The Global Forum for Health Research Forum 2009: Innovating for the Health of All took place in Havana, Cuba from 16-20 November. This is the fifth in a series of posts from the conference. Only one or two more after this one.

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.

Nota bene: These are a few highlights from CGI – please do add your inspirations/ideas in the comments!

Clinton Global Initiative – Making things happen through Commitments

Action speaks louder than words. At CGI, you’ve got to commit – and that has an amazing impact.

What will your commitment be?

CGI was the birthplace, in past years, of projects like Matt Damon’s water program (water.org, expanding this year to Haiti), the Goldman Sachs 10,000 Women Initiative, and so many more. In the five years of CGI, there have been 1,400 commitments made (participants are required to make commitments to existing projects or commit to creating new projects), valued at $46 billion dollars, and impacting the lives of 200 million people in 150 countries. This year’s meeting will give birth to 30 more of these programs – more by Andrew Mersman over at Passport Magazine/ Change by Doing blog.

Check out CGI Commitments here.

Innovation!

Business Week highlighted innovation as a top priority for the global economy, and President Obama announced a new strategy for innovation: A Strategy for American Innovation: Driving Towards Sustainable Growth and Quality Jobs. Download white paper.

Judith Rodin of the Rockefeller Foundation identified innovation strategies that could be applied to social problems – user-driven innovation, crowd sourcing and collaborative competitions reported here by Alexandra Cheney at Fast Company.  And Innovate Today: 8 Ways Business can End Poverty - superb post by Steve Enders over at tonic.

A few people – including Muhammed Yunus and Ngozi Okonjo-Iweala of the World Bank at CGI had an Innovation Wish List. Yunus talked about the edible yogurt pot, and Judith Rodin announced a new initiative to help the poor – the Global Impact Investing Network. This gets my vote for one of the most exciting developments to come out of CGI – read the Economist article.

Investing in Women and Girls

Women make up half of the world’s population, but do 2/3 of the world’s work, produce 50% world’s food, earn 10% world’s income, own 1% of world’s property.

Read the rest of this entry »

In my work in the field, I am no longer surprised to see test stockouts, essential medicines stockouts, supply stockouts, broken or missing diagnostic machines, or patients who are afraid of healthcare workers. It is a complete tragedy, and as I work to help, I think of all the people who are sick or die because of failures of the healthcare system, who cannot tell anyone their stories. For those who do not work in the health system, or haven’t had an experience of health system failure, transparency and data on implementation is practically invisible – so there’s no public awareness of the issues.

So I was thrilled to see recent developments in accountability – the Stop the Stockouts campaign, and the creation of the Budget and Expenditure Monitoring Forum in South Africa.

Power to the People: Stop the Stockouts

Stop the Stock-outs , a multi-country Africa campaign, is using text messages sent by activists and members of the public to expose stock-outs of essential medicines at public health facilities and put pressure on governments to address the issue. It was launched in Kenya, Uganda, Malawi and Zambia by Health Action International (HAI) Africa. During Pill Check week in June, facilities were surveyed, and a map of stockouts was created. The image below incorporates July 2009 data. It was found that many government health facilities were routinely running out of, or just not stocking essential medicines to treat common diseases such as malaria, pneumonia, diarrhoea, HIV and tuberculosis (TB).

“We were finding availability levels in rural, lower-level health facilities of 40 or 50 percent for essential medicines,” said Christa Cepuch, a pharmacist at HAI Africa. Read more from IRIN here

Show me the Money: HIV Policy AND the Budget and Expenditure Monitoring Forum in South Africa

With a new government in South Africa as of May, there have been some very positive signs. Read the rest of this entry »

Beyond the current debate on US health reform, which has us all posting on Facebook “No one should die because they cannot afford health care, and no one should go broke because they get sick “, the fact of the matter is that the accident of your birth largely determines your future health.

And no, it isn’t fair. If you are born in Sierra Leone, 1 out of 6 babies do not survive. In the developed world, 1 out of 10,000 babies die.

The WHO released a landmark report last August on health equity “Closing the gap in a generation”

Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others….Within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. Differences of this magnitude, within and between countries, simply should never happen.

