Designing mHealth for Scale: Lessons Learned from Pathfinder

Marion McNabb, MPH, DrPH(c), Senior Technical Advisor, mHealth ICT4D Principles #3 Meeting - October 27, 2014

ENHANCING SERVICE DELIVERY AND QUALITY IMPROVEMENT

THROUGH MOBILE TECHNOLOGY

PATHFINDER mHEALTH AND MOBILE MONEY PROGRAMS

Community Health Worker Mobile

Applications and Mobile Money

Behavior Change

using SMS

Mozambique – mCenas! - Youth Focused SMS for FP and SRH

Ethiopia – m4Youth - Youth Focused SMS for FP and SRH

Tanzania – EngageTB – TB Client Self Screening and Referral

Kenya - MNCH and OVC Application, Pay for Performance

Nigeria - MNCH Application, Mobile Conditional Cash Transfer

Haiti – Integrated CHW application, Stipends with mMoney

Tanzania – MNCH, FP, HIV and Client Feedback mobile money for maternal emergencies

Vietnam – NIH RCT – SMS for Continuing Medical Education

Pathfinder’s Approach

HEALTH SYSTEM STRENGTHENING AND mHEALTH

PATHFINDER APPROACH TO MHEALTH AND MOBILE $

Scale Evidence Based Interventions Drive Quality and Performance Improvement

Integrated Service Delivery at Community and Facility Levels

-Through-

Public Private Partnerships Engaging Youth

Building the Capacity of Local Partners Generating Evidence

A mobile phone is just a means to an end, not the end in itself

MHEALTH AT PATHFINDER, CONT.

• A does not deliver a

• Ensuring sexual and reproductive health services are available and of quality is key

–What are we driving clients to?

• Mobile money implementation depends on infrastructure, adoption, users needs

• Choosing simple technologies in tech nascent environments is key to scaling

DIFFUSION OF INNOVATIONS…HOW DOES THIS TRANSLATE TO SCALE?

IF YOU WANT TO INSTITUTIONALIZE AND SCALE mHEALTH, UNDERSTAND YOUR AUDIENCE….

KEY CONSIDERATIONS FOR SCALING mHEALTH TOOLS

• Employ user centered design techniques

• Retrofit tools to the actual needs on the ground

• Who is your audience, what is the goal of scale?

– Vertical and horizontal scale – ideally both to achieve impact

• Analyze technology solutions through the lens of national and regional needs: integration, collaboration and coordination

• Establish public private partnerships; its essential

• Demonstrate impact before scaling interventions

CONSIDERATIONS FOR SCALING, CONT.

• Business models: MNO, Bank, Clients, Government

• No “one size fits all” scalable solution or framework. Client focused verses health workforce/systems focused mHealth interventions

– They are different!

– Who pays for scale, who OWNs the scaling process, is it holistic and framed within a health systems strengthening framework?

WHICH TECHNOLOGY SOLUTIONS FOR SCALE?

• Simple is best, go too far and you may lose interest

• Technology is 10% of the problem, the issues are rooted in health systems and governance

• Local innovators versus global tech solutions

• Open source, building on pilots, coordination among partners

• Data Storage: how and where? Cloud or local? Laws….

• Government capacity, IT/MNO infrastructure, is mHealth the top priority of the government?

• Mobile money: complex and different

– Kenya mPesa vs. Nigeria vs. Haiti

PUBLIC PRIVATE PARTNERSHIPS

• Essential and necessary. What is the motive for private sector, clients and governments? How do motives align?

• Mobile network operators and mobile money operators (banks and MNOs) have different monetary incentives. Each country is different.

• When to engage, who should engage private sector: Pathfinder/Implementers, GSMA, Banks, Donors?

• Who pays? What is the business model? What do you need to prove its worth it for governments, business and NGOs to be sustainable? Where are the international and local implementers in the scaling process?

DEMONSTRATING THE mHEALTH CHAIN OF EVIDENCE

DEMONSTRATING IMPACT WITH FRONTLINE WORKER SUPPORT TOOLS

• Generate evidence chain through the log frame

– Feasibility, acceptability, effectiveness, health outcomes

– Cost effectiveness

• Follow the chain of evidence to continually build to the base

• Research studies ongoing in Nigeria, Ethiopia, Mozambique, Haiti, Tanzania, Vietnam – CHW tools, SMS program impact

• Cost effectiveness studies: Nigeria with Brandeis and Abt, Vietnam for SMS based continuing medical education (CME)

Z

Country Case Studies

PATHFINDER SSQH CENTRAL AND SOUTH: HAITI

Integrate mobile tools to strengthen the work of 2,500 CHWs in Haiti through the implementation of an integrated client enumeration and case management tool across all major health domains of CHW work

Objectives:

• Strengthen the quality of CHW community services

• Improve quality of community to facility referral systems and improve documentation

• Reduce reporting burden

• Strengthen ability for supervisors to conduct CHW mentoring and supervision to improve performance

• Integrate the use of Tcho Tcho mobile payments within the health sector

• Built-in care protocols • Priority scheduling of visits

driven by client needs • Targeted SMS/IVR reminders to

improve care retention • Community commodity tracking • Mapping community services

• Information feeds into HMIS

• GIS mapping of services • Data security and

confidentiality • Reports per MSPP needs

• Client referral and counter referral between ASCP and facility

• ASCP performance monitoring: driving quality improvement

ASCPs Decision Support Tool Data and Information

Facility Tool

mSante Implementation Model

HAITI, CONT.

• First Lady of Haiti committed to nationally scaling mHealth

• Pathfinder opened all apps: no need to reinvent the wheel

• Pushing technology to the edge, can it scale? Its complex when you build in referrals

• Building local capacity through NGOs – decentralize management, build supervision app, dashboard

• Human resource capacity? Can we teach local public health and technologists to manage deployments? Where does government step in? Who owns what?

NIGERIA

• Innovation Working Group/UN Foundation Award (2014-2016)

– Pilot test the use of CommCare to track beneficiaries of government-led conditional cash transfer (CCT) program and deliver payments via mobile money (mCCT)

– Co-Lead National mCCT technical working group – goal is to design and pilot for scaling nationwide

– Develop plan to expand from 5 to 1,250 sites post-award!

• Two cost effectiveness studies, dissertation research to develop costed scale up plan post pilot phase

mCCT PAYMENT WORKFLOW (3 OUT OF 9 STEPS)

Client Registration of SIM, Create mobile wallet

1 2

State SURE-P review of eligible women in CommCareHQ

3

National SURE-P approval for payment in CommCareHQ

Immediately

Health facility client registration in CommCare

NIGERIA

• Under the overall ICT4 Saving One Million Lives Initiative led by Government

• Health worker/Facility application (linking primary health centers to hospitals for referrals), client education and receipt of mobile payments and government administration through dashboard

• Government has the money for CCT implementation: delays and need for capacity building

• Mobile money at scale in Nigeria (over 18 mobile money operators) – issuing client sim cards a challange

• HMIS Reporting on the app itself

LEARNING TO TAKE COMPLEX MHEALTH SOLUTIONS TO SCALE

• Nigeria: Costed scale up plan by mid next year, what frameworks and tools to use to support government

• Haiti: Real life deployment of complex solutions, decentralized ownership and management; supporting local NGOs and International NGOs to use the tools

• Pushing the edge of innovation; simple solutions vs complex solutions at scale

• Importance of PPPs and government ownership of scaling and maintaining

Thank you!

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For more information contact Marion McNabb - mmcnabb@pathfinder.org