Abstract

Mobile health technologies have the potential to strengthen health systems by increasing transparency and accountability in those systems. In Uganda, researchers are partnering with UNICEF and the Ministry of Health to develop a mobile health (mHealth) accountability system and to evaluate its effectiveness in improving the delivery of reproductive, maternal, newborn, and child health services in Uganda.

Policy Issue

Improving reproductive, maternal, newborn, and child health is a key health priority across much of the developing world. Evidence suggests that one way to improve the quality and availability of health services is to improve transparency and accountability in those systems. Mobile technology offers a promising way to enhance communication between levels of the health system by more rapidly and less expensively collecting and disseminating information, particularly since mobile phone usage is widespread.  Given these benefits, it is widely believed that mobile health (mHealth) technologies have the potential to improve transparency and accountability in health systems, but there has been little rigorous research on such efforts. This research aims to help fill this gap.

Context of the Evaluation

In Uganda, child, infant, and neonatal mortality rates have declined in recent years, but maternal mortality rates have remained high, and there is still much progress to be made in infant and child health outcomes. In 2013, UNICEF partnered with the Ugandan government to launch “A Promise Renewed” in Uganda, a strategy that aims to improve child and maternal health outcomes across the world. As part of the strategy, the Ugandan government is rolling out detailed performance metrics to improve accountability in the health sector. 

Details of the Intervention

Researchers are conducting a randomized evaluation to measure the impact of sharing information about health facility performance with facilities and districts via mobile phone on the quantity and quality of care at health facilities. 

The study is taking place at 1,417 health facilities across 95 districts. There are four groups in the study:

1. Facility-level intervention only (374 facilities)
2. District-level intervention only (335 facilities)
3. Both facility and district level interventions (334 facilities)
4. No intervention (374 facilities)

The facility-level intervention: Facilities receive performance indicator reports (PIRs) monthly via mobile phone. These reports use the Ugandan Ministry of Health’s Health Management Information System (HMIS) data and are composed of three parts. First, they reveal the facility’s average performance over the past three months. Second, they compare current performance to performance at the same time 12 months before. Third, they provide the facility’s ranking in comparison to similar facilities within the district. 

The district-level intervention:  Each month, District Health Offices will receive one PIR via text message and one PIR via email. The email report will contain the same information as the facility monthly report, aggregated for each facility in the district. At the same time, a text message will be sent to district health officials identifying the top two and bottom two performing facilities in the district, as well as a reminder to look at the email of full facility level reports.

This design will enable researchers to test not only whether performance feedback impacts performance, but if it does, to whom (districts, facilities, or both) performance feedback should be targeted to have the greatest impact. 

The researchers will measure the impact of the performance reports on health service delivery, and provide support for improvements to HMIS and the mHealth capacity of the Ugandan Ministry of Health.

Results and Policy Lessons

Project on-going; results forthcoming.