With a rapidly urbanizing world – projections of 60% of people will live in cities by 2015. Most of these people are escaping rural poverty, and will live in informal settlements in the developing world.

Guidelines must be developed to ensure health equity, but we also need tools to help us plan.

Read the rest of this entry »

“The SXSW Interactive Festival (Mar 12-16, 2010 in Austin, Texas) is a mega huge social media industry event.” (Beth Kanter) It looks like anyone can submit a panel and then sessions are determined by community voting until September 4th. I saw this idea of selecting topic specific panels from SocialEdge and decided to do it for global and public health. There are slim pickings for global health as a sole topic, however, there are many that are related and have panels with direct relevance now or issues that will have to be dealt with in the future. If you have others to add to the list please let us know. Also check out the Social Edge on social entrepreneurship, Beth Kanter’s eclectic list (definitely check this one out, lots of good choices) and a  list from FI Space. Vote now for your favorites:

“SXSW Interactive features five days of compelling presentations from the brightest minds in emerging technology, scores of exciting networking events hosted by industry leaders and an unbeatable line up of special programs showcasing the best new websites, video games and startup ideas the community has to offer.”

1. Social Media for Global Health: Catalyst or Hype? Eric Becker, New Media Strategist
This discussion will cover how social media has been both successful and totally worthless in bringing about improvements in population health worldwide. We’ll discuss stellar examples, epic fails, and
generate some buzzword-laden “best practices” anyone can use when thinking about using social media to advance a global health cause.

2. Fedex And Coca-Cola: What Can International Aid Learn? Sean Blaschke, UNICEF
Real time data is fundamentally changing the way international aid is being designed and administered. Innovative new platforms leveraging SMS text messaging are transforming basic mobile phones into dynamic devices for key areas including education, health care services and supply chain tracking.

3. Innovation: How The Web Helps Africa Solve Its Problems, Eve Dmochowska, IdeaBank
Africa’s problems are unique and severe. Good Healthcare, education, democracy, entrepreneurship, community, nutrition and communication are either non-existent or under threat in many regions. Yet the web offers hope like no other medium before it. Find out how Africa is solving its own problems through smart, innovative and daring use of technology.

4. Yes, We Can – But How ? Technology for Social Good, Zaheda Bhorat, Google Inc.
Isn’t all open source software for social good anyway ? We will describe innovative concepts using “open” projects impacting key issues such as Climate Change, Poverty and Healthcare. Our ideas will enable you to impact change around the world and also closer to home whatever your passions. Learn, be inspired and take action!

5. Question Box – What the World Wants to Know, Rose Shuman, Open Mind – Question Box
Over 4 billion people aren’t on the Internet. Question Box brings information to people that way they want it, when they want it. We setup hotlines and SMS services in local languages, so a rural villager can call or text a question about anything they want. Users ask about everything from agriculture tips, to health questions, to the names of the President of every country imaginable. Want a look inside the minds of the other 4 billion? Come to the Question Box presentation and find out what they are thinking!

6. When Swine Flew: Embracing Innovation in H1N1 Response , Andrew Wilson, US Dept of Health & Human Services
With social media and emerging technology, public health agencies can utilize more tools than ever in a public health emergency. In this panel, social media strategists and researchers, working in the frontlines of the pandemic H1N1 response, will discuss strategy, innovations and the changing relationship between citizens and government.

7. Gaming and Social Media for Health, Kristi Miller Durazo, American Heart Association
Gaming is increasingly merging with health and fitness as a way to engage larger audiences and change social norms and attitudes about being active. The role of social media to augment these experiences is increasing. The panel will explore how gaming, social media and health intersect to carve out new opportunities. Games run across a broad spectrum from fully on-line to on-line/off-line and even fully off-line experiences.
Read the rest of this entry »

Image courtesy of kiwanja.net

Late last week I read news from three different sectors, all about “South-North” innovation transfer, a topic we’ve discussed here before, particularly in the context of mHealth. Earlier this year Fast Company reported on the concept of trickle-up innovation, citing the examples of yogurt microplants in Bangladesh (Group Danone, Grameen Bank) and Mosoko, touted as Craigslist for the next billion in Kenya (Nokia). In addition to these cases of MNCs from the global North testing out concepts in the South, Fast Company presented examples of corporations from the South, including ICICI (banking, India), Natura (cosmetics, Brazil), and Goodbaby (infant products, China).

