Abstract   

 

Background – The Family Planning Program has been implemented in India since 1951, however, the quality of service delivery at various level is not up to the mark till now. Appropriate and adequate information system is one of the key areas which have significant implication on the quality of family planning delivery services. Objectives – The key objectives of application is to get timely information on various components of family planning and ensure appropriate and effective feedback to grassroot workers as well as clients. Methods– The application has been developed based on various experiments of innovative ideas with grass root level health workers. The methods were pre tested and piloted for its certification in Doiwala block of Dehradun district in the state of Uttarakhand. Findings– The early finding suggests that application operating system is very easy and all health workers who are even simple literate can used it effectively. It also helps workers to understand the trend and performance of family planning at various levels in their area. It is also helping them to give an accurate demand for family planning services and ensuring adequate follow-up services to the clients. Result- The outcomes of the project shows that all the service providers are receiving all the information at all levels and developing effective feedback mechanism and ensuring timely and adequate supply of family planning materials at community level.      

 

 

Introduction

 

The Quality Family Planning Program [i] is an innovative project that has been implemented by Rural Development Institute- Himalayan Institute Hospital Trust in Doiwala Block of Dehradun district in Uttarakhand supported by Population Foundation of India since 2008. The principle objective of the project is to strengthen public health system by ensuring quality delivery of family services at grassroot level. The project is based on public private partnership between Rural Development Institute, State health Department and Population Foundation of India. The projected area of the Quality Family Planning Program is in the Doiwala block of Dehradun district and urban slum of Rishikesh. It is mainly dominated by the urban population and the total population is 1, 93000(Census, 2001). According to Household list, currently there are 30,123 (2008) eligible couples and the contraceptive prevalence rate (CPR) is 59%. Although there was pre existing government family planning services in the area, where the programme paid little emphasizes on quality aspects.

 

In 2005, National Rural Health Mission (NRHM) was launched by Government of India (GoI) with a view to bring about improvement in the health system and the health status of the people, especially those who live in the rural areas of the country. To achieve these goals Government of India is trying to increase access and utilization of quality health services in all the state where NRHM has been implemented.

 

Uttarakhand is the one of the state where NRHM programmes have been implemented. To ensure the accessibility and utilization of health services, the state has already appointed ASHA at community level under NHRM. Earlier an ASHA was appointed on an average of 1000 population but now government is appointing them on 500 populations because of various issues related to access. Even with the geographical constraints, it will not be difficult for ASHA to reach out to the entire household and get the accurate information on eligible couples as with a population of 1000, the number of eligible couple will not be more than 100.

 

For any Project to accomplish its objectives there is a need for a strong management of information Service. At the first stage the project team planned and conducted study of the pre-existing MIS of Government. The study findings indicated that the MIS in the government sector is mainly Provider based not Client based. Therefore during various group discussions, a gap has been visualized in the preexisting MIS system and shows a wide scope of improvement and innovation needed. Therefore the preexisting MIS depicts inadequate information regarding client’s perspective.  In Health care sector any program has to be client oriented for maximum output. With this view point, the Project reinforced its information system through data collected especially from the clients.

 

In the second stage project team developed a Management Information System (MIS) which was based primarily on the client’s perspective and the information collected is solely by community level health workers from the client.  To make this objective functional, management information was carried out from grass root level through house listing. For collection of data a single window system approach was used for accuracy of data. After a in-depth discussion with all the team members, it was decided that ASHA (Accredited Social Health Activist) will collect data from clients at house hold level. The collection of data will be independent from type of providers and their location. During the discussion it became clear that all clients who receive the family planning services have to stay at their home so that data will be collected at house hold level. Another reason behind the selection of ASHA as investigator was that, she is the part of National Rural Health Mission and has existence in every village across the state. Information colleted by ASHAs through house visits include aspects of family planning service e.g. type and frequency of contraceptive use, general information of the service & contraceptive provider and the quality of service & location, use of counseling, pre-examination and follow up services by the clients and level of client satisfaction, which is further submitted to the Area Coordinator on the prescribed format on the first week of every month.  This information is entered according to the prescribed guidelines in a MIS software program by the data operator on second week of every month.

 

This MIS is used to manage the data created within the structure of the Quality Family Planning Programme indicators. This system can store the data, analyze and compile the data with the developed software applications. Reports and analysis obtained from the information system can assist in the directing, planning and decision making needs of managers[ii]. This software application outcomes will provide the reports of various indicators at various levels such as Village, Sub centre, Primary Health centre (PHC) and Community Health Centre (CHC).

