ADA_mHealth White Paper

7/29/2019 ADA_mHealth White Paper

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SCAL ING UP

MOBILE HEALTHELEMENTS NECESSARY FOR THE

SUCCESSFUL SCALE UP OF

mHEALTH IN DEVELOPING COUNTRIES

WHITE PAPER COMMISSIONED BY

ADVANCED DEVELOPMENT FOR AFRICA

Prepared by Actevis Consulting Group

Researched and Written by

Jeannine Lemaire

December 2011


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ABOUT ADAWith operational ofces located in the centerpiece West Arica, Mali, Advanced Development

or Arica (ADA) is an Arican-based, non-proft organization with its major ocus on ostering

maternal and child health in Arica. ADA seeks to accomplish its mission through proven methods

o capacity building, technology transer, orums, and cross-sector partnerships that move

orward the ollowing goals:

Improving maternal and child health and reducing the disease burden on the populationespecially the Millennium Development Goals (MDGs 4, 5 and 6);

To promote educational excellence by giving youth the opportunity to receive training through

Information and Communication Technology (ICT) and virtual learning;

To boost gender equality and empower women by giving them the right tools and equal

opportunities or education;

To combat HIV/AIDS, malaria and other diseases.

ACKNOWLEDGEMENTS

I would like to thank Coumba Tour and Advanced Development

Arica or commissioning this white paper and showing leaders

in supporting the scale up of mHealth in developing countries. H

commitment to mHealth, as well as the empowerment of wom

and local capacity-building, will drive orward the successul in

gration of ICTs to support healthcare development and systems

This white paper would not have been possible without the expe

tise and knowledge-sharing of a select group of experts who

directly inormed the best practices and recommendations

outlined here. Our sincere thanks to David Aylward, Senior Adv

of Global Health and Technology at Ashoka, and former Execu

Director of the mHealth Alliance; Patricia Mechael, Executiv

Director of the mHealth Alliance, and mHealth & TelemedicAdvisor at the Earth Institute at Columbia University; Brooke

Partridge, CEO of Vital Wave Consulting; Anne Roos-Weil,

Co-Founder and CEO of Pesinet; and Getachew Sahlu, eHea

expert and Program Manager at the WHO. Special thanks to Cr

Friderichs, Director of Health at the GSMA, and Yunkap Kwank

CEO of Global eHealth Consultants, for their comments and con

butions to the recommendations; Isaac Holeman, Chief Strateg

at Medic Mobile, or sharing lessons learned rom the feld; a

Sean Blaschke of UNICEF Uganda for his evidentiary graphic.

I would like to extend my appreciation and thanks to our exter

review panel: Katherine Otto, consultant for the World Bank

eTransform Africa initiative and Africa Region Technical Hea

Unit; Sean Blaschke, Technology for Development Specialist a

UNICEF Uganda; as well as Henry Chang and Thrse Lethu

o Actevis Consulting Group or their invaluable comments a

guidance on this white paper.

JEANNINE LEMAIRE

Director, eHealth and New Media

Actevis Consulting Group

[email protected]


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ACKNOWLEDGEMENTS

ACRONYMS

ADAS MODEL FOR ACCELERATED DEVELOPMENT

INTRODUCTIONBACKGROUND

MOBILE HEALTH (mHEALTH)

OVERVIEW

CASE STUDIESCHILDCOUNT+

mPEDIGREE

mTRAC

PESINET

PROJECT MWANA

SMS FOR HEALTH

SMS FOR LIFE

TELE SALUD

TXTALERT

EXPERTS

BEST PRACTICES

RECOMMENDATIONSPROGRAMMATICOPERATIONAL

POLICY

GLOBAL STRATEGY

CONCLUSION

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06

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CONTENTS

OWNLOAD

LECTRONIC

ERSION

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ACRONYMS ADAS MODELADAS MODEL FOR ACCELERATED DEVELOPMENTADAs approach to accelerated development includes an integr

model of ICT for development, which benets health as well

other sectors of the economy. There are compelling argume

for this. Firstly, developments in ICT deployment in countries a

not driven by the health sector, but primarily by communicati

commerce and governance considerations. Secondly, the sam

ICT infrastructure deployed for health reasons can be used f

education, agriculture, small business development and othe

productive sectors o the economy. Finally, and most importa

study o the social determinants o health has shown that su

tainable health benefts can best be obtained by not only addres

health interventions, but by improving daily living conditions

and tackling the inequitable distribution of power, wealth an

resources.1 This white paper, which focuses on mHealth, is th

ore only one, albeit a topical and timely one, o a series o suc

documents which will frame ADAs work.

ART

BOP

CHW

CSR

DfID

DHIS2

GFATM

GPRS

HMIS

ICT

IDRC

IICD

IT

ITU

M&E

MMV

MNO

MOH

MVP

RBM

RDT

SMS

UNDP

UNICEF

USAID

USSD

WB

WHO

Antiretroviral Therapy

Base of the Pyramid

Community Healthcare Worker

Corporate Social Responsibility

UK Department for

International Development

District Health Information

Software 2

Global Fund to Fight AIDS,

Tuberculosis and Malaria

General Packet Radio Service

Health Management

Information System

Information and Communications

Technology

International Development

Research Centre

International Institute

Communication and Development

Information Technology

International Telecommunication

Union

Monitoring and Evaluation

Medicines for Malaria Venture 1. WHO, Final report ofthe Commission on SocialDeterminants of Health

Mobile Network Operator

Ministry of Health

Millennium Villages Project

Roll Back Malaria Partnership

Rapid Diagnostic Tests

Short Message Service

United Nations Development

Program

United Nations Children Fund

U.S. Agency for International

Development

Unstructured Supplementary

Services Data

World Bank

World Health Organization


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08 09DUCTION INTRODUCTION

With 5.3 billion mobile subscribers across the globe and alm

90 percent of the worlds population covered by a wireless s

the mobile phone has become the most widely spread commun

tions technology platform. The spread of mobile phone techn

and networks has not been limited to developed countriesin

developing countries are currently seeing massive growth, w

billion mobile subscriptions in the developing world alone,2 ma

up or 73 percent o subscriptions worldwide. Rural populat

are also gaining access to this platorm80 percent o rural

munities across the globe have access to a mobile network. A

the African continent and within India, the number of mobile

phone subscribers surpassed one billion in 2010 and in some

exceeds basic infrastructure, including paved roads, electricity

even proper sanitation. India has over 826 million mobile ph

subscribers as of 2011, serving nearly 70 percent of Indias 1

lion population, yet only a third of Indias population had acces

proper sanitation in 2008, according to a UN report.3 Additio

the International Telecommunication Union (ITU) reported in 2

that the rapid spread o mobile phones in developing countr

being driven by demand and increasing aordability, particu

India and China where mobile penetration rates are quickly rea

saturation points at over 100 percent.

BACKGROUND

2. mobiThinking. Global MobileStatistics 2011. Retrieved June 3,

2011, from http://mobithinking.com/mobile-marketing-tools/latest-mobile-stats

3. United Nations University. GreaterAccess to Cell Phones than Toiletsin India. Retrieved June 15, 2011,from http://www.inweh.unu.edu/News/2010-04_UNU-INWEH_News-Release_Sanitation.pdf

INTRODUCTION


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The use o mobile phones to improve the quality o care and enhance efciency o service delivery

within healthcare systems is known as mobile health, or mHealth, and is a sub-segment o the

broader feld o electronic health (eHealth). WHO has defned mHealth as the provision o health

services and inormation via mobile technologies such as mobile phones and Personal Digital

Assistants (PDAs). mHealth tools have shown promise in p roviding greater access to healthcare

to populations in developing countries, as well as creating cost efciencies and improving the

capacity o health systems to provide quality healthcare.

