In rural India, frontline health workers—called accredited social health activists (or ASHAs)—are improving the health of women and families in their own communities by offering key preventive health services. Through the Manthan Project, IntraHealth International is testing a promising multi-media mobile phone application called mSakhi as a tool to make ASHAs’ jobs both easier and more effective.

Although India has seen a 60% decline in maternal deaths in the last three decades, more women die in India from pregnancy-related causes than anywhere else in the world—an estimated 117,000 women each year1, 2. ASHAs are a critical component of India’s National Rural Health Mission’s strategy to prevent maternal and child deaths and to meet Millennium Development Goals 4 and 5. 

Frontline Health Workers: Reaching People Where They Are

Since 2006, the Government of India has trained over 820,000 ASHAs to reach some of the most impoverished and remote communities with services including: pregnancy counseling and health education, accompaniment of women in labor to skilled delivery care, and promotion of immunizations and appropriate newborn care. While ASHAs have demonstrated the potential to substantially improve maternal health in areas of extreme poverty3, challenges also persist.

ASHAs receive 23 days of training over the course of four years and are supervised by another cadre of frontline health workers—auxiliary nurse midwives. The ability to quickly train ASHAs is part of the reason India’s approach to community health is scalable; however, health workers with such condensed training need ongoing support and refresher trainings to sustain quality care. Studies4 have identified the need to reinforce training messages, improve the ability of ASHAs to effectively share health messages with community members, and provide ASHAs with more consistent and supportive supervision.

In the State of Uttar Pradesh, IntraHealth is helping the Department of Family Welfare test the effectiveness and scalability of innovations that have the potential to improve the health of mothers and newborns, including improving the performance and impact of ASHAs in two districts: Jhansi and Bahraich. One such innovation is mSakhi.

mSakhi: A ‘Mobile Friend’ Providing Ongoing Support to Frontline Health Workers

A Manthan mSakhi training session

Mobile technology has quickly penetrated the Indian market with the country approaching one billion mobile phone subscribers5. Increasingly the Government of India is looking at ways to leverage the vast reach of mobile technology to address some of its biggest health issues. Last year, IntraHealth pilot-tested an intervention designed to support ASHAs in communicating with and caring for their patients through the use of the mSakhi mobile application.

mSakhi, which means mobile friend in Hindi, is an interactive tutorial that offers 153 key health messages on prenatal and delivery care, postpartum mother and newborn care, immunization, postpartum family planning, and nutrition using a combination of text messages, audio, and illustrations all contextualized with localized illustrations and dialects. Developers created the educational content based on the National Rural Health Mission’s curriculum for ASHAs and sought feedback from ASHAs through a series of focus groups. The mHealth tool was then developed on the open source CommCare platform.

The pilot included 30 ASHAs in two districts in the state of Uttar Pradesh. The ASHAs received initial training on how to use mobile phones, how to operate the mSakhi application, and how to use the application interactively during visits with women and families. Refresher trainings and technical support were also provided. After 12 weeks, a follow-up assessment showed:

• The number of ASHAs who recognized fewer than two danger signs in prenatal, delivery, and postpartum maternal and newborn care decreased from 13 to 2.
• Five ASHAs could identify 6 or more danger signs compared to only 1 at baseline.
• Qualitative data also indicated that after using the tool, the AHSA were more confident in their abilities, felt they were seen as more credible among their clients, and offered better counseling during home visits.

Taking an mHealth Intervention from Pilot to Scale

A common criticism of mHealth interventions is that they remain in pilot studies that never get tested at scale. Moving beyond the pilot, IntraHealth is currently undertaking operations research with 90 ASHAs in the Bahraich District. This research is using a quasi-experimental design to test the effectiveness of the mSakhi tool by comparing the knowledge of 45 ASHAs and the adoption of health behaviors of 480 of their beneficiaries in an experimental group with 45 ASHAs and 480 beneficiaries in a control group. ASHAs in the control group receive training and support with the same content but using conventional training materials and job aids such as flip books.

The study will not only assess the impact of the tool but will also calculate the cost of this intervention to provide the Government of Uttar Pradesh with an assessment of the benefits, feasibility, and costs of scaling up this mHealth intervention.  

The Manthan Project is led by IntraHealth International and funded by the Bill & Melinda Gates Foundation.

1. Hogan, Margaret C. et al. 2010. Maternal mortality for 181 countries, 1980-2008 : a systematic analysis of progress towards Millennium Development Goal 5. The Lancet 375:1609-1623.

2. Center for Reproductive Rights. 2008. Maternal Mortality in India: Using International and Constitutional Law to Promote Accountability and Change.

3. National Health Systems Resource Centre. ASHA: Which way forward? Evaluation of the ASHA Programme. 2011.

4. Bajpai, Nirupam and Ravindra H. Dholakia. 2011. Improving the Performance of Accredited Social Health Activists in India. Columbia Global Centers, South Asia, Columbia University. 

5. Tak, Siddarth. Has mobile penetration reached saturation point? May 1, 2012.