Mahfooz –Decreasing Vaccination Dropouts

Globally, every year, 2 million people lose their lives to vaccine-preventable disease. 19.4 million children miss out on basic vaccines and 13 million children receive no vaccines at all. The prime reasons for hesitancy are lack of knowledge and awareness, strained interaction with frontline workers and trust in government. 

 Our solution, through a simple call-in system, provides:

* a caregiver accurate information of their child’s immunization record, schedule and access to vaccination related essential information

* provides a frontline worker to update the vaccination details real-time using a voice app. 

* sends out personalized reminder calls to  caregivers and reminds them of vaccination dates, venues and aftercare information.

Our solution demonstrates that it decreases vaccine hesitancy and increases caregiver’s awareness about benefits of vaccination which decreases dropout rates in the immunization process, promotes behavior change at last point of delivery and decreases the paperwork burden of frontline healthworkers

Globally, every year, 2 million people lose their lives to vaccine-preventable disease. 19.4 million (20%) children miss out on one or more basic vaccines and approximately 13 (13%) million children receive no vaccines at all. In India, 26 million children are targeted each year out of which approx. 10 million children either are unimmunized or partially immunized, 70% of those immunized do not receive their vaccination on time and circa 0.5 million children die every year due to vaccine-preventable disease.

The primary factors driving a caregivers decision to  delay or refuse vaccinations for their children are lack of trust for government immunization campaigns, lack of knowledge and awareness about their vaccination resulting in fear around safety and efficacy of vaccines, lack of access to their child’s vaccination record as well as the experience of a caregiver during the immunization process comprising frontline workers’ attitude towards caregivers, their technical performance and quality of communication.

  Technology so far has played an important part in evolving solutions, but most of these solutions are aimed at people who have access to web, smartphone and are literate.  However,  82% of India’s rural population has no internet available to them and 65% still use non-smartphones.

Our Solution uses voice technology which can be accessed by anyone over any phone.  The Solution consists of:

·      A toll free dial-in system which provides:

o   For caregivers:

§  access to their child’s vaccination records, history and upcoming schedule

§  access to their child specific vaccination information compendium- aimed at hygiene and post immunization symptoms

o   for frontline workers

§  real-time updation and creation of a child’s immunization information

§  access to list of children due for next vaccination session

§  access to vaccination related knowledge compendium for reinforcing best practices, hygiene, knowledge base and behavior change.

·      A completely automated dial-out system which provides:

o   For caregivers:

§  personalized reminders of their child’s vaccination due dates

§  pre-immunisation and post-immunisation aftercare information and thanking and reassuring them of the number of children vaccinated that day

o   for frontline workers

§  reminder on the due list and the vaccines required for their next vaccination session 

Backend AI engine: intelligent cloud-based platform which hosts the immunization records, integrated with IVR system and uses text-to-speech technology to dynamically relay personalized messages and reminders. The engine analyses the inputs  to improve the call flow making it more relevant and easier to use.

Our solution provides the caregivers with access to their children’s immunization record anytime from anywhere as well as personalized reminders for their child’s upcoming vaccine and information. This keeps the caregiver up to date with their child’s immunization schedule and reduces dropouts. It also reduces the burden on the frontline workers to go from door-to-door reminding caregivers of the same

Lack of awareness and misinformation amongst caregivers coupled with a bad experience due frontline workers attitude and quality of interaction and communication leads to  caregivers decision to  delay or refuse vaccinations for their children. Our solution increases caregivers awareness and knowledge about benefits of vaccination, shares personalized reassuring messages revolving around do’s and don’ts, hygiene and post immunisation symptoms as well as number of people in their community who had vaccinated their child with the same vaccine. This helps in overcoming the lack of trust in the public health system, busting myths and reducing vaccine hesitancy amongst caregivers leading to increase in vaccination demand or reducing dropouts.

By providing the frontline worker with real-time immunization record updation system which generates their due list and sends out reminders, our solution drastically reduces the burden of paperwork of frontline workers

By providing easy access to a mother or caregiver to information and knowledge about her child’s vaccination by using a simple toll-free phone calling and receiving system which requires no smartphone or internet connectivity, our solution bridges the information gap leading to high quality affordable care for mothers who face a challenge in navigating the immunization healthcare system. Also by enabling a behaviour change at the last point of delivery – both to bring in more hygienic and safe practices and enabling a change in attitude we are reducing the dropout rates. 

The vulnerable under privileged sections of society living in Rural India or any LMIC neither have adequate medical facilities, nor the wherewithal to access accurate and updated information through a medium easily available and understandable to them.  While Technology so far has played an important part in evolving solutions, Most of the technology interventions in India so far has been internet and app based requiring users to have access to smartphones, possess literacy and have bandwidths.