Recent evidence rom randomized scientifc trials and studies has demonstrated that the capa-

bilities o mobile phone technology, particularly SMS messaging, can positively impact treatment

outcomes. Results o the WelTel Kenya1 clinical trial, the frst study o its kind in Arica, were

published in The Lancet4 in November o 2010. The trial ocused on the impact o SMS messaging

on HIV-inected adults starting antiretroviral therapy (ART) in three clinics in Kenya. The study

showed that patients who received SMS support had signifcantly higher adherence to ART and

higher rates o viral suppression when compared with patients in the control group. A scale up osuch a mobile phone support system in Kenya could suppress viral loads in 26,000 extra people

at the cost o less than USD 8 per person per year, according to Richard Lester o the British

Columbia Centre or Disease Control and the studys lead researcher. Another cluster-randomized

trial at 107 rural acilities in Kenya ound that SMS message reminders sent to health workers

mobile phones improved and maintained their adherence to treatment guidelines or outpatient

pediatric malaria in Kenya.5

A multitude o mHealth solutions have emerged over the years in countries such as Ethiopia,

Kenya, Nigeria and South Arica, which are leading the way in using mobile health services,

according to the Global Observatory or eHealth at the WHO. Getachew Sahlu o the WHO identifed

the convergence o the ollowing actors as the driving orce behind the current rapid mHealth

growth in developing countries: (1) a record growth o mobile phone users, (2) rapid expansion

o mobile networks, (3) the decline in mobile phone costs, and (4) the innovation in mobile technol-

ogy. The mobile platorm presents the unique capability o delivering healthcare services wherever

people arenot just in healthcare acilities. mHealth initiatives have also been eective in reaching

underserved populations, particularly those in rural areas, changing health behaviors and outcomes,

and addressing a wide variety o healthcare challenges, including:

The shortage of skilled healthcare workers in certain developing country settings

Treatment adherence and compliance

Lack of timely and actionable disease surveillance

Poor drug inventory and supply chain management

Use of counterfeit drugs

Lack of medical diagnostic treatment

Slow rates of information ow and reporting delays.

mHealth represents a cost-eective technology solution to many o these challenges i imple-mented correctly and brought to scale. The costs o mobile handsets and usage are declining as

demand or mobile services increases and mobile networks are being rapidly expanded.

Graph o the decline in cost o telecommunications technologies, specifcally mobile phonesSource: The Economist, http://www.economist.com/node/21517126

ester R et al. Effects of a mobilene short message service onretroviral treatment adherence inya (WelTel Kenya1): a randomised

. The Lancet Online, 12 June 2011,://www.thelancet.com/rnals/lancet/article/S0140-6736(10)61997-6/fulltext

urovac D et al. The effect of mobilene text-message reminders onyan health workers' adherence

malaria treatment guidelines: aster randomised trial.Lancet Online, 3 July 2011,

://www.thelancet.com/rnals/lancet/article/S0140-6736(11)60783-6/fulltext

MOBILE HEALTH (mHEALTH)


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Despite the strong promise demonstrated by mHealth tools and applications, the current land-

scape o mHealth development in developing country contexts is characterized by a prolieration

o unsustainable pilot projects that oten expire once initial unding is exhausted. For example, in

Uganda alone there were 23 mHealth initiatives in 2008 and 2009 that did not scale up ater t he

pilot phase (see fgure below). In India, there were over 30 mHealth initiatives in 2009 that did not

go beyond the pilot phase.6

Current policy environments, business models and unding schemes around mHealth have ueled

the prolieration o pilot projects without enabling them to scale up in a meaningul, replicable way.An additional, and perhaps most signifcant, obstacle to improving and scaling the implementation

o mHealth initiatives is the lack o monitoring and evaluation (M&E) and use o meaningul, consis-

tent indicators and rigorous evaluation methods.

Given the obstacles within the current landscape, this white paper was commissioned by Advanced

Development or Arica (ADA) to assess current implementations o successul mHealth programs in

developing country contexts. The objective is to identiy elements necessary or successully scaling

up, with the aim o highlighting best practices and specifc programmatic, operational, policy and

global strategy recommendations that can promote scale up o mHealth.

Map of mHealth Pilots in UgandaSource: Sean Blaschke, Technology for Development Specialist at UNICEF Uganda

Profled in this report are several select mHealth programs that have been piloted and a

rently in the scale up phase, and have proven enough success that they should be conside

models or other initiatives to ollow. As the ollowing case studies will demonstrate, throu

accurate and timely data, disease surveillance, decision support and health inormation man

mHealth can eectively inorm policy-making and planning within healthcare systems

improve the health o local communities, particularly remote populations. The scale up o

within national health agendas should be supported by all departments within the Minis

Health and across other relevant ministries and agencies including Telecommunication

internal stakeholders, such as end-users and benefciaries, and external stakeholders, s

mobile network operators and donors, should be engaged in the planning and business

design and scalability assessments. The primary goal o this white paper is to provide evid

recommendations that will allow mHealth initiatives to better plan their own scale up bey

cessul pilot phases.

Pilotitis, the biggest disease in

Health. Retrieved on June 13, 2011,

m http://www.slideshare.net/

ttochange/pilotitis-the-biggest-

ease-in-mhealth

OVERVIEW


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CASE STUDIES

STUDIES CASE STUDIES

Millennium Villages Project (MVP)

Rapid Response, a RapidSMS-based mobile application

Remote Data Collection & Health Management Inormation System (HMIS)

Scaling up

Kenya, Tanzania, Ghana

Primary healthcare and MDG-related issues ocusing on maternal-newborn-child health s

malnutrition, malaria, and other diseases that aect early childhood development; PMTCT

pneumococcal vaccination coverage

ChildCount+ is a community health events reporting and alerts platform aimed at empowering comm

improve child survival and maternal health. Using any standard phone, community health extensio

(CHEWs) are able to use text messages to register patients and send in health reports to a central

board that allows a health team to closely monitor the health of their community and reduce gaps inThe pilot in Sauri, Kenya started in July 2009. A mobile application, initially known as Chi

was used by 100 CHEWs to actively monitor 9,500+ children under fve. ChildCount supported th

o community-based management o acute malnutrition (CMAM) programs; home-based tes

malaria using Rapid Diagnostic Test (RDT) kits and immediate dispersal o treatments; and hom

treatment o children with diarrheal illness. CHEWs used SMS messages to register patients a

in their data. The more recent ChildCount+ added support or maternal health by registering al

mothers and providing support or antenatal care. The PMTCT (prevention o mother-to-child tr

sion o HIV) module o ChildCount+ was launched in Ghana in August, 2011. This marks the se

site to implement the PMTCT sotware, with the frst site being the Sauri Cluster in Western K

The ability to track and promptly attend to children who need nutritional or medical int

is a main strength o the ChildCount+ program. Key strategic partners supported the initiative

An important provision of phone handsets for CHEWs to initially launch the service,

by Sony Ericsson in early 2009.

Airtel Kenya, then known as Zain, assisted in setting up a toll free number.

ChildCount+ aims to help CHEWS to:

Register every child under ve and provide a basis for monitoring health statuses

Screen for malnutrition every 90 days

Monitor for and treat malaria, diarrhea and pneumonia

Support child immunizations

Record all local births and deaths

Recording pregnant womens due dates to make antenatal visits systematic

ChildCount+ is in active use in the MVP site in Kenya. At Sauri, ChildCount+ covers over 6

people with child and maternal health care services. The system has also been deployed at t

MVP in Kenyas Garissa County. ChildCount+ is in the process o being rolled out across the re

14 MVPs representing approximately 500,000 people100,000 o which are children undeUNICEF is in the process o rolling out a variation o ChildCount+ in Senegal and consider

activities in other countries.

Adopts a holistic, comprehensive approach to tackling various local health priorities in

antenatal, post-partum, maternal, and primary health issues o children under fve

Focuses on alignment with existing information management systems

Local capacity-building

Earth Institute at Columbia University, UNICEF Innovation Group, Millennium Promise, E

Sony Ericsson, Airtel Kenya and MTN.

2009ongoing

ORGANIZATION

mHEALTH TOOL

CATEGORY

PHASE

LOCATION

TARGETS

SUMMARY

GOALS + RESULTS

SUCCESSFUL ELEMENTS

IMPLEMENTING +

FUNDING PARTNERS

DURATION

CHILDCOUNT+


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ORGANIZATION

mHEALTH TOOL

CATEGORY

PHASE

LOCATION

TARGETS

SUMMARY

GOALS + RESULTS

SUCCESSFUL ELEMENTS

IMPLEMENTING +

FUNDING PARTNERS

DURATION

HP and mPedigree

mPedigree


Scaled up

Nigeria, Ghana, Kenya

Sale and use o countereit drugs

HP and mPedigree, a social enterprise based in Ghana, have teamed up with pharmaceutical

companies to oer a way or patients to check the authenticity o their medicines ree o charge,

with a basic mobile phone. HP provides the inrastructure linking the pharmaceutical companies,

telecommunications companies, and mPedigree together to make the initiative possible.

mPedigree developed an SMS-based system to fght the prolieration o countereit drug sales

in developing countries. The enterprise produces scratch cards that reveal a single-use numericcode on drugs that users can text or ree rom their mobile phone, instantly receiving inormation i

the drugs are genuine or countereit.

The frst drugs to use the system, rom May & Baker and KAMA Group, debuted in December 2010

in Nigeria and Ghana. HP and mPedigree plan to make the service available or other medications

and in more countries in the near uture.

