The use of digital health for maternal care in Timor-Leste
Author
World Health Organization
This action brief is extracted from the series of key action briefs on “maintaining the provision and use of services for maternal, newborn, child and adolescent health and older people during the COVID-19 pandemic” published by the WHO Department of Maternal, Newborn,Child and Adolescent Health and Ageing. To access the series, please click here.
This brief was developed using information collected from existing documents as well as information captured through discussions with key institutional stakeholders. The views in this brief do not necessarily represent the decisions, policy or views of the World Health Organization.
Country
Timor-Leste
Key learning points
• Infrastructure, such as electricity and internet, was essential to successfully implement mHealth interventions.
• Training health workers to use technology was important. Equipping them with skills and experience in the technology helped them use technology effectively.
• The rapport established between women and health workers before the pandemic positioned the platform as a trusted source for COVID-19 information.
• The data from the dashboard were useful to support decision-making and allocation of resources.
• Digital health contributed to the acceleration of MCH service delivery across the country.
Background
Timor-Leste has progressed towards achieving its reproductive, maternal, neonatal, child and adolescent health (RMNCAH) goals in the last decade. The Government is committed to decreasing maternal, newborn and child mortality and ensuring universal health coverage in all geographic areas across the country. The National health sector strategic plan II 2020-2030 and the National strategy on reproductive, maternal, newborn, child and adolescent health 2015-2019 have identified target indicators to contribute to reducing maternal, newborn and child mortality.
Impact of COVID-19 on essential health services
The first confirmed case of COVID–19 in Timor-Leste was detected on 24 March 2020, and the country since experienced three waves. The Ministry of Health implemented several public health measures in response to the pandemic including social distancing, public sensitization, health worker training on infection, prevention and control measures and COVID-19 surveillance protocols, and launching the Health Emergency Operation Centre.
During the COVID-19 pandemic, routine essential health services were disrupted. Initial comparison of 2020 data on RMNCAH services from the health management information system with 2019 data indicated a minimal impact on coverage. However, subsequently, data showed a significant decline in the use of most maternal and child health (MCH) services.
Photo credit: MCH department, Ministry of Health
Actions to maintain essential services
As one of the strategies to address the low coverage of MCH services it was decided to strengthen and expand Liga Inan, Timor-Leste’s first mobile health (mHealth) programme. Liga Inan is a national health programme which aims to reduce high maternal and infant mortality. Using mobile phones to connect pregnant women with health providers, the programme supports Timor-Leste’s aim to improve RMNCAH by increasing access to antenatal care (ANC), attended childbirth, postnatal care (PNC) and family planning services, and supports efforts to improve maternal and newborn family care practices and care-seeking.
During the COVID-19 pandemic, the Liga Inan Program was leveraged to facilitate continuous health messages to registered women and communication between women and health workers through text messages and direct calls. Health workers used Liga Inan to:
• send text messages to pregnant women ensuring them of the safety of attending ANC and to continue planning for birth with skilled health personnel;
• stay engaged with pregnant and postpartum women;
• share information on the importance of COVID-19 vaccines for pregnant and lactating women;
• collaborate with their peers during the pandemic.
Photo: Liga Inan keeps mothers and their health providers connected during COVID-19.
Photo credit: MCH Department, Ministry of Health
Message on the phone screen translates as, “Children aged –2 - 18 who do not attend school can receive COVID-19 vaccinations at the health facility centre in Dili, Fatumeta Clinic, and Hospital NationalGuido Valadares from –5 - 19 November”
Outcomes of the implementation
Data indicated a decrease in enrollments into Liga Inan in seven municipalities in 2020 during the peak of the pandemic compared to the same period in 2019. This may have been due to the fear of infection with COVID-19 and mandatory quarantine for all positive COVID-19 patients. During 2021, the number of pregnant women enrolled increased in four municipalities compared to 2020, while the number decreased in nine municipalities. In five of these nine municipalities with decreases in 2021, the reported number of enrollments was nonetheless higher than 2019.
There was a decrease in health facility births in five municipalities in 2020 during the peak of the pandemic compared to the same period in 2019. Three municipalities also reported a decline in enrollments into Liga Inan. A further decrease was observed in 2021 in eight municipalities, although five municipalities reported an improvement in health facility births.
Efforts to encourage facility births were made through Liga Inan including routine messaging twice a week as well as during antenatal care visits. Pregnant women were educated on the risks of COVID-19 for them during birth and the postpartum period as well as preventive measures, encouraging them to go to health facilities for childbirth. The Ministry of Health considers Liga Inan to be one of the contributing factors for the increase in the number of facility births in Lautem in 2021.
Challenges
• Not all women had access to a mobile phone and many users have shared phones.
• Some geographical areas are not covered by all the internet providers. As a result, both women and health workers experienced internet interruptions.
• Some health workers initially oriented and assigned to the programme moved on to different roles and/or to other municipalities, and newly-assigned health workers were not knowledgeable about the programme.
• The programme experienced a high level of dropouts due to women changing phone numbers or relocating from their initial registration area.
• Most health facilities at the municipality level had limited human resources, and implementing Liga Inan was considered extra work.