ClickDiagnostics has been operating in Bangladesh for over a year now, and has been working with several large NGOs to empower their systems using mHealth. In this post I will be sharing our key insights from close interaction and involvement with health workers over the past one year, and  also include some interesting observations from the patient angle:

• CHWs can be the strongest champions of mHealth, because it simplifies their work and reduces redundancy (e.g. monitoring, reporting, etc.). However, they need to be kept deeply involved in the planning or designing of the system, without which they tend to offer the greatest resistance because of a ‘fear of the unknown’. In our case, initially there was a lot of resistance to change because they feared this would increase their workload, but once we involved them in deciding the features and functionalities of the system, they grew ownership and eventually started lobbying for replacement of their previous systems with ours.
• In order for CHWs to understand the value of the system, we showed them the data coming in real time on a computer screen, and how a doctor can see the patient data and respond with an advice. This got them very excited about the possibilities of the system and helped them understand the true scope of the technology.
• We made short video documentaries of their work, and also interviewed them for their feelings about the system. These videos were later shown to them, and they were informed that people all over the world will be benefited by their work and see their work as pioneering examples. We also showed top management executives of our partner NGOs these videos to show them how much ownership the ground level personnel had over this system. They were surprised to see it, and it went a long way in convincing them that this was a generally acceptable solution which would not lead to ground level discontent.
• It is important to repeatedly remind the CHWs that their mobile phone is only a tool, and that their goal is to achieve health outcomes (e.g. a reduction in maternal and child mortality) through real-time interventions. This, we found, motivates them and keeps the focus strongly towards health impact.
• In order to give CHWs ownership over the system, we remained flexible to incorporate any feedback they brought from the ground. M-health interventions should therefore be a looked upon as long term iterative processes of designing solutions and testing them on the ground, and bringing back for fine tuning.

Process and HR optimization

• Job roles and time distributions of various HR levels (including CHWs), along with other processes and structures, need to change with the introduction of technology. In BRAC’s case, the pilot was imposed on top of their existing structures which made it suboptimal at times.
• Personnel in existing systems also need to be taken through a process of change management to avoid friction and suboptimal results. This typically has been a significant portion of our work beyond technical management.

CHW Training and usability

• We trained health workers through a practice session, where they interviewed each other, with one posing as patient.
• During implementation phases, we tried to deploy modules in phases, starting with demo modules with a limited number of questions for CHWs to try out and practice in the field for a few weeks. During this period, they were asked to give extensive feedback about how the system could be improved to make their work easier.
• Extensive localization is a crucial deciding factor for CHW and patient comfort – simple translations often miss out important differences in dialect and connotations which can even vary between neighboring communities.

• With respect to gaining trust with patients, even the simple act of taking a picture of the patient made them feel important and want to be registered in the new system. The picture also helped remotely monitor the work of CHWs, and ensure that they were indeed with the patient while collecting their data.
• M-Health not only provided better services, but ensured patient compliance. Generalized advice from health workers are often not heeded by patients and their families because health workers are not deemed to be knowledgeable enough, and because the same advice given to everyone receives less importance. However, when a personalized advice for a patient comes from a “city doctor”, the advice carries a lot of weight and is often closely adhered to.
• Patients in Bangladesh seemed not to be particularly bothered about data privacy – rather, the fact that their information was being reviewed by a doctor and customized advice was being given to them gave them a lot of confidence. Nevertheless, in the roll out stage, we will voice record patient’s agreement to disclose their data to doctors and BRAC personnel.

Sorry for the really long post, if you have gotten through this far! A lot more to come from Click Bangladesh in the coming months. Stay tuned!