The system is operational in Ghana and Nigeria since late 2010. A pilot in Kenya was underway

in early 2011 with the aim to scale it up.

Win-win social enterprise business model, with the service being funded by the participating

pharmaceutical companies

Partnership approach eliminates costs to the user, thereby increasing accessibility to the initiative

All GSM mobile network operators in Ghana and Nigeria are signatories to the scheme

HP, mobile network operators, pharmaceutical companies, and governmental authorities

2010ongoing

ORGANIZATION

mHEALTH TOOL

CATEGORY

PHASE

LOCATION

TARGETS

SUMMARY

GOALS + RESULTS

SUCCESSFUL ELEMENTS

IMPLEMENTING +

FUNDING PARTNERS

DURATION

UNICEF Uganda

mTrac


Scaling up

Uganda

Track disease outbreaks and medication at Ugandas 5,000 health acilities and 8,000 com

based drug dispensers

mTrac is an SMS, USSD and web-based data collection tool built on RapidSMS that enables

workers at district health centers to submit weekly HMIS reports, with a current ocus o

outbreaks and essential medicines. mTrac also has an Anonymous Hotline or reporting

delivery complaints to strengthen community monitoring, and the inormation is triaged

ofcial data to immediately identiying bottlenecks. SMS alerts are sent to District and NStakeholders based on a predefned list o thresholds, who are expected to investigate a

on the outcomes, creating a clear accountability chain. Working through UNICEFs Urepo

tive, Ugandan Parliamentarians and over 35,000 community-based leaders receive upda

perormance o their constituencies. The mTrac project was initially piloted by FIND Diag

and the Millennium Villages Project (MVP) in roughly 170 health acilities in the Gulu an

districts o Uganda.

The goal o mTrac is to support the eorts o the Ugandan Minisitry o Health (MOH) in digi

countrys health inormation management systems.

The mTrac pilot was handed ully over to the Ugandan government in 2011. With supp

UNICEF and WHO, the Ugandan MOH is in the process o rolling out mTrac nationwide at th

trys 5,000 health acilities and 8,000 local medication distribution centers. The roll out is e

to be completed by the end o 2012. One year ater the handover rom FIND Diagnostics,

still a response rate o about 90% on a weekly basis rom acilities using mTrac.

The mTrac project meets national health priorities and has been integrated into the nati

health inormation system and the governments district health inormation sotware data

(DHIS2)

mTrac was designed and developed with sustainability and scalability factors built in fro

starte.g. mTrac runs on basic mobile phones

Uganda MOH and WHO (previously FIND Diagnostics & MVP)

Funding: UK Department or International Development (DID) or developing the mTrac sy

Uganda MOH or project implementation

2010ongoing

mPEDIGREE mTRAC



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Pesinet

Pesinet JAVA application (SMS/GPRS)


Planning scale up

Mali

Child health with a ocus on respiratory illnesses, diarrheal disease and malaria; early detection

and disease prevention; urban populations

Launched in pilot phase in October 2009, Pesinet uses mobile phones to support the reduction o

child mortality by acilitating access to early treatment, and raising awareness o disease preven-

tion. Pesinets service leverages the GSM network in Mali and open-source sotware to record

and transer health inormation and then reduce the amount o time a doctor needs to access and

analyze it. A mobile application has been developed to collect and transer data on the ground byhealth monitoring agents. An online application linked to a database allows or remote monitoring

o health data by the local doctor, activity management and tracking o key impact indicators.

Healthcare agents are recruited by local healthcare centers and assisted technically by Pesinet.

They make weekly home visits to enrolled patients (cost: 1/month), look or fve key symptoms

(ever, vomiting, diarrhea, cough, and weight loss), record the data onto a Java mobile application,

then send the data to a doctor at the local healthcare center. Mobile technology allows a model

whereby a greater number o children can be seen by just one healthcare agent and remotely

ollowed-up by just one healthcare centers doctor.

The goals o the program are to prevent child mortality rom preventable and treatable diseases

through regular home-screenings, and to create an aordable insurance plan so that health prob-

lems do not bankrupt amilies. Changing the local perceptions o prevention is also a key target or

Pesinet as disease prevention is not recognized as a vital component o health care.

Pesinet aims to adhere to a fnancially sustainable business model by ocusing on maximizing

the sel-sustaining component o the model, while maintaining aordability o the program to ben-

efciaries. This has translated to slow growth compared to ree o charge programs.

Originally implemented in Saint Louis, Senegal, Pesinet ailed to achieve the fnancial

sustainability needed and properly integrate into the health system. But the lessons learned and

its innovative solutionsincluding strategic partnerships and technical and fnancial improve-

mentshelped Pesinet successully re-launch in Mali in September 2007 and begin their mHealth

pilot in 2009.

Secured strategic partnerships and buy-in from government agencies and private sector players

Planning for integration into existing local health structures and long-term sustainability by

adhering to a fnancially sustainable business model

Performed evaluations supported by the National Agency for eHealth and Medical Informatics of

Mali and independent external quantitative and qualitative evaluations, including a SWOT analysiso service, to assess the efcacy and efciency o services

Public sector: Mali MOH and its eHealth Agency, the Regional Health Department, local district and

local healthcare centers.

Private sector: Ashoka, BNP Paribas, Sanof Espoir Foundation, Terre Plurielle Foundation, NSA,

Alcatel-Lucent Foundation, Antropia, Medicament Export, and Orange Mali Foundation

2009ongoing

ORGANIZATION

mHEALTH TOOL

CATEGORY

PHASE

LOCATION

TARGETS

SUMMARY

GOALS + RESULTS

SUCCESSFUL ELEMENTS

IMPLEMENTING +

FUNDING PARTNERS

DURATION

PESINET


ORGANIZATION

mHEALTH TOOL

CATEGORY

PHASE

LOCATION

TARGETS

SUMMARY

GOALS + RESULTS

SUCCESSFUL ELEMENTS

IMPLEMENTING +

FUNDING PARTNERS

DURATION

UNICEF Innovation, rog design, Country MOHs

RapidSMS-based mobile application

Education, Awareness & Health Promotion

Scaling up

Zambia, Malawi

Inants (Early Inant Diagnosis); HIV; Maternal Health

Project Mwana ocuses on using mobile technology to strengthen health services or moth

infants in rural healthcare clinics. It was initially deployed in Zambia to deliver HIV test r

instantly via SMS to rural clinics and reduce the delay between testing and treatment rom

months to a ew weeks.

Project Mwana is composed o tw o related initiatives: Results 160, ocusing on acce

the transmission o lab results or early inant diagnosis o HIV/AIDS; and Remind Me, atracking system that notifes community health workers (CHWs) to check up on mothers an

Both make use o mobile networks and SMS technology as a support tool to link CHWs to

mal health system to coordinate and measure children receiving treatment.

Project Mwanas pilots ocused primarily on early-stage antenatal care or pregnant

and immediate and long-term post-natal care. Specifc points within these timerames h

identifed as optimal in diagnosing and treating HIV-positive mothers to best prevent trans

to their child and ensure their health during the pregnancy and birth.

The immediate goal o this project is to increase mothers visits to clinics signifcantly by J

2012 in rural Zambia and peri-urban Malawi by leveraging mobile technologies. The long

goal is to develop a communication system that can be scaled across many dierent count

partnership with other UNICEF country ofces.

Project Mwana is now moving from pilot to implementation phase in Zambia and so

Malawi. In Zambia, the project was piloted in 31 clinics across 6 provinces and evaluated.

phase is to scale nationally using a 3-year plan. Project Mwana is also being replicated in M

Identied local health priorities in implementation areas as primary objectives of the to

maternal health, early HIV diagnosis or inants)

Working with the government and private sector, including mobile network operators, to

scale up ater the success o the pilot phase was assured

Planned for scale and sustainability before the pilot phase

Evaluated program to inform national scale up

Zambia MOH, UNICEF Zambia, Malawi MOH, UNICEF Malawi, and several implementing a

nical partners, e.g. Caktus.

Pilot was unded by UNICEF, Boston University and the Clinton Health Access Initiative.

2010ongoing

PROJECT MWANA


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ORGANIZATION

mHEALTH TOOL

CATEGORY

PHASE

LOCATION

TARGETS

SUMMARY

GOALS + RESULTS

SUCCESSFUL ELEMENTS

IMPLEMENTING +

FUNDING PARTNERS

DURATION

Text to Change (TTC)

SMS

Education, Awareness and Health Promotion

Scaling up

Uganda

HIV workplace program or employees and suppliers

Text to Change uses SMS quizzes to challenge mobile phone users on their health knowledge, reer

them to HIV testing sites and gather sex and age data rom participants which can be analyzed

alongside the location o the caller.

