mHealth Working Group Meeting Notes
Monday, December 13, 2010, 10:00 AM – 12:30 PM (Eastern US)
Held at Family Health International (FHI), Arlington, VA
 
 
Thank you to FHI for hosting this meeting. The next meeting will be on January 19, 2011 from 9 to 11 am at USAID. If your organization would like to host a future meeting, please contact either Kelly Keisling (kkeislin@jhuccp.org) or Laura Raney (lraney@fhi.org), mHealth Working Group co-chairs.
 
Meeting Discussion Items
1.      How health and ICT organizations partner in mHealth
2.      Developments in the mBCC Technical Group
3.      Recapping the best of the mHealth Summit
4.      Maternal mHealth Initiative
 
Notes and presentations are available on the mHealth Toolkit, filed by date, at:
/toolkits/mhealth/working-group-materials
 
1. How Health and ICT Organizations Partner in mHealth
 
We invited presenters from both ICT and health partner organizations to share information on health-ICT partnerships including: 1) the partner process - how partnerships are selected, structured, and maintained; 2) the design process - how programs/systems are designed; and 3) the role of each partner.
 
The first speakers were Heather Vahdat, FHI, by videoconference from FHI’s Durham, NC office and Hajo van Beijma, Text to Change (TTC) via telephone from Amsterdam. Heather Vahdat, Associate Scientist in FHI’s Behavioral and Social Sciences Division, is the co-investigator for FHI's Mobile for Reproductive Health (m4RH) program. Hajo van Beijmaworks on new programs and partnerships and is the head of financeatthe non-profit organization Text to Change (TTC).  Text to Change specializes in interactive and incentive based SMS programs addressing a wide range of health issues such as HIV/AIDS, malaria and reproductive health.
 
Heather spoke about the steps that FHI went through first in developing the concept for a basic SMS system for the distribution of contraceptive knowledge, then finding a technology partner to work with. They solicited for partners, narrowed the list, and then chose Text to Change (TTC) based on the key decision points of flexibility, reliability, and sustainability. Flexibility was important for a pilot in order to refine it repeatedly during the development process. Other considerations in choosing a partner were: quality control in terms of checking the system and data; cultural considerations (having a partner in region is extremely helpful); and having a partner knowledgeable in public health. (See attached slides for further details.)
 
As nonprofits, both organizations have similar goals which made the affiliation easy to manage and grow. The partners also had a clear definition of roles. FHI developed and tested the system content, designed the research process, and undertook system usability testing. TTC provided programming, input on design and the proposed algorithm, and data monitoring. Working with TTC, FHI designed and developed the Mobile for Reproductive Health (m4RH) project, an interactive platform with text messages on family planning methods that users can access via their mobile phones. The launch was promoted by and integrated with a larger field program already in place. The project piloted nationwide in Tanzania and Kenya, see http://www.fhi360.org/en/Research/Projects/Progress/GTL/mobile_tech.htm.
 
The big considerations with regard to a pilot program are sustainability and cost. FHI offered three lessons learned:
1) Having a good IT partner is critical but finding a partner can be a daunting process. When all else fails, just ask!
2) Location, location, location. Regional expertise is a benefit.
3) Be clear in expectations regarding upfront and long-range costs.
 
During group discussion, questions were raised regarding messaging costs. FHI benefitted from reduced costs since TTC had negotiated lower rates to support expansion to a national level. Participant comments highlighted TTC’s negotiations for fixed price transmissions in 16 countries. Additionally, UNICEF is planning a report on case studies for negotiating agreements with local carriers. In the coming months, as FHI further explores additional programs and platforms, it will make available a global kit with how-to guidance and information on replication of the project. Another discussion item was the use of audio messages for countries with low literacy rates. Several organizations are exploring this option (Abt Associates, Johns Hopkins Center for Communication Programs and FHI). However, it was noted that audio costs are higher and some communities are not accepting of the technology or credibility of the information presented. The possible trend toward SMS in Africa and audio in India was mentioned, though it has not been measured.
 
Merrick Schaefer, a technical project manager at UNICEF, presented on types of partnerships and the institutional attributes that make potential partners want to partner. He drew on experiences his team had from a myriad of mHealth and other technical projects from the last three years. He used his current project as an example to contextualize various types of partnerships. He started by describing Project Mwana, a UNICEF initiative that uses mobile technology to strengthen services for mothers and infants in Zambia and Malawi. Thus far, the project has created, implemented and is scaling two tools: Results 160 that delivers infant HIV testing results and materials from clinics to cities with tracking capabilities; and RemindMi that allows community health workers to register child births and track the visits and care given to mothers and newborns see, http://projectmwana.posterous.com.
 
