Technology for workforce performance improvement of community health programs

Community health workers (CHWs) are integral in promoting healthy practices to rural populations in low-income regions. CHWs are in the best position to provide information, encourage healthy practices, and be the most accessible point of entry into the national health system. However, CHW programs are difficult to run for several reasons: CHWs are embedded in low-resource communities; many CHWs are volunteers; and programs have a large number of CHWs spread over disparate regions. Technology can begin to bridge this gap and strengthen CHW programs. Ubiquitous and inexpensive mobile phones can provide support for improved monitoring and supervision of CHWs. We first look at challenges for achieving high-CHW performance. Next, we present field work from three community health programs in Tanzania and Uganda and the resulting framework for a mobile phone-based application that allows CHWs to collect and manage data, CommCare. The framework allows organizations to share content and metrics and allows their application to be device-independent. We then demonstrate that clinicians adhere more closely to treatment protocols when using guided software on a mobile device compared to conventional methods. We present a case study of health surveillance, demonstrating that two CHWs using CommCare to serially interview a mother can achieve high levels of response concordance for certain symptoms. Finally, we present a randomized study where we significantly improved timeliness of CHW visits by sending automated SMS reminders that can escalate to phone call from a supervisor. In a follow-up study, we demonstrate that removing the escalation step leads to significantly poorer performance. This work represents one step in a continuing research agenda for designing, building, and deploying technological innovations to strengthen health systems and address health inequities worldwide.