Thank you, Neal Lesh, for your story.
One story that has stuck with me over the years (so you may have heard it from me before) is from when we tried to introduce newborn care information in Dodoma, Tanzania. Dimagi had equipped about 35 community health workers (CHWs) there with our mobile application, CommCare. The CHWs were using the app during monthly visits to the households they served, to promote various good health practices and utilization of relevant health services available in the area.
After some deliberation, we concluded that one of the most useful additions to the CommCare app we could make would be to add a new module with specific guidance for newborn care. There was a high rate of neonatal mortality in the area, as is the case for much of the region. And there are also a number of actions families could take that had been shown to reduce mortality, such as a mother holding her infant against her body for warmth, or seeking immediate care and potentially getting antibiotics if there are signs of possible infection. It’s important that these practices are done very soon after birth, and there is a lot of urgency around having a CHW visit within 24-48 hours after a home birth.
We developed a module that would guide a CHW to promote these activities, based on international standards. We then asked the CHWs to use it for every birth, and to let us know what worked and didn’t so we could improve it. The initial uptake was very slow. We further encouraged the CHWs to figure out which of their clients were pregnant and expected to deliver soon, and ask to be notified when there was a birth. But we still were seeing only a few births per week. I recall repeatedly doing calculations based on the fertility rates of the area to confirm that there really should be more births happening in the areas served by these CHWs. (I might mention at this point that I was doing all this from afar, working with colleagues based in Dodoma.)
Out of desperation to get more feedback on our newborn module, we decided to add in an incentive. After consulting with the CHWs about items the mothers might be interested in for newborn care, we decided that the CHWs would give a small gift package to mothers they visited within 24 hours of birth: soap, a blanket, a knit hat for baby, and cloth diapers. This did the trick. There was palpable excitement among our CHWs, and the number of births in the area seemed to shoot up overnight! The team continued the practice of these gifts for new mothers for as long as Dimagi helped support the program. The 35 CHWs eventually went on to run a number of enterprises in the area, including a pharmacy in an underserved area, and were excited to continue the practice even then, if they could.
This has stuck with me as an important lesson to always think about what is valued by the various users in our system. It was a bit too easy for us to decide that the information we were providing would be very motivating. From our perspective, we were providing incredibly high-value information to the community, information that could literally be life-saving. But the community may have been used to getting lots of public health messaging. On the other hand, there was clearly a lot of excitement around the CHWs providing something of tangible, concrete value to their clients—rather than just gathering data or providing advice. This connected us in a much more positive way: welcoming CHWs into the homes of new mothers celebrating this happy moment.
Dr. Neal Lesh is currently the Chief Strategy Officer at Dimagi.