Project Mwana has benefitted from a series of different partnerships in the last year. With regard to partnering, Merrick said the most important factors for the ICT partnerships UNICEF has utilized are 1) having staff that can function as technology translators for the rest of the organization, and 2) adopting a project approach that is appealing to ICT and design firms. Merrick’s team is an Innovation Group inside UNICEF composed of software developers and designers who help the programmatic staff understand how technology can strengthen their work and convene partners to help them do it. The team “speaks” the same language as the teams they are working with and can take the programmatic goals of the UNICEF and present them as technological or design issues to groups they partner with. Having this type of expertise makes the partnership process much more effective. Additionally, the projects are designed with sustainability in mind. They work with local offices to further train local developers and managers allowing the projects to be more easily sustainable on a global level. This is appealing to partners as it demonstrates that the work they are contributing to will carry on after the immediate engagement is over.
 
The project approach that the team takes also makes partnering with UNICEF desirable. The team follows the current best practices for technology and software development including having a user-centered design approach, creating and using open source software and using agile and iterative development methodologies. Many private sector organizations utilizing these approaches in their own work are attracted to the idea of working with an organization which has already adopted this mindset.
                                                                                         
Further, Merrick explained 7 types of partnerships that are often used for collaboration including implementing, academic, informal, formal, open source and community, internship and fellowship, and telecom. For Project Mwana there were many implementing partners in country, including the Clinton Health Access Initiative, Boston University, Zambia Prevention, Care and Treatment (ZPCT) and Worldvision that either worked with the team on implementing or programmatic pieces or utilized the tools in their own pilots. Second was an academic partnership with Columbia’s School of International and Public Affairs program where four graduate students did a series of field visits and created a report that explored the clinics programs and cell phone use. Third was an informal partnership with a big 5 consulting firm, that wishes to remain anonymous, which dedicated consultants over 4 months to give weekly meetings and advise the team on how to effectively structure the project. The informal nature of the partnership allowed minimal overhead for both organizations. Fourth is a long-term, formal partnership between UNICEF and frog design which sent a team to do user research and help with the qualitative analysis of the project. Fifth, the tools were built using an open source platform, RapidSMS, and tapped into the 200+ member community and was able to reuse a fair amount of code from others projects which significantly reduced software development time. Sixth included internships and higher-level fellowships.
 
His last point was not to partner with telecom companies for pilots but rather think about such partnerships when it is time to scale.   This is partly because getting a reduced rate for the cost of data or messages at a pilot scale is much less important than at scale. If you can’t afford the messages when the project is small, it will make scaling difficult. You also lose leverage for corporate social responsibility funding by giving the telecom partner exposure for the pilot. Additionally, for projects to work at scale, it is often necessary to work with all of the telecom providers in country since some parts of countries are only covered by one. Being locked into a relationship with one can make partnering with the others much more difficult.
 
Convening many and different types of partners around Project Mwana allowed the small team to act as a bigger team, leveraging the experience and resources of many organizations for the success of the project. For a presentation about Project Mwana, see http://dl.dropbox.com/u/16799705/Project%20Mwana%20-%20for%20Malawi%20for%20IATT.v2.pptx
 
Steve Ollis of D-Tree International was the next speaker on mHealth partnerships. Steve is a Project Manager for mHealth projects around maternal and child health in Tanzania and India. Steve spoke about D-Tree’s mobile applications for health care providers in clinics and communities and various partnerships that they have formed. Pathfinder and D-Tree are working together to assist community health workers in home visits for PLHA and chronically ill patients, guide management of patient schedule visits, and provide referral reminders for follow-ups all referred patients. With JHPIEGO, D-Tree has developed facility and community protocols for antenatal, neonatal and postnatal care in accordance with Tanzania MOH guidelines, as well as prototype applications ready for field refinement. With UNICEF, D-Tree developed protocols to support outpatient treatment of severe acute malnutrition in Zanzibar, and an application to support screening, registration, treatment and prescribing to be done at the health facility. With CARE, they have developed protocols for Individual Birth Planning and ANC, Active Management of 3rd Stage of Labor, Immediate Newborn Assessment and Postpartum follow-up for mother and child, and are establishing a server for integration of all patient data in OpenMRS.
 
