Healthy Pregnancy, Healthy Baby: Best practices from a Tanzanian mHealth service

today on International Women's Day we are very happy to be presenting a service that we believe is making great strides and actually empowering women in Tanzania to achieve better health outcomes for themselves and their families the service that were actually representing today is healthy pregnancy healthy baby and before I actually go into the presentation I would just like to that you know that we will be accepting questions so should you have any throughout the presentation please drop your questions and then tap in the chat function and we will address them at the end of the presentation so we will allow for roughly ten minutes of Q&A at the end of the session right so before I get more into the service itself I'd like to first give an introduction to mobile for development as a division within the GSMA mobile for development works within mobile industry to identify opportunities and delivering innovations with socio-economic impact within mobile for development the EM health program is has a mission to support commercially sustainable health services that transform the lives of people in need and promote the well-being of mothers and families in developing countries since 2013 PMF program has supported over 1/8 services that have provided over 1.5 million users across sub-saharan Africa with mobile health and nutrition information and this has been done under the in nutrition initiative that is funded by UK made Deford so we'll be covering four sections within this webinar the first part of this webinar is going to look into why M health as in health as a proposition in Tanzania and we'll be looking into the health burden in Tanzania and the Health Authority opportunity that Mobile presents in response to this health need and then I'll briefly and describe the healthy pregnancy baby service will then go on to discuss two features of the holding the hell pregnancy healthy baby service that we believe our success factors that are wisher and the first is that the healthy pregnancy healthy baby service has achieved remarkable scale and there are three key partnerships that will be elaborating on that having pencil to achieving the scale the second is that health healthy pregnancy healthy baby has evidence of achieved health and nutrition outcomes amongst its users and we'll be elaborating on the insights from surveys contacted with users around actual nutritional knowledge and behaviors and then we'll also be looking into some of the service design features that we believe have contributed to this success in achieving nutrition outcomes and then lastly we'll conclude with a future roadmap and some kinds of considerations around service design and sustainability priorities for the foreseeable future so why am health in Tanzania like many countries in sub-saharan Africa the health burden in Tanzania remains high with women and children singularly vulnerable the maternal mortality rate is at 400 450 for maternal deaths per 100,000 live births and for every 1,000 live births in Tanzania 81 children will not make it to see their fifth birthday additionally is estimated that 40% of rural women in Tanzania do not have timely information on signs of pregnancy thirty percent of the general female population in Tanzania are not actively participating in significant decisions regarding their own health care this demonstrates a need to empower these women with information to make better decisions for both their health and the health and well-being of their families the mobile phone ownership rate of the general population in Tanzania is currently an sixty-two percent which means that mobile is well positioned to be leveraged to address this need and although there are disparities between phone ownership rates amongst rural and urban populations and as well as female and male populations it is estimated that around 88 percent of the population will have access to a mobile phone in the GSMA M health deployment tracker the 17 services that are currently leveraging mobile and to deliver health care services and information to the Tanzanian population in some way or form and one of these services is healthy pregnancy healthy baby over the last four years the GSMA has worked very closely with a healthy pregnancy healthy babies service or otherwise known as was an even journey and for purposes of this presentation age of PHP for short and it is a nationally available SMS service offering free maternal child health and nutrition information to subscribers on for needing mobile matrix in Tanzania so the formal operators the Hatter apartment winter services Airtel Vodafone chido ungentle the services owned by the Tanzanian government and managed by Cardinal Tanzania who are an environmental services company that have specific expertise in the development and improvement of physical and social infrastructure for communities around the world and the services are partly funded by CDC as well so I'd like to go into the typical customer journey so how users with it would engage with the service the first step is obviously being made aware of the service which happens in predominately in two ways or three ways rather there are either exposed to information through mass media campaigns and/or they're told about the service by community health workers or members of their family or communities once they're made aware about the service they can either self register or community health workers can actually assist them through in registering for service on this phone in registration they can provide information as to their instrument updated in the reves their pregnant woman and if they're a mother then they're we give the age of the child and dependent on this information they received timely sms's relevant to where they're at users who no longer wish to receive messages can opt out so they can unsubscribe from the subscription or they will simply start receiving messages when there's their content bundle comes to an end so we mentioned that HP HP has achieved scale and I think in this section we'd like to focus on how they went about doing that before we actually get to that third the scale that we're talking about is that since its launched 20 in 2012 HP HP has reached 1.8 million users and insights from our user surveys revealed that 73% of HP HP users record to be sharing information with at least two people which means that the multiplier effect or the extended reach of the service is well over four million people within Tanzania we know that there are three main partnerships that have been essential in driving this scale the first of which is the partnership with the government as owners of the service the government actually guides with the service strategy and validated all the content that's embedded in to service they have also funded the development of a