KhushiHealth: Digitally Empowering ASHAs

One million, government-employed, community health workers known as ASHAs provide primary health care to 845 million people in rural India. They spread awareness, maintain a village health census and conduct home-based follow up care. Our solution seeks to shift the work paradigm from an unaccountable and inefficient paper-based system to a digital continuum of care for these ASHAs. Now being scaled by the Rajasthan Department of Health, our mobile app will empower 50,000 ASHAs to conduct India's first state-wide digital health census of 50M citizens. This system will also provide the ASHA with remote in-field training, prioritized duelists, earning projections, streamlined data sharing with nurses and medical officers, and assistance in the form of automated follow-up reminders and awareness messages to beneficiaries. Real-time, GPS mapped, data and in-built accountability checks, designed to minimize false reporting and left-out populations, will provide confidence to officials to track health and deploy resources.

ASHAs, serve as local, trusted facilitators of public health delivery for 845 million citizens in rural India. ASHAs maintain 11 paper registers to track and provide care for all national health programs - from family planning and reproductive child health to NCDs and TB. This format is designed for reporting, not for action - lack of data sharing from higher facilities, leave ASHAs without the insight required for follow-up care. Finally, once a month, ASHAs take up to a week to tabulate, travel, and share reports of 300 columns with data-entry operators at primary health centers.

Cumbersome reporting detracts from effective health service delivery and accurate field data. Last year, in Rajasthan, an estimated 200,000 home deliveries and 2500 infant deaths were unreported, while home based neonatal care visits and COVID-19 active surveillance visits were grossly over-reported. This false reporting occurs due lack of accountability and perverse incentives to meet an inaccurate denominator - generated from paper-based health census data. 

During COVID-19, when reliable census and field data was essential for governments to track disease spread, deploy adequate resources, identify high-risk beneficiaries and build the capacity of frontline health workers, the ASHA, our primary link to rural India, was underutilized. 

Our mobile platform enables the ASHA to conduct a digital health census of her village, report resource gaps, and follow-up with residents across all national health programs with an integrated due list. Our continuum of care referral system, which includes an offline mobile application for the ASHA, frontline nurses and doctors in the catchment area, enables streamlined sharing of beneficiary health data, ensuring informed action.

ASHAs are trained with blended modules on mobile app use and delivery of assessments, counseling, or treatments in tandem. Learning is supplemented with contextualized alerts, videos, and graphics within the app. ASHAs can use the app to call for assistance, monitor progress towards learning and health targets, and estimate monthly earnings from direct benefit transfers linked to health milestones.

Household-level, GIS-mapped data, collected by ASHAs, are aggregated for officials to efficiently deploy resources to meet local health needs. Automated outbound and IVRS calls, in the local dialect, share health awareness messages and reminders with beneficiaries, and follow up to check health status and to confirm interaction with the health provider. Accountability is also ensured through mapping of application use patterns, GPS data, and randomized review of satellite imagery (to ensure no left-outs).

Our solution's primary beneficiaries are ASHAs - female community health workers, who are elected by their villages to facilitate rural primary health in India. ASHAs visit families, door-to-door, to spread awareness, and conduct check-ups and home based treatments for all national health programs. Having worked with ASHAs, in the field, to design our solution, we have witnessed the burdens of a paper-based healthcare and reporting system. ASHAs must travel kilometers through tough terrain, carrying heavy paper registers, to households to provide care or local primary health centers to ask for help, receive trainings and deliver data to the data-entry operator (DEO). ASHAs are dependent on DEOs to receive their monthly payment, which often results in bribes being requested to get the job done. We believe that our capacity building modules, integrated mobile platform, referral system and automated voice call solution will not only improve work efficiency and purpose, but also financially, educationally, and technologically empower the ASHA to protect the primary health of her community. By empowering the ASHA and building a continuum of care, we can improve access to informed, timely, accountable and longitudinal health care for 845+ million citizens in rural India.

Primary health for 845+ million citizens of India begins and ends with the ASHA. During COVID-19 access to 1) essential medicines and 2) chronic disease care and 3) maternal and child care has been disrupted. But, the ASHA worker lacks tools for timely reporting of resource gaps, COVID-19 suspect cases and non-COVID-19 high risk cases. During health security threats, our solution empowers the ASHA to, in a timely and safe manner, report cases and resource requirements, provide follow up health care, and spread awareness about state guidelines and essential health practices to hard to reach, poor and low literacy populations.

Previously mobile health pilots have been trialed for ASHAs in UP, Bihar, and Gujarat. These solutions – focused on offline data capture -  have not facilitated capture of a complete digital health census or follow-up across all national health vertical programs for which the ASHA is responsible. These solutions also do not include a continuum of care between the ASHA, frontline nurses and medical officers of the catchment area. Our solution will not only be India’s first state-wide application of a digital health census, but will also include a comprehensive a follow-up module for the ASHA and a continuum of care as per national program guidelines. Moreover, follow-up will be uniquely connected with an automated voice call system in the local dialect to targeted beneficiaries.