A few have been based on voice but these are either traditional voice with a human being from a call center or a recorded voice based messaging that is fixed, cumbersome to change and does not cover all emerging areas. 

Our solution utilises voice as a technology which can be accessed by anyone over any phone at any given point of time. It is an easily administered tool that can be used by the underprivileged, un-educated and can be easily modified to keep it contemporary over the period of time. Since we have no human intervention (we use a Text to Speech interface) our solution is scalable, easily reproducible and information is dynamically modified and relayed . The Artificial Intelligence at the backend keeps updating the flow logic and choice of language constantly making it easier to keep improving the user experience.

·      An intelligent backend platform which is seamlessly integrated with the IVR system and uses text-to-speech technology for communication.

·      The backend platform is an intelligent cloud-based system consisting of the health vault which stores updated immunisation records of the child. User can access this system by dialing-in to a toll-free number through their registered mobile number. The IVR telephony systems sit on an intelligent backend platform which provides predictive options for information access.

·      A text to speech engine mapped to the communication and query output sought from the user to relay the message in vernacular language as well.

·      An Artificial Intelligence engine studies the patterns of queries and helps to dynamically rearrange the information flow so that a caller reaches the desired information in minimum number of steps

A voice-based updating system uses DTMF signals which interacts with the IVR and the backend system to convert the voice responses shared by the CHW to update the child’s immunisation information.

Once the immunization session gets over two lists are generated, the aftercare list and the due list.

The aftercare calls are sent out within 3 hours of the child getting vaccinated and the vaccination due reminder calls are sent 3 days and 1 day prior to the vaccination due. calls are considered as complete if the caregiver listens to the entire call. Calls are considered incomplete if the call is disconnected within the first 15 seconds. Calls are considered missed is the caregiver does not pick up Incomplete and missed calls are tried twice over at an interval of 40mins.

 Early impact showcases an increase in 24.17% of the total number of calls completed. The number of incomplete calls have reduced from 4% to 0.91% and a decrease of circa 21% has been seen in the number of incomplete calls. From the frontline workers and the due and aftercare list being generated, comparing with the trend of last two years for the same demography, dropouts have decreased by 7.3%, the demand for DPT-3 vaccine which was around 62% for the target population covered has increased by 11.4>#/span###

we believe in using appropriate technology and people driven processes to empowering communities to make a difference through social impact technology and bridging the urban-rural and digital divide. Our Theory of Change has organically evolved from the ground up and is based on our experience of working in the rural communication and technology space over the last three years. We believe, participatory communication can be used to enhance community level dynamics such which are access to relevant contextual and accurate information and sustained accountability loops. This would lead to social change. We aim at  changing the way frontline services are delivered in health and education sector through designing relevant data-driven technology solutions for low-resource settings which are key to improving the quality and efficiency of global development program. Our process:

·      Information sharing: sharing information with the community which helps them learn from each other.

·      Improved awareness: improves awareness of their rights and entitlements more than traditional forms of media

·      Demand for services: increase in awareness helps in creating demand for services

·      Accountability: demand for service increases and improves accountability amongst the community

·      Citing deficiencies: sharing and increased awareness helps communities to cite deficiencies and gaps in service delivery

·      Data on service delivery: generating critical data on service delivery that can be used by policy makers to understand problems and arrive at data driven objective solutions

The Solution is currently rolled out in 3 Primary Healthcare Centres in a district catering to:

·      2500 mothers

·      3100 children; and

·      50 frontline workers

In One year’s time we look at expanding to 3 districts catering to at least 20 primary healthcare centres:

·      15000 mothers

·      25000 children; and

·      200 frontline workers

In 5 years time we look at expanding to 26 districts in 3 states catering to:

·      1 million mothers

·      2.5 million children

·      5000 frontline workers

·     Increase coverage:In One year’s time we look at expanding to 3 districts catering to at least 20 primary healthcare centres:

·      15000 mothers

·      25000 children;

·      200 frontline workers

In 5 years time we look at expanding to 26 districts in 3 states catering to:

·      1 million mothers

·      2.5 million children

·      5000 frontline workers

· Add other languages: currently, the solution supports only English and Hindi Languages. In the next 1 year we look at expanding to 1 more vernacular language and in 5 years time at least 7 Indian vernacular languages and 5 international languages

·       Attract stakeholder participation – CSR funds, Government Subsidies. Since the beginning of the pilot we have tied up with the local government authority to roll out the intervention. Since public health is a state subject we will look at tying up with the government as well as various civil sector and development organisations to attract subsidies and make the solution self-sustainable.

