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Chitra: Supporting localized healthcare provision by community health workers using a mobile mapping and visualization tool

Mobile platform for health workers to map community environments and disease incidence. Leverages machine learning for contextualized care.

Photo of Azra Ismail
18 10

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*Please Upload User Experience Map (as attachment) and any additional insights gathered from Beneficiary Feedback in this field

A user experience map has been attached. Primary users of the mobile application are the community health workers, and beneficiaries are underserved communities. A typical user will: 1. Download the mobile application. 2. Collect data using the app instead of on paper. 3. Receive notifications about potential disease outbreak. 4. Open the app to get more information about the area and disease risk factors. 5. Take action by following the app's suggested steps. 6. Improve health outcomes!

Why does the target community define this problem as urgent and/or a priority? How is the idea leveraging and empowering community assets to help create an environment for success? (1000 characters)

The target community is severely resource-constrained. Many of them cannot afford to visit a free government clinic due to long waiting times that cut into working hours. They also lack belief in government services. Living in slums near the polluted Yamuna river in Delhi, they are at high risk of disease. However, their conditions are overlooked by the local municipality and other authorities because there is no one holding them accountable for poor health in the area. Chitra leverages existing community health workers who have close ties to local communities, and are tasked with improving health and conducting routine surveys. Chitra helps health workers record robust data and view aggregated community health profiles. With this information, they can not only improve health by carrying out relevant interventions, but are also empowered to hold the local government clinic and authorities responsible for poor health. Thus, Chitra provides a sustainable and empowering solution.

How does the idea fit within the larger ecosystem that surrounds it? Urgent needs are usually a symptom of a larger issue that rests within multiple interrelated symptoms - share what you know about the context surrounding the problem you are aiming to solve. (500 characters)

Health is often an outcome of community surroundings. This includes the physical environment that slum residents are exposed to in open dwellings, the cultural backdrop where certain unhealthy practices may be acceptable (e.g. outdoor defecation), poor infrastructure (e.g. unclean water), and social context (e.g. community unity). Currently, these aspects are not considered by local authorities. Chitra targets this larger issue of lack of attention to community perspectives in healthcare.

How does the idea affect or change the fundamental nature of the larger ecosystem that surrounds it (as described above) in a new and/or far-reaching way? (500 characters)

E.g. A health worker who has on record (on the app) that malaria in a community is being propagated by the stagnant water, can now inform local authorities to take action and also motivate the community to fill this in with sand. This addresses the root problem and goes beyond the current approach of recording malaria cases and referring patients to local clinics (where community members often don't agree to go). Currently, there is a lack of a medium for collecting and presenting data.

What will be different within the target community as a result of implementing the idea? What is the scope and scale of that difference? How long will it take to see that difference and how will it be sustained beyond BridgeBuilder support? (500 characters)

Chitra aims to effect longer and deeper interactions between communities and health workers, and decrease disease incidence over the long-term by facilitating health interventions that impact underlying factors for the disease. We estimate that it will take 6 months to evaluate change in these areas. Beyond BridgeBuilder support, the changes in the community will be sustained through the efforts of health workers. The mobile app will also be put on the Google Play Store for widespread use.

How has the idea evolved or responded to your user research during the Beneficiary Feedback Phase and any further insights provided if you participated in the Expert Feedback Phase? (1000 characters)

After user research, we have a more nuanced understanding of the needs of health workers and communities. During the beneficiary feedback phase, we identified the primary areas of focus of the community health workers. This included immunizations, disease outbreak, and maternal and child health. Of these, the community health workers shared that they had the least support with identifying and addressing disease outbreak due to its complex nature. This is the area that our mobile application will focus on providing visualizations and predictions. We also identified the areas of concern for local communities, which were the frequent disease outbreaks they faced and limited engagement with community health workers. These insights will form the basis of interventions suggested by the app. They also inform our success measures, i.e. increase in frequency and length of engagement between communities and health workers, and decrease in frequency and scale of disease outbreaks.

What are the key steps for implementation in the next 1-3 years? (You can attach a timeline or GANTT chart in place of a written plan, if desired.) (1000 characters)

Y1 - Conduct co-design exercises with community health workers to determine appropriate visualizations and modalities for mapping and presenting community health profiles. - Complete development of the mobile application. - Train community health workers to use the mobile application. - Carry out regular data collection using the mobile application with 20 health workers and 20,000 residents. At this stage, only aggregated community health profiles will be available. Predictions will not be available. - Monitor healthcare provision activities and use of the app during deployment. Y2 - Fine tune machine learning algorithms with collected data. Y2 and Y3 - Deploy the mobile application with the same workers and residents. This time, predictions will also be available. - Monitor healthcare provision activities and use of the app during deployment. Y3 - Evaluate success including impact over time. Also compare activities initiated before and after adding prediction.