In 2009, TTC ran a pilot with HIPS (Health Initiatives or the Private Sector), a USAID unded

program, to carry out several SMS-based workplace programs in Uganda. In May 2011, TTC imple-

mented the second part o the program (ollowing the successul pilot), working with Kakira Sugar, arenowned sugar company in Uganda.

The programs purpose is to improve Kakira Sugars internal communication and increase access

to health inormation and services amongst employees and their amilies. The program targets not

only the 3,000 employees o Kakira Sugar but also the 7,500 armers who supply cane to the company.

The program conducts awareness campaigns on the topics o amily planning, medical male circumci-

sion, HIV/AIDS and other sexually transmitted inections, multiple concurrent sexual partnerships and

malaria. Participation is ree and backed up with reward incentives (or example, a ree mobile phone

or airtime).

The goal o the program is to increase participation in voluntary HIV counseling and testing (HCT)

programs, and increase patient knowledge o available health services and clinicsall via SMS. Last

years program demonstrated an increase o up to 40% in HCT services partnering clinics. At the

launch o the second implementation phase in May 2011, at least 200 people responded to HIV test-

ing and over a 100 people sought other health services ollowing the initial awareness campaign.

Through the IICD and the Connect4Change consortium, TTC aims to scale its mHealth initiative

to 16 countries in 2011 and 2012.

Research-based, with 9-month long impact study

Content was adapted to local contexts to ensure successful uptake

Achieved scale through model of adding value to the health policies of companies via mHealth

Developed strategic partnership with network of like-minded organizations focused on ICTs for

development

TTC projects are supported by African mobile providers (including ZAIN), the Dutch Ministry of

Foreign Aairs, FC Barcelona and other partners such as Royal Tropical Institute o Netherlands

(KIT) and USAID.

Ugandan pilot partner: Health Initiatives or Health (HIPS) Uganda program (unded by USAID).2009ongoing

SMS FOR HEALTH


Novartis, Vodaone Health Solutions and Roll Back Malaria partnership

SMS, Vodaones Mobile Relationship Manager platorma data management tool with a

web dashboard


Scaled up: nationwide roll-out in Tanzania; new pilots in Kenya and Ghana

Tanzania, Kenya, Ghana

Malaria

SMS or Lie is a public-private project in conjunction with the Roll Back Malaria global partn

that aims to demonstrate that visibility o weekly stock levels or fve selected malaria dru

three Tanzanian districts will promote action to eliminate and/or reduce stock-outs. The na

roll-out o this malaria treatment access initiative is planned or Tanzania. The roll-out o

successul pilot project where mobile and electronic mapping technology was used to track levels o anti-malarial drugs at health acilities to manage supplies o these essential treat

Launched in 2009, the SMS or Lie pilot ran across three districts in Tanzania, en

access to essential malaria treatments or 888,000 people. 99% o health acilities involved

stock-outs o the artemisinin-based combination therapy (ACT), one o the main anti-ma

medicines. Based on the successul pilot, SMS or Lie will now be deployed nationwide

5,000 health acilities in 131 districts in Tanzania, covering a population o over 40 million

SMS or Lie was initially piloted across three districts o Tanzania, covering 129 health a

and 226 villages, representing 1.2 million people. During the frst ew weeks o the SMS

pilot the number o health acilities with stock-outs in one district alone was reduced b

75%. When launched in 2009, 26% o all health acilities did not have any ACTs in stock, b

end, 99% had at least one ACT dosage orm in stock. In addition, 888,000 people in the thr

districts had access to all malaria treatments at the close o the pilot, versus 264,000 peo

start, which helped to reduce the number o deaths rom malaria.

In addition to the roll-out in Tanzania this year, two urther pilots will start. Kenya, wit

rom Novartis via the global employee survey donation program, will implement a fve dis

to track ACTs and rapid diagnostic tests (RDTs), in addition to collecting weekly case manag

data. The Medicines or Malaria Venture (MMV), through partnership with University o O

provide technical support or the implementation and evaluation o the pilot project. Gha

unding rom Swiss TPH, will implement a six district pilot to track malaria medicines, an

and RDTs.

Under the auspice o the Tanzanian Ministry o Health and Social Welare, this roll-out

Novartis and supported by Vodacom, Medicines or Malaria Venture (MMV) and the Swiss A

Development and Cooperation, all under the umbrella o the global Roll Back Malaria Par

Public-private partnership model involving strong buy-in from many key stakeholders fr

government, private sector and bilateral agencies to support implementation and scale up Identied key metrics to measure effectiveness of program and demonstrate success

Tackles key national health priority (malaria control)

Supports advocacy within the government in recognizing mHealth as a concrete soluti

Tanzanian Ministry o Health and Social Welare and the National Malaria Control Programm

(NMCP), Novartis, MMV, Swiss Agency or Development, Vodacom, IBM, RBM Partnerships S

2009ongoing

ORGANIZATION

mHEALTH TOOL

CATEGORY

PHASE

LOCATION

TARGETS

SUMMARY

GOALS + RESULTS

SUCCESSFUL ELEMENTS

IMPLEMENTING +

FUNDING PARTNERS

DURATION

SMS FOR L IFE


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22 23 STUDIES CASE STUDIES

TulaSalud

Episurveyor; Frontline:SMS (and Clickatell)

Disease & Epidemic Outbreak Surveillance; Point-o-Care Diagnostic & Treatment Support

Scaling up

Guatemala

Maternal and Child Health; Disease Outbreaks

TulaSaluds vision is to use ICT and mobile technology to reduce maternal and inant mortality

and to monitor disease outbreaks in the remote highlands o Alta Verapaz, Guatemala, which

has the largest rural and poor indigenous population in the region with limited access to health

care services. Using mobile phones, TulaSalud has been able to improve the ow of information

between health proessionals based in hospitals and community health workers (CHWs), or tele-

acilitadores, in remote villages.In 2009, TulaSalud distributed mobile phones to 60 community health workers. With the mobile

phones, the CHWs could call a doctor or diagnostic or reerral support and collect inormation

about each patient consultation using DataDynes EpiSurveyor.

TulaSalud uses mobile phones to:

Monitor disease outbreaks in real-time based on the data aggregated from patient consultations

through EpiSurveyor

Send text message alerts and reminders to CHWs using FrontlineSMS

Evaluate the productivity of CHWs working in the eld

Deliver remote health training via mobile-based audio conferencing

Data collected by the CHWs was instrumental in the early detection o meningitis, rabies and H1N1

in the region. The original paper-based data collection system oten took up to 40 days to get data

analyzed and communicate risk management directives. TulaSaluds EpiSurveyor data collection

system enabled epidemiologists to assess the data as soon as it came in and the CHWs to respond

as necessary within 3-4 days.

By 2010, over 19,000 consultations were made and more than 400 patients were reerred to

health centers. O these reerrals, 156 cases were identifed as being high-risk pregnancies and 83

women were at risk o dying. Currently, TulaSaluds database has over 38,000 patient consultations

and continues to grow.

The 60 CHWs currently cover 22% o the rural regions o Alta Verapaz. Incrementally, over

the next fve years, TulaSalud hopes to expand the program to include 330 CHWs equipped with

mobile phones.

In coming years, TulaSalud plans to work closely with the MOH as they increase the number

o CHWs in Alta Verapaz and consider incorporating data collection at a national level. TulaSalud

intends to place more emphasis on collecting inormation on pregnant women in order to identiy

high-risk pregnancies early on.In 2011, the organization will begin scaling their epidemiological monitoring program and

potentially introduce new mobile surveys. By 2015, it hopes to integrate processes with Guatemalas

national health inormation system.

Designed initiative with a thorough understanding of local healthcare structures, conditions and

environment

Episurveyor surveys were based on mandatory Health Information Management System forms

required by the MOH

Hardware (mobile phone) selection was adapted to end-user needs and local conditions such as

network signal reach and capture

ORGANIZATION

mHEALTH TOOL

CATEGORY

PHASE

LOCATION

TARGETS

SUMMARY

GOALS + RESULTS

SUCCESSFUL ELEMENTS

IMPLEMENTING +

FUNDING PARTNERS

DURATION

Close partnership with the MOH, ensuring the p rogram was not a parallel system but ra

complementary data collection system running alongside existing government systems

Buy-in from the national system securedas evidenced by physicians with no afliatio

TulaSalud providing consultations to TulaSaluds CHWs

Planning to integrate processes with the national health information system

Partners: Guatemala MOH and the Cobn School o Nursing.

