My reason for attending Forum 2009 was to participate in a session title “Innovation for Remote Populations”. This post is a about that session. What follows is taken from my recent report to the Global Forum for Health Research – edited only slightly.

Innovation for Remote Populations

Thurs-19-Nov-2009, 14:00-15:45, Global Café, Palacio de Convenciones, La Habana, Cuba

Coordinators/Facilitators:

• Patricia Mechael, mHealth and Telemedicine Advisor, Millennium Villages Project, Earth Institute, Columbia University, USA & Egypt (organizer & facilitator)
• Tim Hurson, Facilitators Without Borders (facilitator)
• Charles Gardner, Global Forum for Health Research (focal point)

Speakers (alphabetical order):

• Simon Adebola, NEPAD Council Global Health Commission, Geneva
• Najeeb al-Shorbaji, Director, Knowledge Management and Sharing, WHO
• Caren Serra Bavaresco, Student, Epidemiology, Universidade Federal do Rio Grande do Sul, Brazil
• Karl Brown, Associate Director, Rockefeller Foundation
• Arul Chib, Assistant Professor, Wee Kim Wee School of Communication, and Assistant Director, Singapore Internet Research Center, Nanyang Technological University
• Dziedzom Komi de Souza, Ph.D. Student and Research Assistant, Parasitology, Noguchi Memorial Institute for Medical Research, Ghana
• Bastiaan Hoefman, co-Founder, Text2Change
• Bernardita Labarca, Project Coordinator, Zoltner Consulting Group, Chile
• Claire O’Neill, Chairperson, Cell-Life-South Africa
• Ravi Ram, Head, Monitoring & Evaluation, African Medical Research and Research Foundation (AMREF), Nairobi Kenya
• Marco Salmen, OHR-GMCP Initiative for HIV/AIDS, Global Micro-Clinic Project, United States
• Jaspal S. Sandhu, Design Researcher, College of Engineering, University of California, Berkeley, USA
• Joel Selanikio, co-Founder and Director, Datadyne.org, USA
• Garance Upham, General Secretary, Direction, Safe Observer International, France

Additional participants – from the audience:

• Elmer Zelaya – Fundación Chica/Nicaragua
• Timothy Dye – SUNY Upstate Medical School/USA
• Jane Kengeya – WHO
• Oyewale Tomori – Redeemer’s University/Nigeria
• Lishandu/Zambia (full name/affiliation not available)
• Vargas/USA (full name/affiliation not available)

Summary:

1. Diverse users and uses: The speakers presented a variety of mHealth/eHealth applications involving a wide variety of users, including both the health workforce and community members, e.g. educating teenagers about HIV/AIDS in South Africa (O’Neill), Internet access in western Kenya to improve uptake of HIV VCT (Salmen), mobile emergency response systems in Aceh (Chib), electronic IMCI in Tanzania (Brown), text-based health education and health service promotion in Uganda (Hoefman), training for health workers as a downloadable game package for phones in Kenya (Ram), telemedicine to improve the skills of health workers at primary levels in Brazil (Bavaresco), delivery of health information to communities in Chile (Labarca), a general set of tools for mobile data collection being used worldwide (Selanikio), and handheld computers to support rural healthcare delivery in Mongolia (Sandhu).
2. mHealth/eHealth is about enabling access: A common theme across diverse applications was that information and communication technologies are being used to enable access to health information and services in places where access is difficult because of remoteness and/or cost.
3. Coordination among the various players: Coordination among donors and projects is necessary to avoid unnecessary duplication of effort and to share what works. This is the role of the mHealth Alliance, supported by Rockefeller Foundation among others (Brown). While there were questions from the program side as to what data donors want (Chib), there was a simultaneous sentiment that donors need “stepwise” guidance (al-Shorbaji).
4. De-emphasizing technology: The mHealth Alliance has recently been discussing development of an “mHealth Toolkit”, to provide a common technical architecture and platform for those planning to implement mHealth programs (Brown). The existence of free technology platforms – in this case DataDyne’s tool – enables programs to focus on developing health content (Labarca). It is important to have a generalizable tool, as DataDyne has done, that can be used by anyone; if individual governments must approve technology “you’ve lost the battle” (Selanikio). Programs must focus on understanding people and applications more than technology; in response to a question from Dye about the use of ethnography in this field, three examples were given: ethnography of teen chat rooms in South Africa (O’Neill), multi-year ethnographic fieldwork as the basis for the program in western Kenya (Salmen), and design ethnography of the information management practices of rural health workers in Mongolia (Sandhu).
5. Defining good evaluation: There are challenges to seeing change in population health outcomes (Chib). It is difficult to measure behavior change (Hoefman) and to evaluate systems that provide health content to people (Labarca). Ethnography should be considered more seriously as a complementary evaluation strategy in mHealth (Sandhu). In evaluation, the metrics should match the intervention – mHealth is another intervention; in addition, we want to see the unintended effects of technology (Ram).
6. New modalities of engaging people: Mobile phones enable fundamentally new ways of engaging with people. As opposed to mass communication that is often used in social marketing, phones allow for interpersonal communication that can be tailored and cost-effective (O’Neill). There are two modalities, moving messages out to people and demand-driven services, where people demand the information that they need (Ram). Salmen lent his support to the importance of demand-driven services and argued that phones will bring more equity. This is all supporting the shift to citizen-centered healthcare (Mechael).
7. Cautions moving forward: In natural disasters, the cellular network is the first to go (Zelaya). An open question: Who owns the data? (al-Shorbaji). Nobody is thinking about “real sustainability” (Adebola). Reliable phone networks are a challenge (Lishandu). We should be careful that we don’t become too dependent on one tool (al-Shorbaji).
8. Need to think more creatively: We should be bolder with approaches; if we are, poor countries “could leapfrog” in health and development terms (Upham). Many of the applications discussed focused on SMS and telephony capabilities; we should think about leveraging more advanced capabilities of mobile phones (Kengeya).
9. Who should design technology? There is an assumption that Africans cannot develop software, but that is not true (Adebola). DataDyne software was already developed by Africans (Selanikio). Africans should develop software, but they shouldn’t redesign what has already been built (Brown).

