Building an evidence base to support and enhance community health workers' (informal) use of mobile phones in Ghana, Malawi and Ethiopia

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Africa's recent communications 'revolution' has generated optimism that using mobile phones for health (mhealth) can help bridge healthcare gaps, particularly for rural, hard-to-reach populations. However, while scale-up of mhealth pilots remains limited, community health workers (CHWs) across the continent possess mobile phones. CHWs form a vital part of healthcare delivery across Africa and many countries are scaling up their deployment (target of 1 million CHWs).There is thus enormous untapped potential here. While much research has focussed on formal mhealth initiatives (small-scale successes, challenges of scale-up), we know almost nothing about what CHWs across Africa are doing with their own mobile phones, and with what implications for healthcare. Last year, we published what we believe to be the first study to have looked seriously at this issue (Hampshire et al, 2016, Health Policy & Planning) Our very small-scale preliminary study, based on interviews with 16 health-workers in Ghana and 18 in Malawi, revealed that CHWs used their own mobile phones regularly (often on a daily basis) to communicate with colleagues and patients, obtain help in emergencies, seek information, organise work logistics such as drug supplies, etc. By contrast, only one had ever participated in a (now defunct) formal mhealth programme. The potential for what we have called 'informal mhealth' to enhance primary care in resource-limited settings could thus be very significant. The CHWs we interviewed were innovative and adept at harnessing new features on their phones to help manage their work. However, our study also pointed towards challenges, both for patient care and health-worker wellbeing, including: the financial burden of phone costs and emotional burden of being available to patients 24/7; decreased face-to-face interaction with patients; concerns about patient confidentiality when communicating through personal phones; and difficulties in accessing reliable online information, etc. Our aim for this Foundation Grant is to build a strong evidence base of current mobile phone use among community health workers in Ghana, Malawi and Ethiopia (three countries committed to major CHW programmes), in order to enhance the effectiveness of 'informal mhealth' and address challenges. If our hypothesis is correct, and CHWs' 'informal' mobile phone use is widespread, this study could provide crucial evidence to support innovative ways to strengthen health systems in resource-limited settings. Methods:1) Comprehensive policy reviews of CHW programmes and mhealth initiatives in each country, plus analysis of health systems and contextual factors affecting implementation.2) Questionnaire survey of CHWs in each country to estimate levels of work-related mobile phone usage and collect comparable data on: (a)Split between formal and informal mhealth usage, and function/purpose (e.g. communicating with patients, colleagues, logistics, information seeking, etc.); (b) Estimated financial costs of phone use and who meets these costs; (c) Perceived benefits and challenges arising from this 'informal mhealth' for CHWs and patients.500 CHWs in Ghana and Malawi and 1000 in Ethiopia (where the total number of CHWs is much higher) will be sampled across multiple sites to cover a range of urban, semi-rural, rural settlement types. 3) Two sets focus groups of CHWs (minimum 14/country) and patients (minimum 6/country) will be convened before and after the survey, to reflect on current practices and experiences (incorporating survey findings), and to identify possible ways of supporting, enhancing and sharing good practice, and addressing challenges.4) Meetings and on-going discussions with national stake-holders throughout the project to feed into policy/practice (see impact summary).