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

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
The first piece on mSakhi appeared in Youth Ki Awaaz here.

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