Questions/Answers

TeCHO+ is a mobile & web based application which works as a job-aid for health workers and administrators for improving coverage and quality of health services. It provides name based tracking of pregnant women, children and entire population using mobile phone application in hands of frontline health workers and linkage with health facilities.Our vision is: A world 1. Where every person has the information they need to keep themselves and their family healthy no matter who they are or where they live 2. Where every health worker has the tools she/he needs to provide consistent and excellent care 3. Where the health system supports continuity of care through better information, logistics and management. The objectives of TeCHO+ is to improve following health outcomes FOR CITIZENS: (1) Maternal Mortality Ratio, (2) Infant Mortality Rate, (3) caring of low birth weight babies, (4) complete immunization, (5) under nutrition,(6) anemia among mothers, (7) mortality and morbidity from epidemics, (8) sex ratio at birth, (9) mental health, (10) family planning/spacing methods, and (11) prevention, screening and treatment of non communicable diseases. Above objectives are being achieved through real time, point-of-service data entry by community and facility based health providers and engaging communities through technology based tools for social behavior change communication. TeCHO+ also aims to improve efficiency of the HEALTH WORKER through digitization of record keeping and remove the need of paper registers. For HEALTH SYSTEM, TeCHO+ is providing real time data for monitoring & supervision through real time paperless service data entry

The initiative is linked to category of "Promoting digital transformation in public sector institutions” because: 1. Longitudinal, digital tracking of citizens' health status and services by digitization of record keeping of frontline health providers through use of mobile-phone application. 2. Digital tools for health managers to facilitate supportive supervision of health providers and logistics management 3. Targeted client communication using multimedia to transmit targeted health information to citizens 4. Scheduling, activity planning, triaging and decision support in form of digital mobile based checklist to encourage frontline health workers to adhere to protocols and ensure quality.

Primarily, it is relevant to SDG-3 "Good health and Well-being". Additionally, SDG-2, 5, 8, 10 and 17 are fulfilled. 1. Reduce global maternal mortality ratio, 2. End preventable deaths of newborns and children 3. Reduce premature mortality from non-communicable diseases, 4. Ensure universal access to sexual and reproductive health-care services. The initiative contributes towards the above objectives through DIGITIZATION in the following ways: 1. Improving coverage and quality of community and facility-based interventions such as antenatal care, facility delivery, home-based newborn care, exclusive breastfeeding, vaccination, integrated management of childhood illnesses 2. Better prevention, screening, and management of non-communicable diseases 3. Fulfilling unmet family-planning needs. The TeCHO+ application provides IT backbone for Universal Health Coverage through digitization of health records of the entire 65 million population in Gujarat, India and strengthening primary health care along with linkages with secondary and tertiary care health facilities. The interoperability of the IT platform with other IT systems is opening opportunities for inter-sectoral collaboration across various social sectors which is helping various government agencies to coordinate efforts towards achieving SDGs

The initiative is in the complete alignment of government policy to digitize public services which assure it’s economic sustainability. The paperless system has saved 1.8 hours every day of health workers by removing paper-based record keeping and saved many trees. The technology has empowered health workers greatly in the health system and their communities giving impetus to gender equality and creating a better working environment. The initiative has a special emphasis on vulnerable populations such as the indigenous population, women, and children to reduce inequalities. It’s one point solution institutes self-sustaining arrangements ensuring improved health care across the state.

The pilot project was implemented first in a hard-to-reach, under-served area with 80% indigenous population. The primary target population is pregnant women and children under the age of five years. Moreover, evaluations have noted that the benefits of the initiative are distributed equitably. India carries the largest burden of maternal, and infant mortality and malnutrition in the world. To hasten the improvement of the coverage of health services, a new cadre of village-based frontline workers, called Accredited Social Health Activist (ASHA), was introduced by the Government of India in 2005. Unfortunately, coverage of some of maternal and child health services to be delivered by frontline health workers remained low, especially in tribal areas. Inadequate institutional capacity leading to insufficient supervision, support and motivation of health workers were thought to be some of the most important reasons for sub-optimal health services. To overcome the above-mentioned governance problems, the TeCHO+ initiative was developed. TeCHO+ is a mobile phone and web application to increase the performance of the ASHAs and Primary Health Center (PHC) staff by creating a digital platform to improve supervision, support, and motivation for improving coverage of health services to be delivered by ASHAs and PHC staff.

