9 789460 223693

ISBN 978-94-6022-369-3

Over the past decade, Sierra Leone has made progress in rebuilding

its health system and offering its citizens better access to improved

health care services. Yet, maternal and child mortality figures remain

unacceptably high.

The use of mobile communication technologies for health (mHealth)

has the potential to transform health services and improve health

outcomes, among others by strengthening communication between

clients, providers and managers. The evidence base for this claim, long

unsustained, has slowly grown over the past years.

It is against this background of challenges and opportunities that

the Sierra Leonean Ministry of Health and Sanitation embarked on

the intervention research reported on in this publication, aiming to

contribute to improving maternal and newborn health, including family

planning, while at the same time adding to the evidence for mHealth

effectiveness. This was done in close collaboration with its partners

the Medical Research Centre, the University of Sierra Leone, KIT Royal

Tropical Institute, Mannion Daniels and Text to Change.

This report covers the context, study design, methodology and findings

of a mixed-methods, quasi-experimental study that aimed to assess the

effect of integrating mobile communication strategies on maternal

and newborn health service utilization in the Sierra Leonean district

of Bombali. It ends with formulating recommendations on the scaling

up of low-technology mobile communication between health workers,

their managers, traditional birth attendants and clients, the role of

mobile communication in health information and promotion, a number

of logistical issues around network coverage and phone battery

charging, and further research. It thereby also dwells on equity concerns,

highlighting the risks of unacknowledged selection mechanisms that

may accompany innovative, technology-driven tools such as mobile

communication.

Mobile health: Connecting m

anagers, service providers and clients in Bombali district, Sierra Leone Mobile health: Connecting managers,

service providers and clients in Bombali district, Sierra Leone

Intervention study on mHealth for maternal and newborn health

in resource-poor community and health system settings

Mobile health: Connecting managers, service providers and clients in Bombali district, Sierra Leone

Mobile health: Connecting managers, service providers and clients in Bombali district, Sierra Leone

Intervention study on mHealth for maternal and newborn health

in resource-poor community and health system settings

Final report

DFID New and Emerging TechnologiesResearch Competition, Phase 2

April 2014

Authors Heidi Jalloh-Vos, Medical Research Centre, Freetown

Hermen Ormel, KIT Royal Tropical Institute, Amsterdam

Korrie de Koning, KIT Royal Tropical Institute, Amsterdam

Alpha Mohamed Jalloh, Medical Research Centre, Freetown

Kathy Herschderfer, KIT Royal Tropical Institute, Amsterdam

Rolla Khadduri, MannionDaniels Ltd, Bath

Fernando Maldonado, KIT Royal Tropical Institute, Amsterdam

Sarian A.Y. Kamara, Ministry of Health and Sanitation, Freetown

Abdul K. Jalloh, Medical Research Centre, Freetown

Liezel Wolmarans, KIT Royal Tropical Institute, Amsterdam

Bailah Leigh, University of Sierra Leone, Freetown

Edward Magbity, Ministry of Health and Sanitation, Freetown

David Daniels, MannionDaniels Ltd, Bath

Hajo van Beijma, Text to Change, Amsterdam

Samuel Kargbo, Ministry of Health and Sanitation, Freetown

Isaac Palmer, University of Sierra Leone, Freetown

Lynda Foray-Rahall, Ministry of Health and Sanitation, Freetown

Peter Hessels, KIT Royal Tropical Institute, Amsterdam

The project consortium partners are:

This publication was made possible thanks to the financial support

of the UK Department for International Development (DFID) with

co-funding from the Public Private Partnerships Sierra Leone

programme within MDG5 Meshwork.1

For enquiries, contact:

Medical Research Centre (MRC) Royal Tropical Institute (KIT)

Dr Heidi Jalloh-Vos Mr Hermen Ormel

5 Frazier Davies Drive Senior Advisor

Freetown PO Box 95001, 1090 HA Amsterdam

Sierra Leone The Netherlands

Tel +232 76 684 337 Tel +31 20 568 8578

E-mail hjallohvos@mrc-sl.org E-mail h.ormel@kit.nl, www.kit.nl

This is an open access publication permitting unrestricted use, distribution and reproduction in any

medium, provided the original author and source are credited.

Disclaimer: this document is an output from a project funded by DFID for the benefit of developing

countries. However, the views expressed and information contained in the report are not necessarily

those of, or endorsed by, DFID, which can accept no responsibility for such views or information or

for any reliance placed on them.