technical platform that these services currently embedded on along with several other mobile health services and being operated in Tanzania this government ownership enables and primarily enables three things so firstly having the government brand associated with service makes partnership bargaining easier in the sense that other organizations are attracted to the proposition of working more closely with the government it's also enabled easier rollouts and facilities because the government has actually validated or endorsed the activities at the facilities and the use of healthcare workforce to to enable this and then thirdly and I think most importantly actually the trust from users Inc is increased because the Ministry of Health brandings attached this service and we have a great quote from a rural user who says that she trusts HP HP because it is something that's certified by the government but because the government actually supports the service and she leaves that she is fine and all the information that she's getting is actually good for her and the second partnership that has has really been incredible is the partnership between for needing mobile operators and we've not seen many examples of witnesses being able and where this is being achieved and so this is really quite remarkable each of the mobile operators have agreed to zero us two in Jesus this is renewed reduced operating costs by 63% which means that the service can be operated at the scale without the prohibitive price tag that's associated with actually delivering the messages to the users you'll recall that I mentioned we reach over all of the services reach over 1.5 million users since its launch and cumulant 70 115 million messages have been sent to these users so you can imagine that this is a huge cost saving and as far as offering and is is yeah then secondly enabling a free service to end-users has led to wide scale adoption so there is no cost barrier to actually adopting the service and then lastly the fact that the services available to subscribers across all four network just means that you're able to make the content available to so many more people as not any one of these mobile operators has coverage across the entire country and so together the population is is reached by local we know that in return mobile operators expect to build some kind of loyalty and – this user base so as uses US subscribers this content and the content bundles typically span and time pregnancy and then happen to be age of five years old for young child my Barbara does expect that users will be less likely to turn or leave their network as they're really invested in the service offering the third partnerships that we'd like to addresses and the partnership with the continuously expanding network of NGOs or when a person non-governmental organizations and the main way in which these organizations support hph e is through training their workforce justice users and registering for the service so this is enabled two things must be the fact that it's easier registration for end-users which is obviously meant great reduction so we we realized through our user research that even though SMS on you assist your registration might seem like like quite a simple mechanism many of these users struggle to actually complete these registrations on their own successfully and so the support from the community health workers overcomes that take literacy barrier and then promoting the service of the clinics and antonis across the country is a a great way to cache your target audience and when when and where you should so when women are going for their antenatal checkups and when they're giving birth to their babies you're able to provide the service to them when they need it most in addition to that historically several mass media campaigns have been employed that these are prohibitively expensive and so liberating a community health worker network as promoters of the service reduces the costs of marketing in general we also know that in return it actually makes the work of NGO staff easier so we have a great quote from a Gerber who says that she really values HP HP because it tells women wanted to do and when and makes her work easier so they also want to provide the information to the mother and the service is actually helping them do that so not only have you got an approved worker for satisfaction but you also have added value to the end users whose lives all of these community health workers are trying to impact I'd like to take a quick pause just to say that if you have any questions please do drop them in the chat we will be allowing for some time at the end to actually address and address these questions so we're going to take a brief break just to give me some time to think about those right so the third part that we wanted to address in this webinar is talking about the outcomes that HP HP has managed to achieve amongst its user base and then elaborate a bit more on the futures that we think have enabled us so through the work that DG has amended with the HP HP service we conducted surveys with two different groups just of users essentially to establish the impact of the service on nutrition knowledge levels and also actual behaviors of these users we interviewed two different groups which one was experienced users who had been subscribed to the service for for longer than six months and therefore had been exposed to many of the messages relating to the topics that we actually tested in the survey and then we interviewed a group of what we refer to as non users who are essentially users who had just subscribed to the service and had therefore not been exposed to the messages communicating the practices that we were testing in the survey so essentially there were a counterfactual group for this and this particular survey we we identified through this research that across all of the topics experienced users are more likely to demonstrate improved nutritional knowledge and behaviors over nine users and so we also noticed that behavior change was strongly aligned to the level of knowledge that users had for example as well behaviors with were if I can give an example when we look at the same supplementation to treat diarrhea and children the knowledge levels around us were in severely low for both groups so even users of a service only had a 21% so only 21% could correctly recall the appropriate knowledge in comparison to 10% of mine users so this was an 11 cent improvement in knowledge around sim supplementation and my Sai users already but what we did see that it correlated well was an improvement in behavior change of 80 percent more users were able to report that they were implementing the appropriate behavior and now household over non users yeah we also have several anecdotes that sure exactly how users are changing their behaviors so we have one anonymous who is a user