inafu6212-001-2012-3



external image 7-childcount_plus_logo.png


ChildCount+ is an mHealth platform developed by the Millennium Villages Project (MVP) aimed at empowering communities to improve child survival and maternal health. Reducing child and maternal mortality, by 66% and 75% respectively, have been identified as core Millennium Development Goal (MDG) targets. In much of sub-Saharan Africa, 10% to 20% of children die before turning five, and the death of mothers during childbirth, occurs far too frequently.
In the health sector, MVP emphasizes integrated delivery of a free minimum package of maternal-newborn-child health services, with the goal of achieving universal coverage. ChildCount+ is a mobile phone and paper-based informational tool used by Community Health Workers to reach this goal by actively monitoring children for malnutrition, malaria, and other childhood illnesses.

Contacting to the author:
lc2873@columbia.edu(Le Chen, First-year student in MPA-DP)

1. OVERVIEW


ChildCount+ is an mHealth platform developed by the Millennium Villages Project aimed at empowering communities to improve child survival and maternal health.
ChildCount+ has three primary objectives:
  • To establish a community health events reporting and verbal autopsy system for Community Health Workers (CHWs). Our hypothesis is that timely information on the burden of disease alongside better understanding of preventable mortality and challenges faced in accessing care has the potential to critically inform the targeting and delivery of interventions. By building upon existing site personnel and resources, a low-cost Millennium Villages Project-CHILDCOUNT+ System is being developed to test this hypothesis.
  • To develop and implement a two-way mobile phone-based community health events reporting, feedback, and illness alert system. This system will monitor and manage follow-up on births and deaths; pregnant women and newborns; children under 5 years; and adult illnesses such as Tuberculosis (TB), malaria and non-communicable diseases. ChildCount+: A Community Health Events Reporting and Alert System, will integrate with existing information management systems and catalyze action around these significant community health events.
  • To improve tools and reporting formats to enable the use of data for active case management, decision-making and performance monitoring of health workers. The ChildCount+ system will provide the basis for longitudinal information tracking at an individual and household level within the Millennium Villages. Integrated with an existing platform known as the Millennium Global Village-Network (MGV-Net), ChildCount+ will take advantage of the multilingual, multinational, open source information system being implemented throughout MVP. Capturing information via paper, mobile phones and computers will bring together information from community, clinic and referral centers to provide an overarching view of health within the villages.
Child Mortality
Child Mortality

Community Health Workers Training on Submitting Data
Community Health Workers Training on Submitting Data
By accomplishing these objectives, ChildCount+ will help community health workers to:
  1. Register every child under age 5: Create a “living” registry of all children under age five and pregnant women in a community. This list provides the basis for community health teams to monitor the health status of children and women who are to give birth.
  2. Screen for malnutrition every 90 days: Record the Mid-Upper Arm Circumference (MUAC) of every child from 6 months to 5 years every 90 days. When a child with acute malnutrition is detected, the program provides support for Plumpy’nut based malnutrition treatment (where available) based on community based management of acute malnutrition (CMAM) protocols.
  3. Monitor for malaria, diarrhea and pneumonia: track and treat these three major, preventable causes of death in children under age five. ChildCount+ provides support for home-based malaria Rapid Diagnostics Tests (RDTs) and Artemisinin-based combination therapy (ACT) dosing, oral rehydration salt (ORS) usage and pneumonia diagnosis and treatment with CHW administered antibiotics.
  4. Support child immunizations: Group all children in monthly age groups to easily systematize an immunization schedule.
    Mid-Upper Arm Circumference (MUAC) Assessment
    Mid-Upper Arm Circumference (MUAC) Assessment
    Record all immunizations and follow-up with children who are behind on their immunization schedule. Manage vaccination campaigns.
  5. Record all local births and deaths: Register all newborns and record child and maternal deaths, as well as miscarriages. Investigate cause of death and share findings with local health teams and communities.

What is working process of ChildCount+ through mobile phones? Let’s watch a video from Matt Berg, vimeo.com.

ChildCount+ Overview from Matt Berg on Vimeo.


From the video, we can see that each individual in the database will soon have one unique number, which may be used to track patient progress, generate monthly reports, assess medical supply needs, etc.

In terms of management, ChildCount is administered by a team composed of a health coordinator, CHWs supervisors, CHWs, and IT specialists. CHWs are assigned to communities at an ideal ratio of one CHW per 100 children under five. The minimum requirements for a CHW are: a) they come from the community they serve, b) have achieved some level of secondary education, and c) work on part-time bases with a monthly stipend. The supervisors have some level of college education in health-related studies and are part of the permanent staff of the organizations implementing the project.
How do CHWsfeel about working with ChildCount+?
The story of a CHW Steven will lead us to his new mobile world.


