MomConnect is a relatively new intervention that uses mHealth to improve both the demand for health services and, through feedback mechanisms, the quality of the supply side as well. Six times as many women were complimentary about the health messages and services that they received, compared to those who complained. In several districts, the same facility received more complaints. All facilities having three or more complaints were highlighted and pointed out to the relevant managers, including the provincial head of health.
These complaints helped pinpoint deficiencies in the health system. Some of these complaints are local and relevant to a particular health worker or facility, such as rudeness and shouting at patients. These led to remedial action being taken with particular staff at particular health facilities.
Other complaints are more systemic in nature, such mortality due to iron deficiency. Anaemia contributes to mortality from obstetric haemorrhage, one of the most important causes of maternal mortality17 in South Africa. Providing iron supplements to every pregnant woman is one of the key interventions of antenatal care services. MomConnect complaints have had the effect of ensuring that in at least two provinces, Gauteng and North West, reports of iron supplementation shortages at particular clinics led to improvements in the drug management system (e.g. overall stock re-ordering systems at facility level), not only in the particular clinics but also in the district and province at large. At the national level, weekly reports of specific facilities which had a medicine or vaccine stock-out related complaint are sent to the national managers in charge of pharmaceutical services and the Expanded Programme on Immunisation. These managers then look at the issue from a national perspective to see if there are system-wide issues that need resolution. Drug shortages are investigated and remedied both from a bottom up (facility) level as well as from a top down (system-wide) perspective.
The feedback mechanisms from the DOH to the provincial, district, and facility managers took some time to establish. Resolution of complaints improved substantially over time, with a greater proportion of complaints attended to and resolved in the second six months of the programme than in the first six months.
Direct feedback, via compliments and complaints, from users of the system, is potentially useful for users and providers alike. It provides direct feedback of the perceived quality of service and augments the government’s own system for review of quality via the recently established Office of Standard’s Compliance. This gives users the sense that they have a voice, especially as the helpdesk contacts them to check whether they were satisfied with the follow-up. This system also gives feedback to providers on whether they are doing well. Most health providers get professional satisfaction from receiving a compliment. It also provides an indication of where there are shortcomings in the system, which are usually relatively easily remediable.
There are a number of limitations to this study. The definition of whether a complaint is resolved is open to interpretation. This may account for an over-estimation of the resolution rate. There are a small number of complaints relative to the numbers of women registered, with the potential for some bias in the type of complaints made.
This analysis suggests areas in which the programme could improve and has implications for health system policy. Health workers, specifically nurses dealing with pregnant and postpartum women should be supported and empowered to deal with complaints. mHealth is an ideal medium to do this and MomConnect could be extended to provide nurses with information and motivation for providing better quality of care.
Currently most attention is given to complaints. Compliments should be used as a motivator of nurses and compliments should be directed specifically to the facility/health worker to whom they are related. In addition MomConnect should be extended to empower nurses by giving them access to useful information related to pregnancy, child health and family planning. It should also give them a route to give feedback about the facilities at which they work, as sometimes issues are beyond their scope to influence.
For those women who have smartphones, and their numbers are increasing exponentially, MomConnect should be tailored so that more information is available on a cell phone optimised website. MomConnect should also be tailored to enable greater interaction between the helpdesk and the women through the use of data services that are far less cumbersome than SMSs. The effect of this, however, may be detrimental to equity, as users at the low end of the socio-economic spectrum will probably be the last to get smart phones.