from over in Tanzania who said that she used to feed parts to all of her children after just one month but after receiving several messages around exclusive breastfeeding she tried very much to follow the six month rule and after doing that she said that you know everything's going very well and she's actually even continued to share this knowledge amongst her user base we know about the services achieving outcomes amongst us users but what's also important is that the service is reaching right users so it's serving the underserved 68% are the users and now we interviewed a female and then 46% were rural users so it's encouraging to see that female user base the female user base is so high considering that I mentioned earlier that only 52% of the female population actually only friends and in addition though the fact that we're reaching 46% of rural users use some room for improvement as the pocket majority of the population roughly 70% of the Tanzanian population live in rural areas so there's still somewhere to be done to reach a larger audience 45% are the users that we are the HP HP users are also below the basic needs pirates we learn one of the great insights that we did get was a 22% of users actually did clear that they had of nutritional information so HP HP was there any source of this type of information available to them and their families and a further 15 nine percent actually declared that the knowledge that they were being given the practices that were being advocated by the service were completely new to them and a further 27 percent said that they knew some of the practices but many of the processes were new to them users who reported lower education levels appeared to be deriving more value from the service so 16 percent of lower educated Jesus declared that all of the nutrition practices that were advocated by the service were new to them so this is very encouraging that not only are we reaching populations that need advice but we can see that the populations that need of most are really deriving and value from the service so there are several aspects of the service that I'm pivotal to achieving these – health outcomes amongst users and they're all centralized around adopting a user centered design approach so there were within the HIV HIV service there was a strong focus on developing high quality content content was tested ice recipe with users and there were a number of valuable insights generated through this some of which I'll share with you now the first is that a lot of the technical terms and concepts are not always understood by users so some vocabulary for example fortified foods or iodine these are terms that are new to users and actually resulted in the reduction of overall message comprehension so the encouragement is that they use some chain language for simple terms and that the local target audience of all education levels can actually understand is essential and especially so caution is needed especially when translating to be sure that you find terms that are because not all the technical names are always available in the local languages and so care should be taken that when you do identify terms that they are understood by your target audience and this lack of understanding in technical terms are actually also extended selves to a bit of confusion around related practices so for example the promotion of Saltire nation was perceived to conflict with a promotion of reducing salt intake in general and so those may have to do with terminology care should be taken when you're reinforcing the benefit of certain practices to make sure that it doesn't contradict with others that are being promoted in the service sometimes even offering more than just one message to explain this fully could be advised the ultimate side effectiveness that we want to try and avoid is obviously when users are confused by what messages are encouraging them to do they actually are neither able to implement the appropriate practice but even worse than that it could lead to a distrust in the service in general which we'd like to avoid the other thing that we would strongly advocate for is identifying what resonates best with your audience so may come as no surprise to you but females really enjoy the messages that retain the two men and encouraging men to support them or along their health journey so we have a green remote where this user says that the one or the message for fathers is good most of the father's see the babies belong to the mothers but this concept can educate them on supporting their women that are so yeah both men and female as female users actually had a great response to this message men felt empowered to actually play this role for their partners so this use of centered approach to content development has actually result in really high satisfaction rates amongst users with users rating the content and nine out of 10 overall for different aspects relating to clarity of content passion ability relevance and usefulness there were other design features that we believe really encourage a higher value for end-users or delivered higher value for end-users and the one that almost all users that we we engaged with reported on what's reminder notifications and so this quote is an example of one of our users who said that it reminds us a lot of a lot of things there's a month we get reminded to attend the clinic we're reminded about how to be this passion they will keep reminding you on the phone all the time so nothing comes as a surprise to you and what's also really great is that through our user service we realize that not only do people really value these messages but 73% of the experienced users that we spoke to recalled receiving these messages so they could actually say that they did get them and after this group 78 percent reported that they did in fact go to the clinic in response to receiving the reminder messages so there's a high value around reminder messages but also high adherence to these messages we also fact identify other service features that that for that were beneficial for users so the one is around repetition of messages which we actually thought would be a bit of annoyance for users but actually it's found that messages are more easy trusted by users when they had line to advice that they've already heard before so either advice that they've heard from community health workers or messages that have been repeated several times in the service itself and then the other aspect that many users reported back on that added a lot of value for them was once again the assistance by community health workers so we had users telling us that they never subscribed to this type of service before in this way and so the assistance with the community health worker and that engagement with them as a promoter the service was very helpful for them also to understand the value of the service for