Kopernik: Connecting Innovative Technologies with Poor Communities
We are lucky to have a guest post today by Ewa and people like her in general who are doing what they can for global health. She and her team have just launched a new web platform connecting you with poor communities and technologies that might be needed there via an online store. I cannot emphasize enough that is this is long long overdue and that we should all be embarrassed that this hasn’t happened before. So major kudos to Ewa and her team for pulling this platform together and giving it a shot. Please visit their website and spread the word (you can also read there Tech for development blog here):

Guest Post by Ewa Wojkowska, a former UN worker, is the co-founder of TheKopernik.org.
As the rubble is cleared in Haiti, as a measure of stability comes to Sudan, as Sri Lanka holds a bitter peace and as Burundi faces its first election in the wake of massive civil war, a new development opportunity presents in some of the world’s poorest and most troubled places.

Online social entrepreneurship for the poor is one of the most compelling ways to fight poverty—and to reshape our development practices. Examples like Kiva and Global Giving are already leading the way, linking people anywhere in the world to better assistance and real results. The internet has created the opportunity for a transparent virtual marketplace: communities in developing countries identify their local needs, individuals anywhere in the world directly respond. Today our site—www.thekopernik.org—joins the force, connecting breakthrough technology to the poor through an online marketplace. It’s a simple, direct idea for real assistance to people in need.

Here’s our idea: Registered local organizations provide short proposals explaining their needs—simple water filtration in Freetown, Sierra Leone, self-adjusting eyeglasses in Manado, Indonesia. Any visitor to the site, anywhere in the world, can review the proposals and make donations to fund the plan of his or her choice. We connect these breakthrough technologies—water filters and drums, self-adjusting eye glasses, and solar lights, just to name a few—to the people who need them most.

What sets us apart is the focus on technology and a review mechanism for local organizations, or ‘technology seekers’, to rate the products. By including a feedback mechanism on the effectiveness of these technologies, Kopernik gives voice and choice to local communities and organizations – simple elements that are so frequently missed in international development efforts. We’re looking to take out the delays and to spark new ideas in international aid, one click at a time.We believe this is the new face of development.

If more people everywhere have safe, unfettered access to clean water, more efficient means of transporting that water, clear eyesight, and reliable light, how would their choices change? How would they see the world and their place in it? What could their empowerment achieve?

We now have the technology to improve everyone’s lives, and the internet is the window to get these life-changing technologies into people’s hands, directly and efficiently. We’re building a resource that those in need can access for themselves.

Ewa Wojkowska, a former UN worker, is the co-founder of Kopernik.org. The website launched this past week.

Related articles by Zemanta

• Kopernik Sells Technology To The Developing World (techstartups.com)
• Sierra Leone link to India medics (news.bbc.co.uk)

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.

Credit: PATH

As reported recently on Xconomy.com, scientists at PATH—a Seattle-based nonprofit organization working to improve global health and well-being—have found a cheap and simple way to tackle the challenges associated with protecting hepatitis B vaccine effectiveness when the vaccine gets too hot or too cold. Given how important this development seems, I contacted PATH to ask them some additional questions about this important breakthrough which they have kindly taken a lot of time to answer (many thanks to Amy for working with me on this). The e-interview consisted of the following 8 questions:

1. What was the primary breakthrough?

2. How did you get this done?

3. Why was no one else able to do this before?

4. What are the barriers to applying this to other vaccines? AND how does this change the costs of delivering vaccines in general (does the cost structure change in any way)?

5. What was the approximate cost to achieve this?

6. On the surface this appears to be a major breakthrough, is that how PATH scientists are viewing this?

7. Have you done projections on the increased number of vaccinations that can be done with this new technology?

8. Is this something that can be used in OECD markets?

Temperature regulation is one of the biggest challenges to vaccine use worldwide. According to PATH, keeping some vaccines at stable temperatures requires the use of a vaccine cold chain — a global distribution network of refrigeration equipment and procedures for maintaining vaccine quality during transport and storage. Cold chain storage and exposure to extreme temperatures presents a critical obstacle to delivering needed vaccines to some of the most at-risk regions around the globe. Other research teams in addition to PATH’s are currently using various innovations to address the problem. A group of researchers at the University of Colorado at Boulder, for example, is developing a powdered, inhalable version of a measles vaccination that is ready for human testing. With regards to PATH’s work, the full e-interview is below:

E-INTERVIEW WITH PATH

What was the primary breakthrough?
One of the biggest challenges to vaccine use is temperature regulation. World Health Organization guidelines recommend that nearly all vaccines be stored at 2°C to 8°C. These temperature requirements necessitate use of a vaccine cold chain—a global distribution network of refrigeration equipment and procedures for maintaining vaccine quality during transport and storage.