Describe the individual or team that will implement this idea (if a partnership, please explain breakdown of roles and responsibilities for each entity). (Feel free to share an organizational chart or visual description of your team). (500 characters)

Georgia Tech's TanDEm Lab (Atlanta, GA, USA) will design the mobile application, leveraging its significant expertise working with and designing mobile technologies for diverse underserved communities around the globe. The Chitra organization will carry out the development of the mobile application and will implement the pilot. It will partner with community health workers and communities in South-East Delhi.

What aspects of the idea would potential BridgeBuilder funds primarily support? (500 characters)

The BridgeBuilder funds will primarily be used to complete development of the mobile application and to carry out a pilot with 20 ASHAs operating in a region with 20,000 slum residents in a underserved region of Delhi.

In preparation for our Expert Feedback Phase: What are three unanswered questions or challenges that you could use support on in your project? These questions will be answered directly by experts matched specifically to your idea and needs.

The areas that we could use support on in our project include the following questions: 1 - How can we structure our pilot to be widely applicable and our results to be replicable elsewhere? 2 - How can we determine the robustness of our evaluation measures for the success of the intervention, given its curative and preventative health aspects? 3 - How do we place ourselves strategically during the pilot to be able to target scale at the end of the pilot?

Final Updates (*Please do not complete until we reach the Improve Phase*): How has the idea evolved or responded to your user research during the Beneficiary Feedback Phase and any further insights provided if you participated in the Expert Feedback Phase? (1000 characters)

We conducted a user study with our beneficiaries which gave us more details on what app features were most useful to them. A video of the design tested has been added. Based on expert feedback, we will incorporate the following incentives in our pilot to facilitate use: 1. Monetary incentives: Health workers already receive monetary incentives for collecting data from each household. The app will simply replace existing paper-based data collection and will continue to provide monetary incentives for data collected per household. We have already tested this approach and this is significant motivation for using the app. 2. Work incentives: Chitra eliminates time spent on repetitive data collection also reducing the time spent on mundane tasks such as copying data over to a register significantly. 3. Social incentives: The app will display progress made by the health worker over time. This has been shown to be motivating and to improve performance in a previous study.

During this Improve Phase, please use the space below to add any additional information to your proposal.

Explain your project idea (2,000 characters)

Challenge Around 1,000,000 community health workers (CHWs) collect demographic, environmental, and medical data across India, using paper forms. Despite huge efforts to collect data in the first place, this data is frequently underutilized. There is a huge scope for (1) digitizing the data collection process, and (2) analyzing collected data to help healthcare providers deliver personalized care to communities. Particularly, low-resource communities that rarely access hospitals and clinics could benefit greatly from targeted interventions. Idea To meet this need, we propose Chitra - a mobile application that (1) helps community health workers (CHWs) collect hyperlocal data through map annotations, and (2) builds community profiles by applying machine learning on collected data. This can help CHWs and healthcare providers provide personalized care to communities. Bridge Health and health-seeking behaviors are a product of environmental, socioeconomic, and cultural factors. Recording and understanding these location-based factors (planet) can help develop health interventions that take into account these aspects and community resources. This can result in improved health outcomes, particularly among underserved communities that are most affected by their surroundings (prosperity). How does it work? We build upon existing open source mapping tools such as Local Ground and ODK to enable hyperlocal data collection using map annotations. We aggregate collected data based on location and then apply machine learning algorithms to help identify communities that are at risk of disease and the underlying factors that may be responsible for the threat. User-friendly insights are presented as community profiles to health providers such as doctors, community health workers, and policymakers to help them make data-driven decisions. The project thus leverages and supports healthcare providers' existing competencies and deep understanding of local communities.

Who are the beneficiaries? (1,000 characters)

For the timeline of this project, our beneficiaries are residents of slums along the Yamuna river in South-East Delhi. A major goal of the project is prolonged engagement between communities and health workers. Health workers in the area routinely visit communities once every 4-5 months for data collection. Apart from that, they only visit for maternal and child health because there is little structure and support for other health interventions. We hope to deliver this support and encourage health activism by providing health workers a means of monitoring and addressing community health including risk factors of disease. We will open source the developed mobile application at the end of the project so that other communities may benefit from it. Additionally, we hope to scale our efforts in India in partnership with more community health workers as well as health organizations for whom data collection is a primary effort.

