Salamat: Tackling Maternal Mortality in Afghanistan via Tech

Salamat is the first maternal health application in Afghanistan that supports facilities in improving the follow-up care of maternal patients.

In January 2017, a Guardian news report stated that "maternal mortality rates in Afghanistan may be twice as high as numbers provided by donors and government data." Why is the maternal mortality rate in Afghanistan still so high despite the billions of dollars spent on healthcare alone since 2001? More importantly, why do we not know what this exact number is?

The Ministry of Public Health (MOPH) of Afghanistan recently invested in a Health Management Information System (HMIS), requiring all health facilities to report patient data using standard forms and submit them to the MOPH. The process takes approximately four steps of different paper work and is submitted manually. Our research on the HMIS revealed that patient records are inaccessible at least 70% of the time, and leaves healthcare professionals feeling overburdened and in need of a more efficient solution. Additionally, patients’ data within health facilities are not used for decision making, research, and learning purposes. The main reasons identified for lack of usability of patients’ data are difficulty in retrieval due to large numbers of physical records, improper recording of data, and high patient load. It is common to witness women waiting in line outside hospitals while in labor and delivering a child. The inaccessibility of reliable data has detrimental consequences, especially when it comes to pregnant women, and is why Afghanistan still has one of the highest maternal mortality rates in the world and remains one of the worst places to be a woman.

Salamat is the first maternal health application that aims to improve maternal health outcomes for women in Afghanistan. Created by our WISE team, the mobile application allows health professionals to login and create/update patient profiles with sections that log personal information, patient evaluation, antenatal care, labor, post-natal care, and final diagnosis. Salamat is focused on improving data quality and increasing communication with pregnant patients—pre and post birth—who lack appropriate education and resources. With information registered on the application, providers can efficiently track patients’ progress and can reach out to them for follow-ups via telephone or schedule appointments.

Salamat has been piloted in 5 health facilities where results and success show promise, and the demand for the application is represented through qualitative and quantitative data. The most beneficial features found was the ability to connect with pregnant women over the phone. These women are often uneducated and do not have a proper understanding of their health. In addition, the application is based off of the HMIS, which all health professionals are familiar with and do not need additional training on. Finally, the application provides comprehensive care, decreases the need for manual paperwork, and easily retrieves patient records.

The long-term vision for Salamat is to provide a platform for doctors and patients to make informed decisions about the time and type of medical intervention necessary. WISE plans to develop a sustainable solution by expanding Salamat to all public hospitals, and has already received support from leadership at the Ministry of Public Health and the Afghan President's office. Salamat translates to health in several Central/South Asian languages--salamat is the ultimate state of being that we wish for all pregnant women in Afghanistan, and we are determined to work towards that.

Through our partnership with Afghanistan’s Ministry of Public Health (MOPH), we completed a needs assessment on patient health records and found that there is currently no other electronic medical record system being used. Additionally, the majority of pregnant women who visit the facilities are uneducated and are unable to recall basic information, such as their infant's date of birth, their tazkira/national identification number, and phone number. Salamat is a platform that keeps track of such information and supports the MOPH and health facilities with making informed decisions about a patient's health. 

Salamat utilizes technology to record key maternal health indicators on the application. Technology is integral to our solution because we are using it as a platform to improve maternal health care. Moreover, the application is able to contact patients through automatic phone calls and text messages when they are overdue for an appointment. Salamat’s technology also helps doctors retrieve patient records through the medical record tracking system based on a patient's name, date of birth, phone number or tazkira number.  

• Ensure that all pregnant women in areas of Salamat operation are registered on the application and receive monthly reminders via call or text message.
• Educate women about general information that helps them maintain their own health as well as that of their children.
• Work with doctors to improve the application’s functionality.
• Expand Salamat beyond our pilot to other hospitals and clinics throughout the area.

Our vision is to ensure every pregnant woman is registered on Salamat. We hope to collect key maternal data for each patient so that not only can our stakeholders make informed decisions about patients’ health, but patients can also be more informed about best practices during and post-pregancy. WISE aims to collaborate with leadership at the MOPH so as to significantly improve women’s health throughout the country. Our organization firmly believes Salamat has a large potential to go beyond maternal health and include any and all patients in the future.

Our solution will be deployed through partnerships with health facilities and the MOPH. WISE was recognized by the Minister of Public Health for introducing the first maternal health application in the country and for a successful pilot. We hope to leverage this support to expand further and access patients without the tools and resources to improve their health and well-being. 

Approximately 1,300 women are registered on Salamat during the pilot thus far, and 5 health facilities in Kabul are using the application. The women who come to the facility are usually illiterate and do not know how to best care for themselves while pregnant. Our Salamat interns provide educational sessions and register them on the application for text messages and phone call reminders/information. Patients are taught healthy practices for mother and child, like not to lift heavy weight or the importance of breastfeeding. These sessions, in combination with Salamat's reminder feature, have helped Afghan women healthily manage their pregnancies.

In 12 months we hope to have 10,000 pregnant women in Afghanistan registered on Salamat. Like the women already registered, we hope that these 10,000 see improvements in their overall maternal health and patient care when they go see providers. In three years, we hope to have all women registered on our application. By 2025, we expect to see lower maternal/infant mortality rates in Afghanistan. With the application's efficiency in recording and retrieving patient information as well as follow-up features and patient education, pregnant Afghan women will know how to take better care of themselves, their unborn and newborn children.

Our local team has decades of experience in women's health, monitoring and evaluation, and finance. We have developed a strong working relationship with the Ministry of Public Health, and our team members are very familiar with the challenges present among health facilities throughout Afghanistan. Our US-based team has designed state-of-the-art technology in Silicon Valley, and managed large teams that design mobile technology. All of this talent combined has enabled us to launch a successful pilot and will be key in the expansion and growth of Salamat. 

Our revenue model is still in its early stages and we hope to utilize our network with MIT Solve to strengthen this model. We plan to partner with hospitals and charge them a monthly fee for use of the Salamat application. We are positioned for long-term sustainability because the application is already developed and very minimal funding is needed to continue its use. As long as the facilities are committed to using the app and the support from MOPH leadership is maintained, WISE will be able to successfully expand Salamat throughout the country. 

Solve will assist us in using technology to reach thousands of maternal health patients in Afghanistan. Funding provided by Solve can assist WISE with further development of Salamat and expanded functionality to include more features. Long-term, funds can be utilized to create versions of Salamat that can serve all patients.

Being selected would also allow us to be part of the Solve community. The opportunity to connect/collaborate with and learn from others around the world is exciting! WISE can look to other Solvers for suggestions and feedback, and we can offer advice about using technology in countries with unstable infrastructure.

Some barriers for the Salamat App are lack of access to technology, lack of trained healthcare providers on the application, and stereotypes that discourage women from visiting the doctor unless it's an emergency. The latter challenge often leads maternal and child mortality because it is often too late by the time the women seeks care. Solve can help WISE address these barriers by (a) designing a campaign around maternal health awareness, (b) providing tools to ensure providers are properly trained to successfully utilize the application, and (c) providing funding as well as a strategy that will expand our impact.