Here are the three articles from this past week:

1. HEALTH SERVICES: To Fix Health Care, Some Study Developing World, Wall Street Journal, 2 Jul 2009. The University of Alabama-Birmingham AIDS clinic turned to Zambia for a model of increasing the number of patients who showed up for treatment. Based on early successes, they are continuing under the project name “Zambama”.
2. FINANCIAL SERVICES: DOCOMO to Launch Mobile Remittance Service, NTT DOCOMO press release, 2 Jul 2009. Later this month Japan’s DOCOMO will enable individual subscribers to use their mobile phone to remit money to other subscribers. Such a branchless banking/financial remittance service is certainly prompted by Safaricom’s M-PESA service from Kenya.
3. CLEAN TECH: Worldchanging Interview: Shawn Frayne, 2 Jul 2009. The interview is about wind technology, but touches on broader issues related to South-North innovation flow. Frayne thinks that “the constraints of the developing world can provide the necessary inspiration to make significant technological leaps that can benefit the Global South and Global North simultaneously”.

There are various other examples from the last several years suggesting a growing trend in countries from the North learning from the South. Here are examples just around financial services for the poor:

• Opportunity NYC was the first conditional cash transfer (CCT) program in the U.S., based on the Oportunidades program developed in Mexico.
• Less than one month ago international development micro-lender Kiva launched a pilot program in the U.S.
• Grameen Bank supports microcredit in places like Norway

Add to that the various management principles we’ve learned from the Aravind Eye Care System and Mumbai’s dabbawallas. Extending the argument presented by Fast Company, these examples show that South-North innovation transfer doesn’t have to be focused on corporations.

While it’s enticing to think about mining untapped innovation potential in the South for the benefit of the North, the real potential is much broader. Innovation can (and does) flow in all directions, not just South-North, but also North-South, South-South, and within countries. The challenge is to learn from different ways of approaching the same problem. Or even similar problems: see how Kaiser-Permanente visited a flight school to reduce medication errors and how the NHS worked with Formula 1 team to improve ICU procedures.

Given this potential, the big, open question is this… How do we increase global sharing of ideas and models to spur innovation?

This is a fascinating 10 minute interview from PRI’s Global Health and Development Podcast, definitely worth listening too:

Can Yogurt Slow the Spread of HIV?

12 Jun 2009

Scientist Gregor Reid joins The Takeaway to talk about his work with HIV patients in Africa. He has helped teach a group of ‘yogurt mamas’ in Tanzania how they might serve up disease protection one cup at a time.

Play:

Quote from the podcast: “We have changed from a human spieces that ate a lot of plant foods to food with essentially no organisms at all because we are so paranoid about getting sick.”

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Possibly Related Posts:

• What We’re Reading 5/27/09 (one.org)
• Visiting HIV Clinics in Ghana (one.org)
• HIV in South Africa ‘levels off’ (news.bbc.co.uk)
• Albino trials begin in Tanzania (news.bbc.co.uk)

This morning I attended “On the Move: Mobile Health” (session D2). From the conference website:

Presenters Discuss: the overall strategic approach to mHealth taken by the Millennium Villages Project and use the experiences of pilot testing and implementing mHealth activities and applications in Ruhiira Uganda (Uganda, Africa Region); the present use of mobile phone technology in the microfinance industry (MFI) and new and expanded applications for mobile-based services (India); why the mHealth Alliance was created and how it will develop and incubate the framework and solutions for the nascent mHealth sector (global); and how rapid HIV tests and handheld technologies are being used for population-wide door-to-door HIV screening (Kenya).