Suggested citation: Jalloh-Vos H et al. (2014), Mobile health: Connecting managers, service providers

and clients in Bombali district, Sierra Leone. mHealth for maternal and newborn health in resource-

poor community and health system settings, Sierra Leone. Final report. Amsterdam: KIT.

Cover photo: clients queuing at health facility (photo: Medical Research Centre (MRC)). Other

photos by MRC and KIT.

ISBN 978-94-6022-369-3

1 The MDG5 Meshwork for Improving Maternal Health is a cross-sector, cross-disciplinary network of more than 30 organizations based in Sierra Leone, Afghanistan and the Netherlands (www.mdg5-meshwork.org).

Medical Research Centre Government of Sierra Leone University of Sierra Leone

Contents

Abbreviations and acronyms 8

Acknowledgements 9

Executive summary 11

1 Introduction 23 1.1 mHealth feasibility study results 23 1.2 mHealth intervention study 24

2 Context 29 2.1 Maternal and newborn health worldwide 29 2.2 Maternal and newborn health in Sierra Leone 30 2.3 Bombali district 32 2.4 Priorities for MNH in Sierra Leone 33 2.5 mHealth in the international context 34 2.6 The scope for mHealth to improve maternal and newborn health 35 2.7 mHealth for maternal and newborn health in Sierra Leone 38

3 Study design and methodology 41 3.1 Intervention study objectives 41 3.2 Interventions 41 3.3 Methodology 46 3.4 Study limitations 54

4 Intervention descriptive information and process 59 4.1 Health facility information 59 4.2 Participant characteristics 60 4.2.1 Participants in qualitative interviews and FGDs (midline and endline) 60

4.2.2 Health worker survey respondents 62

4.3 Intervention stages 64 4.4 Client enrolment 65 4.5 Enrolment challenges and sensitivities 69 4.6 Phones and solar chargers 74 4.7 VPN, network coverage and network providers 75 4.8 Health workers ownership of and access to phones 79 4.9 Paying for phone calls 80

4.10 Charging the phone 82 4.11 Calling versus texting 84 4.12 TBA involvement 85 4.13 Scheme administration, supervision and phasing out 87 4.14 Mapping of other interventions 88

5 Findings regarding research objectives 93 5.1 Objective 1 MNH/FP service utilization 93 5.1.1 Communication between health workers and clients (quantitative) 93 5.1.2 Communication between health workers and TBAs (quantitative) 95

5.1.3 Reasons for communication (qualitative) 96

5.1.4 Communication sensitivities and confidentiality 100

5.1.5 Effect on service utilization 104

5.1.6 Reasons for increased service utilization 112

5.1.7 Perceived benefits 117

5.2 Objective 2 Health worker job satisfaction and communication 120 5.2.1 Frequency of communication among health workers 120 5.2.2 Reasons for health worker to health worker communication 123

5.2.3 Reasons for communication between health workers and TBAs 125

5.2.4 Job satisfaction and communication 126

5.2.5 Benefits 132

5.2.6 Continuation of the intervention 136

5.3 Objective 3 MNH referral systems 138 5.4 Objective 4 Maternal death notification reports 143 5.5 Objective 5 Health system issues 146 5.6 National phone line 148

6 Discussion, conclusions and recommendations 153 6.1 Utilization of MNH/FP services 154 6.2 Health worker job satisfaction and communication 160 6.3 Referral 165 6.4 Maternal death reporting 166 6.5 Implications for the health system 167 6.6 Recommendations 173

7 References 177

Overview of annexes 185

TablesTable 1: Factors affecting maternal and newborn health in Sierra Leone 35Table 2: Framework of mHealth domains 36Table 3: Overview of Bombali district interventions by stages and wedges 43Table 4: Overview of wedges and chiefdoms by PHU density 47Table 5: Data collection plan and variation 49Table 6: Average PHU distance in km to district headquarter town 61Table 7: Inventory of factors influencing workload 130

FiguresFigure 1: Diagram of mHealth interventions 42Figure 2: Client cards to promote Mami en Pikin wellbodi fone line (117) and PHU line 46Figure 3: Map of Sierra Leone with Bombali study district 47Figure 4: Distribution of PHUs by number of staff at endline 59Figur