In many parts of the world, the need to keep vaccines cold during transport and storage requires allocation of scarce resources to cover costs for refrigeration equipment and special handling procedures. A growing body of research indicates that cold chain storage facilities are insufficient to handle the increasing number of vaccines that are being introduced in immunization programs. In addition, vaccines are frequently damaged when they are accidentally or inadvertently frozen or exposed to heat—which, in turn, greatly affects vaccine effectiveness. Improving both the heat- and freeze-stability of a vaccine can help with these issues. Heat- and freeze-stable vaccines are more resistant to damage when temperatures rise and fall due to power outages, faulty refrigeration equipment, or handling errors. Heat-stable vaccines could potentially be moved to storage at higher temperatures (with appropriate controls) to provide space for less heat-stable vaccines.

The heat-stable hepatitis B vaccine recently developed by PATH and partners could be kept in alternate storage facilities (such as air-conditioned rooms) and under alternative transport conditions (such as insulated packaging without ice packs) for potentially its entire shelf life without compromising the effectiveness of the vaccine. The added heat stability can also facilitate outreach to remote areas and enable better heath outcomes when health care providers, for example, travel to remote areas to deliver the necessary birth dose of hepatitis B vaccine to hard-to-reach populations.

Altogether, the heat- and freeze-stabilization of common vaccines, like hepatitis B vaccine, has the potential to improve immunization effectiveness and efficiency—to help to extend immunization coverage by simplifying the logistics and reducing the costs associated with transport and storage of vaccines in regions of the world where the cold chain is insufficient, impractical, or otherwise constrained.

How did you get this done?
PATH and partners tested many formulation approaches and perfected a particularly promising one that combines a freeze-protection method developed last year by PATH with a heat stabilization method previously developed by Arecor. The approach, once tested and refined, includes the addition of common stabilizers to hepatitis B vaccine formulations.  The stabilizers used include propylene glycol—a compound that is found in many consumer products, foods and medicines, and protects the vaccine from cold—and an amino acid called histidine, which contributes to the vaccine’s heat-stabilization.

According to research findings recently published in a July issue of Vaccine (volume 27, issue 34), this freeze- and heat-stable formulation was found to be well tolerated in animal models without any significant local or systemic side effects.  Tests of the new formulation also showed it to be heat-stable for 12 months at 37°C in addition to proving freeze-stable at ?20°C. In partnership with Arecor and the University of Colorado Denver School of Pharmacy, PATH published more recent findings in the August issue of Human Vaccines (volume 5, issue that describe the new hepatitis B vaccine formulation exhibiting nine week heat stability at 55°C and at least six month stability at both 37°C and 45°C.

Why was no one else able to do this before?
To our knowledge, researchers have not previously sought solutions to protect vaccine from freeze-damage through formulation methods. Vaccines that are freeze-sensitive are simply labeled as such and the burden is on health care providers to keep the vaccine at appropriate temperatures. A concerted effort by PATH scientists over a number of years—with support for our project work in vaccine stabilization, funded by the Bill & Melinda Gates Foundation—allowed PATH to tackle this issue head on. The freeze-stabilization method should apply equally-well to all vaccines containing aluminum adjuvant. The heat protection method also arose out of PATH’s vaccine stabilization project and applies a technology from commercial partner, Arecor, to hepatitis B vaccine, which is an important childhood vaccine that is often distributed and used in difficult settings—thus requiring outreach to hard-to-reach areas (to deliver it to newborns in their home).

What are the barriers to applying this to other vaccines? AND how does this change the costs of delivering vaccines in general (does the cost structure change in any way)?
The costs of both additives, propylene glycol and histidine, are neglible.  Scientists at PATH say that the additives cost an extra one-tenth of one US penny per vaccine dose. However, the hepatitis B vaccine is a mature product that has been on the market for some time. To stabilize this vaccine now requires reformulation—plus all the necessary laboratory, preclinical, and clinical work to validate that the new product is still as effective as the existing product. The product must also receive regulatory approval.