How is your idea unique? (1,000 characters)

Current players in this space are global organizations such as Medic Mobile, DHIS2, Dimagi, and Nafundi. All of these are data collection companies with a particular focus on working with community health workers. However, current efforts to analyze collected data rarely go beyond recording disease outbreak and service coverage. This results in underutilization of rich collected data despite massive efforts to obtain them in the first place. Our core competency lies in the use of machine learning techniques to provide customized care. We go beyond current efforts that are focused on data collection to also analyze the collected data and make hyperlocal disease predictions and healthcare delivery recommendations. We thus complement and build upon existing efforts. We also follow a human-centered approach---working closely with health workers on the ground and understanding their current data workflows and work priorities to be able to leverage and support them meaningfully.

Idea Proposal Stage (choose one)

  • Prototype: I have done some small tests or experiments with prospective users to continue developing the idea.

Tell us more about your organization/company (1 sentence and website URL)

The core work on the project is being carried out by the Chitra organization. Website: http://chitrahealth.com. The technology is being developed and deployed in collaboration with the Technology and Design for Empowerment (TanDEm) lab at the Georgia Institute of Technology, Atlanta, Georgia, USA. Website: https://tandemlab.tech.

Expertise in sector

  • 1-2 years

Organization Filing Status

  • No, but we plan to register in the future.
  • No, but we are a formal initiative through a university.

In 3-4 sentences, tell us the inspiration or story that encouraged you to start this project.

From May to August 2016, we conducted ethnography in an underserved region of Delhi. Our goal was to gain a ground-level perspective on private and public healthcare infrastructure. Through interviews and observations, we found a major disconnect between patients and healthcare providers. Health was often a product of circumstances (environment, culture, economics) unknown to healthcare providers. This motivated Chitra, which aims to deliver healthcare providers a picture of target communities.

Please explain how your selected topic areas are influenced, in the local context of your project (1,000 characters).

In the underserved communities targeted by Chitra, health is often an outcome of community surroundings. This includes the physical environment, which slum residents are exposed to in their open and close dwellings (e.g. the polluted Yamuna river). It also includes the cultural backdrop where certain unhealthy practices may be culturally acceptable (e.g. tobacco chewing and open defecation) and healthy practices may not be part of daily life (e.g. hand washing and institutional deliveries). It also includes infrastructure (e.g. electricity, water, and sanitation) and social context (e.g. community support). Thus, health is closely tied to Planet. Prosperity is directly affected by health. Poor health results in lost days of work and decreased productivity. In the target context, families frequently slip into debt because of health issues and often forgo visiting a hospital or clinic in favor of work and money in the pocket. Hence, non-clinical alternative interventions are needed.

Who will work alongside your organization in the project idea? (1,000 characters)

We are closely working with community health workers and slum communities in Delhi on this project. We follow an iterative process, taking input from health workers on the functionality, design, and appropriateness of our proposed intervention. We make them primary stakeholders and privilege their superior understanding of local communities. So far, we have conducted participant observation with community health workers to better understand their interactions with local communities and the challenges they face. From January to May 2018, we deployed an initial data collection prototype with 5 community health workers and 600 slum residents. The collected data is being analyzed and preliminary machine learning algorithms have been developed. In February 2018, we also conducted 2 co-design sessions with 17 community health workers for the mobile application. Using insights we gained during the co-design process, we have developed an initial design for the mobile application.

Please share some of the top strengths identified in the community which your project will serve (500 characters)

Some of the strengths that we have identified in the community include close-knit relationships with community health workers, strong support networks among community members, and activism of local mosques which often hold local gatherings and announcements.

Geographic Focus

This particular project will target underserved slum communities in South-East Delhi, India.

How many months are required for the project idea? (500 characters)

31 months We will first conduct co-design exercises with CHWs to determine appropriate visualizations and modalities for mapping and presenting community health profiles (3 mths). Using these insights, we will develop a mobile mapping application (4 mths). After training (1 mth), we will carry out mapping exercises with 20 CHWs and 20,000 people (4 mths). We will tune machine learning algorithms (4 mths). Finally, we will monitor healthcare provision activities during deployment (15 mths).