 

In the third stage, after six months the project team reviewed the information system once again and found the system is in urgent need of some innovation for quick response. A senior team of resource persons which included medical, health and social sciences professional discussed the key issues and recommended that mobile phone can play a significant role for the collection of information from the client. After this foundation meeting, the senior project team organized a meeting with area coordinators and ASHAs and tried to seek their views on the mobile application. The key points of this meeting became the thumb parameters for development of Mobile application. Before developing the Application the programme team suggested that there is a need to conduct a study of village based health workers on mobile phone status, network and their knowledge, attitude and practices (KAP) on mobile phone

 

To conduct the study of ASHAs, the resource cell developed a pre designed and pre tested questionnaire and the study was conducted within four hours with the use mobile phone. For this study calls were made to all the 167 ASHAs on their mobile phone and there was response from 160 ASHAs in the first time. The study finding suggested that 99% of ASHAs have their own mobile phone however 80% of ASHAs have basic set of mobile phone which has only basic facility and they all were using different networks. The study also revealed that all ASHAs were using mobile phone independently although only 10% of ASHAs were using SMS services regularly.  In relation to their education qualification, more than 80% of ASHAs had passed high school examination and 15% of ASHAs have education qualification of more than High school and only 5% of ASHAs education level was below that of 10th standard. The study also found the knowledge of English language, where 50% of ASHAs could write their name in English without any assistance, 25% write their name by support of other person, however 25% of ASHAs were not able to write their name. Regarding, using of SMS, 90% of ASHAs were comfortable with digital words, however only 7% of ASHAs were comfortable with both digital and alphabet.   

 

The study findings were discussed by the project team with technical agency for developing mobile phone based application. Based on the findings the team decided that the application should be handy enough to be operated from any basic set, it should be independent from net work and SMS (Short Message Service) should digitalize so everyone can use it. The team felt that general, demographic and biomedical information should enter directly in software. Therefore it was decide that the task for submission of report be given to the ASHAs seeing their increased importance and role in the delivery of health & family planning services at the grassroot level and also being a important connect between the providers and the community. The ASHA having a key role in implementation of the NRHM program at the grassroot level have been assigned to reach out to the community with awareness education through counselling services and mobilising the community for various activities and program and have information collected from every house hold at the village level in relation to family planning services, health, nutrition etc. Under family planning service she collects information on various components e.g. name, age, parity, type of contraceptive users, place, and type of providers, package of services being provided and client satisfaction and sending it to CIRO in prescribed format through SMS.

 

The team also decided that application should focus on, to see the status of family planning programme at individual, village, sub centre, primary health centre and community health centre levels. Secondly the system provides accurate number of new users, switch of cases, switch over cases and required number contraceptive at different levels. Thirdly, it also provides information about family planning services at all levels. Finally the application data can directly transfer in to XL and SPSS for the analysis. Based on above requirement the task was given to technical agency for the development of application.

 

Application Purpose

 

The purpose of this application is to establish  effective and efficient mechanism for information system under the Quality Family Planning Programme. The MIS software has been developed based on pre existing reporting format, feedback and inputs with an objective to reduce travel time, making reporting more users friendly, to keep track of ongoing activities and to make service delivery at every individual level more effective and choice based. The MIS system has been developed on Java Platform in multiple modules/sections and reports are generated in MySQL format covering aspects of direct services, forecast on client needs, scheduling, services & follow-up. The MIS also has a SMS alert system to update the filed workers on up coming schedules, events and trainings to make easy communication and keep regular update. The MIS contains client wise information at community level to keep trace of individual client  and understand responses to various aspects of family planning services. Secondly, the system also provides numbers of contraceptive users with types of contraceptive used, number of switch over cases (who change the contraceptive), and number of switch off cases (stop the use of contraceptive) at various levels to help providers develop effective planning and strategy. Finally it helps health workers to provide effective feedback to clients on various services as per felt needs of the clients. Ultimate, outcome of system is it reduces the workload of providers at various levels and provides accurate information for the programme to ensure adequate supply and timely feed back to grassroots health providers and clients level.  

 

Application Description

 

MBIMS (Mobile based Information Management System), as its name suggests, registers all eligible couples electronically through mobile phones. There is a basic identification number which is build into other population database that can be shared with other public health agencies. This project focuses to ensure the use of mobile phone in eligible couple’s registration system. This concept was basically promoting usage of mobile phones for eligible couple registration and services by a SMS.  The ASHA used mobile for sending their messages at the Central Information Registration Office (CIRO). The CIRO was located at RDI- HIHT.  The primary information received by ASHAs at community level was forwarded through a mobile phone to the CIRO on prescribed digitalize formats. ASHAs are playing the key role in this process. In this process each ASHA was provided with a universal Key with a separate password.  ASHA collects information directly from the client and transfers it by SMS to the CIRO at anytime from community level on a prescribed digitalize format. Once it reaches CIRO it goes automatically to related household in village list. The CIRO received the information and automatically linked it to its village, Sub center, PHC and CHC location. The system also automatically generates the reports at all the levels.