Receives support rom the Tula Foundation based in Canada.

20092015

TELE SALUD


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24 25 STUDIES EXPERTS

ORGANIZATION

mHEALTH TOOL

CATEGORY

PHASE

LOCATION

TARGETS

SUMMARY

GOALS + RESULTS

SUCCESSFUL ELEMENTS

IMPLEMENTING +

FUNDING PARTNERS

DURATION

Right to Care, Praekelt Foundation

TXTAlert

Remote Patient Monitoring & Support

Scaling up

South Arica

Youth living in poverty; HIV/AIDS

Praekelt Foundation developed the open source SMS communication tool called TxtAlert which

was launched in conjunction with Right to Cares Themba Lethu Clinic at the Helen Joseph Hospital

in 2007. The TxtAlert program supports both HIV patients on ART and their healthcare workers to

improve adherence. It aims to increase appointment attendance o HIV patients on ART by notiying

patients o their upcoming appointments via SMS and requesting that they reschedule i they are

unable to attend (via Please Call Me or PCM messages which are popular ree text messagesin South Arica that ask the receiver to call them back). It also serves as a tracking mechanism or

healthcare workers to identiy which patients miss appointments or medication pick-ups.

In 2010, the program is expanding to prove that it can be used or any disease management

protocol that requires regular doctor ollow-ups or medication reminders. The expanded version

will contact patients with TB, malaria, diabetes, and any other chronic illness that needs long-term

care. TxtAlerts end goal is to oer adherence support and monitoring across a range o diseases to

strengthen public health systems.

The project was successully piloted at the Themba Lethu Clinic at the Helen Joseph Hospital

in Johannesburg starting rom August 2007. O the 9,438 ART patients registered at the clinic in

November 2008, 9,414 voluntarily opted into TxtAlert. More than 30,000 visit reminder messages

have been sent to patients rom April to October 2008.

The TxtAlert system depends on electronic records systems, so the Praekelt Foundation has

aced challenges in expanding the project to rural areas where systems are not yet digitized. The

system currently only runs in Johannesburg because it is dependent on clinics and hospitals having

electronic patient databases, which many rural clinics do not have. TxtAlert is being integrated into

Project Masiluleke in South Arica.

The success o TxtAlert is telling: missed appointments have allen rom 30% to 4%. Lost to

ollow-up rates have declined rom 27% to 4%, said Dr Ian Sanne, CEO o Right to Care.

Tool is designed with the end-user in mind, providing simple yet powerful functionality

Integration within existing healthcare information systems

Utilized locally relevant service, PCM messages, to create successful and sustainable business model

Right to Care

2007ongoing

Interviews with mHealth experts inormed the ollowing set o best practices and recom

dations to grow a project beyond a successul pilot phase and achieve scale up. The expe

interviewed (listed below) are involved in various felds o mHealth including research, evalu

advocacy, policy, program design, implementation and global strategies.

David Aylward Senior Advisor, Global Health and Technology at Ashoka

Former Executive Director of the mHealth Alliance

Patricia Mechael Executive Director of the mHealth Alliance

mHealth and Telemedicine Advisor at The Earth Institute

Author of Barriers and Gap Affecting mHealth in Low and

Middle Income Countries: Policy White Paper

Brooke Partridge President and CEO of Vital Wave Consulting

Anne Roos-Weil Co-Founder and CEO of Pesinet

Getachew Sahlu eHealth Expert

Program Manager at the World Health Organization (WHO)

EXPERTS

TXT ALERT


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26 27

1

2

The case studies assessed in this paper highlight a set o common elements that are ne

or ensuring successul scale up that are applicable across programs that all into dier

matic ocus areas o mHealth. Drawing rom these case studies and interviews with expe

feld, the ollowing best practices or implementing a successul pilot phase and ensuring

were identifed.

Plan or scale up and sustainability on a large scale. Sustainab

and scalability actors must be built into the program rom

beginning.

All pilots should plan or scale up and sustainability rom the beginning, according to Br

Partridge. Scalability and sustainability actors include ensuring hardware and sotwar

or the pilot can be used on a broader scale, developing a long-term unding plan, evalu

and measuring the impact o the intervention, and others described in the rest o this doBuilding these actors into the program rom the start will ensure that a successul pilot pre

an eective intervention can achieve scale. Implementations may work sustainably on a sm

but may not translate to implementation on a larger scale.

Perorm assessments to identiy real needs and demands o

get beneiciaries, local health priorities and to understan

local landscape (existing players and solutions, policies, l

settings and practices, etc.) in the area o implementation. T

into account the local conditions, environment, stakeholders

barriers identied through the assessment during the design

planning phase.

Important dierences between local contexts can determine what is an appropriate mHeal

mentation or a specifc location. Brooke Partridge highlights the need to take these into

during the planning and design phase o the project.

The local conditions, including existing healthcare inrastructure, mobile network sig

literacy levels, language requirements and cultural practices, can have a signifcant impa

success o the project. The goal is to identiy the current barriers and challenges to tailor

tive to best serve the populations needs given the local conditions. For example, Pesinet i

an application that automatically switches between transerring data via SMS and GPRS b

the wireless signal available and stores the data or uture transmission i no signal is a

The capability to operate in poor coverage areas and areas in which electricity is a limited

should be taken into account as needed. In areas where literacy levels are low, using voice media communication (such as images) would be a more locally appropriate solution.

Understanding the environment the mHealth solution is being brought into is key, t

Patricia Mechael recommends perorming ethnographic studies and local assessments t

a concrete understanding o the health system environment and norms within which the s

be operating. This includes identiying both cultural and social norms that aect patient

and uptake o the mHealth intervention, as well as the political and policy environment th

implementation and scale up o the intervention. For example, i there is a gender gap in

phone ownership, this may render an intervention ineective i its target audiencewo

not have regular access to a mobile phone. Creating a program with skilled designers, a

community and end-user input, can bring a more anthropological and user-ocused app

BEST PRACTICES

PRACTICES BEST PRACTICES


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28 29

the program while also bringing a perspective that can support the long-term sustainability and

potential scale up o the program.

Assessments can also ensure there is a real need or demand within the benefciary popula-

tions or mHealth solutions. For example, in some developing country settings the problem may not

be a lack o health resources but rather the actual use and demand by the local population. This is

the case in Mali where in urban areas, such as Bamako, the challenge is getting the local popula-

tion to take advantage o the available medical resources, particularly or disease prevention, and

increasing their d emand or health services.

Another important component is understanding the policy ramifcations o scaling up and strat-

egizing on how the mHealth program can be aligned with a countrys existing healthcare structures

(such as a national health inormation system). Anne Roos-Weil, CEO o Pesinet, an organization

implementing an mHealth program in Mali, recommends that implementers learn very specifcally

the economics o healthcare within the government and healthcare structures and how to inte-

grate the program within that system. Pesinet spent the last three years in Mali understanding how

the local community healthcare structures were fnancing their activities, whether and where thegovernment and local collectivities were involved in that fnancing and what would the benefts o

government involvement be.

Identiy existing similar initiatives and players. Do not duplicate

eorts; collaborate with other organizations or deeper impact.

An eective way to achieve scale is to link the mHealth program with other relevant programs in

the area and build o o their successes and learn rom their ailures. According to Sean Blaschke,

Technology or Development Specialist or UNICEF Uganda, the goal should be to collaborate to

leverage existing eorts rather than run parallel solutions and duplicate eorts. Duplicating eorts

can dilute the efcacy o mHealth and can prevent the program rom acquiring unds and partners

to support scale up.

Identiy what other initiatives and players are present and whether there are already other

solutions present that might meet the need in a less costly or more eective way. Patricia Mechael

suggests mapping what existing players have already done and identiying what works and what

doesnt in the local context.

Educate and engage end-users and target beneciaries in the devel-

opment o the mHealth intervention to support successul uptake.

Local stakeholders, particularly community and traditional leaders, CHWs and local popula-

tions, should be educated on the mHealth solution and how they can support and beneft rom it.

Furthermore, engaging local people rom the target benefciaries or end-user groups in leadership

roles in the development o the mHealth intervention can strongly support uptake o the intervention

in the long-run. The capacity o end-users and any necessity or capacity-building must also betaken into account.

Align the mHealth program (including objectives and target out-

comes) with the local and national health priorities and any existing

health inormation systems.

The mHealth initiative must have clearly defned objectives or what the program is trying to achieve

with the technology as well as target outcomes that are in sync with local health priorities and serve

the goals o the national health system. Several o the mHealth projects presented in the Case

Studies section have made this a key element of their program, notably Project Mwana in

and SMS or Lie in Tanzania. This element can ensure that the mHealth program has strong

tion to be integrated into the national health system, which will promote the long-term sust

o the project.