·       Introduce virtual voice-based chatbot for information dissemination: Currently we are using text-to-speech engine to provide real time information on queries which the user can select from. Our AI engine studies the patterns of queries and helps to dynamically rearrange the information flow so that a caller reaches the desired information in minimum number of steps. In the next 5 years we would like to introduce a conversational voicebot which caters to the queries of the users and provide them with correct and relevant answers.

·      Data related challenges:

o   the immunization data is incomplete and inconsistent

o   Data was in a mix of language

o   The percentage of children covered under vaccination in our area is not based on the head count of children but the utilisation of vaccines, which makes it difficult to count the true data.

o   Mobile numbers of majority of caregivers was not available in the system

o   There is also a tendency to change phone numbers frequently rendering the database obsolete.

·      Behavioural challenges: Vaccine hesitancy among caregivers

o   Lack of awareness regarding the vaccine and misinformation

o   Belief that vaccines caused infertility and this was a part of the government agenda to reduce high birthrates in a minority community

o   Fake news on social media stirring fear in people and blaming vaccines for unrelated diseases is a big challenge

o   Free vaccination by the government is looked upon with suspicion.

o   Common side effects lead to mistrust in the vaccine administered by the CHW and the government

·      Technology Related Challenges:

o   Utilizing a text-to-speech engine which had the right accent for people to understand the message being conveyed

·      Financial Challenge:

o   For scaling the intervention requires financial support whether through grants or government subsidies.

·      Data related challenges:

o   Currently, Our field staff took on the task of collecting, updating and making the datasets consistent. Established rapport with the community healthworkers to retrieve maximum amount of data; Went door-to-door with ASHAs to collect the data; established a rapport with the caregivers and called all numbers to check whether the number given is valid and processed the data which was in a mix of language in both Hindi and English individually. We would overcome this challenge by partnering with reputed civil society organisations who have been working in that area for a long time.

o   We created an app which now helps us update, monitor and track the vaccines given to the child individually and in real-time

·      Behavioural challenges: Vaccine hesitancy is a complex and rapidly changing global problem for which there is no one-size-fits all approach. For the current pilot project we overcame the vaccine hesitancy challenges using the following approach however new systems of approach need to be carefully analysed for each demography

o   through our reminder and aftercare calls and access to FAQs we got a positive feedback from a few caregivers and CHWS that it helped alleviate the fears of the caregivers regarding vaccines. The positive reinforcing messages helped in overcoming the challenge of myths and misconception

o   We carried out campaigns involving private practitioners supporting the government’s cause and that the vaccine administered government offers the same immunity as the ones offered by private hospitals and practitioners

Full-time staff: 7

Part-time staff: 5

Sub-contractors: Local Civil sector organization for field operation management and coordination

Consultant:1,  immunization consultant and 1, behavior change communication specialist

Frontline workers: 50 frontline workers

Our team comprises members with:

Program Management & Execution Experience: 40 man-years

Propagation of technology & Technology Based Project: 24 man-years

Scaling Up Technology-based solutions: 6 technology based products

Social Outreach and Advocacy Experience: 10 man-years

Immunisation Sector Experience: 15 man-years

Public Health Experience: 18 man-years

Policy Advisory Experience: 8 man-years

In  our three years of operations we have repeatedly demonstrated our ability to come up with innovative solutions which we have successfully executed on the field showcasing tangible impact. This ability has allowed us to win project funding from globally reputed funders such as Bill & Melinda Gates Foundation, Grand Challenges Canada, US AID, JHPIEGO and locally IIT-Bombay .

We have successfully implemented operations across 5 States, involving about 200 field workers, we have reached out to millions of net users and delivered interventions and we have worked across diverse languages and cultures using local resource

State Government Partnership: tie-up with the Office of the Chief Medical Officer, Mathura District for rolling out the pilot project with support of government and include government manpower for creating sustainable system

Dr Sheela Sharma Memorial Charitable Trust – civil sector organization for coordinating and managing local field operations

The new Immunization Agenda 2030 (IA2030) which sets the vision and strategy for 2021-2030 highlights the need to scale up the immunization services through primary health care and universal health coverage so that everyone, everywhere has access to life-saving vaccines.

Our solution complements the vision and partners with the government to reach out to the beneficiary for availing of the service. Our solution is currently rolled out with support of the local government and funded by a development sector organization. For scaling and sustenance of the solution, this would be adopted by governments across different LDCs. We aim to make this platform available on a pay per use basis to Governments, Institutions that do monitoring of immunization, vaccination and nutrition programs on the field, NGOs and other Civil Sector agencies so that the end beneficiary, caregivers do not bear the cost for it.

Being cloud based there are no limitations to its scalability. Even the voice piece is using text to speech engines so as to make the propagation independent of the need for operators or human manpower.

