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Text Messages: An Essential Tool for Reaching Remote Health Workers in the Kenyan Health System

Like many sub-Saharan African countries, Kenya has a severe shortage of health workers, especially in rural and hard-to-reach areas, which makes it difficult or impossible for people in these areas to receive health care. In 2003, the Kenyan government instituted a hiring freeze for health workers in an effort to comply with the World Bank recommendation to lower the cost of wages in the health budget. In order to offer some stop-gap solutions to this dire situation, the Ministry of Health collaborated with the Capacity Project to implement an emergency hiring initiative to recruit and manage some 830 contract health workers, who were then deployed to some of most remote villages in Kenya. This work continues now under the Capacity Kenya program and has shown that effectively managing short-term hires working in many locations can lead to high operational costs.

Currently, Capacity Kenya manages over 700 workers hired under the rapid hiring plan. Regular communication with these workers is essential to ensure attendance, job satisfaction, and accountability but has proven difficult, often causing frustration for both health workers and the program. For example, until recently, communication about submission of timesheets, payroll-related queries, or disciplinary inquiries would have to be conducted through postal mail, which can take five to ten days to reach Nairobi. Telephone calls are possible, but landline phone costs can be expensive for health workers, and in remote areas the telecommunication infrastructure is very unreliable. Making regular phone calls to 700 workers is time-intensive, and after the first few failed attempts, it leads to a very poor response rate.  

Recognizing these limitations, the Capacity Kenya program began communicating with these hires through individual text messages, but ended up having to hire more temporary staff just to send and receive these messages. Realizing a more sustainable solution was needed, the program sought the advice of information, communication, and technology firms. Following the advice of several firms, the program selected a bulk text messaging system to communicate with the health workers. Setting up this system required the program staff to:

  • Map the standard communication processes to understand the aspects of these that a text messaging system could handle
  • Collate contact information into a Microsoft Excel spreadsheet so the information could be uploaded into the bulk text messaging system
  • Configure a database that would match the fields captured in the Excel spreadsheets. Standard messages are then sent to staff using standard database information. The bulk text messaging software can also capture individual staff responses in Excel and in a PDF format. Information is easily accessed in Excel, allowing for manipulation, while the PDF format ensures that all records remain authentic.
  • Purchase a small server and a desktop computer to manage the bulk text messaging system.

The program has since launched the new system and communicated with all the staff—for example, soliciting current email addresses from all health workers:

In order to serve you better, kindly send us an SMS [text message] with your current email address and other contact information that we may use to send you both timesheets and your monthly pay slips. Clearly indicate your official name and current facility in the response. Please send response to Capacity Kenya on 07161636XX. Thank you.

By building a database of current email addresses, the program was then able to launch an email system for timesheet submission and communicate with the staff via text messaging about the new system:

Thank you for sending us your complete email contacts. In order to serve you better, we have created a new address to which you will send all your scanned and duly approved timesheets to: Timesheets should be signed and stamped by your facility head. Please send your response to Capacity Kenya on 07161636XX. Thank you.

The new bulk text messaging system has proved to be more time- and cost-effective, cut down on errors, and improved communication with staff.

  • The bulk text messaging system has cut the costs of regularly communicating with health workers by about 400% as compared to the cost of calling each health worker individually.   
  • The new system has upped compliance rates with timesheet requirements from 65% to 98%.
  • Information on new staff is easier to gather from remote areas making it quicker to add new hires to the payroll and to remove expired contacts from the system and the payroll.
  • The system has improved response rates from the health workers and created a systematic tracking system for their responses. For example, staff responses are now logged and filed based on the subject of the message. At the end of each month the messages are tabulated and analyzed. This information can then be used to modify human resources policies in ways that respond to the staff’s expressed concerns.

Capacity Kenya’s pilot initiative has shown the value of partnership with the private sector in designing simple communication solutions that can improve cost-effectiveness and that lend themselves to easy scale-up. This work has caught the interest of the Human Resources Directorate at the health ministry, which has since requested the Capacity Kenya program to install a similar service at the Ministry to help them respond more rapidly to personnel concerns.