HMIS 'Mitra' / HMIS Buddy

The Health Management Information System (HMIS), managed by the Ministry of Health & Family Welfare (MoHFW), Government of India, is one of the largest systems that monitors the National Health Mission and other health programmes and provides key inputs for policy formulation and appropriate programme interventions. It provides rich information from over 2,00,000 health facilities, including more than 30,000 PHCs. Across the country about 10 lakh (1 million) frontline workers (ASHAs) report on several indicators, under different portals including HMIS, covering supplies and services related to maternal, newborn, children and adolescent health, family planning, nutrition, and immunization.

ASHAs are dedicated at the village level, serving a population of 1000-2500; they serve as the backbone of the public health system in India. They provide the essential last-mile services and are an important and oftentimes the only conduit between the community and the public health system. They provide door to door services–visit the poorest and the most vulnerable, counsel couples and pregnant women, provide medical care for minor ailments such as diarrhea and first aid for minor injuries, and conduct vaccination drives at the village level. They are also responsible for creating awareness about the various health-related services and schemes available to people, and encouraging them to use those institutional services. Additionally, they work with adolescents, bring married couples to primary health centers (PHCs), provide contraceptives, monitor pregnant women and accompany them to medical facilities for delivery.

Given the crucial role of frontline workers gathering data at the community level, ASHAs are overburdened and lack the basic institutional support. They are considered volunteers, and receive outcome-based remuneration. For example, if an ASHA facilitates an institutional delivery she receives ₹600 (US$7.50), ₹150 (US$1.90) for each child completing an immunization session and ₹150 (US$1.90) for each individual who undergoes family planning.

ASHAs are the primary healthcare providers for millions of citizens in the country but lack the resources and support to drive improvements in quality of services and care for better health outcomes. As part of our research, we found that there is a missed opportunity in including ASHAs within the public health system such that they can make decisions using HMIS to detect and control emerging and endemic health problems, monitor progress towards health goals and promote equity. However, HMIS being the key data source for health planning is critical but rarely actionable; it primarily functions as a data reporting tool, especially at the primary healthcare level for frontline workers (ASHAs). 

The data flow of HMIS follows a one-way, bottom up approach, i.e. aggregated information on services provided on a monthly basis are initially typically entered into paper registers by accredited social health activities (ASHA) workers. These are then compiled by Auxiliary Nurse Midwives (ANMs) at a Sub-Center (SC) level. The data from the compiled registers are then entered into an online HMIS portal at Primary Health Centers (PHCs), although the IT infrastructure may not always be available at the PHC (resulting in the burden of digitizing the data to fall on the personal resources of health workers). Data on the services provided at Community Health Centers (CHCs) and District Hospitals (DHs) are entered directly at that level to the HMIS portal. The data entered at various levels are aggregated at district, state and national levels. 

The specific problem we seek to solve is the lack of data-driven decision making at the primary health care levels by ASHAs, in particular. Health data reported by ASHAs into HMIS rarely is sent back to them with timely, understandable and actionable data to empower them to make evidence based decisions to improve the quality of care. The health system is currently not leveraging their tremendous existing networks and knowledge to fundamentally transform health-seeking behaviors of individuals and the population.

This problem of gatekeeping health related insights and information from frontline workers inadvertently results in a lack of understanding how reporting accurate health data also lead to better health outcomes apart from providing patient care. And since health policies at the national and state level rely on HMIS data, it is paramount to build capacity at the primary healthcare level for frontline workers to make data-driven decisions.

We are creating and piloting a communication tool in the form of a WhatsApp chatbot for ASHAs to learn and build a community of practice by sharing actionable, accountable and accessible insights using HMIS data. The chatbot bridges the communication gap between the frontline workers and the central HMIS team. Our solution seeks to enable:

• Distribution of information, HMIS data and insights in an easy and accessible way using WhatsApp. Our intention is to leverage existing data systems and networks for communication. Share stories of best practices on how good data can lead to good health outcomes to inspire and improve performance in rich multimedia formats for better understanding. Share meaningful and actionable insights, through trend analysis in their village, using HMIS data. All these channels of communication will be marshaled with a centralized system. 

• Two way communication, where ASHAs can share questions that can be answered via AI, other ASHA’s and experts, in order to improve their knowledge and skills to further evidence-based customization of care. Using natural language processing, answers will be suggested to questions that have been previously answered, and a platform to facilitate the ability of ASHAs to answer each other's questions will be created.

• Capacity building through tools and knowledge assets that can be shared over WhatsApp to provide improved care and later translate the services delivered into data for HMIS more efficiently and accurately.

• Easy measurement of the role of data-driven decision making in improving primary health care performance by measuring their engagement with the chatbot.