Presently, the heat and freeze-stabilization technology has been transferred to one vaccine producer that is undertaking this work to achieve a superior hepatitis B vaccine. By comparison, the freeze-stabilization technology is broadly applicable to all vaccines containing aluminum adjuvant and could be added to any new vaccine incorporating this type of adjuvant. PATH has placed the freeze-stabilization technology in the public domain to encourage uptake.

What was the approximate cost to achieve this?
The development of these formulation methods and the research described in both published studies were conducted in conjunction with PATH’s broad project work in vaccine stabilization funded by the Bill & Melinda Gates Foundation.

On the surface this appears to be a major breakthrough, is that how PATH scientists are viewing this?
Yes, it represents a major breakthrough because the research shows how we can now prevent the problem from the beginning through the vaccine formulation itself.  The application of heat and freeze stabilization technologies to new vaccine products represents a sea change, of sorts, in how vaccine producers could optimize vaccine products—and, in turn, ease logistics for immunization programs as well as expand the reach and ensure the effectiveness of life-saving vaccines.

Have you done projections on the increased number of vaccinations that can be done with this new technology?
It is difficult to project because of the many additional factors that effect increases in the number of vaccinations, for example, the availability of health care workers and transportation for outreach.  That said, PATH has analyzed the projected health impacts and the cost-effectiveness of introduction of thermostable vaccines into three countries—Bangladesh, Cambodia, and Ghana.  For more information, please contact us by email (info@path.org).

Is this something that can be used in OECD markets?
Yes, the heat and freeze stabilization technologies have the potential to optimize vaccine products for OECD markets, as well as vaccine products used by immunization programs in emerging and resource-poor settings.  The challenges associated with maintaining vaccine temperature requirements during storage and transport are not limited to the developing world.  No matter the country, vaccine damage caused by heat or freezing is not a simple problem—it is hard to detect.  You can’t always tell whether or not a vaccine has been rendered ineffective simply by looking at it.  The U.S. Centers for Disease Control and Prevention estimates that poor refrigeration wastes hundreds of thousands of doses of vaccine every year, costing the U.S. health care system millions of dollars and, when noticed, requiring children and others who need vaccination to be reimmunized.

As promised earlier, here is a brief account about the design+water workshop I conducted in Mexico in June.

Two months ago, I was in La Paz, Mexico at NGO Fundación Cántaro Azul, helping them build organizational capacity in human-centered design (HCD).  Cántaro Azul works to improve access to safe water and sanitation for disadvantaged communities, not only in Baja California Sur, but in other parts of Mexico, and abroad. Their interest in HCD is two-fold: to improve existing initiatives and to innovate new approaches.

I recently completed the workshop final report for the organization. In the hopes that the work may be helpful to others, I’m posting the synopsis of the report here, along with some workshop photos. If you’re interested in accessing the report, please contact me directly.

Design thinking workshop final report: Safe water options with rural community stores in BCS 

Fundación Cántaro Azul • La Paz, Baja California Sur, México 

Jaspal S. Sandhu, Ph.D. • July 2009 

This document describes the outcomes of a week-long design thinking workshop held at Fundación Cántaro Azul (FCA) in La Paz in June 2009. The workshop aimed to build design thinking capacity at the organization while working on a problem of actual importance to FCA. The most important practical outcomes of this workshop were two complementary models for providing a clean, affordable drinking water choice for rural people in Baja California Sur via community stores. The primary audience for this document is FCA. It is intended to help them with ongoing activities focused on the community store model and in incorporating this approach in their various activities. The workshop was designed and facilitated by Jaspal Sandhu, the report author. Workshop funding was provided by the Blum Center for Developing Economies at the University of California, Berkeley.

Shown below: Field research during Day 2 and Day 3 of the workshop. (1) Using an auto-servicio system in La Paz (top left); (2) interviewing a user at a rural, government-run purificadora in San Antonio (top right); (3) debriefing after the San Antonio research (bottom left); (4) and obtaining water samples to test from a home in Rosario (bottom right).

