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- The Aceh Besar midwives mobile-phone project
The introduction of information and communication technologies (ICT) such as mobile phones to basic health service providers in rural areas can help bridge lacunae in their work environment, resulting from under-capacitated resources, constrained access to information and delayed interventions. The midwife mobile phone project was implemented in 15 health centres in Aceh Besar, Indonesia involving 223 midwives. The study group (121 participants) used project cell phones to transmit health statistics to a central database, contact coordinators and peers for health advice and information, and communicate with doctors and patients.
The ICT for healthcare development model (Author, Lwin, Ang, Lin, & Santoso, 2008) was used a heuristic to determine project effectiveness. Findings from the project indicate that the mobile phone has proven to be an effective and efficient device for facilitating smoother communication, and allowing speedier emergency response. The system also aids in gathering and disseminating health-related information to midwives, who in turn convey this knowledge to the patient community. The Technology-Community-Management model (Author & Zhao, 2009; Lee & Author, 2008) was used as a conceptual framework for probing the design of ICT for development projects. In particular, infrastructural, economic, technological, and socio-cultural barriers were examined to highlight the tension between a top-down hierarchical model of technology diffusion versus a more participatory bottom-up approach.
One of the greatest challenges in the domain of public health in developing countries is the ensuring of adequate maternal and infant health care. Many actions have been taken over the past two decades. One early program was the Safe Motherhood Initiative, launched in 1987 by the World Bank, WHO and UNFPA (Starrs, 2006). More recently, 191 member states pledged to collaborate in realizing the United Nation's Millennium Development Goals. The goals to be achieved by the year 2015 included the reduction of maternal deaths by three quarters, and the infant mortality rate by two thirds (United Nations, 2007; United Nations Development Programme, 2005). Despite improvements, these are still far from being achieved. Globally, maternal mortality rates remain alarming—over half a million die annually due to pregnancy-related causes, with ninety-nine percent of these deaths occurring in developing countries (World Health Organization, 2007). In 2006, 9.7 million children died under the age of five, of which 4 million did not even live past their first month (UNICEF, 2007).
Indonesia, in particular, has a poor record in maternal and infant mortality (Analen, 2007; World Health Organization, 2005), especially compared with regional neighbors. To improve health services, Indonesian government initiatives, such as ‘Making Pregnancy Safer’ and the ‘National Programme for Indonesian Children’, focused on ensuring access to appropriate skilled healthcare (United Nations Population Fund, 2005). However, despite a decreasing number of deaths over the years, “safe motherhood programmes are not yet effective,” according to the Indonesian State Minister for Women's Empowerment, Meutia Hatta Swasono (Agustiar, 2007). Improving maternal and infant health, hence, continues to be a serious challenge in Indonesia. Despite investments in the recruitment and training of novice midwives (Vivio & Kinzie, 2005), the presence of skilled birth attendants during complicated deliveries was identified as an issue (Zahr & Wardlaw, 2001; Romano & Luthian, 2008).
The introduction of information and communication technologies (ICTs) to rural community health workers (CHWs) has been shown to bridge lacunae in their work environment resulting from under-capacitated facilities, constrained access to information and delayed responses to emergencies (Ganapathy & Ravindra, 2008; Kanter, Mechael, Lesh, Dhadialla, & Kramers, 2008). In particular, the use of mobile phones has been noted in the monitoring of pregnancies, for treatment, and for post-natal healthcare support (Maniam, Chin, & Chenapiah, 2007; Mirza & Norris, 2007).
The discipline of mHealth has been gaining ground as mobile device penetration rates grow rapidly, increasingly prompted by plunging hardware and usage costs, as developing world consumers adopt this accessible communication technology (Donner, 2004; Iluyemi, 2007; International Telecommunication Union, 2007; Kinkade & Verclas, 2008; McConnell, Chathoth, Pardy, Boostrom, Boostrom, Louw, et al., 2008; Mishra & Singh, 2008; United Nations, 2007). Case studies have recorded the use of Short Message Service (SMS) for HIV/AIDS prevention and control, and for treatment of tuberculosis in South Africa (Atun, 2005); consultation services and dissemination of critical health information in rural communities in India (Bali & Singh, 2007; Bhavnani, Chiu, Janakiram, & Silarszky, 2008); and the use of Personal Digital Assistants (PDAs) to collect data and teach medical students in Ghana and Uganda respectively (Chetley, 2006).