Currently the pilot project is being funded through support by Bill & Melinda Gates Foundation and rolled out through Office of the Chief Medical Officer, Mathura, Uttar Pradesh

For scaling and sustenance of the solution, this would be adopted by governments across different LDCs. We aim to make this platform available on a pay per use basis to Governments, Institutions that do monitoring of immunization, vaccination and nutrition programs on the field, NGOs and other Civil Sector agencies so that the end beneficiary, caregivers do not bear the cost for it.

Being cloud based there are no limitations to its scalability. Even the voice piece is using text to speech engines so as to make the propagation independent of the need for operators or human manpower.

We are also aim looking at revenues from local advertisers and classifieds. Some networks are also partly supported through micro-donations from the community, we are also exploring the option of partially crowdfunding this intervention and adopting and supporting full immunisation services to a child.

In  our three years of operations we have repeatedly demonstrated our ability to come up with innovative solutions which have been successfully piloted on the field. This ability has allowed us to win project funding from globally reputed funders such as GCC, US AID, BMGF. However, what we require assistance is in partnering with cross sectors and country partners to help us scale the innovation for greater impact. MIT Solve is a platform which brings together such social impact innovators, funders and organisations who closely work with the government sector. While a lot of innovators work in silos, the platform that Solve provides would help innovators and practitioners leverage solutions which complement each other and produce a more robust rapidly scalable solution. We are also looking at such partnerships where we would largely benefit if we can reach out and scale our solutions with partners who are looking at implementing the same.

Product/service distribution: our solution is easily customizable and cuts across verticals. Since it is a cloud-based solution, it can scale across geographies. We would like to partner with partners in other LMICs and scale our solution

Funding and revenue model: for scaling we would require partners who can help us raise funds (grant or equity) to make the model more robust.

Marketing, media and exposure: we certainly need assistance is showcasing our products and out it out their in the common domain so that interested partners can easily reach out to us for implementing the same.

Development & Funding Organisation: for scaling and implementing the solution in other LMIC where they have funded projects in the same sector and where our solution can complement the government’s needs and requirement

Innovators with whom we can tieup for complementing each others solution

Advisors: Advisors who can guide us in customizing and implementing the solution for other sectors which face the same challenges.

By providing easy access to a mother to information and knowledge about her child’s vaccination by using a simple phone calling and receiving system, our solution bridges the information gap leading to high quality affordable care for mothers who face a challenge in navigating the immunization healthcare system. our system empowers the mother to access her child's information and take informed decision take care of her child's health

our solution also enables a behaviour change at the last point of delivery – both to bring in more hygienic and safe practices and enabling a change in attitude of the mothers.

For Community Health Workers our CHW will have an application that she can speak into to update records. Each CHW will be provided with a uniqueusername and password for accessing the app. Information can be updated using a toll-free number and IVR also.  o The timely updation of the child’s immunization details done by the CHW in the voice form reduces the burden of filling up paper-based forms and entering the same into the system. our system also provides the community health workers with due list and the vaccinations that are due to be administered in the next session. 

through our personalised reminder calls to mothers. the community health workers dont have to go door-to-door to call mothers and inform about the vaccination session details for their child. 

our health vault and knowledge compendium which provides easy info access to caregivers frees up community health workers time and reduces their burden as mothers can access their childs details and other vaccination related information anytime from anywhere.

Since we have no human intervention the Artificial Intelligence engine at the backend studies the patterns of queries and helps to dynamically rearrange the information flow so that a caller reaches the desired information in minimum number of steps. in the future we aim to Introduce virtual voice-based chatbot for information dissemination and creating awareness for the CHW and caregiver. Currently we are using text-to-speech engine to provide real time information on queries which the user can select from. in the future we would like to introduce a conversational voicebot which can cater to the queries in vernacular language of the users and provide them with correct and relevant answers.

The vulnerable under privileged sections of society living in Rural India or any LMIC neither have adequate medical facilities, nor the wherewithal to access accurate and updated information through a medium easily available and understandable to them.  While Technology so far has played an important part in evolving solutions, Most of the technology interventions in India so far has been internet and app based requiring users to have access to smartphones, possess literacy and have bandwidths.

A few have been based on voice but these are either traditional voice with a human being from a call center or a recorded voice based messaging that is fixed, cumbersome to change and does not cover all emerging areas. Our solution utilises voice as a technology which can be accessed by anyone over any phone at any given point of time. It is an easily administered tool that can be used by the underprivileged, un-educated and can be easily modified to keep it contemporary over the period of time. Since we have no human intervention (we use a Text to Speech interface) our solution is scalable, easily reproducible and information is dynamically modified and relayed . The Artificial Intelligence at the backend keeps updating the flow logic and choice of language constantly making it easier to keep improving the user experience.

this low-cost affordable solution has the power to affect millions of lives and build healthcare equality.