Secure buy-in rom government, communities and local health

structures as soon as possible. Design a partnership agreemen

can be validated by various stakeholders.

Anne Roos-Weil remarked that a common barrier to scale up is not having the right inter

the government and local communities. To ensure the sustainability o a project, buy-in m

nurtured or secured rom the local and national governmental agencies, as well as loca

nity structures. This means these external stakeholders recognize that the mHealth prog

contribute to meeting local health priorities and its target outcomes are aligned with thetives and plans, and that they, as stakeholders, are included in the decision-making pro

planning to promote local ownership and investment in the program. Anne recommends

signifcant eorts to meet with as many government players, local collectivities and co

organizations, and local leaders as possible rom the outset to really understand where a

decision-making takes place, particularly on unding. The next step is to perorm consist

toring and evaluation to be able to show key stakeholders within the government the cost

ratio o the mHealth program. Providing this type o data can increase the governments b

investment in the program. Promoting ownership within local communities in areas o imp

tion can promote the uptake o the intervention and belie that it provides an additive bene

elements are vital to supporting scale up.

A close partnership with the MOH can promote the integration o the project into ex

health systems and promote enabling policy-making to support mHealth. A partnership a

designed in collaboration with and validated by the MOH and local stakeholders can serve a

to support the expansion and adoption o the mHealth intervention across wider areas

is adopting this approach to create the right partnership agreement that they can then

duplicate their initiative in a variety o local healthcare structures (such as a partnership a

with the ederation o local community healthcare centers). This agreement can help to p

eectiveness and benefts o their intervention as well as help to secure government buy-

Collaborate with local implementation partners.

Local implementation partners are key to inorming the proper implementation o the proje

the local context. The relevant local implementation partners can range rom local healt

agencies and community health workers to social marketing or content developers to tr

and community leaders. Through these partnerships, the initiative gains access to knowled

can help to overcome local barriers to uptake and successul implementation o the projetent is being developed as part o the mHealth initiative, it should be developed in collabor

local partners to integrate local language reerences and themes to ensure relevance and

resonation o the message among benefciaries.

Establish strategic partnerships to support scale up o the pr

Strategic partners, particularly relevant industry partners such as mobile network operator

technology companies, can provide their technical know-how and core competencies, re

and network to contribute to t he scale up o the project. According to Matt Berg, ICT Direc

the Millennium Villages Project, fnding the right partners, listening to them and engagi

6

7

8

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4

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PRACTICES BEST PRACTICES


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30 31 PRACTICES BEST PRACTICES

are critical success actors. A project that works well in one context might be ineective in another

i partners are secured but not engaged in a meaningul way so as to make use o their skills and

knowledge. Common mHealth strategic partners strongly agree that partnerships with various

players in the value chain are necessary i mHealth is to grow beyond the pilot phase.

Perorm monitoring and evaluation (M&E) and assessments o

impact; use meaningul, measureable metrics. Maintain fexibility in

project implementation to adapt to changing needs and priorities o

beneciary populations and avoid ailures.

One o the main drivers o the scale up o mHealth will be the evaluation o initiatives and collec-

tion o data to prove the efcacy and efciency o mHealth projects in achieving target outcomes

and meeting local/national healthcare priorities. According to a recent WHO report, only 7 percent

o mHealth initiatives in developing countries have been evaluated. More data is needed to inormpolicy and decision-making to help create enabling environments or mHealth.

Brooke Partridge cites putting in place meaningul and measurable metrics that not only

indicate success but also guide adjustments that need to be made along the way, as a vital element

to ensuring scale up o a program. Having an M&E plan and perorming M&E activities in the feld

are essential to ensuring the eectiveness and utility o the mHealth program. The implementation

of the program should be exible and respond to ndings from M&E studies that are fed back into

the program so that it remains relevant to the local health priorities and evolving benefciary needs.

Assessment o impact is also crucial or stimulating investment rom strategic partners.

9

Christian De Faria, SVP, Commercial &

Innovation, at Arican operator giant MTN,

talked o the companys strategy to work with

Sanlam Health as its strategic partner in devel-

oping and implementing mHealth initiatives

across all o the operators 21 networks. While

MTN brings inrastructure, distribution reach

and a service mindset to the table, De Faria

said that Sanlam brings core medical knowl-

edge and an understanding o the local medical

operating environment.

We can sell airtime well but we are not

specialists in healthcareour philosophy is

to partner with companies that know, com-mented De Faria. We have to complement

each other and be respectul o the regulatory

environment in every country. By partnering

we know that the service we provide will be

reliable and up to standard.

Meanwhile Carlos Martinez MiguelH

Strategic Analysis & Planning at Spanis

Latin American operator Teleonicas

Healthcare divisionclaimed that net

operators can be the ideal travel comp

or healthcare systems and providers.

that strategic partners are required

mHealth initiatives, Miguel said operato

good partners due to their experience i

munications as well as customer servi

have the ability to invest and oer end-

managed services.

Mobile Health Live

KEYNOTE SESSION AT GSMA-

mHEALTH ALLIANCE MOBILE

HEALTH SUMMIT

STRATEGIC PARTNERS

TO SUPPORT

SCALE UP


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Integrate the program within existing healthcare structures.

Work closely with relevant stakeholders, including the government, to best integrate the

program within the existing local healthcare structures. For example, i a mobile health

designed to register mothers and children and monitor their health outcomes regularly,

types o data collected and types o indicators reported on should match those already use

Ministry o Health (MOH). An immediate partnership with the MOH may not always be e

but is more likely to happen in the long run i the program is already designed to sync w

existing inrastructure.

There may be cases where the existing inrastructure is problematic, or example th

too many indicators that health workers are expected to report on in monthly reports, an

ing that may only add to their work burdenthe real solution would be to renegotiate the c

system expectations with the MOH. This is o course unlikely, especially on small pilots

afliated with the government. However in most cases it will be benefcial to work with

current system, even if its awed, rather than create a separate, parallel structure that

duplication o eorts.

Employ an integrated solution and/or holistic approach rathe

a silo single-solution approach. Identiy innovative ways to in

rate other mobile services using cross-sectoral approaches.

A holistic approach ensures that the mHealth program is tackling multiple local health p

which can acilitate and create a stronger argument or the integration o the mHealth

within the national health system. Further, many single-solution mHealth implementatio

fnding that governments want to cover more than just one health objective i t hey are to

the program (whether through unding, human resources, politically, etc.).

This kind o integration involves pairing mHealth tools with, or example, mobile mon

like those that have grown rapidly in markets in Kenya and Tanzania. One o the biggest

preventing remote populations rom accessing healthcare is simply transportation to the

care acility. Thereore, organizations in Tanzania and Kenya are exploring the use o mobil

services to reimburse transportation and lodging costs to increase access to surgical care. B

Partridge agrees that this type o cross-sectoral approach o linking up with other mobile

such as mobile agriculture, mobile micro insurance, mobile women, etc., can support sc

The key is to identiy what initiatives are already on the ground and ready to be integrated

mHealth program.

Patricia Mechael highlighted that integrated solutions that all within multiple mHea

matic areas are also becoming more widely implemented as the ocus shits toward impr

quality o care at the point o care, enhancing service delivery and then leveraging the data

generated by these various systems as a byproduct t hat then generates the inormation n

data collection. She believes that such integrated and holistic mHealth solutions can mobe mainstreamed into national health initiatives and thereby achieve scale up.

Identiy a sustainable and scalable business model that is ap

cable or large-scale implementations and can bring in valua

strategic partnerships to support scale up.

Designing a business model that clearly identifes how an organization piloting a tool will

fnancially sustainable into the uture acilitates the development o meaningul partnersh

business model should articulate how the intervention benefts the partners and end-use

RECOMMENDATIONS

PROGRAMMATIC

MMENDATIONS RECOMMENDATIONS


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34 35

as well as identiy clear entry-points or the partners. Understanding a partners success metrics

and communicating this understanding in the business model will be key to demonstrating how

the mHealth solution will beneft them, according to Brooke Partridge. Ensuring that the business

model speaks to the incentives o that organization is a critical success actor.

