Community based Management of Acute Malnutrition (CMAM) is a proven high-impact and cost-effective approach in the treatment of acute malnutrition in developing countries, in which the majority of cases are treated as outpatients at community level.
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However, the success of CMAM programmes can be limited by a number of factors, including lack of adherence to treatment protocols by health workers, and inaccurate record keeping, due to a lack of training, sufficient supervision and the absence of up to date information. Moreover, limitations in the paper based system to support referrals make it difficult to track individual children through the different levels of treatment to recovery and discharge.
Currently, the majority of frontline health workers supporting CMAM programmes are trained in standardised protocols but do not have frequent onsite supportive supervision, or job aids, to support protocol adherence and accurate treatment. All tracking and site monitoring systems are paper-based and subject to error and misreporting.
CMAM mHealth Solution
There is strong evidence that mobile device based (mHealth) apps can improve frontline health workers’ ability to apply treatment protocols more effectively and improve the provision of supply chain management
In 2013, World Vision initiated the development of a mobile phone based application for CMAM. Funded by the US Office of US Foreign Disaster Assistance (OFDA), the app was piloted in Chad, Kenya, Mali, Niger and Afghanistan. Collaborating implementation partners International Medical Corps and Save the Children led the contextualisation and deployment of the app in their respective project countries, working closely with the technical partner, Dimagi, World Vision, and local ministries.
As detailed in the working paper, “A mobile health application to manage acute malnutrition“, in Mali, Niger, Chad and Afghanistan, World Vision implemented the CMAM mHealth project, partnering with IMC in Chad, whereas Save the Children led the process in Kenya.
The collaboration between the implementing partners across the different project countries has been highly successful and important to the project, with mutual sharing and learning having a positive effect on all implementation sites. The following lessons and recommendations represent all of the project countries, whereas additional, individual country experiences are documented in the report’s country case studies.
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1. Feasibility and acceptance
The pilot project has shown that with sufficient training and support, health workers are able to use the app, which strengthens their ability to provide improved quality of care for lifesaving CMAM services. Health workers, MoH staff and caregivers of malnourished children have all expressed their acceptance of the tool across the different pilot countries.
The app also improved communication between health workers and their managers by providing a platform for sharing problems and solutions. It also helped follow-up of hard to reach nomadic children between health facilities.
2. Technical landscape
Procurement of suitable, quality devices as well as reliable network operators and data packages within budget was a challenge. Battery life issues, screen size, phone inauthenticity, network speed and coverage were all issues that had a negative impact on participating health workers’ motivation and uptake of the app.
It is recommended that information gathered through the use of the rapid assessment tool (such as network coverage and electricity sources) be used more strategically to plan and document contingency plans with regards to lack of network coverage and electricity, and replacement phones and chargers in case of repairs, faults etc.
These contingency plans should be jointly developed and agreed to with MoH partners, as well as mobile network operators.
3. Local government engagement
Though it can require considerable time and effort to achieve, early buy-in and in-depth engagement by local ministries of health is essential to successful implementation, in particular where the objective is handover and scale up by the governments themselves. This might not be immediately possible, often not until a refined app is ready, but should still be set as a deliverable in the early design and scoping stages.
4. Adapting to national systems
If app development and reporting is streamlined with the project country’s health information systems, national protocols and training of government health workers, it greatly increases the likelihood of uptake by health workers, and scale up by the governments.
5. Internal planning
For a multi-country pilot study, whether for a staggered or simultaneous roll out, a pre-development joint workshop for all key actors, including head office and country staff and technical partner, would be of great value. This would provide a platform for early identification of differences in national protocols, and facilitate better and earlier harmonisation of the app.
6. Flexible timeline
The project timeline needs to allow for external (security issues/travel restrictions) and internal (staff turnover, incorrect assumptions of time required) factors that can cause inevitable delays to project implementation, further supported by flexibility in budgets.
For the CMAM mHealth project, significantly more time than anticipated was required to allow sufficient time between scoping and planning; developing, testing and updating; and training and deployment. Due to initial delays in the project, these phases were conducted almost simultaneously, resulting in deployment of an app that hadn’t been sufficiently tested, causing frustration amongst both users and project teams.
It is highly recommended that the app is thoroughly tested – by programmers, project staff and users – prior to deploying, and that sufficient time is allocated to this key element of the process.
7. Software development, testing and technical support
For the CMAM mHealth project, delays in ironing out software and programming issues had a largely negative impact on users and project staff alike. It is imperative that the technology partner provides ongoing support for troubleshooting, bug fixing and capacity building.
The ideal technology partner would need to provide considerable in-country presence and support, either through country representatives or frequent site visits to build national capacity.
In addition, and particularly for a pilot study where early assumptions do not always match the reality on the ground, significant flexibility to timeline, budgets, and tasks need to be available on the part of the technology and implementing partners, as well as the donor.
8. Project site selection
The contexts in which this type of mHealth innovation is most needed, tend to be more complex and challenging environments. Therefore, there is a definite need to understand the feasibility of deploying projects in these contexts, and to resource and adapt the deployment accordingly.
However, it has been noted that there could be significant value in choosing pilot project countries and sites in lower risk, more stable and accessible areas with more reliable infrastructure. This would minimise delays, frustrations and limited uptake caused by lack of network, electricity and access for sufficient support supervision.
Once app development and testing is at a satisfactory level, and training and support requirements have been identified, a more stable version of the app could be deployed to high risk/poor infrastructure areas.
Overall, the project country teams were understaffed, not least due to the long distances to project sites, and the lack of on-site technical support from Dimagi. It is highly recommended that budgets allow for each team, from the onset and for the duration of the project, to have at least one nutrition specialist in a project coordinator and monitoring role, as well as a dedicated IT person to deal with software and programming issues.
10. Health worker protocol adherence
The use of the app seems to have improved adherence to the treatment protocol and the quality of care, compared to the paper based job aids and reporting tools. However, as the general treatment protocols for CMAM are complex and time consuming, and with the app based on standard national protocols, the app itself was relatively complex and data-heavy. The app guides the health worker through the treatment protocol step by step and the process does not allow steps to be missed or skipped.
By contrast, when using paper forms and manuals, the majority of health workers working under great pressure with limited resources, tend to skip steps in protocols. As the app requires all steps to be completed, it was at times seen to be too time consuming, particularly in the case of this pilot, where health workers were using dual systems – electronic and standard government paper forms – due to the reporting function not being completed on time.
The introduction of the app has therefore highlighted the need to review and better understand what is feasible in terms of capacity and time for health workers in low resource settings, with high patient caseloads (and resulting long waiting times for children and caregivers).
This is a larger issue for discussion with the relevant stakeholders who work on global guidelines for management of acute malnutrition, but the use of an app may help accuracy in case management, and if reporting functionality is resolved, could eventually save the health worker reporting time.