Did you submit this idea to our 2017 BridgeBuilder Challenge? (Y/N)

  • No

18 comments

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Comment
Photo of Sofía Unanue
Team

Hi Azra!
This is such a necessary and important project. We are inspired! We integrate mapping into our participatory design processes as well and work closely with communities in Puerto Rico to digitalize assets and vulnerabilities in their region. Without this documentation, it is difficult to asses needs after a disaster/ cater to populations most in need. We hope this can support easier activation/response should another disaster impact the island. Nonetheless, we want to make sure that the mapping turns into a resource that will be used well before a disaster strikes. How are you going to ensure that the health providers use the applications and information on ongoing bases? Part of what we don't want to happen is for the information and talents in the communities to be activated only when in disaster mode so we are constantly thinking about what will motivate our collaborators to see this information as theirs to use..

Check out our proposal and let us know what you think too: https://challenges.openideo.com/challenge/bridgebuilder2/review/imaginacion-post-maria-designing-justice-after-disaster

Good luck!

Photo of Azra Ismail
Team

Hi Sofia,

This is an excellent question! As also mentioned in our application, to motivate usage of provided information, we will be providing monetary and social incentives to health workers. Health workers are already used to receiving incentives for carrying out different tasks, this system will sit upon that existing infrastructure and continue to provide incentives for carrying out activities suggested by the application. Additionally, the greater visibility of the concerns of the communities they serve was also cited to be a motivation by the health workers.

Additionally, many of the features of our application are simply meant to replace pain points and fit into existing processes. We've been working with and studying the target population for almost two years now and as such have gained a deep understanding of their workflows and pain points. As such, we are not targeting disruption, but more of a streamlining of existing work. Also, by providing visualizations, we hope to make intangible benefits more concrete to ASHAs to further motivate them such as displaying time spent on work (much of which is currently spent on mundane required tasks) and improvement in health coverage and health outcomes.

Your project sounds very interesting, good luck!

Photo of Aline Sara
Team

Dear Azra and Chitra Team,
Thank you for your work! This sounds like an important project and I find the fact that you are trying to tackle an issue in a very preemptive way—i.e. trying to understand the underlying circumstances (environment, culture, economics) that are then leading to health issues and outbreaks is very important. It's also great to leverage an existing resource--in this case the health workers. I do have some questions/concerns about how to incentivize everyone to start using your technology.

While my expertise does not lie in health, here are a few thoughts in response to your inquiries that I hope might be of use!
1 - How can we structure our pilot to be widely applicable and our results to be replicable elsewhere?
I think it would be good to try and make sure of the likeliness of healthcare workers to use your program and have a solid understanding of what might prevent them from doing so. Your product will only work if it is used, and I would say starting there is the most important—namely making sure people will make use of your service. Even if they express that there is an issue and that they love your idea, they might not always change their habits to use the potential solution and new technology you are mentioning—even if they are driven deep down by making a greater and more efficient impact and even if they have been involved in your pilot phase/design thinking. My concern would be about having the proof that you have a strategy to make sure the app will be used. Can the government be involved somehow to create incentives? Is there an alternate way to motivate workers to use it? Apologies in advance of course if this has been addressed somewhere and I have missed it!
2 - How can we determine the robustness of our evaluation measures for the success of the intervention, given its curative and preventative health aspects?
I noticed the funds requested are going to developing the app. That can be expensive and might be a capital cost that can be avoided. Is there a simplified version of the app that can be used before investing money in building the full on version of it? It also sounds like there are many other apps doing something similar so there might be some way to collaborate. Perhaps the greater amount of work is ensuring people will actually use the app rather than the apps’ results. This might be where most of the thinking should go. Monetary investment might also be of use to sensitize the healthcare workers and find ways to motivate them to use the app and eventually create more sustainability.

3 - How do we place ourselves strategically during the pilot to be able to target scale at the end of the pilot?
I think it is worth establishing solid relationships/partnerships on the grounds. This sounds like a project that would thrive through collaboration and support from other players in the space—not just NGO, but private and government sectors as well.

Photo of Azra Ismail
Team

Hi Aline,

Thank you for this feedback! We have been thinking about incentives to encourage people to use the technology as mentioned below. I shall also add these to the description:
1. Monetary incentives: Health workers already collect data on paper and receive monetary incentives for collecting data from each household. The app will simply replace existing paper-based data collection and will continue to provide monetary incentives for data collected per household. We have already tested this approach, and this is significant motivation for them to use the app.
2. Work incentives: The app will eliminate time spent on repetitive data collection, also reducing the time spent on mundane tasks such as copying data over to a register significantly.
3. Social incentives: The app will allow health workers to view the progress they have made over time, this has been shown to motivate health workers to use the app and improve performance in a previous study.

