our work.

Visit the health ministry’s website, ask partners for recommended readings, or evaluation reports.

When I joined Dimagi, I had a clear understanding that my work was “development”.  I was less hesitant about my limited technical background than I was about my limited training to work in the development sector.

Because of this, I was conflicted with the term ‘Field Engineer’. The word ‘Engineer’ is loaded and implies a four year extensive technical education. The label risked my perception to a partner as only a technology vendor, when really I was there to strengthen health programs and be very much involved on the non-technical aspects as well.

So when I talk about due diligence, for me this extends to literature as well, such as NHRM policies, the ASHA model, incentives schemes, evaluations and research relevant to the community health programs in that state or region and so on. If we as field implementers are briefly aware about health interventions and issues, I think we could add more value when consulting with our partners in the design and content development phase.

We have a question at the end of every form in our maternal and newborn care application that informs families that should should care for every child equally, whether boy or girl.  Whether women answer ‘yes’ to agree or ‘no’ may not be informative to the NGO. So naturally, in an effort to streamline applications, partners thought to omit the question altogether.

I recommended keeping the question, because I had observed that this particular message facilitated the conversation on female infanticide without the CHW having to actually mention the controversial issue.  I had also just read an article on high female infanticide rates in that state and realized this was an important issue even though maybe it didn’t fit the partners agenda.

Let’s get better at picking each other’s brains about past implementations so we can replicate, re-invent, and fail fast.

One really important element I can always count on is the extensive technical and health care experience my colleagues and field staff have under their belts from years of implementing technology projects in the health sectors globally. I want to continue to tap this collective knowledge.

Let’s prioritize sharing knowledge internally so we can avoid ‘re-inventing the wheel’ and reinforce best practices. As our team grows and is even more distributed, I think it will call for more visibility into the work we’re doing individually, which is sometimes in silos.  In our last field summit, a project kick-off and post-mortem process appealed to the India field team. By the next summit, we will have tested some interactive methods to ensure internally we’re talking to each other about the strengths, weaknesses, challenges and gaps of each deployment.  We hope this will generate discussion and keep us all in sync.

Our partners are rich sources of information: Give them your ear, they have lots to share too!

Our work with our partners tries to strengthen community health programs that have been operational for years. As I mentioned earlier, the peers I’ve worked India, the program partners, and field practitioners have been the richest most source of knowledge for me this last year.

After 10 months of trainings CHWs in different parts of India, I arrived in Bihar to support a training of 20 new CHWs. I discussed our methods and training plans that I had field tested with over 100 CHWs in other parts of the India. I had perfected the training method, right down to the jokes I used. Was I ever wrong on day one of the training in Bihar. I quickly learned from local staff that in Bihar trainers need to use elaborate storylines to convey technical concepts.   He had been patient to try my methods,  while I hadn’t asked about his at all.

As an international technology vendor, local practitioners may think we have more to offer then they do, even though they’ve been doing rural development work for many more years. Even though we do have lots of experience with implementation and training, I had almost missed the chance to learn an effective teaching method by not listening. That day, I learned we could have been more effective if I was humble and had sought the strengths of our partners before taking-off.

As implementers, let’s think about how we can add value to our partnerships and projects as we try to change big systems. For me, this means being aware of the political context and health gaps in the areas I’m working in; taking the time to read about existing interventions that are not necessarily technology projects; sharing and learning internally; and learning from our partners and leveraging their expertise as much as I can.  What does it mean for you?

P.S. I’m going to pick your brain soon…