Other benefits of using mobile technologies include access to accurate medical information in a timely manner (Angelidis, 2008), pre-treatment of primary healthcare problems (Bali & Singh, 2007), improving internal communication within the complex healthcare system (Malkary, 2006), and with the external patient community (Harper, 2006), integrating data into a central database in the form of electronic medical records for efficient tracking (Anantraman, Mikkelsen, Khilnani, Kumar, Machiraju, Pentland, et al., 2002; Chetley, 2006), and improving the administrative efficiency of healthcare providers (Baker, 2006).
Despite these benefits, drawbacks exist. Mobile technologies need to be integrated into the broader healthcare and social system, such that they complement existing ICTs such as computer- and internet-based technologies, amongst others (Angelidis, 2008; Darby, 2004). In some cases, customized solutions, such as Java-based applications (Domingo, 2006) and mobile interfaces (Sherwani, Tongia, Rosenfeld, Ali, Memon, Karim, et al., 2007), have been developed to codify specific health information. However, such ground-up innovations have been criticized for failing to incorporate learnings from existing innovations across a scattered community of developers (Alampay, 2006). Training is another oft-overlooked component, particularly for the segment most resistant to adoption, such as senior physicians (Fontelo, Liu, Muin, Tolentino, & Ackerman, 2006; Malhotra & Gardner, 2008).
Broadly speaking, the study and application of mobile technologies for healthcare in developing country situations is at a nascent stage, with limited development and application of standards, restricted coverage and generalizability, and little rigorous scientific evidence (Author, 2009; Varshney, 2006). The extant literature needs to provide a robust frame of reference that links to existing theory, a roadmap to policy makers (Broens, van Halteren, van Sinderen, & Wac, 2007), and empirical evidence of effectiveness in the form of multiple indicators (Katz, Rice, & Acord, 2006). The 5C's framework (Drury, 2005) comprising context, content, connectivity, capacity building, and community development is a useful tool, but fails to explicate the challenges in implementing healthcare technology projects.
This paper attempts to address these concerns by situating the analysis within the framework of the ICT for healthcare (ICT4H) development model (Author, Lwin, Ang, Lin, & Santoso, 2008). I examine the deployment of a mobile telephony-based system to rural midwives (MWs), and analyze the impacts and constraints that arise. The broad research question I aim to answer pertains to the design and evaluation of mobile phone-based healthcare projects.
The use of mobile phones in healthcare settings can potentially deliver important benefits, because of their ability to provide and improve access to communication and information resources. This can occur both within the healthcare system, allowing remote community healthcare workers to communicate with physicians (Maru, Basu, Andrews, Acharya, & Khoshnood, n.d.) with external medical resources, and with beneficiaries, such as patients and their communities (Chandrasekhar & Ghosh, 2001). The ICT4H model (Author, Lwin, Ang, Lin, & Santoso, 2008), based on the value-of-ICTs-to-education model (United Nations Development Programme, 2005), suggests that an ICT, such as mobile phones, can act as a producer of opportunity, improving productivity for health professionals; enhancer of capabilities, increasing their capacity and potential; enabler of social ties by strengthening communication links within the medical hierarchy, and with the patient community, and generate knowledge that would allow critical information to be shared and used effectively.
Research question 1. Examine the benefits of mobile usage in the rural healthcare context; specifically opportunity production, capabilities enhancement, social enabling and knowledge generation.
The ICT4H model simultaneously addresses the presence of inter-related barriers that could hinder the translation of benefits into sustainable development goals. It suggests that there is no easy one-to-one correspondence of individual benefits to individual barriers, or even amongst themselves. Further, the obstacles of infrastructural, economic, technological, and socio-cultural factors have been repeatedly noted in existing ICT4H studies. Since the individual barriers associated with this particular study have been studied previously (Author, Lwin, Ang, Lin, & Santoso, 2008), the focus of the examination here is the interplay of these factors at an organizational level.