A simplified version of the app is definitely possible. As mentioned in the description, we will building on top of existing infrastructure so that should considerably reduce cost. We will also begin with data visualization and aggregation as specified in the timeline of the project, later adding more complex data analysis.

We are indeed targeting collaborations and are currently in talks with various entities in Delhi to gather support!

Photo of Anubha Sharma
Team

Hey Azra,
This is a great concept and does indeed have a huge potential for being an effective intervention for health issues which indeed does affect prosperity. Will share the idea with one of the cohorts im part of which has a few people from organisations working in health. Good luck.

Photo of Azra Ismail
Team

Hi Anubha,
Thank you for your feedback on this work! Your support is greatly appreciated :)

Photo of bikash gurung
Team

Hi Azra Ismail , thanks for sharing your wonderful idea. Your idea looks promising and have a large impact bracket. Would love to learn little more about what are the features of the Mobile app you are developing? Are you planning to take this mobile as a product for business or as a service? From your idea above, I can see indirect bridge between Planet and Prosperity. Are there any direct bridges.
One thing I'd recommend is checking out the Challenge Brief (https://www.openideo.com/challenge-briefs/bridgebuilder2) and Evaluation Criteria (https://bit.ly/2whcWuE) if you haven't had a chance yet. Only registered organizations are eligible for the Prize funds. If you are not a registered organization, there are a couple options. We've seen teams seek out partner organizations to submit with. You are also welcome to participate in the Challenge and connect with other innovators and receive feedback for your proposal, even if you have not intention to register your organization at this point.

Photo of Azra Ismail
Team

Hi Bikash,

Thank you for your comment and for the links! Some of the features of the mobile application, as requested by our partner community health workers, include:
1) Flexible data collection using map annotations and forms
2) Aggregated community profiles with demographic, health, and environmental data and suggestions for health interventions to carry out
3) Generated disease and risk factor maps
4) Progress bars for task management such as data collection, health interventions, immunizations, antenatal care visits, etc, including community-specific coverage and not just aggregate data

I'm not quite sure what you mean by this question - "Are you planning to take this mobile as a product for business or as a service?". We're planning to register as a non-profit in the near future, if that is what you were asking. The mobile application will be offered as a product to interested parties and we will work with them to deploy and manage it within their communities.

The bridges I see this project directly affecting are Planet and Prosperity, as well as the relationship between the two. Chitra aims to have a direct impact on health outcomes, helping communities live more prosperous lives. It also aims to affect the physical and cultural environment, including sanitation, water quality, lack of health infrastructure, religious or cultural taboos, and more. While the changes to Planet are carried out with the intention of improving health, they are very much direct outcomes expected from the project. We expect that interventions which are seen as having a direct consequence on a community will be more likely to garner community support and to be executed. We also expect this model to be more sustainable and comprehensive over the long term, over single-focus projects such as one-off cleanups carried out in the area.

For instance, a health worker who knows and has on record (on the app) that malaria in a community is being propagated by the stagnant water, can now inform local authorities to take action and also motivate the community to fill this in with sand. This addresses the root problem and goes beyond the current approach of recording malaria cases and referring patients to local clinics (where community members may not agree to go). Currently, there is a lack of a medium for collecting and presenting such information in a user-friendly way so that health workers have the legitimacy and power to affect such outcomes. This is what Chitra tries to address.

Regarding funds, I am not sure if universities are eligible to receive prize funds as part of this competition, but if they are, then that may be a suitable route. Otherwise, we will seek out partner organizations as you suggested. We are also very interested in registering our organization. Currently, we are operating on a tight budget using personal funds and our impact is local, hence the lack of registration.

This is a rather long-winded answer to your questions but I hope it addresses them!

Photo of Ashley Tillman
Team

Hi Azra Ismail this additional information is very helpful! Universities are able to receive prize funds in the challenge. I think what bikash gurung might be asking about is do you see your self as the team who makes the technology and sells it and works with implementing partners or as the team that provides all the services and support for the program to run and be successful? Also curious, if everything were to go according to plans what would be your big vision for potential impact 5 years from now for this project?

