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How We Made A Health App That Works In Remote Rural Areas Without Internet

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By: Biraj Swain, Dr Meenakshi Jain and Dr Gauri Bisht

Over half a century ago, communications guru and public intellectual Marshall McLuhan predicted that electronic interdependence will make the world a global village. But last month, Simon Tisdall of The Guardian called out the international media for creating a hierarchy of suffering by focusing on Hurricane Harvey more than on the devastating floods in South Asia and South East Asia. The reason: distance!

The distances that marginalize are not just physical. They manifest in governance gaps in justice, cultural atrophy and social dystopia. Nowhere is the tyranny of distance more manifest than in health care delivery. And the Himalayan state of Uttarakhand has the double burden of a hilly terrain along with metaphorical distances to bridge.

This is exactly what mSakhi works to achieve: bridging the tyranny of distance with a digital innovation in the form of an app that empowers the frontline health and nutrition workers. mSakhi is an Android-based app, freely downloadable, and designed for frontline health workers such as accredited social health activists (ASHAs, which also stands for hope) and auxiliary nurse midwives (ANMs). This app doubles as a register that combines the multiple registers these workers have to fill and maintain, and as a job aid cum trainer. It is a registration tool for pregnant and lactating mothers and their children, helps schedule home visits with each pregnant woman and hand-holds health workers through care and counselling sessions with expectant mothers and their family members.

mSakhi is open-source and uses Java and PHP language and MySQL database management system. A detailed story on the rationale for conceptualising and implementing the app in Uttarakhand has been carried by Youth Ki Awaaz here. “Last-mile delivery is the biggest challenge in governance in a hilly state, or for that matter, any state,” says Mr Chandresh Kumar, the current Mission Director Uttarakhand Health Mission. “Frontline workers are the face of any system. Empowering them and monitoring them is important to ensure last-mile delivery. Digital interventions should address precisely that, and mSakhi attempts to achieve exactly that.”

From Planning To Execution

As technopreneurs remind us, designing an app is easy. Deploying it is way more challenging. Deploying it in a remote, rural location, even more so! So how did we make the app work in remote, rural Duggada block, Pauri-Garhwal district of Uttarakhand?

Duggada was chosen by the state government as part of its collaboration with IntraHealth International. Their logic was simple: demonstrate mSakhi in a challenging locale, and that will be the best advertisement for its feasibility and scalability across the state. And the Duggada block is as challenging as they come. On the Shivalik range, it is a back-breaking six-hour drive from the state capital Dehradun through sharp hairpin turns and mountainous roads where landslides and roadblocks are more the rule than the exception. So how do you deploy an app to the frontline workers who are integral to delivering health care to mothers and children in this part of the world?

You start simple, with the worst caveats, shares Ashish Agnihotri of Microware Computing and Consulting Pvt. Ltd., the mSakhi software developer. So let’s assume there is no internet and this is a mobile phone app based on the premise of internet. Msakhi has an offline data-entry provision, with an auto-sync feature. So frontline workers can register mothers, record immunizations, and track complicated pregnancies without worrying about losing data in unconnected, low/no signal zones. They can just feed the data off-line and it will auto-sync once the phone is in a signal/network zone. ASHAs and ANMs can also turn off the data while working on their entries if the nature of their work (immunizations, for example, or conducting Village Health Nutrition Days) requires it.

This app is multilingual with provision to add new languages. So while mSakhi is in Hindi currently, the Garhwali tongue of Uttarakhand can easily be added to both the audio modules and the text. Even dialects can be added to the audio module if required. Training, training, training: practice does make us perfect! Semi-literate ASHAs with limited formal education in rural government schools deserve the training and hand-holding this programme and app offer. While the national average training of ASHAs leaves a lot to be desired (as this article in The Wire explains), mSakhi promotes iterative training for the army of India’s health workers on the fundamentals of public health and maternal and child health. The app has built-in audio counselling messages for pregnant and lactating mothers and their families, which are not just job-aids for the health workers, but also prompts and training inputs. And IntraHealth has supported the government with a team of field workers who support each ASHA and ANM in mastering the phone and the app too.

Power Outages, Downtime And Everything In Between

Power supply is another challenge in remote, rural locations. And this requires the software developer’s vision as much as the user’s ingenuity. The mSakhi app is light, no-frills, and has no background auto-downloads that eat up battery power unnecessarily. ASHAs and ANMs make sure to charge up fully whenever and wherever they find electricity as they embark on field and home visits. Remote, rural locations and gadget downtime go together.

Unsurprisingly, smart phones hanging and hardware crashing are a regular day’s business, but minimising the down time is the objective. IntraHealth has a cadre of field workers who check the phones of ASHAs and ANMs and ensure their functionality. Tying up with a local mobile repair centre is the standard modus operandi, but negotiating with the phone dealer (Samsung’s dealer, in this case) is also an approach adopted, wherever feasible.

