Community-based health workers are the first line of medical support to many persons in Sub-Saharan Africa, particularly in rural enclaves and regions suffering from the effects of war or sectarian violence. In many instances, a CHW is the only medical practitioner asset available and is charged to not only provide basic, but complex and life-saving medical support.

The skills demanded and capabilities inherent in CHW assets vary enormously from country to country and region to region. In some areas a high degree of training is available and demanded whilst in others little or no training or support is provided. Effectively these CHWs are simply members of the community with basic expertise and/or respect and standing within the community.

One of the biggest challenges facing CHW is access to educational content and ongoing training. This content is required to cover areas as diverse as basic medical care advice and instruction through medical procedure best practice to gathering registration and medical data records for patient’s ongoing care. The latter requires compliance to criteria that differ by country to country and region to region, following set procedures such as how to fill out medical forms and records for Health Ministry records compliance.

Providing support to CHW’s and other front-line medical support assets is a challenge external third parties, including charitable organisations, NGOs and pan-regional organisations, have tackled. These players face numerous challenges in providing support. Some of the more prevalent include:

• How to disseminate information in the most efficient manner where literacy rates are low and visual/diagrammatic representation is required.
• The need to create replicable standards for more efficient dissemination of information.
• The requirement to adapt content to cultural, religious and political mores, where certain images or content are deemed inappropriate. In some countries political pressure may limit the efficacy of content if a country wishes to deny the prevalence of a particular disease.
• The need to effectively gauge the impact of any externally funded or Health Ministry run initiative to educate CHWs.
• The demand to evaluate health practitioners and their on-going learning/education.

Role of mobile in sustaining and growing CHW assets

The mobile platform has an important role to play in tackling a number of the challenges highlighted.

In terms of dissemination of information; mobile penetration continues to grow at an astounding rate in Sub-Saharan Africa and remains the largest broadcast platform for the dissemination of information.

In relation to adaptation and challenges of making content consumable for different audiences; mobile content is inherently adaptable, the only limitation being the capability of the end-users device. Content can be static or dynamic, text-based or visual and can be animated to increase the detail and impact of information provided.

There is some capability within the MNO network, including the HLR to measure the effectiveness of training campaigns by recording access, download receipt of pushed SMS and in some instances interaction with content if click- through-rates can be gathered (depending on access device). There remain issues in relation to multi-SIM use and the sharing of devices which are common activities in some African countries, but the data remains useful as an indication of practice and consumption.

But what of the more complex challenges of monitoring improvement in CHW skill-sets, gauging the impact of CHW initiatives and ensuring that the new skills taught are sustained and continuously developed?

Here too, mobile can provide a solution that exploits its unique immersive quality and the capabilities resident in a portable application environment. This opportunity is gamification and the applications that can be designed around it.

Gamification apps role in CHW training competency ‘levelling up’

Gamification is the use of game playing mechanics, in particular desires for competition, achievement, status, and fulfilment (conclusion of a set goal) to encourage particular behaviours and behaviour sets.

The concept of gamification is a relatively new one for the medical industry. There has been some adoption of it in medical apps in developed Western markets and it has been used extensively in marketing, customer relationship management and consumer retention. It has even found its way into end consumer products with the successful Nintendo Brain training series. In developing markets, there have been limited use using games targeted at youth segments to discourage unsafe sex activities and drug use, but little attention has been paid to its potential in regard to medical healthcare practitioners.

For CHW’s gamification provides a ready-made training device and mechanism to evaluate ongoing improvement and to gauge the impact of particular health initiatives or training schemes. The most successful incentives to encourage take-up of gamification are the fulfilment of status achievements potentially linked to small-scale payments themselves fulfilled through the mobile device, providing levels of certification based around achievement fulfilment and encouraging competitive dynamics by comparing regional performance of CHWs in other neighbouring districts. The creation of accounts linked to specific CHW resources would also allow for ongoing tracking and evaluation of health practitioners, while allowing any new healthcare initiatives to be taught in a competitive environment (scoring for percentage correctly completed) and retested as part of an ongoing evaluation process.

The advantages of testing, identifying knowledge gaps and improving health practitioner skill sets using initiatives like gamification apps is particularly important in activities where 100% competency is desired. Putting it in bold terms, if a health worker providing critical care is 80% competent then there is a 20% chance of death. To achieve 100% competency training and evaluation is key. With existing CHW training based around printed texts individuals might only view content once and are invariably not tested on the content itself. With gamification linked to training there is a drive to achieve 100% competency. This idea nicely summed up in a quote from Michael McGar, an early champion of gamification, “Gamify content, seeks 100% competency through levelling up”. Levelling up is the process of attempting, re-attempting and if required attempting again with the desire to reach perfection.

Whilst gamification has the potential to assist in the process of training and on-going development of CHW assets it is critical that applications are developed within the parameters of any successful business service. Objectives must be clearly evaluated, with the target audience being treated as consumers rather than objects of manipulation. Any gamification health care training application must hold up as a business in its own right. If this can be achieved then the app will be inherently attractive and so take-up will be guaranteed.

The GSMA mHealth division is well placed to facilitate relationships between medical industry stakeholders, mobile players and the VAS partners who develop gamification applications. We will continue to occupy this position striving to develop relationships and bring concepts and ideas forward, to successful tackle the challenges facing healthcare in developing markets and toward achieving the Millennium Development Goals. 

For more information on the GSMA Mobile for Development mHealth, please contact us on [email protected]. For information on various mHealth initiatives, click here. For more information on GSMA mHealth resources, click here.