2. TECHNOLOGY


The technology that allows CHW to send SMS is RapidSMS, a free and open-source data collection framework designed for basic mobile phones. This platform enables SMS-driven applications with web-based interfaces to improve monitoring and data analysis. The RapidSMS projects initially had three main functions: a) to maintain a live registry of unique codes for all clients, with variables on the various health interventions; b) to send back automated alerts and notifications, triggered by tailored parameters e.g. a severely acute malnourished child or a mother that missed her antenatal appointments; and c) to generate individual or aggregated reports given location, intervention, age, and other variables.

WORKFLOW:
Two types of workflow: ChildCount+’s original design revolved around mobile phones: community health workers would submit information to the ChildCount+ server by text message (SMS). Based on the submitted data, the server would then periodically send information and alerts to the community health workers. The ChildCount+ deployment in Sauri, Kenya, where Millennium Villages Project first piloted ChildCount+, uses the mobile-phone-based workflow depicted in the accompanying figure.
ChildCount+ mobile data flow diagram.
ChildCount+ mobile data flow diagram.

It is possible to deploy ChildCount+ without mobile phones. In fact, most Millennium Village sites use a paper-based workflow for ChildCount+, since managing airtime credit and fleet of mobile phones is sometimes not possible.
ChildCount+ paper-based data flow diagram.
ChildCount+ paper-based data flow diagram.

3. MAIN PROJECT


Prevention of Mother to Child Transmission of HIV Module of ChildCount+ is the representative and important project of ChildCount+ in Africa.

PMTCT Design Process
The PMTCT module is a system to where the mothers could be enrolled in a certain treatment program. This would have a set schedule for the follow-up appointments, and the mother would be assigned to a particular treatment program at the initial antenatal visit based on her CD4 count. The process of work is as follows –
  1. The CHW registers the pregnant woman into the ChildCount+ system during his/her regular household visit and encourages her to visit the clinic for her first antenatal appointment
  2. A woman visits the clinic for her first antenatal appointment
  3. The CHW at the clinicrecords her visit by sending an SMS to the CC+ system
  4. The system adds the woman’s name to a schedule (i.e. records the date of her next appointment)
  5. Three days prior to the woman’s next appointment, the CHW receives an SMS giving details of the appointment
  6. The CHW reminds the woman of her appointment: The woman attends clinic on day of her appointment
  7. The cycle repeats
external image UNAIDS.png

Workflow of PMTCT
The information of PMTCT has required 3 new forms at the clinic, and for CHWs to carry and fill out two more forms on their household visits. The only pre-existing form in this workflow was form A, and new forms in the workflow have been circled.
external image CC+_PMTCT_Workflow_v2.png

4. ASSESSMENT


While the module seems to be accepted by CHWs and mothers in the community, the following issues were raised (by CHWs) as barriers to performance:
  • Clinic level: CHWs working in clinics are extremely busy; as a result, they often forgot to fill out ChildCount+ forms and send text messages to the CC+ system.
  • Household level: the CC+ method of data collection takes up a lot of time – a single household visit might require 3 or more CC+ forms to be filled; as a result, one could easily spend up to 45 minutes in a single household.
  • Phone issues: CHWs noted that some phones did not have sufficient memory space to store messages. For example, if a CHW sent out a message to the CC+ system and received an error, he/she had no method of retrieving the same message to correct it; they would need to send an entirely new message. Other phone issues were low battery life and poor network capture.
  • Communicating with mothers: CHWs said they had difficulties convincing some mothers of clinic appointments. “Some of these women are really hard to convince to visit the clinic; they can be ignorant and defiant,” says an interview participant in Nyamninia sub-location.
  • Training on PMTCT: CHWs stated that they would appreciate additional training on PMTCT as to enable them to better inform mothers on the benefits of visiting the clinic during pregnancy.
  • Relatively high cost:The cost of setting up and running a RapidSMS system is also another limiting and sometimes prohibiting factor. In ChildCount, about US $12 CHW/month17 are paid in just airtime expenses. Although in few instances MVP has been able to partner with national mobile operators so they can provide a toll-free SMS number for CHWs, those negotiations are difficult and often unreliable for project scale up. In this regard, MoTech has been struggling to continue subsidizing their SMS services now that project’s grant funding has ended. They have turned to the Ghanaian Ministry of Health to cover a portion of the cost.