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Case Study: Wazazi Nipendeni Identifying Potential Strategies in Tanzanian SMS Maternal Health Services

Ali Searle Steve Reifenberg POLS 30595 November 2013

! Project Overview: Objectives, Strategies, and Theory of Change Wazazi Nipendeni (Swahili for Love me, parents) is a national, multi-media Strategic Behavior Change Communication campaign in Tanzania focused on improving maternal and child health. It seeks to integrate all stages of the maternal health continuum under a single platform, including early and complete antenatal care (ANC) attendance, malaria prevention, HIV testing and prevention of mother to child transmission (PMTCT), danger signs, individual birth planning, safe delivery, nutrition and postpartum care. Integral to the campaign is its unique mobile phone text-messaging (SMS) component, Healthy Baby, Healthy Pregnancy, which provides mothers, pregnant women and their supporters with informative text messages, free of charge. The projects ultimate goal is to reduce preventable morbidity and mortality by empowering women and their supporters to take crucial steps toward ensuring a safe and healthy pregnancy, delivery, and child. Evidence of Success Though still in its infancy, the Healthy Baby, Healthy Pregnancy service has made indelible strides toward improving the dissemination of information and services for healthy pregnancy and early childhood care. Within eight months of its launch in November 2012, The Project achieved national scale, confirmed by its subscriber base of over 180,000 Tanzanians. The number of subscribers is predicted to reach over 300,000 by its one-year anniversary. With an average enrollment of 7,000 new registrants every week, it continues to expand with extraordinary momentum. Looking beyond numbers, countless success stories can also be attributed to the innovative campaign. One pregnant mother of three acknowledged that, before receiving texts explaining that breast milk is all the baby needs, she had been unaware of this information and had given her newborns water and porridge. Now, she exclusively breast-feeds her five-month infant. Eliza, a first-time mother, similarly praised: I was happy to receive the Wazazi Nipendeni information. I found the text messages on my phone very useful during each period of my pregnancy. I liked the helpful tips, including the importance of attending clinics regularly. I learned about the need for testing and prevention. I feel that it benefited me to know these things. I was able to go and deliver my baby safely This service also assisted my husband to better understand what I was going through during my pregnancy, so he could be of greater assistance to me. "! !

! Anecdotal evidence also indicates that the campaign has had a significant impact on populations with which it has connected. Health workers recognize an increase in knowledge and heavier demand for medicines and services by patients who are enrolled in the campaign. Applicable strengths 1. Support from a multi-media campaign. The Wazazi Nipendeni complemented its SMS services with a multi-media advertisement campaign (including radio jingles, television ads, billboards and posters that publicize the short-code to enroll), which it asserts, has proven to be critical in building awareness of the messaging service, with registration rates reaching four times their average when there is a full media presence, versus without. 2. Analyze, Review, Test, Monitor, Adjust. The mHealth Tanzania Partnership demonstrated that successful development is a dynamic process. Building an extensive network of rigorous review into their project development, implementation, and expansion allowed stakeholders to achieve realize an effective campaign. Our client would benefit from a similar system of review, including: I. Draft analysis and technical feedback. This should include stakeholders from the Ford Program, the government, and the local community, as well as experts from applicable fields of technology, health, and communication. The Project used this review to reference messages and timing with international guidelines, determine a culturally appropriate density of information, simplify and localize messages for comprehension, include additional resources, and adopt other critical changes. II. Pre-testing and trial, review and modification. Before the project is taken to scale, it should be tested on a smaller scale. Wazazi Nipendeni found significant value in pre-testing the messages at different stages of the content development process, wherein it sought to identify any major service weaknesses, and confirm the demand for, as well as the direction and tone of, its messages. Health impact and attributable behavioral change should also be analyzed. III. Monitoring mechanisms. Routine monitoring of specific indicators, in addition to the development of baseline data, the collection of quarterly data, media monitoring and omnibus surveys, mid-line #! !