Conclusions/Recommendations:

1. There is a need for increased knowledge-sharing about mHealth/eHealth within the global health community. This should definitely include policymakers. As Prof. Tomori elegantly stated, while we are thinking about how to reach remote populations, we should think about “hard-to-reach” African leaders.
2. While there was discussion of both eHealth and mHealth, the discussion focused primarily on the latter.
3. There is a need for a continuing dialogue about mHealth. It is unrealistic to expect policy recommendations to come out of this meeting given the state of the field (many open issues) and the limited engagement at the meeting.
4. Major mHealth topics to be discussed at future meetings: definitions; standards, including how to conduct evaluation; and successes and failures from the field.
5. The value of the meeting was threefold: (1) it helped extend the network of those working in mHealth; (2) it provided those outside the field with an understanding of the opportunities and challenges of using mobile phones to improve population health; and (3) it placed a much-needed emphasis on prioritizing people and applications over technology.
6. Mechael suggested reviving the Mobile Metrics and Evaluation Group as a means of maintaining an active mHealth community discussion outside of official meetings.

Other observations:

1. The fishbowl format was successful in eliciting relevant commentary from a large group of speakers as well as from the audience. Time was an issue, though, as several invited speakers only spoke once and several audience members had comments or questions that they were unable to share.
2. One key issue that was not explored – as I stated at the end of the session – was the link between social entrepreneurship and mHealth. This is especially relevant to issues of demand, incentivization, and sustainability.
3. There is a need for an ongoing discussion of these issues at Forum 2010 and beyond – while the conversation will continue in other settings, the Global Forum for Health Research should continue to be involved because of its systems focus, its emphasis on actionable research, and the unique mix of parties (policymakers, donors, implementers) it brings together.

Presenters Discuss: the potential of competitive vouchers in increasing access to priority services for currently underserved populations (Nicaragua); how subsidized, targeted vouchers can achieve the goal of improving health of poor women and children, elements that improve access to high quality health care services, how targeted voucher subsidies help meet the goal of contributing to development of a national social health insurance system that is accessible, affordable and acceptable (Kenya); a nationwide, high transaction distribution project for insecticide treated nets (ITNs) that has given rise to the application of technologies in the use of a relational database as a means to track each voucher transaction, ensuring security and traceability, providing spatial analysis using GPS coordinates, leveraging data from this project to others by providing a central data repository to government, and exploring SMS and mobile phones for automating voucher transactions and gathering patient information (Tanzania); and how poor pregnant women were selected for vouchers jointly by field workers and community support group members, how the institutionalization process for the voucher scheme was implemented, and how the health facilities were strengthened to provide quality maternal health care (Bangladesh).

