Improving maternal and child mortality rates in Bihar – where traditional customs strongly influence health practices related to childbirth and post-natal care – was dependent upon being able to persuade families to adopt better health behaviours. While this work was generally done by frontline health workers (FLWs), they were all women from the community, inadequately trained and not taken seriously by the families they visited. They needed support, more effective training and tools to enable them to do their jobs more effectively.
Could we create a toolkit that could accommodate 11 priority health behaviours and over 100 attitudinal, normative and belief arguments? That could be carried by a frontline health worker (FLW) at all times? And at the same time create excitement and motivation amongst the user and her target audience?
A mobile and deck of cards
The solution was Mobile Kunji (‘key’ or ‘guide’), our multi-media job aid, which comprises an Interactive Voice Response (IVR)-based mobile service and light, sturdy deck of laminated cards on a steel ring. The Kunji cards were designed to look like a mobile phone, with illustrations, supporting arguments and key messages. Each card has a unique mobile short-code that corresponds to a specific audio health message.
Accessible, Affordable, Innovative
Mobile Kunji delivers audio and visual content without the need to distribute expensive hardware. It is accessible from any handset – no software required – and its simple IVR technology makes it easy to use and navigate.
The FLW 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 short-code printed at the bottom. The recorded voice of Dr Anita – our fictional doctor character who features in all of our mHealth services – provides further information during the call. The FLW can then convey that information to the family, or let family members listen to it themselves.
Mobile Kunji is free for all FLWs registered with the government public health databases. The service was initially enabled by all six major mobile operators in Bihar. Since Mobile Kunji was transitioned to the State Health Society (SHS) Bihar, in June 2019, it is available, free of cost, on the BSNL CUG SIMs issued to ASHAs by SHS Bihar.
Reach and impact
Since 2012, Mobile Kunji has been introduced to 105,046 FLWs across 28 districts in Bihar. In the last six years, over 60 million minutes of Mobile Kunji content have been played in the state by over 500,000 unique users (145,375 are registered FLWs). The service went beyond Bihar and was adopted by the governments of Uttar Pradesh and Odisha, supported by The Gates Foundation in Uttar Pradesh and DFID in Odisha.
The impact of Mobile Kunji has been overwhelmingly positive. Exposure to Mobile Kunji has been associated with significantly improved knowledge and practice of a variety of recommended health-related behaviours, including birth preparedness, complimentary feeding, IFA tablet consumption and exclusive breastfeeding.
FLWs reported that they were more confident in their work when they used Mobile Kunji, that it improved their knowledge, and that families accepted the information they provided more quickly when they used the tool.