! household surveys, and exit interviews, has contributed to the sustained success of the program despite a number of challenges and misconstructions, and would be equally valuable for our client. 3. Integrated partnerships. The project reflects not the work of an isolated organization, which could be devastatingly overwhelming, but rather the combined efforts of numerous unique partners, each with a clearly defined role. Johns Hopkins analysts credit this for the sharing of expertise and pooling of resources that enables the services success. 4. Localizing content. This was found this to be one of the most challenging, yet critical, phases of design, since with limited space and characters to communicate important information to end-users, every word needs to have an impact. The project confronted problems similar to those expected for our client, including cultural suitability, illiteracy, and the difficulty of translating into Swahili (for example, clean water can be said in more than seven different ways, each with a unique meaning). Many of their conclusions and solutions are applicable to the context in Dandora, such as the importance of walking a mile in their shoes, consulting content experts such as MAMA for message referencing, and crafting purpose-specific messages in the local language, rather than translating them from English. 5. Edutainment. Interestingly, pre-tests and subsequent analysis indicate that users consistently perceive the service more favorably when entertaining messages such as fetal development are included in the regiment, a trend that may apply in Dandora as well. 6. Personalized enrollment. The campaign addressed gender gaps in literacy and phone ownership, as well as questions of what content is most relevant, by creating a system in which users can indicate their interest (pregnant woman, mother, supporter, or general interest) as well as their stage in the process (i.e. indicating the age of the fetus or baby). This enables experts to provide sufficient and pertinent information, and avoids overwhelming subscribers with too many messages. 7. Health worker orientation. This enables facility-based registration assistance, helping the campaign to reach a wider population, and also guarantees that health care professionals will be prepared to address questions in regard to content, and meet the resulting demand for service and medication. In Dandora, this model may be extended to include community health workers, as well. $! !

! 8. Free. A system with no user-cost creates an inclusive program capable of reaching its target population of the poorest individuals. Wazazi Nipendeni achieved this by partnering with a mobile server, Text to Change, and utilizing its state-of-the-art Vusion platform. The power to sustainably provide effectively free services, resulting from strategic partnerships and generosity from the private sector, underscores both a challenge and a hope for the Ford Program. Noteworthy limitations Despite the great improvements engendered by Wazazi Nipendenis work in Tanzania, its efforts also highlight a number of shortcomings, which our client should address in Dandora. 1. Illiteracy. The campaign in Tanzania is restricted to a literate audience, however demand suggests that if technology were enhanced to include voice-based messaging, it would be accessible to less educated populations. This is especially pertinent in Nairobi slums, where 3 in 10 women are illiterate. 2. Interactive services. Wazazi Nipendeni provides a wealth of guidance, but users are powerless to ask questions or seek specific information. Technology that facilitates questions and answer capabilities or user look-up functions may further empower subscribers, and personalize service. 3. Enhanced content breadth. Male- and adolescent-specific messages may facilitate more ubiquitous trust, interest, and knowledge of the Ford Programs efforts in the community. Tanzanian data reveals that 1/3 of users are mothers, while less than 1/5 are supporters. Increasing relevance for non-mothers may foster a more supportive environment, capable of preventing and recognizing more complications. Conclusion Comparative analysis demonstrates that Wazazi Nipendeni comprises a valuable model for the Ford Programs goals in Dandora. Its method of harnessing large-scale, innovative mobile technology, and its theory that providing high quality ANC information during pregnancy is crucial to keeping mothers and babies healthy and reducing maternal and newborn mortality rates encouraging women to seek care and treatment can save lives, demonstrates clear evidence of success. However, one must not fail to comprehend the unique context and enormous complexity of maternal health care. If adapted by the Ford Program, the model should reflect information and services based on localized dangers in Dandora (where, for example, failed abortion and anemia %! !

! are frequent causes of preventable maternal and newborn death). While it may benefit from emulating Wazazi Nipendeni, our client lacks equivalent resources, and should therefore scale its goals appropriately. Finally, the Tanzanian Ministry of Healths robust role in the design and implementation of Wazazi Nipendeni emphasizes the clout that stands to be gained when local government is recruited as a project asset, rather than an obstacle.

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Information was compiled from the following sources: "Healthy Pregnancy, Healthy Baby Text Messaging Service." MAMA Spotlight (July 2013): 1-19. Mobile Alliance for Maternal Action. Web. Kenya National Bureau of Statistics (KNBS) and ICF Macro. 2010. Kenya Demographic and Health Survey 200809. Calverton, Maryland: KNBS and ICF Macro. "Largst Scale MHealth Project in Africa: 'Healthy Pregnancy, Healthy Baby'-Text Messaging Service in Tanzania." Text to Change, July 2013. Web. Mitullah, Winnie. "The Case of Nairobi, Kenya." Understanding Slums: Case Studies for the Global Report on Human Settlements. UCL, 2003. Web. "Wazazi Nipendeni: How Text Messages Are Supporting Mothers in Tanzania." CDC Foundation. MHealth Tanzania, 9 May 2013. Web. "Wazazi Nipendeni (Parents, Love Me): MHealth Initiative to Support Maternal Care in Tanzania." MHealth Compendium: Technical Report 2 (2012): 20-21. USAID. African Strategies for Health Project, May 2012. Web. Ziraba AK, Madise N, Mills S, Kyobutungi C, Ezeh A (2009) Maternal mortality in the informal settlements of Nairobi city: what do we know? Reprod Health 6: 6.

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