The emphasis in partnerships for D-Tree is sharing a vision, reinforcing the government’s mission, finding key partners and local experts to provide subject matter expertise, and tailoring the tools to work within the context of the local environment. This includes clarifying vague clinical guidelines into discrete, specific and actionable steps, as well as working to ensure that the questions support the workflow and local cultural norms. It is important to be realistic when balancing local capacity (staffing, equipment, labs, etc.) with national guidelines for clinical protocols, when developing applications. D-Tree International uses a common process: Design of protocol and prototypes; Field refinement to start initial testing of the models; Training and pilot prep stage; Pilot program; and Assessment of the success of the pilot. Steve reiterated that scale and sustainability tend to be the most crucial factors in the development of these applications. D-Tree’s active engagement with partners is an iterative process, working together with partner organizations and field health workers, rather than a packaged, “out of the box”, solution. This engagement also requires champions within partners to ensure that the project is not just seen as a stand alone technology project but as part of the larger effort that the partner is engaging in. For further information about D-Tree, see www.d-tree.org.
 
In response to questions, Steve said that D-Tree uses Nokia phones, but that highly complex protocols can be difficult for even more expensive phones. Group discussion mentioned that Android handsets are scarce in Africa. Also, Android software has difficulty with text in Hindi. Both Merrick and Steve said it is difficult to find reliable solar chargers. Instead, local methods can be used for finding informal sources of electricity.
 
 
2. Developments in the mBCC Technical Group
 
A short update was given on the Working Group’s Technical Group on mHealth for behavior change communication (mBCC) by Stephen Rahaim of Abt Associates and Renald Fleury . The current focus continues to be on further development of the Field Guide (see www.mbccfieldguide.com). All are welcome to contribute to the mBCC Field Guide through the website or further discussion. Please contact Kelly Keisling (kkeislin@jhuccp.org) and Stephen Rahaim (Stephen_Rahaim@abtassoc.com) if you would like to know more or be included in the Technical Group’s listserv and meetings.
 
 
3. Recapping the Best of the mHealth Summit
 
The brief recap of the mHealth Summit focused on identifying and expressing the main themes of the summit which included: “Pilotitis” and the effort to move toward scalable and evidence-based approaches, developing business models, use of mobile money applications for mHealth, and interdisciplinary collaborations. This year’s Summit brought in 2,400 attendees from 50 different countries, including 150 different speakers with keynote speeches by Bill Gates and Ted Turner. The 2011 mHealth Summit is set for December 5-7, 2011 in Washington, DC. Further information is available at mHealthSummit.org
 
 
4. Maternal mHealth Initiative
Cathryn Meurn of the mHealth Alliance spoke about the Maternal mHealth Initiative (MMI). Cathryn described their efforts to unite ICTs, especially mobile, with the expertise of maternal, newborn and child health practitioners, and deliver information-based interventions to reduce maternal and infant mortality and improve the health of mothers and babies.
The mHealth Alliance has launched www.healthunbound.org as a forum for collaboration between sectors in mHealth. As a first step in the Initiative, the mHealth Alliance is encouraging all participants and organizations to register their projects that contain mHealth or eHealth components on HUB, with particular emphasis on maternal and newborn health. The goal is to develop a robust Mobile Maternal Health Innovation Commons to analyze gaps, and ultimately work to create digital health systems with the greatest impact on reducing maternal and infant mortality, using appropriate and scalable technology. The mHealth Alliance is pleased to announce the appointment of Jennifer Potts as Director, Maternal mHealth Initiative. Ms. Potts brings to the mHealth Alliance over 20 years of experience in the fields of reproductive and maternal health.
In addition, the mHealth Alliance is continuing to develop thought leadership pieces, advance on the infrastructure for phase two of healthunbound.org, and organize conference events.  
 
Joining the mHealth Working Group
 
The mHealth Working Group is a collaborative forum for sharing and synthesizing knowledge on mHealth. Over 250 participants and contributors represent more than 100 organizations from the US, Europe, Africa, Asia and Latin America. The Working Group seeks to frame mobile technology within a larger global health strategy. By applying public health standards and practices to mHealth, we promote approaches that are appropriate, evidence-based, interoperable and scalable in resource-poor settings. The Working Group holds regular meetings in Washington, DC to discuss promising approaches, challenges and lessons learned.
 
If you would like to join the mHealth Working Group and listserv, please go to http://knowledge-gateway.org/mhealth. Listserv members are invited to share announcements and materials with the listserv by sending them to mhealth@my.ibpinitiative.org. Information on the mHealth Toolkit is also available at /toolkits/mhealth.