“Apa are you using any contraceptive?” The Shashto Kormi (SK) lowered her voice as she said the word “contraceptive” probably because of the male members of our entourage. The reply was no and the next few questions confirmed that the woman was pregnant. The SK asked more questions, with her assistant diligently writing the answers on a registration card. Finally came out the “technology”. The SK took out her cell phone and began uploading responses on the app developed by mPower. Needless to say, for the mPower team, that was the sexiest part of the whole encounter.
BRAC’s Manoshi program has been in operation since 2007 and boasts impressive results of halving maternal mortality in urban slums from 294 to 135 per 100,000 births. Manoshi creates a comprehensive screening and support system for expecting mothers and sees them through from the start of her pregnancy to the first few years of her child’s life.
As we followed the Shastho Kormi on her morning tour, she explained the key was getting the women not to deliver at home but under the care of trained medical professionals. If the mother has no complications, she is taken to a BRAC delivery center where a certified midwife handles the birth. If the mother needs a C-section or has other complications, the health worker herself will take the mother to the hospital and see her through the red tape – which often let the poor slip through the cracks. Running parallel to the field network is an emergency hotline that the mother can call if she experiences an emergency. Usually, her first point of contact is the SK. In case the SK cannot be reached, the call center ensures a personnel higher up in the Manoshi chain is dispatched to address the concern. In addition to ensuring timely service, which often means the difference life and death, Manoshi also closes the loop in terms of accountability, since the electronic records show who was been proactive in responding and who has been lacking.
The program is impressive because the extensive monitoring and the feedback loop ensure no mother falls through the cracks. It’s an extremely resource intensive model, requiring skilled professionals and both physical and technological infrastructure but it seems to be working well in the urban context. I won’t start the debate on what will happen when Big Money dries up but for any entity that wants to replicate a model like this, the following points behooves reflection:
1) Scope for monetization = the whole service is entirely free from start to finish. The poor can be almost perfectly price elastic when it comes to free vs. not free. Cohen and Dupas show through arandomized control trial in Kenya that the demand for insecticide treated bednets falls by 60% at a price of $0.60 vs free-of-cost. Would the mothers, who now so eagerly welcome the SK into their homes, still demand her service if it were not free?
2) Role of technology = in the Manoshi project, mobile phones have primarily been utilized as a data collection tool. It serves no diagnostic purpose since the SK already knows the symptoms of a risky pregnancy through experience and training and does not need to wait for the app to generate any kind of response. While using mobile phones to create a closed loop information system is a useful application for healthcare, it’s not a revolutionary application for healthcare. Is it possible to deploy technology that will fill a knowledge gap in healthcare?
3) Role of women = we often view the role of women romantically in public health projects as integral to gain access into households and to discuss sensitive topics such as reproductive health. While this aspect is true, there is also an unspoken economic driver that ensures door-to-door models function only with women. The SK in the Manoshi project, who has a high school degree, is paid only BDT 4500 – barely minimum wage. A woman at the low wage skill-set in Bangladesh has fewer employment opportunities than men since most low-paid work is physical in nature. Men can work as a rickshawpuller or day laborer and earn an equivalent amount (probably more). Male workers at the minimum wage level have extremely high lateral job movement due to the large number of options available to them. It would be very difficult to retain a male worker at the wage level that Manoshi pays, let alone one with a high school degree. While we often see the role of women with rose-tinted glasses in public projects, the truth is – they also happen to be a very good bargain.
Posted by Shammi Quddus