This will be my  last post from the Global Health Council conference, but likely not the last from our team. This one is from a morning session I attended “Postpartum Hemorrhage: New Findings and Innovative Technologies” (session F4). From the conference website:

Presenters Discuss: possible risk factors for postpartum hemorrhage (PPH) and the impact of active management of the third stage of labor and its components on postpartum blood loss (Global: Egypt, Ecuador, Turkey, Burkina Faso and Turkey); a demonstration project to assess feasibility, acceptability, and safety of oxytocin in Uniject as a first step to introducing the device on a national scale, and strategies for scaling up use of oxytocin-Uniject™ devices with time-temperature indicator (TTI) for the prevention of PPH (Mali); techniques for estimating blood loss for the early and accurate diagnosis of PPH and cost-effective and reliable techniques for improved blood loss estimation in rural settings (India, Tanzania) and the importance of obstetric hemorrhage as a cause of maternal mortality and morbidity in low-resource settings, the potential contribution of the non-pneumatic anti-shock harment (NASG) to reducing death and disability from obstetric hemorrhage (Nigeria). 

The session was moderated by Suellen Miller of UCSF – who works on NASG among other projects. The panelists, in order of presentation:

• Jill Durocher – Gynuity Health Projects, Determinants of Postpartum Hemorrhage [AMTSL]
• Stacie Geller, PhD – University of Illinois-Chicago, Accessible Techniques for Improved Estimation of Blood Loss [blood drape]
• Dosu Ojengbede – University College Hospital, Ibadan, Nigeria, Non-pneumatic Anti-shock Garment’s Potential for Obstetric Hemorrhage in Africa for Improved Estimation of Blood Loss [NASG]
• Susheela Engelbrecht, CNM – PATH, Implementation Challenges on a Larger Scale [Uniject+oxytocin]

If you think you don’t know enough about PPH, check out this wikipedia entry.

By this point in the conference, I’m sure I’ve exposed my biases- I’m interested in exploring themes across projects, with a particular emphasis on opportunities for innovation. This session was no different. Two key themes emerged: (1) these innovations are not magic bullets – larger supporting systems need to be in place for them to be effective, and (2) there are opportunities for improving outcomes by improving the usability of these products.

No magic bullets

Susheela Engelbrecht’s wording in reference to Uniject syringes preloaded with oxytocin was a bit different: “It is a magic bullet, but many other things need to be in place”. With the NASG, the technology buys critical time but is not a “definitive treatment” alone – it still requires patient monitoring, for which appropriate staffing and essential drugs are essential. The multi-country AMTSL (active management of the third stage of labor) study suggests that steps such as controlled cord contraction and fundal massage are only effective in the context of uterotonic drug administration.

Improving usability

The technological innovations presented all show significant promise. The Nigeria study, using a pre/post intervention design, showed a reduction in blood loss of 61% and a reduction in mortality of 60%. The morbidity numbers were too small to make any inferences. A randomized controlled trial showed that, compared to a gold standard measure, the blood drape (Geller) was 33% more accurate than visual estimation.

Uterotonic drugs were shown to play a critical role in AMTSL and the Uniject+oxytocin solution allows administration at the point-of-care to avoid many of the pitfalls associated with ampoule+oxytocin+syringe administration; however, there are some outstanding issues with cost and policy:

• cost: the Uniject solution will “always” be more expensive, currently a bit less than US$1 based on an Argentine formulation
• policy: at what levels of the health system should this be used? should it be used only for AMTSL or also for PPH?

As we begin to move toward scaling these technologies, it will be important to understand how people will use (and misuse) these technologies in environments that are not subject to the scrutiny of research studies.

Some notes I jotted down about usability innovations and challenges from the talks:

• The blood drape had the unanticipated benefit of keeping things clean (containing blood), from the perspectives of women, birth attendants, and families
• The original blood drape showed quantities (cc) of blood using a numerical scale, but a later version simply used a yellow line (alert) and red line (action) to identify risk level
• For the blood drape, the alert and action values were not based on WHO standards, which are designed for equipped, clinical settings, but were calibrated based on data from deliveries in rural India (e.g. WHO standard was 500cc for alert, and the value used with the blood drape was 350cc)
• Birth attendants and families using the blood drape for home deliveries on the floor came up with the idea of propping up the mother’s head with a dupatta to encourage the blood to flow into the drape
• The blood drape must be placed under the women after birth, so that it doesn’t accumulate amniotic fluid (this is after all postpartum hemorrhaging)
• With NASG the challenges include washing (decontaminating), drying, and folding – if this isn’t done in time, the benefit of the garment may be lost for the next patient – whether it is sent somewhere for decontamination or if it is done locally
• The Uniject+oxytocin solution requires more space in the cold chain since the syringe and packaging takes up more space than standard ampoules for the same volume
• With Uniject+oxytocin, some women though they were receiving a contraceptive injection against their will since their prior experience with pre-loaded syringes was with Depo-Provera
• “Training was a non-issue” with Uniject+oxytocin. Those who read the instructions felt as comfortable as those who were trained by demonstration.