Remoteness is not just a state of geography, it is a state of mind too, says Dr Archana Shrivastava, Director General of Department of Health and Family Welfare, Government of Uttarakhand. It is important to equip people with functional tools which can stand the rough and tumble of distant rural locale and the no-frills mSakhi loaded on the smart-phones and tabs does just that. It is also helpful that its home-screen menu has all the items in pictures and text, in sync with the requirement of low-literate frontline workers in remote rural locations. And the sense of connection it brings also bridges the sense of distance in the mind, which is equally important, elucidates Dr Shrivastava.

Costing for digital interventions has been mSakhi’s Achilles heel. The World Health Organization has been red-flagging the prohibitive cost and lack of scalability of most digital health interventions. While there is merit in that concern, coupled with Digital India and free smartphone, free laptop electoral manifestoes, digital health costs could be managed if planned and leveraged well. However costing is a public finance issue, rather than remote-rural programming issue. Delivering services to far-off areas and marginalised communities does cost additional
resources, hence constitutional provisions of affirmative public financing like Tribal Sub Plan and Scheduled Castes Special Component Plans.

Lest We Forget, This Is About Health And Health Workers!

During the peak of farmers’ agitation, the APMC (Agriculture Produce Marketing Corporation) app was launched for farmers to know the best price for their produce. But without transport and
storage, it was just an information point, not a solution for the farmers’ plight. When the focus on an app exceeds the focus on real service delivery, the brick-and- mortar economy, the tool
becomes the end rather than the means.

mSakhi in Uttarakhand is essentially a public health intervention for healthier children, healthier mothers, and safer deliveries. The app is just the tool for the health workers ensuring those outcomes.

And as African tech prodigy Alain Nteff warns, “A cellphone is not a substitute for a midwife.” mSakhi is about ASHAs and ANMs with their app-loaded cell phones in the remote, rural Dugadda, and about the people they can help. The app is not enough without the health workers!


About the authors: The first author is an international development expert and media critic who advises IntraHealth International. The last two authors are public health experts and work with
IntraHealth International in India, a global public health nonprofit and owners and implementers of the mSakhi app. The authors can be reached at biraj_swain@hotmail.com
The first piece on mSakhi appeared in Youth Ki Awaaz here.

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An ambassador and trained facilitator under Eco Femme (a social enterprise working towards menstrual health in south India), Sanjina is also an active member of the MHM Collective- India and Menstrual Health Alliance- India. She has conducted Menstrual Health sessions in multiple government schools adopted by Rotary District 3240 as part of their WinS project in rural Bengal. She has also delivered training of trainers on SRHR, gender, sexuality and Menstruation for Tomorrow’s Foundation, Vikramshila Education Resource Society, Nirdhan trust and Micro Finance, Tollygunj Women In Need, Paint It Red in Kolkata.

Now as an MH Fellow with YKA, she’s expanding her impressive scope of work further by launching a campaign to facilitate the process of ensuring better menstrual health and SRH services for women residing in correctional homes in West Bengal. The campaign will entail an independent study to take stalk of the present conditions of MHM in correctional homes across the state and use its findings to build public support and political will to take the necessary action.

Saurabh has been associated with YKA as a user and has consistently been writing on the issue MHM and its intersectionality with other issues in the society. Now as an MHM Fellow with YKA, he’s launched the Right to Period campaign, which aims to ensure proper execution of MHM guidelines in Delhi’s schools.

The long-term aim of the campaign is to develop an open culture where menstruation is not treated as a taboo. The campaign also seeks to hold the schools accountable for their responsibilities as an important component in the implementation of MHM policies by making adequate sanitation infrastructure and knowledge of MHM available in school premises.

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Harshita is a psychologist and works to support people with mental health issues, particularly adolescents who are survivors of violence. Associated with the Azadi Foundation in UP, Harshita became an MHM Fellow with YKA, with the aim of promoting better menstrual health.

Her campaign #MeriMarzi aims to promote menstrual health and wellness, hygiene and facilities for female sex workers in UP. She says, “Knowledge about natural body processes is a very basic human right. And for individuals whose occupation is providing sexual services, it becomes even more important.”

Meri Marzi aims to ensure sensitised, non-discriminatory health workers for the needs of female sex workers in the Suraksha Clinics under the UPSACS (Uttar Pradesh State AIDS Control Society) program by creating more dialogues and garnering public support for the cause of sex workers’ menstrual rights. The campaign will also ensure interventions with sex workers to clear misconceptions around overall hygiene management to ensure that results flow both ways.

Read more about her campaign.