The cast:

• Moderator: Neal Lesh, PhD – D-tree International

Presenters and talk titles:

• Anita Katusiime – Millennium Villages Project-Uganda, Mobile Health Implementation Experiences
• Janine Schooley, MPH – Project Concern International, Connecting India to Disconnect Poverty and Improve Health
• Mitul Shah – United Nations Foundation, Inc., Development of a Mobile Technology Alliance for Health [multi-country]
• Martin Were, MD – Regenstrief Institute, Inc and Indiana University, Incorporating Technological Advances In Population-Wide HIV Screening [Kenya]

The issue of trust came up explicitly during two of the four presentations. In the Millennium villages project, one of the major challenges was CHWs “failure to explain the tool to household members”. In India, PCI found that the majority (~70%) of beneficiaries of a microfinance program felt the mobile phone based solution would increase trust.

During the Q&A Ashifi Gogo probed further – he asked about the perceptions people had about their health information when it was collected using mobile devices. The panel answers were largely focused on technological measures to safeguard the data, so I thought it appropriate to mention Karen Cheng’s Angola study, last featured in the Bulletin of the WHO. I’m happy that I did because Patricia Garcia brought up a recent study she co-authored (Bernabe et al., 2008), a study that I didn’t know about, and a study that showed the opposite result. This Peruvian study examined the quality of data using PDAs to collect sensitive data compared to paper-based surveys. The results: there was a high level of agreement among PDA and paper-based responses and there were fewer inconsistencies within individual respondent surveys. [Note: I've only skimmed the paper this afternoon and plan to read it more carefully soon.] 

One of the key challenges Mitul Shah highlighted during his talk was better understanding the relation between people and technology. In his words, we need more “basic market research” and “impact evaluations”. Understanding how cultural perceptions of technology impact social desirability bias seems to be a critical gap since we’ve focused so many of our efforts on issues like cost-effectiveness, efficiency, and technological interoperability. That the Cheng and Bernabe studies showed such different results indicates that context matters. It’s not just a matter of phone (PDA) vs no-phone (np-PDA) – culture, age, gender all matter, too. If we can begin to understand these local factors, we can plan accordingly – e.g. how we train data collectors to prepare survey respondents – to achieve the gains we want in efficiency and cost.

No network in the big conference hall this morning, so no #GHC36 tweets from the Hans Rosling plenary. If you don’t know who he is, check out Gapminder.org and his TED talk. Here’s what I would have tweeted (rough transcription, emphasis is Rosling’s):

• “We need to be more thoughtful [in global health]“
• “Macro levels are always dangerous”
• “War does not explain the high rates [of HIV in Africa]“
• “We have to start to use data in global health”
• “People should be forbidden from talking about ‘HIV in Africa’”
• “There’s no such thing as ‘HIV in Africa’ – it’s so different from country to country”

I recently discovered the UCLA Art|Global Health Center, the mission of which is to “unleash the transformative power of the arts to advance global health“. The arts have the ability to capture issues and tell a story in a way that can make a profound impact on our (social) consciousness and is not something we talk about enough as a tool. One of the more famous examples of this is the AIDS quilt which was conceived of in 1985 by an AIDS activist in memory of Harvey Milk. That quilt has had over 14 million visitors and is the largest community arts project in the world.

The UCLA center has some ongoing projects and last year opened “Make Art | Stop AIDS” that featured traditional art as well as things like condom dresses. Make Art/Stop AIDS “is organized around a series of seven interconnected and at times overlapping concerns expressed in the form of open-ended questions, some of which include direct art historical references to the epidemic: What is AIDS?; Who lives, who dies?; Condoms: what’s the issue?; Is it safe to touch?; When is the last time you cried?; What good does a red ribbon do?; Are you angry enough to do something about AIDS?; and, finally, Art is not enough. Now it’s in your hands.”

Creative art projects have the ability to move the human mind unlike the constant barrage of issues, numbers and headlines that desensitize us over time. If you have seen or heard of any interesting arts based global health projects let us know.

More Sources
Adriana Bertinin’s condom dresses

Addressing HIV/AIDS-Related Grief and Healing Through Art

History of the AIDS Memorial Quilt

Condom fashion show, China