During the Q&A there was one more. Professor Ojengbede mentioned a case where a woman wore the NASG for four days in order to wait for a blood transfusion. As soon as the bleeding stopped, she continued to wear the garment and walked around the ward. In response to a question about complications from wearing such a garment, the team indicated that there were no cases of deep vein thrombosis or pulmonary embolism. Note: the Nigeria study will soon be published in the Journal of Obstetrics and Gynecology.

As with the last post, I’m copying the description of the session I just attended – Vouchers for Health (Session C3) - from the conference website:

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.

In October 2007 I was working in a place called Suhbaatar, a province in the flat and often dusty steppes of eastern Mongolia named after the hero of the 1921 revolution.  The primary activity of this trip was to hang out with community health workers in different sums (counties), a few days in each place, in order to better understand the role information played in their provision of services. The last sum I visited normally has about 4000 people, largely pastoralist nomads, living across an area 1.5 times the size of Rhode Island, with roughly half of them concentrated at the sum center during the fall months. A rough spring for the local pastures meant that many of these 4000 had left on otor, pasturing livestock up to 300km away, making it downright desolate.

On my third day in this sum, I asked the doctor managing the local clinic for a tour of the new clinic being built across the street.  GTZ and Lux-Development had both been here recently on health infrastructure projects, but this time the money was coming from the Mongolian government.  The doctor, a nurse practitioner, and I walked across the street where we met the foreman, a man who had come here from the capital Ulaanbaatar (photo).  Though the work crew was already working on the roof – the construction had started two months earlier – I was surprised to hear the doctor, who had worked here for more than 10 years, asking some critical questions about the layout of the new hospital. After several minutes of interrogation, the exasperated foreman claimed this hospital was the same design as one being completed in another sum. What the doctor knew and the foreman didn’t was that I had just visited that sum.  “Is this true?” the doctor asked me. “Does it have the same number of beds?” “Will our hospital be as big?” “No” was the answer on all counts. In consultation with the nurse, the doctor quickly realized this new hospital wouldn’t provide enough space to meet their patient demands.  So they would have to keep parts of the old hospital working to meet their needs.  So much for the touted energy efficiency of the new vakuum sunh (double-paned windows). This was the result of a top-down approach to hospital design.

Earlier this week the New York Times reported on how health outcomes are driving hospital design in U.S. settings (thanks Dr. Marwah for the article pointer):

In many new hospitals and pavilions … semiprivate rooms have vanished. Single-patient rooms are now viewed as an important element of high-quality health care. The benefits of the single room emerged through evidence-based hospital design, a new field that guides health care construction. More than 1,500 studies have examined ways that design can reduce medical errors, infections and falls — and relieve patient stress.

The idea is simple: change the design of the physical environment to reflect the needs of the people in the system – patients, visitors, administrators, caregivers, insurers – with an eye towards improving health outcomes. There are opportunities both for new construction, but also for retrofits. And the solutions are often simple. From the Times article, Princeton’s University Medical Center is installing larger windows “because studies suggest that natural light can reduce depression and that scenes of nature can reduce reported levels of pain”. From a 2007 SFGate article, Kaiser-Permanente is changing the color of the paint on the walls “to cheery spring shades of pale blue, yellow and green” in an effort to be more patient-focused.

All good and well, but what do systems with limited resources have to take from this approach? Quite a bit it seems…

As an example, consider the recent PLoS study from Peru (Escombe et al., 2007) that showed how natural ventilation – an low-cost alternative to negative-pressure isolation rooms - could be used to reduce intrahospital transmission rates of tuberculosis. The recommendation of the study? Open the doors and windows: “Even at the recommended ventilation rate, the calculated risk of airborne contagion was greater in these mechanically ventilated rooms [in modern facilities built 1970-1990] than in naturally ventilated rooms with open windows and doors [in older facilities built pre-1950]“.