MH Fellow Sabna comes with significant experience working with a range of development issues. A co-founder of Project Sakhi Saheli, which aims to combat period poverty and break menstrual taboos, Sabna has, in the past, worked on the issue of menstruation in urban slums of Delhi with women and adolescent girls. She and her team also released MenstraBook, with menstrastories and organised Menstra Tlk in the Delhi School of Social Work to create more conversations on menstruation.

With YKA MHM Fellow Vineet, Sabna launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society. As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

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A student from Delhi School of Social work, Vineet is a part of Project Sakhi Saheli, an initiative by the students of Delhi school of Social Work to create awareness on Menstrual Health and combat Period Poverty. Along with MHM Action Fellow Sabna, Vineet launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society.

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A native of Bhagalpur district – Bihar, Shalini Jha believes in equal rights for all genders and wants to work for a gender-equal and just society. In the past she’s had a year-long association as a community leader with Haiyya: Organise for Action’s Health Over Stigma campaign. She’s pursuing a Master’s in Literature with Ambedkar University, Delhi and as an MHM Fellow with YKA, recently launched ‘Project अल्हड़ (Alharh)’.

She says, “Bihar is ranked the lowest in India’s SDG Index 2019 for India. Hygienic and comfortable menstruation is a basic human right and sustainable development cannot be ensured if menstruators are deprived of their basic rights.” Project अल्हड़ (Alharh) aims to create a robust sensitised community in Bhagalpur to collectively spread awareness, break the taboo, debunk myths and initiate fearless conversations around menstruation. The campaign aims to reach at least 6000 adolescent girls from government and private schools in Baghalpur district in 2020.

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A psychologist and co-founder of a mental health NGO called Customize Cognition, Ritika forayed into the space of menstrual health and hygiene, sexual and reproductive healthcare and rights and gender equality as an MHM Fellow with YKA. She says, “The experience of working on MHM/SRHR and gender equality has been an enriching and eye-opening experience. I have learned what’s beneath the surface of the issue, be it awareness, lack of resources or disregard for trans men, who also menstruate.”

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A Computer Science engineer by education, Nitisha started her career in the corporate sector, before realising she wanted to work in the development and social justice space. Since then, she has worked with Teach For India and Care India and is from the founding batch of Indian School of Development Management (ISDM), a one of its kind organisation creating leaders for the development sector through its experiential learning post graduate program.

As a Youth Ki Awaaz Menstrual Health Fellow, Nitisha has started Let’s Talk Period, a campaign to mobilise young people to switch to sustainable period products. She says, “80 lakh women in Delhi use non-biodegradable sanitary products, generate 3000 tonnes of menstrual waste, that takes 500-800 years to decompose; which in turn contributes to the health issues of all menstruators, increased burden of waste management on the city and harmful living environment for all citizens.

Let’s Talk Period aims to change this by

Find out more about her campaign here.

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A former Assistant Secretary with the Ministry of Women and Child Development in West Bengal for three months, Lakshmi Bhavya has been championing the cause of menstrual hygiene in her district. By associating herself with the Lalana Campaign, a holistic menstrual hygiene awareness campaign which is conducted by the Anahat NGO, Lakshmi has been slowly breaking taboos when it comes to periods and menstrual hygiene.

A Gender Rights Activist working with the tribal and marginalized communities in india, Srilekha is a PhD scholar working on understanding body and sexuality among tribal girls, to fill the gaps in research around indigenous women and their stories. Srilekha has worked extensively at the grassroots level with community based organisations, through several advocacy initiatives around Gender, Mental Health, Menstrual Hygiene and Sexual and Reproductive Health Rights (SRHR) for the indigenous in Jharkhand, over the last 6 years.

Srilekha has also contributed to sustainable livelihood projects and legal aid programs for survivors of sex trafficking. She has been conducting research based programs on maternal health, mental health, gender based violence, sex and sexuality. Her interest lies in conducting workshops for young people on life skills, feminism, gender and sexuality, trauma, resilience and interpersonal relationships.

A Guwahati-based college student pursuing her Masters in Tata Institute of Social Sciences, Bidisha started the #BleedwithDignity campaign on the technology platform Change.org, demanding that the Government of Assam install
biodegradable sanitary pad vending machines in all government schools across the state. Her petition on Change.org has already gathered support from over 90000 people and continues to grow.

Bidisha was selected in Change.org’s flagship program ‘She Creates Change’ having run successful online advocacy
campaigns, which were widely recognised. Through the #BleedwithDignity campaign; she organised and celebrated World Menstrual Hygiene Day, 2019 in Guwahati, Assam by hosting a wall mural by collaborating with local organisations. The initiative was widely covered by national and local media, and the mural was later inaugurated by the event’s chief guest Commissioner of Guwahati Municipal Corporation (GMC) Debeswar Malakar, IAS.

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