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RWANDA, 2011. A medical doctor looks at data collected by a female medical nurse from a pregnant woman at UNICEF support new maternity ward in Ruhengeri Hospital in the city of Musanze in northern Rwanda. © UNICEF/RWAA2011-00595/SHEHZAD NOORANI

September 12, 2013

Making the invisible visible

5 years ago, if you wanted to know the number of pregnant women in Musanze district (one of the districts in the Northern Province of Rwanda) you would have to manually go through the files in all 12 health centres and possibly even those in the district hospital.

Today, the use of RapidSMS – a SMS based system for faster data collection and real-time feedback – has changed all that. Today you can count the number and find the location of pregnant mothers from your laptop (or better still see the total figure on a map on the report dashboard of the Pregnancy Module of RapidSMS).

What this means is that the formerly “invisible” pregnant mother who may not have been receiving essential life-saving antenatal care is now a thing of the past. The supervisors of Community Health Workers can now tell you: “I have 300 pregnant women registered and they are all being followed up”. The District Medical Director can also say the same for the number of pregnant mothers in their District. RapidSMS allows all mothers to be tracked through their pregnancy, ensuring that they receive the necessary care and that danger signs which can lead to complications and death are recognized early and dealt with.

Simply knowing where pregnant mothers are and being able to follow up with them has increased attendance at antenatal care. Since the introduction of RapidSMS, Community Health Workers can now focus more of their attention on finding the remaining “invisible” pregnant mothers.

Rwanda has 15,000 “Animatriste Santé Maternelle” (ASM) or community health workers for the 15,000 villages in the country. They are trained to send in data via SMSs, which is then automatically analyzed by the system. Doctors and health officers use this data to better manage and oversee their programmes.

RapidSMS Rwanda: a short history

RapidSMS was introduced by UNICEF to the Ministry of Health in 2009. It went through a number of iterations including the establishment of a national taskforce (a committee consisting of the Rwandan Ministry of Health, UNICEF, and other partners charged by the Minister of Health to see to the development of RapidSMS in Rwanda under the eHealth Department of Ministry of Health). RapidSMS was first deployed in the District of Musanze to track pregnant women and ensure they received antenatal care. It is now being expanded to ensure that children receive their immunizations, and their weight gain is monitored. This tracking has the larger goal of reducing maternal and newborn deaths.

Within nine months of the initial deployment, the Government requested that RapidSMS be scaled up. Not only could mothers be traced to their various villages, but deliveries at health facilities were increasing; and Community Health Worker performance was able to be monitored.

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RWANDA, 2011. A community health worker sends a Rapid SMS message for an ambulance from the house of Assuma Mukandoli (28), pregnant for the first time, in Rukoro neighbourhood in the city of Musanze in northern Rwanda. © UNICEF/RWAA2011-00479/SHEHZAD NOORANI

The government also requested that RapidSMS Rwanda be expanded to track the entire cycle of maternal and child health – the 1,000 days from conception to when a child becomes two years of age: the time when the majority of maternal and child deaths occur. The system has now been aptly renamed: RapidSMS Rwanda version 2-“Tracking the First 1000 days along the maternal and child continuum of care”.

RapidSMS expands from antenatal care to cover maternal and child health

In November 2012, the First RapidSMS Retreat took place where the group expanded RapidSMS from one module that tracked the Pregnancy cycle (version 1) to version 2 which consists of 6 modules: the Pregnancy cycle, post-delivery period, newborn care, childhood killer diseases of Pneumonia, Diarrhea and Malaria) to nutrition and children living with disabilities (Cleft palate/cleft lip). Four years ago, children with cleft palates and cleft lips (easily treated by surgery) would often not make it in to school. RapidSMS Rwanda has changed this predicament; the ASM, who visits the mother at home on first day after she gets back from the health facility where she delivered her baby, will report a cleft palate to  RapidSMS. Children living with this disability are found, and are scheduled for corrective surgery before their first birthday. The two year old will never remember that he or she ever hard a cleft lip or palate. She develops like any other normal child and goes to school. This is the dividend of innovation.

The 2nd Annual RapidSMS Retreat took place in the border town of Gisenyi for one week from August 12-16, 2013. The Retreat, a technical review and upgrade of the RapidSMS system occupied more than 40 technical experts, programme managers, Ambulance directors and District Medical directors who reviewed RapidSMS Rwanda version 2 and developed protocols for operational procedures. 12 documents including technical card codes, key messages, feedback messages, Newborn protocols, Hygiene and sanitation protocols etc. were reviewed and updated.