According to David Aylward, there is a clear win-win business model or pharmaceutical industry

players to engage more in mHealth development in the domains o drug adherence and combat-

ting the sale and use o countereit drugs. Although ICTs have not been part o the pharmaceutical

industrys core competencies, there is a clear business case or them to get involved in supporting

mHealth initiatives. Other sectors, such as network operators and other telecommunications indus-

try groups, are looking or mHealth players to develop fnancially sustainable business models that

they can engage with. David Aylward also spoke about how the consumer product industry players

can tap into the mobile revolution to access base o the pyramid (BOP) populations and helping to

meet health objectives. Targeting the BOP, whose market size was recently estimated to be our

billion,7 can quickly bring a project to scale upon a successul pilot phase.

David Aylward recommends the social enterprise model as another type o business model thatcould promote the scale up o mHealth. Using a type o pay-and-use business model has proven

to be fnancially sustainable or an eHealth initiative in rural India by Healthpoint Services Global,

Inc. Healthpoint adopted a horizontal approach to tackling various local health priorities (sae drinking

water, aordable primary healthcare delivered via telemedicine and supported by electronic health

records, modern diagnostic tests and licensed pharmacy operations). This eHealth initiative has

been particularly eective in reducing healthcare-related costs or their benefciaries and providing

a positive cash ow to the company to support further scale up of the program in more communities.

This type o social enterprise model also serves to create local employment opportunities thereby

creating a win-win-win business model or the company, the benefciaries and local communi-

ties. This type o business model can more eectively attract investments rom strategic corporate

partners. David Aylward believes there still needs to be more evaluation o this type o model or

mHealth on a wide scale beore other types o investment unds, such as impact investments, can

willingly support scale up in developing countries.

The unding component o the business model is key to ensuring scale, and this scale cannot

be achieved i a business model is abandoned or the acceptance o corporate social responsibility

(CSR) investments or short-term grant opportunities. While these unding sources may be easier

and quicker to acquire to fnance the initial pilot phase o a project, the project may run the risk o

becoming reliant on short-term unding thereby jeopardizing its sustainability in the long-run.

Build partnerships with the private sector ater a successul pilot

phase.

The local mobile network operator whose services your mHealth tool relies on can be an important

strategic private sector partner. The goal is to create relationships that go beyond corporate social

responsibility and one-time unding o a project. A more sustainable relationship can be cultivatedby leveraging the network operators technical capacity and core competencies to support the

mHealth intervention. Factors that most commonly aect building such a relationship include und-

ing, timing, capacity for technology and the scope of the project. For Project Mwana in Zambia, the

money saved by partnering with Zain during a 20-clinic pilot was very small compared to what could

be saved i the team brokered an arrangement later to support 1500 clinics. 8 During the scaling up

phase, the project could then use the much higher volume o messages as a leveraging point.

Identiying entry points to engage private sector actors and showcasing how the p roject can

serve their business interests can support the creation o strategic p artnerships. In addition to

looking at the benefts o such partnerships, it is also important to look at what are the drawbacks

to partnering with certain private sector actors (or example, exclusivity contracts).

4

ow to Work With Operators. Mobileve. Retrieved on July 3, 2011, rom://www.mobileactive.org/Working-

h-Operators-part-one

he Next 4 Billion: Market Size andiness Strategy at the Base of the

amid. World Resources Institute.rieved on October 20, 2011, rom

p://www.wri.org/publication/the-t-4-billion


1

2

3

Seek out and invest in building local capacity to minimize cos

support local ownership o the project.

Dont underestimate the human resources needed to deploy, use, and maintain mHealth

tions, advises Patricia Mechael. Technical IT expertise is oten critical to the success and l

sustainability o a project that involves the use o ICTs. Training local counterparts to supp

implementation, customization and trouble-shooting o the platorm is important to min

costs as well as promoting local capacity-building and ownership o the project. This expe

oten be ound not only in the private sector, but also within local universities.

The sotware and mHealth application should be geared towa

the objectives o the program, suitable or local conditions an

designed with the end-user in mind.

The choice o sotware should depend on the resources (including IT expertise) available

project. The sotware should be suitable or local settings and be user-riendly. Anne Ro

highlighted the need to understand the local networks by identiying what types o data tr

are cheapest and provide the highest range o connectivity in the area o implementation.

determine what types o applications are best or the initiative. For example, Pesinet uses

cation that by deault would send data via GPRS where coverage is available because the c

transer via GPRS locally is cheaper than SMS and network coverage exists in many area

However, GPRS is not consistently available and connections can be unstable thereore Pe

application includes an ofine mode where data is stored until a future time where conne

available. For areas where GPRS is not available a eature to switch to SMS transmission

rently being developed.

Pesinets application is also specifcally geared towards the collection o data to relay b

doctors, which is their primary objective, rather than provide diagnostic support or other t

mHealth applications can provide. Maintaining user-riendliness to support the achievem

such implementation objectives is key or successul uptake o the technology by end-us

choice o hardware (i.e. mobile phones) is also important or the scalability o the program

hardware should be cost-eective, robust and also highly user-riendly to ensure consiste

eective use by end-users as well as lower the costs o maintenance.

Identiy what motivates the end-users, not just what the obje

o the program are. Use incentives to promote the consistent

eective use o the mHealth tool.

For an mHealth data collection platorm, the end-users (or example, CHWs) ability and m

to use the mHealth tool is key to the success o the program. For example in the ChildCouect, the goal was to collect data, however that did not typically motivate the end-user. The

ound value in the eedback and point-o-care support that the mHealth tool provided an

what motivated them to consistently and eectively use the tool, which also resulted in th

collection o health data and real-time monitoring o health outcomes as a byproduct.

Another tool to motivate end-users is the use o incentive-based systems and identiyin

kinds o incentives encourage the wide-scale adoption and proper use o the mHealth tool b

stakeholders. One recent Text to Change project piloted in Mbarara, Uganda, aimed to incre

untary HIV/AIDS testing. Participants received weekly quiz questions, and at the end o th

they had the opportunity to win prizes at a local HIV counseling and testing center. Partic

OPERATIONAL


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4

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6

clinics saw a nearly 35 percent increase in frst-time visitors immediately ater the program, according

to Text to Change.

Another method is to oer minutes or SMS message units to encourage compliance by the gen-

eral public. According to a recent report on Barriers and Gaps to mHealth,9 salary payments through

cell phones could also provide immediate reward or eective usage o mHealth applications.

Perorm social marketing.

An integral component o achieving scale is ensuring there is uptake among local populations. In

order to achieve this, Anne Roos-Weil recommends social marketing as an essential tool in promoting

the service; educating, communicating and discussing with the community their needs and how

the mHealth intervention can beneft them; mobilizing them around the service and its concept.

One o Pesinets biggest lessons learned rom their pilot phase, according to Anne Roos-Weil, was

that one should try and involve stakeholders rom dierent groups in the benefciary population at

the beginning o the project. Thereore, she recommends that communication mechanisms shouldbe ormulated in the planning phase to inorm the programs objectives and exchange ideas with

benefciaries to increase their ownership and confdence in the intervention.

Empower users through the mobile phone technology, particularly

women.

For example, i the mHealth initiative alls under the Education, Awareness and Health Promotion

thematic area, the content should take advantage o the mobile platorm as a two-way communica-

tion tool rather than a single directional communication tool by encouraging users to respond.

One o the design goals o the program should be to enable and empower the users to take advan-

tage o the technology and promote innovative thinking on how best to use the technology within

local contexts. Training women CHWs or mothers w ithin households to use mobile technology and

promoting womens ownership o mobile phones can have ar-reaching eects beyond mHealth

objectives and serve as a mobile women (or mWomen) component o the program. Various social

and economic goals can be advanced via an mWomen component, including emale empowerment

and increased sense o saety, increased economic opportunities and access to inormation to make

better decisions or themselves and their amilies.

I an area o the project is ailing, ail quickly and publicly; adjust

the program accordingly.

Failures are integral to inorming uture successes. While a particular aspect o a project might ail,

it can lead to innovation and redesign in other areas. Sean Blaschke o the Tech4Dev initiative with

UNICEF Uganda advises implementers to ail quickly and publicly to promote knowledge-sharing

and prevention o recurring ailures among other organizations. The key is also to look at otherlocal project implementation and learn rom their ailures in similar contexts.

Mechael P et al. (2010). Barriers

Gaps Affecting mHealth in Low Middle Income Countries: Policyite Paper. Retrieved June 3, 2011,m cghed.ei.columbia.edu/siteles//mHealthBarriersWhitePaperAL.pdf


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Mainstream mHealth in the MOH and relevant government bo

One o the major issues with scale has been the way that mHealth projects have been fn

A lot o the unding or implementation has come rom outside the governments via pr

philanthropies and bilateral donors. A byproduct o this unding environment is limited a

ability and additive impact o current programs. According to Patricia Mechael, one o the

policy issues that needs to shit to address this is or mHealth to be mainstreamed and t

by government in partnership with the private sector, including the NGO community and

industry players such as pharmaceutical and telecommunications companies. This will

to increase in-country ownership and buy-in rom local healthcare structures and incre

likelihood o sustainability and scale up.