them so adopting this user centered design approach has actually German already active and engaged and loyal user base so there are currently over 270,000 active users on the hbhb service obviously user groups 67% are experienced users so these are users you have been engaging with the service for more than six months and this was quite an interesting insight considering that I mentioned earlier that mobile operators are interested in the loyalty aspect that the service campaign rate amongst their customers and so this is already some summary evidence leading to the fact that these services can keep users engaged and tied in for long periods of time so other users that we interviewed 73% were wanted to share messages in their communities and 62% of these were actually sharing information with this house and when we probed us even further we realized that the vast majority of these individuals who are sharing information of this past is actually men sharing information with their wives this is very encouraging considering once again the low female phone ownership rates in Tanzania so this information although not necessarily going directly to a woman's phone is being communicated to her by our husbands or by apartment in addition to that 59% of the users report to actually be saving the messages of which a surprising 80 percent go as far as writing the message down when they run out of storage space on their phone once again showing behind that II that these users attributes you these messages and the information that it provides in addition 52 percent actually report to read the messages more than once which proves the strength of SMS as a delivery channel and that it allows users to access the intimate information over and over as many times as they wish to so the last section that we're gonna touch on is a feature or a map and as I mentioned there is there's the two main things that we're hoping or that that we'd like to / or that we'd like to see prioritize for HP HP in the near future the first is around service design features so when we when we engage with users we identified that many users have very passive usage behaviors so when things go wrong with the service itself so messages start coming for whatever reasons users typically don't know what to do and one of the recommendations around this is to actually provide more frequent administration messages most tips about what to do when when messages start coming how to resupply and so forth and actually we had a really touching quote of a user who who was just really upset that the messages were no longer coming but they had no idea how to get these messages in the game and yeah they were just really hoping these messages would start start coming again so we really feel that these an administration messages could be a great way to retain users on the service and then when engaging with community health workers a lot of them actually said that they would appreciate more feedback regarding their engagement with the service so firstly on an immediate level when they're registering clients to know that the registration has been successful so some kind of feedback to that enables them to say okay fine yes this prisoner successfully registered but then more broadly regularly feedback on their employments as a whole and how how many registers they're subscribing and then also notifying them of users who are no longer subscribed so that they can actually engage with these users again and try and encourage them to get to reset scribe to the service in addition community health workers also expressed the need for refresher training saying that you know some of them have said some of the colleagues I'd given up because they forgot them while they learn in the training and they would benefit greatly from more follow-up and more frequent refresher training on a sustainability side we believe that there are three main focus points for the HP HP service and the first is that because the service sustainability at its current scale hinges on the continued funding and in-kind contributions from its existing partners HP HP needs to demonstrate value to these these partners and it needs to continue to do so in order to guarantee their at their continued investment for example mobile operators who have an in-kind contribution to zero if the messages need to see the demonstration of the value add to their core business goals in order to continue zero rating these messages for the foreseeable future secondly we believe we should be prioritizing investigation to alternative B to B models and some of the models that that are coming out in Tanzania specifically but that needs to be investigated further R is the potential for sponsorship of content and this is obviously a bit of a challenging approach in the healthcare space but with careful navigation this might be a viable Avenue to explore and there may be other potential businesses who are interested in gaining access to the rather large network of users that HP HP has acquired and then thirdly and I'm going in first to reduce operating costs will also help as far as that sustainability goes one of the ways in which HP HP are currently doing this and will continue to do this is to find other partners who like the existing NGO partners and would benefit from promoting the HP H service within their existing activities and so help promote the and extend the service to to more the Tanzanian population so we've turned on HP HP and some of the insights from the case study I encourage you to please go in look at the case study if you haven't yet but also retard us a few if you would like to know more than what we shared today but we also have other resources currently available and a few that are coming out over the next month so we have an M&M hull design toolkit which speaks more to this user centered design approach to developing services that really do create engaging customer service experiences and then we have another report which is around scaling digital health in developing markets and then we have some forthcoming publications including a report which will compile all of the learnings across the eight services that the mobile health program has been engaging with over the last four years and then we also they have a case study honor and that is a service within our portfolio and which is living Goods Uganda which is a Community Health Service Corps so leveraging mobile technology in addition to these resources all of this content that was developed for the HP HP service and for all of the other services that we've been partnering us across and each of the eight markets is available it is freely and available to be used by any services that could benefit from this so if this is our interest to you please to recharge and after this webinar all right so I'm going to allow for a few moments just to quickly reflect on some of the