Most of the health providers of TeCHO+ are female front-line health workers from rural areas who are first time users of technology. The technology has empowered them greatly in the health system and their communities. Such empowerment is giving impetus to gender equality in their communities and creating a better working environment. The initiative has a special emphasis on vulnerable populations such as the indigenous population, women, and children to reduce inequalities. The initiative improves health, undernutrition, gender equality, working environment for health providers, and equality through effective partnerships.

The target groups are 1. Citizens, 2. Health providers and 3. Health managers. The citizens are now receiving better quality of primary health care services with improved coverage. This has been made possible through improvement in the performance of health providers and supervision by health managers through the use of technology. The following are some of the ways how TeCHO serves the target groups. Citizens:  Targeted client communication using multimedia to transmit targeted health information and improve counseling for behavior change communication Health providers  Longitudinal, digital tracking of the entire population’s health status and services  Scheduling and activity planning in the form of reminder  Decision support in the form of a digital checklist to encourage adherence to protocols during home visits.  Receive training content in the form of multimedia files  Decision support in the form of a digital checklist and In-built algorithms to screen and risk-stratify a high-risk case Health managers  Referral coordination to facilitate referral to the functional facility and emergency transport  Manage electronic health record of  Notify stock levels and stock out of health commodities  Manage financial transactions

The implementation of TeCHO+ was divided into two phases. The first phase (2013-2017) was software development, pilot and evaluation in two tribal districts of Gujarat. The second phase (2018-present) included scale up in all 33 districts of Gujarat among 65 million population. The second phase was further divided into customization software to accommodate scale, importing of legacy data, change management, procurement/distribution of 11,000 mobile devises, and training of all 11,000 frontline health workers and 2,200 health facilities. All 11,000 frontline health workers (all women) were given an android smartphone with a postpaid data plan in 2018. This was followed by the digitization of population enumeration/census of entire Gujarat to create a single denominator. Subsequently, reproductive and child health module, non-communicable disease module, mental health, ophthalmology were introduced in a phase-wise manner. As a result, 99% of the population, 95% of pregnant women, 90% of children under the age of five years have been registered through TeCHO+ application by frontline health workers. A mobile phone-based monitoring dashboard in form of “State of Health, Gujarat” application, freely available on Google Play Store, was developed to quickly access critical health indicators by the block, district and state-level technical, administrative and political leadership as well as citizens. Such free access to health data to all has improved transparency. Lastly, a mobile phone application is recently introduced for citizens for targeted client communication. Private health provider uses an application to record services provided in the private sector. It’s important to note that the aforementioned applications are on a single IT platform and have one single population denominator so that there is a single source of truth for the entire state. The systems and processes of implementing the project were accredited by the International Standards of Organization(ISO9001:2015).

Change management to ensure uptake of TeCHO+ was an important challenge. Health workers were accustomed to using paper registers, initially resisted use of technology. However, effective communication, leadership and providing non-monetary incentives helped to manage this change. Gujarat collected health-related data over last decade through another web-based application and preservation of this legacy data was important technological challenge. However, two IT agencies worked diligently to ensure that almost entire legacy data was preserved. Non-availability of a unique identifier for citizens is an important challenge to ensure interoperability with other IT systems. However, India’s unique identifier number, Aadhar, is now available to overcome this challenge.

TeCHO+ is first initiative globally in which multiple mHealth strategies are implemented in a Low and Middle Income Country, through frontline health workers in existing public health system throughout the continuum of care towards improving a wide range of maternal and child health outcomes. The mHealth strategies include a digital decision support system for triage, behavior change communication, data-management for supervision with special emphasis on hard-to-reach populations using a robust research methodology to attribute effectiveness to the initiative. TeCHO+ intervention uniquely targets the entire scope of potential beneficiaries of mHealth solutions including health providers, beneficiaries and health-system managers.

Not relevant

Yes. Initially, the project was piloted in one administrative block in the form of the "Janani (motherhood) Project". Subsequently, it was expanded to 2 rural, tribal districts of Gujarat. Then, it was expanded to all urban areas and all 33 districts of Gujarat state. Additionally, the TeCHO+ mobile application has been adopted by a non-governmental organization as well. Recently, the Government of India and many states have shown an active interest in replicating the project outside Gujarat.

NA

A variety of resources, including financial, knowledge, social capital, and cultural resources are used to design and develop the software. The one-time resources required are: software development cost, training cost, mobile phones; Ongoing resources required are: data transfer cost (internet), software maintenance, quality assurance costs, refresher training. A cost-effectiveness study found that the TeCHO+ initiative is a cost-effective intervention from a program perspective at an incremental cost of 78 USD per life-years saved and 5,298 USD per death averted.