The mediatory role of mobile phones depends not merely on access and adoption by the different players in the health system, but on their willingness to communicate across the levels. Organizational resistance from those higher in the hierarchy to participate in information-sharing to remote CHWs has led to limited effectiveness (Kouroubali, 2002). Such an analysis needs to be cognizant of inter-related constraints within the sociologically gender-bound roles in traditional societies, such as the lack of economic decision-making power, limited technological education opportunities, as well as mobility issues (Ahmed, Islam, Hasan, & Rahman, 2006; Dunn & Dunn, 2006; Hafkin & Taggart, 2001; World Bank, 2004).
The development paradigm, sometimes characterized as a Western agenda, focuses on economic benefits as a significant component of opportunity made available by ICTs. However, the broader mobile phone literature suggests that the economic impact in the developing nation has often been negligible; instead the greater opportunity production has come via enabling social ties (Donner, 2008; Richardson, Ramirez, & Haq, 2000). The economic issues presented by mobile technologies vis- à-vis technologies such as computer access to the internet have been lessened due to the increasingly cost-effective market-driven system (International Telecommunication Union, 2007). Scholars note , however, that that an individual's economic background can affect one's adoption of ICTs (Neelameghan, 2004).
From a sociological perspective, scholars note the issues of control of technology, particularly decision-making, within the context of roles and responsibilities assigned to women (Gadio, 2001; Chiwara & Sibanda, 2006; Tshukundu, 2002). Hafkin (2002) has criticized development projects for failing to address the lack of gender-neutrality of technology within already disparate social systems.
ICT4D projects need to recognize the multiple roles of women, such as family- and community-oriented roles, in addition to their work functions (Ramilo, 2002). The social connectedness function of the phone for women (Lee & Robbins, 2000; Rakow & Navarro, 1993) should be incorporated into the project design to allow for greater communication across the health infrastructure. The potential of greater mobility offers the ability to pursue opportunities farther afield while maintaining familial relationships from afar (Alcántara, 2001; Kopomaa, 2000; Mechael, 2006), but could strengthens the bonds of these responsibilities, leading to an increased burden. Enhancing capabilities in terms of technological familiarity and specialized capacities can also come at the cost of loss of freedom, with the technology being perceived as an “instrument of control” for monitoring and surveillance (Rakow & Navarro, 1993), particularly for women at the lower rungs of social or institutional hierarchies.
From a technological point-of-view, Henwood (1993) suggests that women need to be producers of technology in addition to becoming adopters, especially since technology production and manipulation have traditionally been appropriated by men (Ling, 1999). Thus, the opportunity to be involved in the bottom-up design of an ICT4D project ensures a level of participation that can also impact the consumption and creation of knowledge (Thas, Ramilo, & Cinco, 2007). Further, for those with limited or no access to modern technologies, traditional forms of communication in the form of social relationships and ‘old’ media need to be maintained even within the deployment of a technology project (Geray, 1999).
Socio-cultural constraints extend to educational opportunities, particularly within the realm of technological design, in the lack of technical training provided and lower incidence of English as a spoken language amongst these women (Elnaggar, 2007; Hafkin & Taggart, 2001). Given these barriers, technological design needs to focus, beyond usefulness, on ease of use (Venkatesh & Morris, 2000), and supplemented with training in the use of modern approaches to healthcare (Ganapathy & Ravindran, 2008).
Research question 2. Examine the inter-related constraints to mobile usage in the rural healthcare context; specifically infrastructural, economic, technological, and socio-cultural factors from an organization perspective. Specifically, probe the tension between hierarchical (top-down) versus participatory (bottom-up) approached to development projects as related to these factors.
The organization of this paper first details the design of a specific ICT4H project and then describes the research design. Next, the findings are presented in two sections; the first explaining the baseline results and the resultant design changes made, while the second part comprises the evaluation of the effectiveness by comparing the endline results versus the baseline. In conclusion, I discuss the implications of the findings, list the limitations, and offer suggestions for future research.
The Aceh Besar midwives mobile-phone project
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- The Aceh Besar midwives mobile-phone project
The rural province of Aceh, located at the northern tip of the Indonesia island of Sumatra, suffered from a lack of widespread health infrastructure. The Aceh Strategic Plan estimated infant mortality at 42 per 1,000 live births and maternal deaths at 373 per 100,000 live births (Smidt, 2007). Despite national policies and programmes initiated by the Indonesian government (United Nations Population Fund, 2005), there remained room for improvement. Particularly worrisome was the scarcity of medical, transportation and communication infrastructure due to the protracted decades-long civil unrest (Chalk & Rabasa, 2001; Kell, 1995), now ended.