questions and then we will respond to those right so thank you we've had actually quite a few questions so far so we're gonna try and address some of them but we won't be able to address all of them and I I would like to encourage you just to reach out again if you feel we haven't done we haven't answered any of these satisfactory before I get into answering the questions I just like to mention that all of these resources are available on our website and the mobile for development resources page and actually this publication is also by myself and I was I was brought to my attention that I didn't actually introduce myself right in the beginning so let me tell you about i'm kimberly and insights management for the m health team and so yeah please feel free to reach out to me and directly or through our our mobile health with an email address as well alright so we had a question around content development on the process that was a darted so content was actually developed on the back end of fact sheets so firstly fact sheets were compiled by so we have a global content consortium which is cavy who develop fact sheets which provide RC relevant information available and based on best practice around various nutrition practices and then also it provides the sources of all of the all of this information these fact sheets were then converted into locally relevant messages so it was translated developed into messages translated and then tested in several different points with users to ensure relevance a – the target audience okay we had a question around sorry I'm just okay yeah so yeah so we have a question about mail users and given that 32% of users on men how are they actually using the service and what do they do with the information so as I mentioned earlier when users subscribe they can say whether they are actually a pregnant women whether they're a new mother or whether you're a supporter of this mother as a supporter men would be given information on how better they can support these women in adopting better nutrition practices or better health practices in general so they would receive messages for themselves on their phone and then could share the information with their partners if they wish to and as I mentioned to you we saw that a vast majority of users who were actually sharing information with the apartment so was men sharing information with their wine so there are also several questions around the methodology for the for the users feedback surveys so mmm are the differences observed statistically relevant so yes it's worth mentioning that the the sample sizes so for the for the experience users we ended up reaching a song call over over 415 experienced users and for non users so those who have not not been exposed to the topics that we tested we had a sample every 814 non users all of the differences we we cite in the case study and that are listed in and the presentation that we just given we're in excess of 3% they sit on one area which I'll talk to you now but essentially the confidence interval was around 3% so any difference greater than 3% was statistically relevant the only behavior where we weren't able to observe the difference between experienced users and non-users around appropriate supplementation for nutrient intake during pregnancy but in other areas such as early initiation of breastfeeding the difference was much larger so 11% so 71% of experienced users were able we're reporting to start breastfeeding their children at the appropriate time which is immediately or as soon as possible after birth in comparison to only 60% of nine years assess an 11% difference between the two groups which is definitely statistically relevant so we had a question around the other in nutrition countries that we where we've been working and so we've done work in Nigeria Ghana Zambia Malawi Mozambique Uganda Kenya I've mentioned Ghana sorry I'm trying and Tanzania obviously this kinda thing you've got my team here trying to help me there is we've been working in these markets for four years but I still need help to do them on demand but yes so and like I said we've got learnings across all of these which we are going to be sharing in our global report and a lot of our learnings are around the support that we provided to each of these partners which was largely run oversee the content development but then also user experience research business intelligence and analysis and then also in many surveys that we conducted for each of these services across into these markets and that report is due to be published beginning of April as well then we've had a question around how easily you can this particular model B so the HP HP model be replicated to other countries and I think in order to answer that one appropriately I'd like to just refer back to the main points that we said we're essential for scale so we we mentioned that there were three key partnerships that that contributed to achieving the scale which was firstly the partnership with government which is one that we would strongly advocate for when engaging with government those supplies to start those engagements early on as can be doesn't quite lengthy and complex but engaging with governor do and also ensures that your services will align to government objectives and their digital health strategy as well so positions the service lines a service better with government needs and then secondly the fact that the services actually achieved a partnership with all four mobile operators is I know is no small feat so I think what's made it quite achievable possible within the hbhb model is that there was a formal resource allocated to managing and brokering these relationships and it should be mentioned that these did take time to establish it didn't happen overnight and so if this is to be replicated in other markets you so we had a question around whether for electric users are there alternatives so actually we had a few anecdotes that I didn't really share in the presentation around you know even amongst electric uses they still prefer SMS and not just in in Tanzania we've seen this across some of our markets as well that there's a preference for SMS even if they can't really read them because they can find people who can read them and they can always get people to reread them as well and in some of our other markets though where SMS was not seen as a viable mechanism to reach users with this kind of information we didn't pursue other channels such as IVR or interactive voice response so it's basically recordings that users can interact with and that becomes the literacy barrier yeah and in particular this so the question was around in rural Mozambique many people cannot read actually so in mostly in particular the service that and we partnered with there actually uses IVR as a channel to reach users with this content

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