Our proposed solution further stands out for how it ensures data accountability (GPS, satellite, IVRS calls, data quality checks) and how it gamifies the experience so ASHAs can project their monthly earnings. Finally, beyond the technology, the blended approach to training both the app and core skills is a key innovation to building the ASHA’s overall capacity to deliver better health care.

Our innovation comprises of an offline-capable mobile application for ASHA community health workers, a dashboard for health officials, and an automated voice call reminder/awareness system for beneficiaries. We will also provide a offline mobile application to front line nurses and medical officers in the catchment area which will have the capability to share beneficiary health data in an offline and online manner with the ASHA mobile application. This system will cover all national programs including reproductive child health, non-communicable disease and TB. Finally, we use GPS data, randomized satellite imagery mapping, IVRS calls to the beneficiaries, and a comprehensive data quality index, developed with Google AI for social good, to weigh and incentivize the accountability of the data reported. Data is stored on a secured server at the Rajasthan State Data Center, a Tier-4 secure government data facility.

A beta version of this mobile application was used in 2 blocks of Sikar, Rajasthan to perform a health census of 700,000 people over the course of 6 months. A beta version of our automated voice call system has been used in Udaipur, Rajasthan and has been shown, in a 2-year, randomized-controlled trial to improve infant immunization rates by a factor of 1.66 and decrease infant acute malnutrition by a factor of 0.26. Inspired by these promising results, the Department of Medical, Health, and Family Welfare has evaluated the overall solution and has selected it for scale-up with its workforce of over 50,000 ASHAs beginning this summer 2020.

Our primary outcome is early identification of high risk members in the community for early referral and follow-up care. To reach this outcome we seek to a) empower the ASHA, technologically, financially and educationally within her community, b) count everyone, including minority, left out populations across the state through the digital health census, c) facilitate longitudinal follow-up within the community through our mobile platform for the ASHA, frontline nurses and medical officers, and d) to ensure accountability to the work performed by the ASHA to ensure communities are not left out and that vulnerable populations are actually visited by the ASHA when required. 

We believe we can empower the ASHA through the mobile application by: removing the paperwork requirement, automating her reporting (and saving her travel time), automating some follow-up (through voice calls), motivating her by showing projected earnings, helping organize her daily and weekly plans (with integrated due lists within the app), and by refreshing her core counseling and health delivery skills in our blended virtual trainings.

Through the government’s mandate for the digital health census, we can ensure that everyone’s house is visited, a GPS is taken, and a health profile is recorded for members which are available. With use of GPS, satellite imagery, and interactive voice response calls to the beneficiary we can help ensure that this process takes place with high fidelity. This exercise will indicate members of the community that have high risk symptoms when the data is synced. Beneficiaries that go to the referral center for follow-up will receive diagnoses and treatments and their data will be captured by offline mobile applications used by frontline nurses and medical officers, which then feeds back into the ASHA’s follow-up care module – with prompts and notifications to ensure the care plan continues at home.

Currently: 0 (launch was postponed from April 1 to end June due to COVID-19)

By the end of this year: 50M+ (target out of 75M estimated residents of Rajasthan) people will be followed up by over 50,000 ASHA workers in Rajasthan

5 years: 250M+ across Rajasthan, Uttar Pradesh, Bihar

Next Year:

Successfully launch India’s first state-wide digital health census in the State of Rajasthan

Identify hundreds of thousands of otherwise left-out groups and vulnerable populations in the State of Rajasthan

Next 5 Years:

Digitally empower India’s largest community health workforce of 1M ASHAs to deliver informed care and receive structured continuing education through their smartphone. Rajasthan’s successful model can easily be replicated to other states that share common national vertical health programs.

Smartphone ownership by the ASHA varies from 20-70% depending on geography. First, ASHAs will need to locally procure phones. The government is still working to see if budgetary allowance can be provided for this effort.

Second, tens of thousands of ASHAs will need to be trained on not just the mobile health application, but on how to operate a smartphone in the first place. Our team, which leads master trainings (training of trainer’s model), will be limited in its ability to be present at block and sector level trainings – due to the scope and travel limitations with COVID-19.

We have designed the application to work on budget smartphones which can be locally procured. The government is planning to add a 2000 INR incentive for ASHAs to help them procure the phone. The mobile application will also help the ASHAs better capture their work and should generate more earnings in the long run.

Trainings have been adapted to ensure virtual VC participation at the district, block and sector levels. Standard operating guides, user manuals and shareable WhatsApp videos have been developed for offline and asynchronous training on the platform. With the strong leadership of the Health Secretary, support of the state’s administrative and training machinery, we will use a training of trainers model to overcome barriers.

38 full time, 4 part time

Our multidisciplinary team oversees the end-to-end implementation of this solution: public health research, design, software development, backend development and integration, master trainings, local implementation support, and policy level support. This integrated approach appreciates the challenges of the field and our end-users. Over the past 3 years, 15 of our team members have spent their full work weeks shadowing 150 frontline nurses and ASHAs across 400 rural villages of Udaipur, Rajasthan. With this experience, our team is well balanced to handle software development, analytics, capacity building and policy support for the Department of Medical, Health and Family Welfare.