This solution will, in the long term, enable better processes and healthcare providing behaviors through evidence-based decisions while at the same time improve governance and accountability of frontline workers. We hope to enable frontline workers, in particular ASHAs, to contribute to and understand the connection between good health outcomes and good health data.

• Accredited Social Health Activists (ASHA) volunteers are the first and sometimes only point of contact for millions of people in villages and marginalized communities and the healthcare system in India. They are indispensable to the healthcare system. ‘Asha’, a Hindi word, which means hope. ASHA workers were recently honored at the 75th World Health Assembly for their crucial role in connecting the community with the health system to ensure primary health care services. 

• There are over 10 lakh ASHAs who administer medicines, vaccines, first aid, offer health advice and many other services across India. Due to the dynamics associated with their job, they play multiple roles – health care facilitators, health activists and service providers. However, while ASHAs do provide a myriad of services and play a potential role in providing primary health care, their lack of recognition in terms of pay and status means that they are systematically excluded from receiving any benefits from the system that they support. They are mostly women volunteers, and they earn money through task-based incentives under the National Health Mission (NHM), which is funded in a 60:40 ratio between the central and state governments. On average, ASHA workers do not earn more than INR 10,000 or USD 125 per month.

• In addition to a lack of financial incentives, some of the routine challenges they face include misunderstanding with the ANM’s, family issues, transportation issues, social insecurity, lack of self-confidence and increasing workloads, especially in the context of the Covid-19 pandemic. 

• ASHA’s ability to address the immediate needs of rural and marginalized communities means that they are as valuable as service providers. It is therefore essential to:

  • Build a community of practice where ASHA’s can learn and communicate, build relationships with other ASHA’s and community health workers, as this will have a positive impact on community health

  • Enable ASHA’s to measure data driven decision making at the primary health care level and enable them to do this more effectively

• The solution will enable the health system to fulfill a part of its responsibility for not only the recruitment and training of ASHA workers but also retaining and supporting them, and recognizing them as crucial pillars of primary health care. The health system can:

  • Leverage the  trust and community relationships that ASHAs build in their communities, and learn from their knowledge and experience

  • Ensure that ASHA’s can see and understand how their work contributes to evidence and data, and how in turn this evidence and data can affect and impact health outcomes 

This would be a novel intervention that would bring together frontline workers and the health system. 

As a human-centered design and innovation studio in India, we have more than a decade of extensive experience working with various projects and partners on understanding the needs and contexts of different health workers and stakeholders in the health system.

In 2022, we completed a project with the Population Council (supported by the Bill and Melinda Gates Foundation) in partnership with the Ministry of Health & Family Welfare (MoHFW) that sought to leverage human-centered design methodologies to improve the Health Management Information System (HMIS) data reporting and entry experiences for health workers. HMIS is a Government to Government (G2G) web-based Management Information System that has been put in place by the Ministry of Health & Family Welfare (MoHFW), Government of India to monitor the National Health Mission and other health programmes and provide key inputs for policy formulation and appropriate programme interventions.

This project involved research in six states in India. Multiple workshops and stakeholder consultations were conducted at different stages with the HMIS officers, project partners, health facility staff and frontline community workers. We combined insights and learnings from the field research with strategic knowledge from domain experts and allied knowledge from existing interventions in other parts of the world. 

While the research focus was largely on exploring problems that impact data quality, one of the most critical research insights was that  healthcare workers rarely connect health data with healthcare outcomes. Health data has a one-way journey, and doesn’t make its way back to health workers once they submit it. They rarely know how this data is used. Relatedly, ASHA workers (community level frontline workers) who are the first and sometimes only point of contact for millions of people in villages and marginalized communities and the healthcare system are excluded from this system, even though they are instrumental in delivering crucial health services at the primary health care level. 

This solution was one of three that was presented as a prototype to the HMIS team at the Ministry of Health & Family Welfare (MoHFW), Government of India. While the prototype presented to the HMIS team targeted health supervisors as the key users, upon reflection and further research, we feel this solution has the potential to dramatically impact health outcomes at the primary health care level, targeting ASHA workers as its key users. Through our research, we were able to engage with a range of health workers including ASHAs and other health system stakeholders, and include their ideas and inputs into our solution.

We are applying to the Challenge because the regular government procurement systems in India are very challenging to receive financial support from, for solutions like this. We would utilize the prize funding as a seed grant to demonstrate the value proposition of this solution, and how at scale it has the potential to positively impact the measurement of health outcomes at the primary health care level.

India has over 10 lakh ASHA workers, the largest workforce of frontline health workers, who are the only link for millions of people in villages and in marginalized communities. If they were to be equipped with relevant and actionable health data insights, it could be catalytic in enabling not just improved and measurable data-driven decision making, but also improved access and quality at the primary healthcare level, increased community participation, health literacy and care-seeking behaviors, and ultimately lead to better health and well-being of individuals and populations.