As this research shows there are plenty of opportunities to change the way we work within existing facilities to improve outcomes. And there are plenty of opportunities with systems that are renovating and building new hospitals and clinics. A couple current examples: (1) the Millennium Challenge Corporation is renovating 150 health centers in Lesotho; (2) the Asian Development Bank is building 17 new clinics and renovating 7 facilities, including 3 provincial hospitals as part of the Third Health Sector Development Project in Mongolia (PDF).

The human-centered approach can improve health outcomes with simple innovations derived from a better understanding of the needs of a facility’s users. The open question is whether we’ll take advantage of such an approach or whether – in the words of   Roger Ulrich from Texas A&M’s Center for Health Systems and Design - we’ll simply “pay lip service to the evidence”.

Guest post by Ada Kwan a Hopkins graduate student:

I’ve had a good two weeks now to settle my thoughts on the CATER workshop held on April 17th, 2009, and given the rapid pace of technological development in the social space, I thought it would be great to offer the THD readers a glimpse of an initiative at New York University.

The CATER initiative is a multidisciplinary space for Cost-effective and Appropriate Technologies for Emerging Regions.  It seems to be an active junction for the Courant Institute of Mathematical Sciences, NYU School of Medicine, NYU Wagner School of Public Policy, and the NYU Department of Economics.

Fronted by Professor Lakshminarayanan Subramanian and many others, the workshop on April 17th masterminded 18 talks, 3 breaks, a lunch session, and a follow up panel discussion in 8 hours!

The lineup included a variety of topics, such as: rural communication, low-cost communication alternatives, SMS-based mobile health records, automated detection of diabetic retinopathy, the spectrum of latency (low–> high) across the spectrum of bandwidth (low –> high), microfinance and mbanking, watermarking solutions (Paper Speckle), mobile educational tools, teaching modules (WiSEMD), WiRE architecture and MESH networking, and mHealth in the Millennium Villages Project, just to name a few.

So what’s in the gonklit for emerging regions?  We learned that it’s pretty costly to be poor in the Indian slum of Dharavi, where 85% of slum dwellers own a TV, 50% have a pressure cooker, and 21% have a telephone.  In Bangladesh, 7% of income is devoted to communications.  Field survey experience demonstrated that people generally like mobile phones more than notebooks because of privacy, and if four students are placed in front of a computer with one mouse, the “alpha child” will control the mouse.  Studies show that if the mouse is taken away from the “alpha” child” and given to another member of the group, then there will be more conversation among the children, as well as a tighter grouping around the computer monitor.

Personally, it was great to hear what’s in the pipeline for mHealth.  The capabilities of mHealth are great, but a lot of what is happening in the mHealth space right now is occurring in application development and research.  Because these applications aim to improve health outcomes, I’m surprised that we are not looking more closely at how much of an impact on health outcomes mobile phones and networks there is, let alone if there is a measurable impact in decreasing local morbidities, mortalities, incidence, and prevalence.

Ken from Microsoft Research India dispelled a few myths on technology, and I could almost feel every member in the audience transpire through the levels of acceptance.  The myths from Ken’s presentation are as below:

As someone who is supportive of the potential for ICT4D, I think this list is quite humbling.  As one of the attendees remarked after Ken’s presentation, it’s pretty powerful when ’someone destroys my world view, and then I find myself agreeing with every word he says’.

I wish I could tagcloud the following: sustainability, self-sufficiency, impact, scale, illiteracy, UX, UD, transferability, and trust.  It’s great to see the constructive discussion over these issues, since having the vision is part of the battle.  The challenge is getting these technologies to a place where they can be easily transferred into the communities.  (And having the patience to know it takes time!)

After all, the best part of technology is what we humans can do with it.

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Update: To see a more thorough depiction addressing academia’s role in the mobile movement, please check out Heather Cole-Lewis’ blog entry on MobileActive regarding a recent session held at the DC MobileTech4SocialChange Barcamp. Heather is currently a PhD student at the Yale School of Public Health.

Please vote for Ben’s mobile payment for health systems project. Voting closes Friday.

VOTE – NETSQUARED: By introducing a smartphone and web-application system for submitting and reviewing claims, we hope to reduce the delays and errors, increase clinics’ profitability and improve communication. Below is a related post by Melissa Ho who is working with Ben on this project which fills a critical gap. Cross posted from ICTDCHICK:

First HealthyBaby Birth

The mother receives the baby from the nurses at the clinic.

