Digitizing Lady Health Worker Diaries

In Pakistan, Lady Health workers (LHWs) play a crucial role in immunizations. LHWs track household health status, including childhood immunization, in their catchment area through a personal paper-based diary. This data has the potential to uniquely identify all children in the population, however, it is not utilized due to inefficiencies of paper-based systems, preventing data aggregation.

We aim to leverage mHealth tools to improve immunization campaigns through enhanced microplanning. A mobile-based platform for LHWs will be developed digitizing existing diaries, enabling accurate estimation of target population. The dashboard will empower workers to access interactive and adaptive micro plans, leading to improved campaign planning and performance.

For the global health community, a digitized health worker’s registry provides a replicable and sustainable platform requiring affordable health system investments. Therefore, the scale-up can benefit through formulation of well-targeted campaigns resulting in substantial savings in treatment costs for vaccine preventable diseases.

Pakistan has one of the highest maternal (140 per 100k live births) and childhood (57.2per 1000 live births) mortality rates worldwide. To address this an extensive network of Lady health workers (LHW’s) was developed to provide primary care services to high-risk underserved populations. LHWs record their visits and detailed health status of households in their personal paper-based diaries, which remain an untapped source of information for health campaigns.

Determining the target population for LHW routine activities and campaign features prominently during the planning phase, whereby detailed micro plans are drawn for reaching every last individual with the desired intervention. Presently weak health information systems constrain campaigns, whereby the target population is estimated by projecting old, unreliable census data or utilizing erroneous techniques to extract data from old paper-based LHW diaries. Skewed population estimates further prompt poor planning, stock management, and human resource allocation. Furthermore, LHWs face a broad spectrum of field challenges, ranging from poor performance management, lack of feedback, and limited avenues for on-job self-assessment, resulting in poor job satisfaction, low performance, and non-compliance. These factors frequently contribute towards reduced effectiveness of health campaigns in achieving target coverage, especially in hard-to-access areas. 

We aim to develop a mobile-based dashboard and digitalize existing LHWs diaries containing household records on children, thereby enhancing the precision of micro plans for campaign coverage. The dashboard will be developed in collaboration with technological and software experts and will be piloted before the field deployment.

Through the dashboard, LHWs will have access to automated, digitalized, and adaptive micro plans that incorporate accurate population estimates and real-time campaign data. The platform will also provide real-time individual-level campaign targets and performance indicators e.g., the proportion of target population covered, and lists of high-risk areas. Additionally, daily push notifications (or SMS) will be sent to provide a summary of field activity, including the age-wise and community-level target achieved. The daily performance of each LHW’s catchment area will be compared against the top-performing area, motivating them to modify and develop the most suitable work plans. Collected data will be transferred from the device to a central server in real-time. Data will be stored in the OpenMRS medical record system, a free and open-source system already deployed in >40 countries. OpenMRS allows for extensible, flexible and customizable medical record storage and has a powerful data model, making it well suited for this project.

Since our digital diaries will improve planning at every level, our solution will benefit the mothers and children for whom targeted campaigns are launched. At the LHW level, developing an individual-level mobile-based dashboard is an innovative solution to provide adequate resources to the health workers, enabling them to efficiently achieve health campaign targets. The digitalization of grassroots-level data collected by LHWs is expected to increase the reliability of coverage statistics compared to the conventional paper-based system by providing an accurate denominator for the catchment population. Access to interactive and digitized micro plans will provide holistic and systematic field guidance to the LHWs, enabling them to achieve the stipulated targets. The engagement of LHWs at the phase of piloting will ensure the dashboard to be user-centric. Furthermore, the collection of the campaign and operational monitoring data would further help in evaluating and analyzing population estimates, coverage rates, and missed areas, feeding into the process of strategizing and planning for successive campaigns. We, therefore, expect that provision of accurate and interactive micro plans through the dashboard will provide accurate reporting, enabling LHWs to ‘reach the last mile’ without leaving behind any unreached population. 

Developing an individual-level mobile-based dashboard is an innovative solution to provide adequate resources to the frontline health workers, enabling them to efficiently achieve health campaign targets without leaving behind any un-reached population. The digitalization of grassroots-level data collected by LHWs is expected to increase the reliability of coverage statistics by providing an accurate denominator for the catchment population. LHWs will also be able to review their daily performance giving them a sense of ownership and accountability, motivating them to perform better.

Digital diaries will not only reduce the burden of LHW’s work, but they are expected to increase the reliability of immunization coverage statistics generally and polio campaign coverage statistics specifically for EPI Program compared to the conventional paper-based system by providing an accurate denominator for the catchment population. Enumeration of all eligible children in the registry will serve as a resource for health workers and governments, enabling them to identify service delivery gaps. Better and more accurate data on immunization coverage will lead to informed decision making and optimal allocation of resources across catchment areas.  Accurate reporting of immunization coverage due to the digitized LHW registers will enable FHWs to ‘reach the last mile’ without leaving behind any unimmunized child particularly in polio eradication efforts. Eventually, we expect that these new technologies will lead to a reduction of child morbidity and mortality caused by infectious diseases in developing country settings.

The LHWs will be required to enter information about their household visits on a smart phone based android application. An Android-based platform will allow improved usability through visuals and intuitive user interfaces including design aspects such as color-coding, consistency of icons, tabular displays, charts and graphs etc. Data will be transferred from the device to a central server in real-time where possible, or alternately stored offline until connectivity is available. 

Through the dashboard, LHWs will have access to utilize automated, digitalized, and adaptive microplans that incorporate accurate population estimates and real-time campaign data, allowing an iterative process of planning and implementation. The platform will also provide individual-level campaign targets and performance indicators in real-time e.g., the proportion of target population covered, lists of high-risk/un-reached areas to ensure LHWs have access to the updated information required to achieve campaign targets. If the LHW is offline, offline data stored at the back-end will be used to display micro plans. If they are online, the application will fetch the latest data from the server. A last synced timestamp on the home screen will indicate the previous time back-end data was updated. 

Currently, the idea is in the prototype stage so we can only provide estimates about the number of people  we will be able to serve. 

Currently: None. But in the start we will start with engaging 5 LHWs, who will be expected to provide feedback on the design and usability. 

One year: We will target approximately 20,000 LHWs working in one province. Through this, we will be indirectly serving more than the 200,000 population that the LHWs serve by developing targeted plans for them.

Five years: We will be targeting all more than 100,000 LHWs by this time who cover more than 60% of the population of Pakistan.

LHWs have an extensive network of more than 100,000 workers. An individual-level mobile-based dashboard is an innovative solution to provide adequate resources to the lady health workers, enabling them to efficiently achieve health campaign targets. 

Within one year we will be able to target the LHWs in one area of Pakistan. We will be able to collect accurate information and subsequently formulate targeted plans for women and children in that area. 

In the next five years, we will be able to scale up this idea to the national level and the digitize diaries will completely replace paper based record keeping system of LHWs all over the country.

The main barrier will be to train the LHWs to become adept at using smart phones and this android based platform. 

LHWs will be given extensive training to learn to use the new sofware application. They will be provided with training manuals, which will be updated on a regular basis according to the feedback provided by the LHWs themselves.