 

Information collection Process

 

The development process was completed within the provided time frame (90 days). After that the project team and technical agencies develop a training manual for field staffs and provided 2 days orientation training programme for all the ASHAs and area coordinators. The project was launched on 1st of November 2010 and it is working efficiently and helping field workers enormously.

 

ASHAs are responsible for collecting the information from the eligible couple and maintain the information in her mobile at community level and simultaneously send it by SMS to central data system at any given time. Under the process ASHAs have to send separate SMS for every eligible couple. Each ASHA name and mobile is linked with specific village code. ASHAs are using two types of keys in which one is update entry and other one is new case entry. In case of update entry ASHAs are not required to send name, age, number of children of the client. In case of new entry ASHA has to sent all the details.

 

General Information – The name of ASHA,   eligible couple name, education and social status, community, name of ANM centre, PHC and CHC. This is automatically linked and information is sent once or in case there is a new case.

Mobile Phone entry keys- description of Contraceptives, types of services, type of providers, place of service and status of users (update and new entry keys)

 

Feedback system

 

The CIRO after receiving the SMS from registered mobile number, sends automatically a SMS back to ASHA within second of their confirmation. The message is not accepted if it is incorrect or incomplete or has not been filled in prescribed format. The ASHA will also get a SMS for unaccepted messages with clarification. Inside the system there is provision of creating various lists of providers according to their designation and location. Through this system we can send free SMS to individual or group as per program requirement. For example education materials can be send directly to clients and ASHAs, information on meeting to ANMs and demand related information to medical officers.

 

System specification

 

• Independent of the Specific Mobile Handset

There is no software that is to be loaded on the handset and hence does not require any business or GPRS or specialized operating system based handset. It works from any basic handset capable of sending & receiving SMS.

 

• Independent of the Telecom Operator

The solution is not bound by any one specific operator so it works on any readily available, cost effective network operator in the respective urban / rural India.

 

• Keywords Simplicity

The software is designed to make things simpler for the user and a person with basic education can also use the system. Thus more of binary or numeric entries are required rather than theoretical inputs.  

 

• Master Databases Management

Exhaustive recording of various Master Databases required are maintained and are interlinked based on the required hierarchy mapping in the same system for better recording, smooth functioning and MIS generation from the system.

 

• Integrated Auto Push, Pull, E-mail (or Voice if required)

Since communication is the backbone for any ideal solution so the software is not merely a data dump but provision of auto Push SMS i.e. announcement based by selecting required parameters & similarly use of E-mail technology for various information/ notifications/ Reminders/ Reports etc. to the stakeholders are provided live and interactively for any updates.

 

• Validation of Input Information

Provision of validation i.e. edits information is given to authorized users by the user management for the specialist to rectify the error in data send by School Representative workers.

 

 

• Predictive Analysis

For better monitoring and subsequent strategy formulation, proper reports are required. Exhaustive report generation for predictive analysis is provided in graphical format.

 

• Scalable Approach

The application can be scaled up / upgraded with the modular architecture in phases as and when required.

 

• Automated Quality Analytics Feedback System

The performance of various field staff i.e. School Representative in this case can be monitored by collection of feedback directly from the end user i.e. the sample of parents etc. and the graphical quality analytics can be generated for improvisation.

 

• Interactive Voice Response System (IVRS) Integration

The facility of IVRS can be added to the existing application as required in future for broadcasting the Voice SMS or collecting the information in to the system.

 

Benefits of the System

• The system is total Customized Solution built on latest tools & technology

• Highly Scalable Multi User Solutions over Wired/Wireless/GSM/CDMA Networks

• Fully Integrated Automated SMS & E-mail Mode

• Integration with ERP, MIS, Databases, OEM Equipments, Vertical Systems, Legacy Systems

• Automated Secure Information Transfer to Multiple Points

• Immediate Information Transfer

• Time Efficiency (Reduces Time Lag)

• Economical (Cost Effective)

• Reduction of Manpower/ Man Hours

• Accuracy of Information Flow

• Personalized way of Communication

• Bulk Communication on touch button

• Lowers Administrative Cost

• Handy & Automated Accurate Information

 

Result

The initial feed back shows workers satisfaction and providers getting regular update at all levels. It is quite early to say that mobile application has helped overall health system. However it  is clear that it will help providers to improve the status of family planning quality at grassroot level. It is interesting to  point that workers are enthusiastic  and energetic to use technology in their work.

 

Acknowledgement

 

I would like to thank Ms B Maithili, Director, Rural Development Institute-HIHT for her guidance and support during the process of development of application and its implementation; Population Foundation of India (PFI), New Delhi for financial support and technical inputs; Dream Sol for developing the MIS software and the entire project team of Quality Family Planning at RDI-HIHT.