Establish an e/mHealth structure to support the multi-secto

mainstreaming o mHealth and advise the decision-makers

on creating an enabling policy and regulatory environment

mHealth scale up.

Governments are beginning to adopt the idea that mobile technology is the way orwar

achieving national and localized health objectives in resource-limited and remote settin

support a long-term strategy around the use o mHealth (and eHealth) within national h

systems, mHealth must be mainstreamed within existing government institutions. This

achieved by setting up an e/mHealth structure, such as a National eHealth Council, to ac

the mainstreaming o mHealth solutions by:

Advocating and convincing the MOH, other relevant government bodies and mini

donors and private sector partners that mHealth on a large scale is an eective and

solution to achieve national health objectives and meet health-related MDG targets

Providing enabling policy and regulatory recommendations and advice to support

up o mHealth.

Creating a structure outside the MOH is necessary because building the inrastructure to

eHealth, such as getting a national ICT agency to run fber-optic cables to all district hos

goes beyond the purview o the MOH. However, one o the major risks is contributing to

lieration o institutions within heavy and bloated public sectors, which is oten a charac

public sectors in Arica and India. One o the lessons learned is to create light structure

port mainstreaming within existing institutions with the tasks o advocacy, advising, and

the national capacity or eHealth.

According to a ramework or eHealth by Dr. Yunkap Kwankam, 10 there should be t

structures within the National eHealth Council: (1) an eHealth Corps to serve as a pro

category o health workers; (2) an eHealth Steering Committee to advise the MOH on s

policy and strategic direction or eHealth; and (3) a national center o excellence or eHe

best practice, capacity-building and policy coordination.An important contributing actor that supported Pesinet to grow beyond the pilot p

was the support they received rom Malis eHealth agency. They helped us get an agr

rom the government to set up our activities and negotiate the partnership agreement w

Ministry o Health. Theyve promoted the Pesinet program through dierent ways, both l

and regionally, said Anne Roos-Weil. mHealth implementers also need governmental s

ensure their program meets local regulatory specifcations, part icularly on a wide-scale

mentation, and ensure coordination among existing initiatives.

10. Kwankam Y et al. GeHCs-ISfTeHFramework for eHealth.

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Create an inter-ministerial working group and collective agree-

ment involving stakeholders rom the various ministries to support

the scale up o mHealth programs.

mHealth implementers need to interace with and be supported by more than just the in-country MOH or

e/mHealth governmental structure due to the nature o mHealth o incorporating health, ICTs and edu-

cation (and perhaps more) within their programs, according to Brooke Partridge. Thereore, they need

to deal with the policies and regulatory issues o multiple ministries and agencies within the country.

mHealth programs are also becoming more comprehensive and holistic in nature to tackle

multiple local health priorities and achieve scale up. Patricia Mechael identifes collective engage-

ment across various ministries within the government, including Health, Finance, Gender, Social

Planning/Development, Education, ICT or Telecommunications, and others (depending on the type

o intervention) as a critical actor in supporting scale up. Getachew Sahlu advocates or strong

communication links between these critical stakeholders: The more they start talking to one

another, the more eective governments would be in addressing eHealth and mHealth scale up.A collective agreement between these various stakeholders in the inter-ministerial working

group to support mHealth can ensure there is alignment between local health priorities and

mHealth ocus areas, common standards, clear strategies to support scaling up, prioritization and

allocation o resources, and knowledge-sharing and communication on challenges and progress.

Patricia Mechael recommended holding a one or two-day workshop with relevant stakeholders

rom the national level as well as some o the main implementers on the ground to perorm land-

scape mapping and inorm the agreement.

Identiy and promote the use o specic data, technology and

interoperability standards.

Governments should play a stronger role in the regulation and meeting o standards by mHealth

technologies. Without identiying data and technology standards and interoperability architec-

tures, mHealth programs will continue to produce competing and duplicate sets o data. To achieve

integration within local healthcare structures and within national health inormation systems (and

thereby scale up the solution), program designers and implementers need to know what the local

data and technology standards are and how to design their programs to ensure interoperability.

Getachew Sahlu highlighted WHOs role in supporting this recommendation within countries

by holding workshops, seminars on health inormation, and making mHealth a component o their

advocacy in WHOs member countries.

Advocate or the integration o mHealth within local public and

private healthcare initiatives; prioritize mHealth training or

healthcare workers.

Governmental support o mHealth via the prioritization o mHealth training w ill resonate strongly

with local healthcare workers who are not yet aware o the benefts o mHealth in data collection,

diagnosis and treatment support and improved health information ows and reporting. Along

with the e/mHealth structure, the MOH and other public agencies should advocate or the use o

mHealth to organizations implementing healthcare initiatives within the country in order to broaden

the implementation o mHealth in the feld and beneft rom it. With data and interoperability stan-

dards in place, organizations can easily use these systems to share data with relevant stakeholders

to improve allocation o resources and prioritization o health needs.

MMENDATIONS

Establish a global network o key institutional players to ino

an overall global approach to support the scale up o mHealt

developing countries.

Generally, countries have dierent mHealth strategies based on their local priorities and

However, Getachew Sahlu argues or an overarching global approach to mHealth implem

in countries which would help address cross-cutting and yet inter-linked issues, such as

technology, fnance, regulatory policies, governance, national development priorities, and

ownership. Most o these issues are within the mandate o and being pursued by one or m

institutions, such as WHO, ITU, UNDP, WB, GSMA, and other regional organizations. Institu

the ITU and GSMA can also contribute to the cost-cutting and regulatory measures neede

the country to support scale.

Patricia Mechael elt strongly that the Global Fund (GFATM), the largest external do

health initiatives, could play a strong role in p romoting the scale up o mHealth, particul

unding the M&E and perormance evaluation o mHealth as well as promoting the use otechnologies within GFATM proposals. Having the GFATM involved in supporting the scal

mHealth could signifcantly improve outreach, service delivery and supply chain manage

mHealth was supported within their proposals.

Establish a global repository o mHealth applications, tools, b

practices, recommendations and evaluation data. Institutio

players must be willing to share and connect their existing

repositories.

mHealth repositories are being developed by various institutional players, including the m

Alliances Health UnBound, or HUB, which provides a platorm or various mHealth play

connect and collaborate, and the GSMAs Mobile Health Live p ortal, which provides real-

content that inorms, educates and empowers successul deployments o mHealth techno

global repository linking these existing repositories and databases should be set up to sup

the successul implementation and scale up o mHealth initiatives by providing a one-sto

or mHealth players to access inormation. According to Getachew Sahlu, such a global re

tory would enable improved access to mHealth resources, enable inormed policy decis

while providing necessary data to researchers, solution developers, and the general public

eect will ease the scale up o mHealth projects in countries. WHO is working with institut

establish linkages between the repositories and is currently in the discussion stages o cre

enterprise sort o inventory on all successul mHealth initiatives and applications to sha

the general public.

Create rameworks or success targeted towards inorming p

makers, project designers and implementers, and donors.

Such rameworks can help inorm decisions and ensure sustainable models are used in m

implementations. One o the main elements needed in a ramework or success or policy

is the development o reerence architectures or interoperability and data standards. In o

achieve this, Patricia Mechael recommends analyzing successul adoptions o architectur

handul o countries representing dierent contexts and using that to inorm a template o

to demonstrate to other countries how dierent types o standards and architectures can

A critical actor to the success o such an endeavor is the systematic and detailed docume

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o the process and steps taken to establish these successul architectures and standards.

Governments can derive a lot o value rom this type o step-by-step inormation.

The donor community also should have a ramework o success to ollow to ensure their

unding ocuses on ensuring sustainability and scale by requiring the implementation o the best

practices mentioned above and requiring reporting on this. This is particularly important to create

a shit in unding schemes to ocus on monitoring and evaluation, which needs to be prioritized by

donors. Also, implementers should be required by donors to adhere to interoperability and data

standards or mHealth.

According to Patricia Mechael, utilizing a back and orth iterative process o analyzing at the

local level and bringing recommendations up to the global level can bring about tools that are

universally useul. She believes these global rameworks can be established through a partner-

ship between various institutional players including the WHO, ITU, GSMA, mHealth Alliance and the

Broadband Commission. Existing international collaborations that are starting to emerge could

help convene and shepherd this.

Advoca

Documents

ADA_mHealth White Paper