The initiative is designed and implemented within the government-run program based on the existing roles of all stakeholders, in the complete alignment of government policy to digitize public services. Direct entry in TeCHO+ ensures environmental sustainability by making it a paperless register system. TeCHO+ removes duplication in record keeping which saves health providers' time for better healthcare. Most of the health providers of TeCHO+ are female front-line health workers - rural areas, being the first time users of technology empowers them greatly in community, empowering great impetus to gender equality. The initiative has a special emphasis on vulnerable populations - indigenous population, women, and children to reduce inequalities.

Yes

Effectiveness was evaluated through an open two-arm, parallel, stratified, cluster-randomized implementation research trial involving 22 Primary Health Centers (Total population 476943) located in six tribal blocks of Bharuch and Narmada districts, Gujarat. The evaluation happened from 2015 to 2018 with support from WHO-Geneva and Indian Council of Medical Research-Delhi. Acceptability of initiative was evaluated through a series of qualitative interviews of health providers. Cost-effectiveness from a programmatic perspective was tested.

1.Infant mortality rate 2. Coverage of health services: 2.1 Home visits by health providers, 2.2 Counseling services 2.3 Home-based newborn care, 2.4 Early and exclusive breastfeeding, 2.5 Care seeking for antenatal and postnatal complications. 3. Cost-effectiveness measures: US dollars per life-year saved, US dollars per death averted 4. Process indicators: Login rate, task closure rate to know actual use and uptake of the mobile phone application

1. The infant mortality rate was 16% lower in the project area compared to the control area. 2. Coverage of following health services was higher in project area compared to control area: 2.1 ASHA home visit during antenatal period was 80% higher in project area 2.2 Satisfactory counseling during antenatal period was 90% higher 2.3 Home-based newborn care was 49% higher 2.4 Exclusive breastfeeding was 64% higher 2.5 Significant improvement in care-seeking 3. Highly cost-effective: 78 USD per life-years saved and 5,298 USD per death averted 4. Login and Task closure rates were more than 75%

TeCHO+ is an integrated IT solution for public health by integrating various levels/cadre of users, different locations of service provision, and a wide range of health services. TeCHO+ is used by ALL the cadres in the health system based on their roles and responsibilities. Its users range from state-level political leadership and administrators/bureaucrats, international development agencies, district and block level supervisory cadre, and service providers. TeCHO+ is used at community, health facilities and free emergency ambulance services. This helps with referral linkages and continuum of care. Techo is an integrated platform to support comprehensive primary care ranging from reproductive and child health, non-communicable diseases, mental health, and ophthalmology. TeCHO+ is integrated with the national IT portal by creating interoperable systems. Hence, it is integrated vertically and horizontally.

A multi-disciplinary team is involved in this initiative. The Government established partnerships with civil society organizations, like-minded software companies, academic organizations, international agencies, research organizations, and public health organizations. 1. Government, SEWA Rural (Civil society organization) and software company (Argusoft India Ltd) were involved in designing the software and piloting the initiative. Argusoft India Ltd has provided the software at free of cost to the Gujarat Government. Local tribal communities actively participated in developing the requirements for the software and their cultural aspects were taken into consideration while designing the software. 2. SEWA Rural, Indian Council of Medical Research and World Health Organization-Geneva evaluated the initiative. Indian Institute of Public Health did a cost-effectiveness study. 3. GVK EMRI (another non-governmental organization) and UNICEF were partners with the Government in scaling up the initiative in the form of a public-private partnership. 4. A variety of civil service organizations from health and non-health domains are involved for cultural folk form for social and behavior change communication.

Digital job-aids can improve health outcomes when programmatic objectives (ie. reducing mortality rates) are aligned with personal priorities of health providers (eg: timely payment of incentives). We aimed at using technology as a job-aid to make health workers’ and health managers' tasks more efficient by saving time from paper-based record-keeping and effective towards health outcomes. This approach resulted in higher uptake of technology-based interventions, improved coverage of health services equitably and improve skills, knowledge, and self-confidence of female health providers. To further improve the initiative, we have plans to expand the scope of the initiative by including other health domains. Attempt is underway to make TeCHO+ interoperable with other health and non-health IT systems. The Government of India is seriously considering replicating the success of TeCHO+ to other states outside Gujarat.