Why should we care about voucher schemes? Three reasons from where I sit. These schemes provide:

1. An attractive model for extending the reach of services without significant infrastructural investment
2. Incentives for competition to improve the quality of service delivery
3. A mechanism for reducing financial barriers for the poor

Despite this promise, my experience over the last few years – including stumbling through a poster presentation about vouchers in Uganda for Ben at APHA in Boston a couple years back – has taught me that the concept tends to be elusive to “outsiders”. The World Bank’s Private Sector Development Blog has a concise overview of output-based aid for those that aren’t familiar. I won’t try to explain myself, since I’ll probably make some errors.

This session brought together diversity in geography – the talks covered Latin America, Africa, and Asia - and in services – anti-malarial bednets, safe motherhood, family planning, STI prevention and treatment. What was most interesting to me then was not the details of any specific program, but what we might be able to learn from having these different experts in the same room.

So what were the common themes?

1. Vouchers work. Nicaragua saw increases in service utilization, condom utilization, family planning uptake, and KAP. Much of this across different subgroup analyses – age, level of sexual activity, type of residence. The others similarly all saw positive gains in what they were trying to achieve.
2. Institutions matter. In Tanzania, the market is being flooded with free ITNs (possibly LLINs) under a new policy to achieve universal coverage – the fate of the 7000 bednet retailers under the Tanzania National Voucher Scheme (TNVS) is unknown. In Kenya, Nairobi and Kiambu saw better results for the voucher scheme because of existing infrastructure. Nairobi actually had provided more voucher-based services than vouchers sold in Nairobi because of women coming in from outlying areas. Tanzania benefits from a manufacturing base that can produce ITNs and a system that encourages people to pay for a portion of their health care.
3. The system will be gamed. The much higher reimbursement for providers of C-sections than vaginal deliveries has led in some cases to higher rates of C-sections than is necessary. April Harding who was moderating said that multiple schemes have been used/proposed for dealing with this, including capitation (e.g. for 100 women, X% will be reimbursed for C-sections). Fraud is also a problem. While nobody discussed incidences of counterfeiting, the Tanzania program has taken big steps to prevent counterfeiting, including watermarks, microprinting, and a bar code. The bigger issue with fraud is related to ineligible participants obtaining and using vouchers intended for other populations, whether by income or geography. Which leads us to the next point…
4. Equitable distribution is hard. Ineligible participants seem to be a problem with all these programs. In Bangladesh they responded by bypassing governmental decisions about who would get vouchers and relied on CSGs (community support groups) to make the decisions. Another trend is that those who are more poor tend to utilize vouchers less – it is unclear if this due to cost, education, and interaction among the two, or something we’re not thinking about.
5. Understanding redemption is complicated. This was my one question. In both Tanzania and Kenya – the others didn’t present these numbers or I didn’t catch them - the rate of redemption (number of people receiving services under the voucher scheme divided by the total number of vouchers distributed) – was around 80%. After I asked the question and before the panelists responded, my neighbors said that: (1) 80% is pretty good, and (2) the Tanzanians unlike the Kenyans don’t pay for their vouchers until they use them. In Tanzania then, the reasons are grounded speculations: perceived value of the ITNs, access, cost. In Kenya, the majority of the outstanding 20% is due to accounting. The real utilization is expected to be much higher since the cutoff for the evaluation excluded women who had received vouchers, but had not yet delivered (safe motherhood program). Still a minor portion of this is due to women who are unable to deliver at contracted facilities due to a lack of transportation or the timing of the pregnancy.

Sustainable Health Enterprises (SHE) is a 6 employee startup founded in 2008 by Elizabeth Scharpf. SHE Is looking to “create female-run franchises that manufacture and distribute low priced, high quality, and eco-friendly sanitary napkins for domestic and international consumption.” Their goal is to develop “a sanitary pad for women and girls intended to be low-cost and environmentally friendly. The company’s product is focused on women in developing countries, where women miss up to 50 days of school or work per year when they menstruate because existing pads are too expensive.”

I’ll get a lot more details up in a couple of weeks. In the mean time here are some other reproductive health innovations/technologies we have covered before:

• Maternova: Life Changing Technology for Women and Children, link
• Misoprostol (Venture Strategies): how to stop postpartum hemorrage, link
  
• Microbicides: Where are the now? link