It’s really great to see so much effort being channeled towards innovation in international maternal and child health. The text4baby service was launched just one month ago. Our last post was about a USAID-supported mHealth eConference for maternal and child health. This post is about a maternal health innovations competition put on by Ashoka.

There are now nine days left to enter the Healthy Mothers, Strong World competition, billed as THE NEXT GENERATION OF IDEAS FOR MATERNAL HEALTH. The best innovations will be awarded prizes totaling US$600,000. More information is available at the competition website.

Two early entry prizes have already been awarded. One of the prizes went to Aadharbhut Prasuti Sewa Kendra, a privately-run birthing center led by nurse-midwives in Nepal. It is described “the first and only initiative taken by Nepalese nurses in a low resource setting, where they have never ever taken such a step independently”. The other prize went to Maternova, an portal for innovations in maternal and neonatal health that we first reported on in November 2008.

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• The New National Health Plan Is Texting (science.slashdot.org)

We are really glad to have another guest blogger. Kriti from Epidemiology Tales: Stories Exploring Public Health & Life
is the author of the post below. We look forward to more posts in the future, be sure to check out her global health blog for more information.

Female Feticide: from Motherland to Diaspora

Up- country: Diya, an activist who educated women on female feticide, was recently married. She was 20 years old, and about to give birth. She was riding in a car hurtling over potholed roads toward the town hospital. Although at home, they claimed they would be happy for any child, “We like girl-children as much as boy-children,” her father-in-law would say, but she knew the reality was far different. Her mother in-law was next to her, looking tense with anticipation. She lived with her in-laws, customary in rural India, and did not have good relations with them: they were angry she had a love marriage with their son and a mind of her own.

“You had better give birth to a boy,” her mother-in-law hissed to her, as Diya’s labor pains intensified.

City: Jassi, the wife of a successful, well-known Bombay businessman, and already mother of two beautiful daughters, was pregnant with a third child. The women in her society (apartment complex) were anything but congratulatory. They admonished her, “why don’t you have a test done?” implying that she should make certain not to have yet another girl.

I was shocked to hear these stories. Both of these women, loosely based on women I’ve known, had healthy baby boys. But their problem is real, and getting worse: the number of girls for every 1,000 boys (sex ratio) went from 962 in 1981, and with the improvement of sex-testing technology, dropped to 927 in 2001. It was as low as 814 in Delhi.

At first glance, it seems like this is an economic issue, as some middle class families claimIn Spite of the Gods: The Strange Rise of Modern India, he talks about a woman from such a wealthy family, that her dowry included a Mercedes and Switzerland vacation. Even she was forced by her husband’s family to abort her baby girl, although many women themselves believe in this practice.

Shockingly, this practice continues in the US. Census data shows that for every child born subsequent born after the first in Chinese, Indian, and Korean families, the likelihood of that child being a boy increases.

Female feticide is because of many traditions and perceptions, as well as economic and social factors coming together. Girls are seen as economic liabilities destined to leave their homes, as they traditionally go live with their husband’s family after marriage. Male children, who never leave their parents (and doing so would raise eyebrows), support them in old age. Male children earn money for their parents through jobs and dowry. Female children, however, do not. Many are not allowed to work nor offered education, and dowry continues, even among educated, well-traveled, urban elites – furthering an already insidious gender bias.

There are some successful interventions, like empowering women through education, economic power, and allowing them to take greater control of their lives – and this is where I’d like my life to focus. Before translating and preparing training materials at CORD, I never realized how deeply rooted this practice is in Indian culture. To me, Indian culture is laced with quirks, visible and invisible, but I always felt some pride and loyalty in my heritage. But this level of hypocrisy and brutality is astounding. A sign in Mumbai reads, “It is better to pay 500 Rs now than 50,000 Rs (in dowry) later”.

Though the topic makes periodic appearances in international news, and many interventions are taking place, ultimately it rests on changing social norms: At weddings, including mine, there is a prayer to bless the new couple. It states tellingly, “May you have sons”. But Babaji (my grandfather-in-law), the eldest person at the event, added “or girls, because everyone is equal now.”. Andhra Pradesh, a more progressive state, offers hope with a girl-favoring sex ratio, closer to natural patterns. – but female feticide is rising fastest among wealthier couples. In Edward Luce’s

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Thanks for checking back to this blog after a long time! I’m getting re-started, and continuing to explore issues in public health that pique my interest (or deeply sadden me, like this one). You’ll notice some changes in the look and layout, all to be easier for you. Would love your feedback, or forwards this if you know someone interested!

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 »

This year’s Clinton Global Initiative takes place from 22 – 25 September 2009, where heads of state, government and business leaders, scholars, and NGO directors work together to analyze, discuss, and debate possible solutions to urgent global issues. Each participant is then asked to take action on one or more issues by making a Commitment to Action.

The Economist calls the meeting ‘an important part of the global elite’s calendar’, so join online and watch the live webcast!

As noted in our post on Girls Count: The Girl Effect, one of the major themes this year is Investing in Girls and Women. The four focus areas are Innovation, Human Capital, Infrastructure, and Equitable Futures.

Read the rest of this entry »

“Women hold up half the sky,” says the Chinese proverb, but in most of the world women are second class citizens – “girls are uneducated and women marginalized, and it’s not an accident that those same countries are disproportionately mired in poverty and riven by fundamentalism and chaos.” If girls and women cannot reach their full potential, then we as a world cannot either. In this century, the great moral imperative is empowering the women of the world, write Nicholas Kristof and Sheryl WuDunn in an impassioned article in the New York Times Magazine special issue on Saving the World’s Women

Investing in girls and women is the new focus of foreign policy. The brilliant Girl Effect video and New York Times special were based on the report Girls Count: A Global Investment and Action Agenda by Ruth Levine and colleagues from the Center for Global Development, who are releasing a report on the global health agenda for adolescent girls today. See here for Ruth Levine’s reflections on the NYT article. And, the Clinton Global Initiative is dedicating its annual conference starting on 22 September to the issue (join online on the webcast or podcasts).

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).

I just discovered an interesting blog: healthcare + design and they had this post up on design excellence awards. Not sure how much this Breath Counter costs, but worth investigating further:

“Fighting Pneumonia: Breath Counter The Breath Counter is a simple, effective testing device to help detect pneumonia in children under five, living in remote areas in developing countries. Pneumonia is the number one cause of death in the under five worldwide, killing an average of two million each year. The disease is diagnosed by counting the number of breaths taken by the patient in one minute, as those infected will have a much higher count than healthy children. But despite the relative simplicity of detection, the current timing device distributed by NGOs is too basic and unreliable.  Philips Design has created a reliable, easy to use solution that addresses the problems identified by the NGOs in the field. Powered by solar cells, the Breath Counters lifespan is potentally five years longer than what is currently available. An LED screen logs three test results, making them easy to compare. Aesthetically, the Breath Counter looks like a medical tool, to give the user a feeling of commitment and contribution to this important issue. For users who cannot read, Philips Design created a simple manual with clear visuals that explain the procedure.”

Philanthropy by Design
“The Breath Counter was created within Philips Design’s Philanthropy by Design program, established in 2005 in which, together with partners such as Non-Governmental Organizations (NGOs), public bodies and social players with complementary expertise and values, Philips Design donates its creative expertise and socio-cultural knowledge to create solutions to improve the health and environment of the more fragile categories of the world’s developing societies.”

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.