In rural Bihar, traditional customs govern childbirth.
Many people believe that a woman should deliver her baby at home, that the umbilical cord should be treated with mustard oil or turmeric, and that there is no need to immunise children.
The result is that Bihar has some of the worst maternal and child mortality rates in India – over 300 mothers die for every 100,000 live births, and 16 per cent of infants die on the day of their birth.
A mobile and deck of cards
Improving those rates depends heavily on being able to persuade families to adopt better health behaviours. Much of that work is done by frontline Anganwadi and ASHA health workers.
To make their task easier and more effective, the Shaping Demand and Practices project has developed a simple, convenient audiovisual job aid called Mobile Kunji. It lends medical authority to the health worker as she counsels families on pre- and post-natal healthcare, and is free to use for registered health workers.
Mobile Kunji (‘kunji’ is roughly translatable as ‘key’ or ‘cheat sheet’) consists of a mobile phone, and a light, sturdy deck of laminated cards on a steel ring. The cards are printed with information relevant to various stages of family planning, pregnancy and postnatal care for children up to two years old. The information covers eight life-saving behaviours, and over a hundred arguments for life-saving attitudes, norms and beliefs.
Making it easy
The health worker can look up the card related to pre- or post-natal health, whether it is nutrition during pregnancy or cord care, and call the unique shortcode printed at the bottom. The recorded voices of Dr Anita or her assistant Nishant Kumar provide further information during the call. The health worker can convey that information to the family, or let family members listen to it themselves.
If, for some reason, the health worker is not carrying the deck of cards, the interactive voice response system will still enable her to navigate to the relevant information.
Mobile Kunji helps the health worker make persuasive arguments for why the family should adopt particular behaviours. It ensures that all the relevant information is accurately covered, instead of relying only on her memory. Information is summarised in a simple, easy-to-remember couplet on the back of each card and at the end of each recorded piece.
Mobile Kunji allows a certain amount of free call time per month, subsidised by the Government of Bihar. The service is enabled by six major operators, and works on any handset. Shaping Demand and Practices expects that it will scale up from the current 40,000 frontline workers to 200,000 by December 2015.
In Bihar, Community Health Workers are mostly women from the local community, with only a high school education. They are often inadequately trained and not taken seriously by the families they visit. They need training and tools that empower them to do their job more effectively.
Mobile Kunji is an audio-visual job aid designed to be used by Community Health Workers in interactions with families. Using an Interactive Voice Response (IVR)-based mobile service and a printed deck of cards, Mobile Kunji gets round the challenge of delivering multimedia content without distributing expensive hardware.
The Kunji cards have illustrations and key messages on maternal and child health, nutrition and sanitation. Each card has a unique mobile shortcode that corresponds to a specific audio message that can be played to the family. The audio content is delivered by a female doctor character, called Dr. Anita. Call costs are subsidised by the Bill & Melinda Gates Foundation to make Mobile Kunji available free of cost to Community Health Workers.
Each card beings with a question as a conversation starter, followed by a visual cue. A rhyme at the end of each card summarises the message. A unique mobile number (known as a shortcode) is printed at the bottom of each card. It can be dialed from any mobile phone, with no additional software, to play recorded health messages.
Made of weather-proof plastic material, the cards are designed to endure the wear and tear of a rural environment over time. They are colour-coded from pregnancy until the child is two years old. With the help of this colour index, a Community Health Worker can easily choose the cards specific to needs of the family she’s counselling.
While counseling families, Community Health Workers show the illustration on the front of card, talk through the messages using the guide on the back of the card, and then play the complimentary audio content by dialing the shortcode on the front of the card. This makes it easy for her to deliver high quality, standardized health advice.