Our key partner is the Department of Medical, Health and Family Welfare (DMHFW) for the Government of Rajasthan. The DMHFW works closely with our team to set requirements for the health indicators and overall platform design. By extension of our affiliation with the DMHFW, we are also able to use resources for deployment and scale of our platform with support from the Department of Information Technology & Communication, Government of Rajasthan. Other notable partnerships: 1) Google AI to develop a data quality index for frontline health staff,  2) JPAL to assess the impact of COVID-19 on maternal child health and 3) Harvard Medical school to assess barriers to referral care in rural Udaipur.

We are a non-profit in a 3-year, legal agreement with the Department of Medical, Health, and Family Welfare (DMHFW), for the Government of Rajasthan. Our contract ensures the DMHFW owns the solutions we build and implement. The DMHFW pays for the program costs, but does not pay us for our services. We have been recognized explicitly as the Nodal Technical Service Partner for the DMHFW’s flagship integrated health platform, Nirogi Rajasthan. Accordingly, we use our affiliation to raise funds from donors and funders to support our internal operating costs, while we scale impact through IT-enabling the government's vast public health delivery system.

We primarily raise funds from a combination of grants and partnerships with established funders. A small proportion of our funding comes through individual donors as well. 

Our path to financial sustainability comes from continued and scaled delivery of our innovative platforms for demonstrable impact in the maternal and child health space, which leads to follow-on funding. Our R&D expands access to new grant and research-based funding as well. Right now, we are in the process of raising a 1.5M ticket from private organizations to trigger 100% matching from the Bill and Melinda Gates Foundation, as a GAVI Infuse Pacesetter.

We are looking to partner with experts in big data and GIS technologies to ensure that we can use the best approaches to ensure no communities are left out of community health follow-up. We are also looking to design innovation educational modules for these frontline health workers.

When successfully implemented, our platform for ASHAs will be the second most used mobile health platform in the world after ICDS-CAS (for nutrition and early childhood workers in India). We will need to stay updated with the best methods to ensure optimized and secured use of our platform and experts at MIT and through SOLVE can help us perform at this scale

There may be opportunities to work with Blink Identity Touchless Identification and others to add new accountability mechanisms to ensure the ASHA worker is actually meeting due beneficiaries in offline settings.

We would like to nominate Ruchit Nagar, 26 years old, CEO and co-founder of Khushi Baby for the Elevate Prize. He is also a final year candidate at Harvard Medical School. Ruchit grew the organization out of a design course, as an undergraduate at Yale in 2014. He then completed his Master's in Public Health at Yale School of Public Health in Epidemiology and Global Health, where Ruchit was recognized as the Eric Mood Young Alumnus grantee and by Forbes 30under30 as a leader in health care. He has been motivated to apply his training in public health and medicine to create and scale innovations for mothers and infants at the last mile - all while leading a team of 38 and balancing his time learning on the hospital wards. Now Ruchit and his team are poised to transform the approach to community health in India through digital empowerment of over ASHAs, ANMs (frontline nurses) and Medical Officers. Our technology solutions aim to elevate primary health in other LMICs which share common challenges to health delivery.

Our digital continuum of care for the ASHA presents a big data set (50M+ beneficiaries) with longitudinal health outcomes, across health verticals. From this data set AI/ML models will be applied to pick up early sensors and develop a composite risk score for each individual. Geographical clustering analysis will help policymakers proactively deploy resources to make a difference on health behavior outcomes and health outcomes from family planning to management of NCDs. 

These AI/ML models will be used to develop early sensors for high risk beneficiaries and develop individualized health risk scores. The GIS models will also assist policymakers in proactive deployment of health resources.

We are empowering 50,000 female frontline health workers in the next year. With Khushi Health’s mobile health solution over ten thousand ASHAs will step into the digital world for the first time. Under the new digital health census, they will be empowered to locally procure their own phone (note only 20-30% of women in rural Rajasthan have ownership of their own phone). Not only will training on the smartphone unlock opportunities to gain independence, it will also directly aid them in the efficacy of delivering care to vulnerable populations in their communities (especially for adolescent and pregnant women). By showing earnings projections, this tool will help economically empower these ASHAs. And finally, through our blended training models – through sessions and via the app –  technical and health literacy of the ASHA will improve their ability and confidence to better serve their communities. 

The nature of the digital health census necessitates that everyone be counted, including migratory populations. With the help of partners like WHO, we have identified over 2000 high risk settlement areas where additional supervision will be provided to ensure these communities are not left out. This health census is especially important in the setting of COVID-19, which has caused great displacement and strife, particularly for migrant laborers across India. Inclusion of these populations by ASHAs into this system will ensure that national program health services be available universally. For example, if migrants are currently residing in the catchment area, even on a temporary basis, they will be included in the due-lists of the ASHA, frontline nurses, and medical officers to receive longitudinal follow-up care