Photo of Azra Ismail
Team

Hi Ashley - Thank you for clarifying! We see ourselves primarily as the team that builds the technology and sells it to organizations. These could be organizations that either perform data collection (such as health organizations and local governments) or develop technology for data collection (organizations such as Dimagi, Medic Mobile, and DHIS2). The former allows for more flexibility in terms of technology implementation while the latter allows for scale. We would provide technical and material ground-level support for training community health workers in data practices and technology use to make the most out of the mobile application, as well as support for deployment, but not human resources.

At the moment though, we are also performing the grassroots work of organizing health workers, training them, arranging for mobile phones, etc. We are able to do this because this is a community that we are highly familiar with and have worked with for a while. However, we think that more generally, deployment would be better facilitated by technology partners and organizations already familiar with the communities and used to carrying out interventions.

My big vision is for Chitra to be a more robust and involved system for organizing, facilitating, and evaluating community health interventions globally. In five years, I would love to see this being used at the scale of DHIS but at the hyperlocal level! DHIS has allowed for the organization of health information at the district level, particularly with local health program officers and primary healthcare clinics. I would like to similarly see those doing the ground-level work---community health workers---more involved and engaged in their communities and better equipped to serve community needs.

Also, at a global level, barring data concerns and boundaries (which are high), the possibilities for comparing and learning from data across state and national boundaries for better policy and interventions are numerous!

DHIS:
https://en.wikipedia.org/wiki/DHIS
https://docs.dhis2.org/2.22/en/user/html/ch01.html

Best,
Azra

Photo of bikash gurung
Team

Thanks Azra Ismail , thanks for the additional information. Best Wishes :)

Photo of Anjali Nayar
Team

Hey Azra Ismail -- Great idea! I'd love to chat a bit more about the tool you are developing. We've actually implemented something similar with AMPATH in Western Kenya and designed and built a similar app to what you're describing here (see: www.timby.org). If we could be of help, let us know. We're always open to a new collaboration. Keep us posted here or on info@timby.org and we can plan a call.

Photo of Azra Ismail
Team

Hi Anjali,

Thank you for reaching out! TIMBY looks like a very interesting project! And AMPATH is very much in line with what we're trying to do. I think there is a potential for collaborating, and perhaps adapting what you think are the strengths of AMPATH. Would love to chat more with you!

Will also reach out to you at the email you provided!

Photo of Anjali Nayar
Team

Hi Azra Ismail - wonderful -- we look forward to speaking more.

All best,
Anjali

Photo of Asel Zoe
Team

Hello Azra,

I love the idea of bringing the health rpboblem to the top - on my personal blog @aselzoe I also and alway she the idea that the health and taking care of it is the love that people share not only with themself but with their beloved once.

Good luck in you project. And i also love the wide you think - please check my project and would appreciate useful feed back Cultural Atlaz - Fantastic Faces of Open Minded Humanity

Photo of Azra Ismail
Team

Hi Asel, Thank you for your kind words and your support! Will definitely check out your project!

Photo of Janet Ilott
Team

This sounds like an interesting project. I would like to know more about how community healthcare workers have been involved in the design process and also how this technology would deal with things like network outages.

Photo of Azra Ismail
Team

Hi Janet,

Thanks for expressing interest! Throughout the project, we have been (and plan to be) in close touch with community health workers both offline and online, through Facebook, Whatsapp, phone calls, and organized group meetings. This includes more informal conversations and group discussions, which is how the idea for Chitra emerged when community health workers pointed out that they found their existing data collection process to be limited and limiting. In addition to these, we have been holding more formal design iterations. We started with paper prototypes of maps, data forms, and an initial layout of what a mobile app could look like. We iterated over the data form six times and the health workers directed what questions should be on there and what format was most comfortable for that data field - numeric, text, image, multiple options, etcetera. We have so far conducted two co-design exercises with health workers for the mobile application format. These were held in at the home of a senior health worker who is respected and popular among the other health workers and the local communities. The exercises were moderated but were mostly self-directed by the health workers as they grew enthusiastic about sharing their perspectives.

As for network outages, the technology is designed for intermittent network access. During the deployment of our initial data collection prototype, health workers collected data from local communities offline. At the end of their day or when they had network access, they submitted data online using mobile data. There are also other issues such as unreliable GPS location data, which we have been circumventing by allowing healthcare workers to collect data both using GPS and through text so that these can be cross-verified.

Hope this answers your questions!