Following this, a special event took place on the 3rd of September 2013. The Ministry of Health in partnership with UNICEF invited all 42 District Medical Directors from 30 districts to demonstrate RapidSMS-version 2. During this event, the Ministry of Health showed that the number of districts recording zero maternal deaths have increased from 2 in 2011, to 4 in 2012, to 10 districts by June 2013. In her speech opening the Meeting, the Honourable Minister said, “you think that the ownership of RapidSMS-Rwanda lies with the Ministry of Health. You are wrong. The ownership of RapidSMS-Rwanda lies with the Office of His Excellency the President of the Republic of Rwanda”. “Now we are not just thinking of achieving MDG 5, we want to go further than that” we want to ensure that no woman dies of preventable maternal deaths during and after pregnancy and also have a healthy newborn. You have the RapidSMS tool that can help you achieve this objective, let us use it in all districts to achieve this important goal”.

No women should die during pregnancy

There was general excitement among the District Medical Directors who quickly understood that this was an essential tool to help prevent the deaths of ‘invisible’ women and children who too often die during pregnancy, delivery and the early days of life, by ensuring that they get the essential health interventions they need to survive and thrive.

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RWANDA, 2011. A female health worker performs antenatal check up of a pregnant woman at a UNICEF supported MCH clinic (Maternal and Child) in the city of Musanze in northern Rwanda. © UNICEF/RWAA2011-00386/SHEHZAD NOORANI

Today, 16 districts are now running RapidSMS Rwanda. The remaining 14 districts in the country will be included by the end of November 2013. The ambitious goal is to make each pregnancy “everyone’s business” and to ensure that no woman dies in pregnancy” and to have all 30 districts record zero preventable maternal deaths by December 2014. This milestone marks the transition of trying out an innovation to that innovation now supporting a mass national movement to achieve a global objective, one year before the global 2015 target.

Essential partners

UNICEF Rwanda has supported the government all through the process by reaching out to its partners and donors. General Electric, Frog Design and Access are UNICEF’s Innovation partners, working to strengthen, iterate and add new modules onto the current RapidSMS platform. UNICEF has also secured multiyear funding from the Korea International Cooperation Agency (KOICA) to support the national scale up in 10 districts. There has also been a strong public-private partnership with the mobile network operators in the country. UNICEF Rwanda has pledged that we will continue to support this innovation that not only helps attain national development priorities in the health sector, but goes also as a key part of achieving and meeting the global MDG 5 target of reducing maternal mortality.

From one district to a national movement

The September 3, 2013 meeting has transformed the RapidSMS-Tracking of the First 1000 days to a national movement. The District Medical Directors agreed to quarterly meetings specifically to review progress made on improving maternal outcomes as well as reduction of preventable maternal deaths. Other activities include advocacy and social mobilization activities for family support to pregnant mothers and early demand by mothers for registration into RapidSMS.

By the end of November 2013, RapidSMS Rwanda will be tracking nearly 400,000 pregnant mothers and newborn pairs each year, killer childhood diseases, faltering weight gain of children for proactive nutrition intervention, as well as automatically reporting on stunting rates, and provide an early detection system for children living with disabilities. All of these things go straight to the heart of UNICEF’s equity agenda of shining a light on the most vulnerable and ensuring that they get the care they need to survive and thrive.

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RWANDA, 2011. Holding their babies, a group of women wait outside an immunization clinic (EPI/PEV) at a Kimonyi sector in the district of Musanze in northern Rwanda. © UNICEF/RWAA2011-00393/SHEHZAD NOORANI

More is still to come. The newly minted RapidSMS Nutrition module. This social and behavioral campaign will support the change of cultural practices that adversely impact malnutrition. The campaign will reach all households to support household and maternal education to improve the early nurturing of children.

“And now the work begins”

Since 2009, there have also been challenges to RapidSMS Rwanda. Providing a mobile health service at national scale comes with its challenges. The registration into the RapidSMS electronic database of 45,000 CHWs in 15,000 villages of Rwanda (15000 ASMs for maternal and newborns and 30,000 Binomes for Childhood killer diseases) is a huge task. Today 95 percent of this exercise has been accomplished. Mobile ownership and ease of use also comes with its challenges. Beyond mastering the use of a phone, supervisors must continue to support Community Health Workers as they use the phone as an essential tool to track their community’s health.

As the Minister said, “And now the work begins!”

Friday Achilefu Nwaigwe
Chief Child Survival and Development, UNICEF Rwanda
fnwaigwe(at)unicef.org

Read more about RapidSMS:

Photo essay about RapidSMS Rwanda

RapidSMS Rwanda for safe pregnancy and delivery

New RapidSMS website launched

Nigeria – Using RapidSMS for birth registration

1000 days: A mHealth product overview

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