Getting the Message Across

Tayeb Noorbhai talks about the new healthcare initiative he helped set up which is using SMS messaging as part of a package of measures to help address high maternal and child mortality rates in Tanzania.


‘Sudden swollen hands/face, headaches, excessive vomiting/nausea, stomach pain may be eclampsia. Go to the doctor since this is a risk for you and the baby’…. ‘Delivery is approaching. Have a birth plan ready, where to deliver, transport, who is joining you as well as sanitary pads, clothes and diapers for the baby’.

These are just a couple of the text messages expectant and new parents can sign up to receive as part of Totohealth, an SMS-based healthcare initiative being rolled out in Tanzania under the leadership of ODID alumnus Tayeb Noorbhai and colleagues in a bid to reduce deaths and complications among pregnant mothers and children under the age of 5 years.

Every year in Tanzania, 7,900 women die of pregnancy-related complications and 98,000 children under five lose their lives. Part of the problem is that only 50 per cent of mothers in the country deliver in healthcare facilities with the assistance of a skilled birth attendant, due to the distances involved and the uplanned out-of-pocket costs often encountered once reaching the facility, as well as widespread distrust of the healthcare system. Poor general health awareness and misconceptions about healthy behaviour also contribute to the problem.

This is where Totohealth comes in. It provides parents with twice-weekly text messages tailored to the mother’s pregnancy stage or the age of her new baby, offering professional advice on everything from how to ensure a healthy pregnancy and mental health issues, to vaccinations, feeding and development milestones to watch out for once the child is born.

Culturally, people treat healthcare providers with great respect and this barrier often does not give clients the freedom to feel comfortable and restricts questions during the brief time they have together.

Tayeb Noorbhai, MPhil in Development Studies 2009-10

The texts, which are personalised with the baby’s name and written so as to fit into one message of 160 characters when translated into Swahili, take into account regional and district variations, for example in dietary habits or cultural beliefs and practices. Parents can also send individual questions directly to Totohealth’s experts via an SMS helpline and there will be a voice messaging option for subscribers who cannot read.

As well as reducing mortality, the service – which is free to users – aims to ensure early detection of developmental delays or disabilities in babies, conditions such as club foot, autism, epilepsy, or hearing and visual impairments. Some of the texts require a ‘yes/no’ response from parents regarding the baby’s progress that can trigger a suggestion to seek further help, depending on the answer.

The system is useful not just for those who have difficulty accessing existing healthcare facilities, but also because it provides an alternative, more relaxed, way of interacting with health experts.

‘Culturally people treat healthcare providers with great respect and this barrier often does not give clients the freedom to feel comfortable and restricts questions during the brief time they have together,’ Tayeb explains. ‘In small communities it is also difficult to ask sensitive questions in fear of being judged by healthcare providers who typically live in and are an important part of the community.’

As well as permitting parents to ask questions privately and anonymously, the service enables them to refer back to messages multiple times, rather than relying on advice delivered orally during sometimes rushed clinic visits, and provides a source of information that is different from that traditionally passed down by elders in their communities. It also allows for greater involvement of fathers, who are generally excluded from maternal health discourses, both at home and at health facilities – fathers are free to sign up for the Totohealth text messages too.

The texts are just part of a package of measures that Totohealth offers. In addition, it supplies clinics with Clean Delivery Kits (CDK), which provide clinicians with supplies to use during labour to ensure a safe and hygienic delivery and a ‘Totokitbox of essentials for the mother and baby after delivery. The CDK and Totokitbox are available only via healthcare facilities ­– during delivery or at the postnatal care visits – so act as a ‘pull factor’ to encourage parents to opt for a clinic-based delivery and attend the four recommended check-ups after the birth.

The service has already produced remarkable results in Kenya, with infant mortality falling from 31 per 1,000 live births to 18 in one of its first counties, Machakos.

Totohealth was originally established in Kenya in 2014 by entrepreneur Felix Kimaru, where some 18,000 parents are currently signed up. The service has already produced remarkable results there, with infant mortality falling from 31 per 1000 live births to 18 over the course of a year in one of its first counties, Machakos, just south of Nairobi, according to Totohealth. In addition, of a sub-sample of Totohealth users, 87.5 per cent reported delivering in a health facility with a skilled birth attendant, compared to a national rate of 62 per cent in 2014.

Tanzania is the first country into which the service has expanded, and Tayeb, who completed his MPhil at ODID in 2009, became involved via his relationship with the Unreasonable Institute East Africa, which provides support and mentorship to early stage companies working on solving social and environmental challenges.

‘As a Tanzanian, I’m passionate about finding innovative solutions that allow systemic shifts in the ways things are being done in the development sector and work to grow and scale existing and proven methods to improve development outcomes and impact,’ Tayeb says.

Now his aim is to bring Totohealth Tanzania to 100,000 subscribers by 2019.

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