mHealth Support Tools for Improving the Performance of Frontline Health Workers: An Inventory and Analytical Review

With the goal of providing a foundation for further investigation into the use of mobile health tools to support the performance and accountability of front-line health workers (FLHWs) in low- and middle-income countries (LMICs), this mHealth Alliance report outlines research that involved a 3-pronged approach:

• Establishing a database of existing mHealth tools related to FLHW performance and accountability - yielded 223 entries of approximately 100 unique mHealth tools globally;
• Conducting a literature review on the evidence base of using mHealth tools to improve FLHW performance and accountability - found 66 articles that matched the inclusion criteria for further analysis. In general, the majority of mHealth tools identified were being implemented in India and East Africa and focused on supporting patient monitoring, reinforcing learning, and strengthening counselling efforts during home visits, through pre-loaded java-based applications; and
• Developing a framework to guide the adaptation of paper-based content into mobile-friendly content, which involves 2 routes to consider: (i) an open-source platform that houses mobile-friendly content across formats (i.e., basic mobile phones, Android), technologies (i.e., SMS (text messaging), voice), and select languages; or (ii) the development of open-source mHealth tools across categories and technologies that include the appropriate content for organisations to use as a base and then repurpose as required. In both cases, the framework outlines the process for adapting paper-based content into mobile phone-friendly content in a way that takes the end-user's needs, literacy, technological feasibility, and human resource capacity into account.

As detailed here, the United Nations (UN) Commission on Life-Saving Commodities for Women and Children ("the Commission") was established in 2012 to increase access to and expand the use of 13 life-saving health commodities for women and children in LMICs by 2015. Recommendation 9 focuses on improving the performance and accountability of FLHWs, and this paper explores the contribution that mobile technology can make to support those goals.

For example, the paper observes a shift from "single-disease" and "single-function" tools to more integrated solutions that cut across the roles and responsibilities of a FLHW, as well as content related to multiple diseases and commodities. It is suggested that the Commission should consider, among other things, content evaluations of a short-list of mHealth tools to understand how and which commodities are represented, followed by establishing a committee to drive the development of identified content gaps using the content adaptation framework.

An excerpt from the report follows:
"Lessons Learned

1. High mobile phone ownership amongst FLHWs has created the infrastructure and foundation required to scale mHealth support tools.
2. The most common type of mHealth tools developed to support the performance and accountability of FLHWs are those focused on patient monitoring, mobile learning and counseling. The least common were those related to human resource management functions, including work planning and scheduling and compensation and performance management.
3. The majority of mHealth tools are designed to support increased access to and expanded use of multiple commodities. In cases where mHealth tools are created for specific commodities, they usually focus on HIV, reproductive health and child survival.
4. Preloaded applications on java-based phones were the most common method of building and delivering mobile tools for FLHWs.
5. Patient registration and patient monitoring programs are typically part of an information system that allows for remote data access, enhanced case management and more timely provision of health services.
6. Ministries of Health in Pathfinder countries are increasingly considering mHealth as a priority, illustrated by the establishment of enabling national policies and inclusion of mobile phones on equipment lists.
7. Overall, mHealth tools are most commonly being developed and implemented in India, Tanzania, Uganda and Kenya. According to our research on Pathfinder countries, Ethiopia appears poised for implementation and growth of mHealth tools for FLHWs.
8. Adapting and developing content for mHealth tools for FLHWs must align with strengthened commodity procurement management and harmonization across regulatory guidelines at the country level, to ensure that commodities recommended within mHealth tools are available for patients.
9. The process of adapting paper-based content to mobile phone-friendly content is a three-step process that requires understanding the end-user, choosing the appropriate communication medium, and consistently testing the content with the end-user for feedback.

Recommendations

1. The Commission can benefit from conducting content deep dives into a shortlist of scaled mHealth tools for FLHWs to evaluate which of the 13 commodities are being represented and how. The mPowering Frontline Health Workers program has conducted a similar exercise, which the Commission can leverage as part of its process.
2. Since mHealth tools for FLHWs have advanced from single function tools to integrated solutions, a need for new evaluation methodologies and taxonomy is required to better align research, decision-making and policy development with rapidly advancing technology.
3. The scale-up of platforms that enable the development of mobile tools for FLHWs has led to an increase in the number of small-scale solutions, calling for a re-evaluation on how 'scale' is defined and measured.
4. The Commission should consider one of two routes to support the development of mHealth tools for FLHWs to increase access to and expand use of the 13 commodities: 1) establishing an open-source platform that houses mobile-friendly content across commodities, formats, technologies and languages or 2) developing open-source integrated mHealth solutions across categories and commodities that can be implemented and adapted as necessary at the country level. Either way, the Commission should factor in the heterogeneity of FLHWs globally, and ensure that the content and/or mHealth tools developed support country-level adaptation.
5. Further research is required to understand the time and resources required to implement the content adaptation framework. Other organizations working on similar efforts include AMREF, Digital Campus, Hesperian, mPowering Frontline Health Workers, and Text to Change."