The situation was further compounded by the 2004 tsunami that caused unprecedented destruction, with an enormous humanitarian disaster, impacting medical services severely. Estimates of midwives killed or missing ranged from nearly 600 by the midwives association, Ikatan Bidan Indonesia, to 1650 (United Nations, 2005), causing further decline in the standards of maternal health services and newborn care.
With scarce healthcare facilities available to scattered and remote rural communities, the importance of midwifery services was identified as paramount (JHPIEGO, 2005). To provide healthcare expertise, an ICT4H intervention1 aimed to improve maternal healthcare in the region. The intention was to utilize mobile communications technology to facilitate, accelerate, and improve the quality of health services by supporting midwives (MWs) in close proximity to these rural communities (Author, 2007). The pilot project used simple voice communications to facilitate communication between midwives and obstetrician-gynaecologists (OBGYNs), while simultaneously using mobile phones data-transfer as a reliable, efficient, timely, and cost-effective tool for data collection.
Within the Indonesian context, the health service delivery system is organized at five levels: central, provincial, districts, sub-districts and villages. Puskesmas, the primary health centres (PHC) at the sub-district level, deliver primary health care services, and are responsible for delivering neo-natal, delivery, and post-partum healthcare services, particularly for patients with birth complications. MWs are associated with PHCs, where midwife coordinators (MWCs) are located. For perspective, only a fifth of births occur in some form of healthcare facility, while up to 7% of births take place with professional assistance (Statistics Indonesia, 2003).
Phones were provided to MWs, MWCs, and OBGYNs at the provincial hospital. A technical infrastructure was developed for the health centres, the provincial hospital, the midwife association, as well as the administrative and research staff on the project—linking a communication infrastructure through provided computers, as well as locating a central server with the telecom provider for receiving, collating and uploading data. An application provider developed a Java applet for the mobile phones to transmit data to the server, as well as a database for managing the health information.
All levels of the government health infrastructure, and partner organizations such as UNICEF and UNFPA, would be able to access the system via an internet interface to monitor and track health statistics in the populations served. Mobile use thus aimed to facilitate access to time-sensitive information by midwives, improve the quality of information accessible to them by connecting with senior staff, create an information sharing system within their networks, and allow tracking and collection of health related information.
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- The Aceh Besar midwives mobile-phone project
This article demonstrates that mobile phones have generally proven to be a beneficial means of improving the healthcare system. The project permitted new ways of addressing systemic constraints, by accelerating access to information, reducing response time on critical cases and expanding network's of communication amongst health workers. The findings indicate that the intervention was appropriate for MWs, given the nature of their peer networks, the geographical spread of their work, time-sensitivity of the medical service, health knowledge insufficiency and lack of training.
This study addresses a critical current problem in public health, and the results can be generalized to other remote, rural locations, especially in developing nations. Mobile phones not only provided an efficient means of communication, but also improved access to information, particularly in conjunction with the computer-based data delivery system. The project enabled helped to improve communication and enhance relationships among healthcare workers and with the community. There was also better collaboration within the healthcare system, a stronger referral system and more efficient data collection.
The ICT4H model proved valuable as an analytical tool for evaluation. However, it was less practical for practitioners and policy-makers involved in the design and facilitation of development projects. An examination of the inter-related infrastructural, economic, technological, and socio-cultural factors within the context of top-down versus bottom-up development approaches requires a project management framework. The Technology-Community-Management (TCM) model (Author & Zhao, 2009; Lee & Author, 2008) is a conceptual framework more relevant for project management. This proposed that software and hardware dimensions of technology, project management dimensions of finance, legal, and stakeholder issues, in conjunction with community participation in needs assessment, ownership, and training, would lead to greater financial and social sustainability.
From a technological standpoint, much of the software design and hardware procurement was conducted from a technical specifications perspective. However, designing the technology was aided by conducting needs assessment. Designers recognized infrastructural constraints of limited connectivity associated with MW mobility to remote areas without telecommunication coverage. Also recognized was the cumbersome nature of a data-entry system based on SMS requiring multiple button clicks. As a consequence, the application was designed to alleviate such problems. The JAVA application offered a menu-driven system instead of using a laborious texting system to deliver health indicators. Design issues regarding ease-of-use, however, needed to be balanced with security of the data. Password access to the application was retained when moving from the instant connectivity to the store-and-send system.