As I have been pre-occupied with writing lectures for my class, and setting up my research, my collaborating partners at Marie Stopes International Uganda have been busy launching a new phase of the output-based aid voucher program, financing in-hospital delivery of babies, in addition to the in-clinic treatment of sexually-transmitted infections (STIs). The new program, called HealthyBaby is eligible to mothers who qualify under a specific poverty baseline and covers four antenatal visits, the delivery, and a postnatal visit. Last week they just started distributing vouchers, and this past weekend was the delivery of the first baby whose birth was covered by the program.

Like the HealthyLife program, the mother purchases a voucher for 3000 USh (approximately 1.50 USD, the HealthyLife program charges 3000USh for a pair of vouchers treating both sexual partners). The voucher then can be broken into several sticker stubs, one of which is submitted with a claim form on each visit.

The first mother puts her thumb print on the HealthyBaby claim form

The hospital then submits the claim form with the voucher to the funding agency (my collaborating organization), who then pays the hospital for the cost of the visit – labs, any prescriptions given, the consultation fee, etc. You can see in the picture to the right the nurse filling out the paper form and the mother putting her thumbprint on it. Filling out the forms can be tedious and error prone – this particular clinic had almost 18% of their STI claims rejected for errors last October. In the same month another clinics had 38.6% of their claims rejected. I am trying to work on digital systems that can help improve communications between the clinics and the funding agency, and also decrease the cost and burden of claims administration.

The Claim Mobile project actually focuses on the HealthyLife program – the STI treatment program, rather than the HealthyBaby program, but I hope to demonstrate the sustainability and replicability of the system that I’m developing by training the engineers here to retool my system for HealthyBaby – so by the time I leave, I am hoping it will be in place for both programs.

By coincidence, this first birth occurred in one of the two clinics where I’m running the pre-pilot of the Claim Mobile system.

The WHO has decided to focus this World Health Day on hospital infrastructure during times of emergency. The folks over at Global Health Progress have a good round of what some bloggers are saying and include health journalism folks as well as thoughts from the AvianFlu diary. I thought I would go off theme and briefly throw out some thoughts on the bigger picture and encourage you to use this day to think about what is the future of global health? In this context of thinking about the future in 10, 20 or 30 years, the world is in turmoil and we are questioning the fundamental nature of market driven economies, why not use this as an opportunity to do the same for global health in a forward looking way? Think about where we are and whether we are prioritizing the right things and moving in the right directions?

Approximately 10 (only TEN!) years ago there was no Google, Kiva, Gates Foundation or knowledge about the cost differences between generic and brand name drugs (see this great talk on the Future of Global Health by Jim Yong Kim and his discussion of how they reduced the price of treating MDR TB patients by 80-90% in 1999) amongst major care organizations (absolutely stunning). Mobile phone penetration was less than 1% in developing countries and social entrepreneurship wasn’t hot, the vast majority of us probably hadn’t even heard of that term.

Where we were ten years ago is arguably a profoundly different world from where we are today and per the video below “we are living in exponential times“. To give you further inspiration to think differently today definitely watch the below (via 2173):[youtube=http://www.youtube.com/watch?v=Mmz5qYbKsvM]

The acceleration of technology for social change and global health is going to increase, in this decade alone the convergence of movements in philanthropy, entrepreneurship and technology all enabled by the internet and mobile phone revolution have allowed people to collaborate, innovate and communicate on an entirely different level. I don’t know what the future of global health is – but I wonder how open source collaborations will contribute to solutions and whether twittering for global health will be around in five years and for whom and what purpose? Or will we just be doing more of the same. I wonder if we will be doing entire marketing and health education campaigns via mobile phones and how this will evolve. Will there be convergence of people and ideas working on global and domestic health? Will the flow of innovation and products from “South” to “North” become the next hot topic? I wonder if we will have a TED just for Global Health?

We might face a global crisis in 2030 but we will also be better equipped to face that crisis.Today is a day we should be thinking about what all the possibilities are and how we can get there in the fastest way possible.  The last idea I will throw out as food for thought is to think about what have been the top 10 biggest developments in global health in the last decade and how will these shape the future?

Other thoughts on World Health Day:
UN Dispatch, link
Human Rights Watch, link
The Lancet Student, link
Global Institute Blog, link
Charity Navigator, link