While such system re-configuration, despite being based on user testing, can be argued to be a centralized design response, the emphasis on usability led to a focus on understanding not only MW needs, but their psychological motivations as well. Beyond fixing problems, the project was designed to encourage user-led innovation as well. It was discovered serendipitously that MWs were using the mobile phones to capture images of new-borns within their care. While not a part of the design, the visual nature of the data was encouraged as an additional reference point, particularly as this increased MW engagement with the iterative design aspect.
From a community perspective, the needs assessment suggested that newer technologies like the mobile phone applications needed to be bolstered with directed training. Further, MW engagement was furthered by the participatory design of the training modules, allowing them to develop skills to access and analyze patient data. By responding to MWs requests to be analyzers of data, rather than mere recorders, the project aimed to alleviate perceptions of MWs as mere recipients of technological change, rather as producers of knowledge (Henwood, 1993). Further, the organized action of MWs instead of as individual users, had the possibility of leading to collective empowerment (Martinez & Reilly, 2002).
In terms of medical knowledge, alternatives to the inadequacy of training the midwives was made available on a regular basis, through both centralized and de-centralized means. Information about medical resources available was disseminated via SMS updates, and disseminated through more traditional forms of media, through incorporation of printed materials such as brochures and magazines for distribution to the health centres. MWs were thus encouraged to develop self-learning skills that would make them less dependent on the hierarchical system. Developing capacity for women, both technological and occupation-related, has the advantage of increasing motivation and ability to engage in ICT projects, and increase chances of programmatic success (Mijumbi, 2002)
From a management perspective, project managers overcame the major hurdle of economic constraints by completely subsidizing the mobile phone system. However, issues of misuse needed to be reconciled with allowing freedom for social connectedness. Thus, protocols for limiting excessive usage were developed, though rarely used, to balance the rejection of a system that allowed professional calls solely within the health network. Thus MWs were able to extend their social networks within the community, gaining prestige and developing self-esteem as professional women (Hafkin, 2002). Finally, the interactions across the different levels of the medical infrastructure eased, though not completely eliminated, the hierarchical constraints binding the women at the bottom. The system itself benefited from being perceived as a dynamic response system rather than a method of policing, i.e., collecting data from the lower levels as a form of marking attendance and ensuring compliance.
It is evident that the project administrators aimed to, and succeeded to an extent, to involve participatory approaches, particularly in relation to hierarchical issues. Less visibly acknowledged was the gender aspect of the project. However, it should be noted that no development project operates in isolation of the broader socio-cultural, political, and organizational environment. Moreover, development projects, by their very nature, focus on specific development objectives. Project managers, given the exigencies of their deliverables, thus have to deal with the very real tensions between delivering project goals versus nurturing broader social change. Certainly, taking a longer-term societal perspective may be desirable, but can be seen as a luxury in the field.
Limitations The analysis could have been strengthened by an examination of ultimate benefits, i.e., health indicators of maternal and infant mortality. However, we came to realize that, such as in the post-conflict and post-disaster situation in Aceh, legacy data was not available. The lack of reliable mortality records to form a baseline certainly hinders a rigorous evaluation effort, but can prove useful as future baseline.
Suggestions for future research Financial sustainability is dependent on a viable exit strategy by the implementing agency and donors, with an effective hand-over to the government medical agencies ensuring MWs continue to get the subsidy. A cost-benefit analysis could provide critical evidence for policy-makers to base future investment decisions. However, beyond notions of financial sustainability, the social benefit of the program should be incorporated into determining future support levels. The social benefit themselves should include a gender analysis, an issue recommended for further examination (Morgan, Heeks, & Arun, 2004), in addition to the direct impact on maternal and infant health.
By addressing the issues above, ICTs have the potential to help developing countries achieve not only the ultimate goal of improving maternal and infant healthcare, but can also contribute to sustainable social change as well. Proceeding with valid and tested conceptual frameworks can aid greatly in the design and evaluation of such programs, as well as increases the chances of meeting broader development goals.