Proveer atención médica de acceso inmediato, presencial y a distancia, a través de un sistema de membresías y una red de proveedores médicos, con calidad y descuentos garantizados, e incorporando conocimientos y tecnologías vanguardistas.

Translation (forgive my Spanish translation…it’s been a while): To provide immediate and live medical attention at a distance through a membership system and a network of medical providers with quality and guaranteed discounts and incorporating knowledge and advanced technologies.

The skinny:

- 1 million households subsribe

- 90,000 calls per month

- 62% of calls are resolved over the phone

- $5/month/household

Thanks Ashsish for passing along the info.

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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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HOW CAN MOBILE PHONE TECHNOLOGIES IMPROVE FAMILY PLANNING,

MATERNAL AND NEWBORN SERVICES IN THE DEVELOPING WORLD

Online Conference May 5, 2010

The United States Agency for International Development’s (USAID) Strengthening Health Outcomes through the Private Sector (SHOPS) Project is launching an annual eConference to advance private sector innovations in the sustainable provision and use of quality family planning/reproductive health and other health information product. and services. The theme of the 20l0 eConference is mHealth which is the use of mobile technology to improve health program effectiveness and efficiency.

Abstract submission deadline: March 17, 2010

Call for abstracts: The SHOPS Proiect and die mHealth Alliance invite you to submit an abstract by March 17, 2010 to present at this online conference which will focus on how mobile technologies can improve family planning, maternal and newborn services in the developing world. Priority will be given to those submissions that are evidence-based. Abstracts should fall into one of the five categories below:

• Family planning
• Pregnancy
• Delivery
• Post partum (newborn care. family planning)
• Cross-cutting (e.g.. gender barriers, low literacy populations, training requirements, administrative management, supply chain)

The deadline for abstracts is March 17th and the conference is on Cinco de Mayo. Let’s hope they have some results and some data,  all info in the image below:

It’s now been a month since Forum 2009, so it’s time to wrap up any remaining thoughts from the meeting. My intention with these posts was never to provide a comprehensive view of the conference. If you’re looking for that, or simply additional insights into the meeting, I recommend the following resources:

1. Priya Shetty’s coverage of Forum 2009 for the SciDev.Net blog, five posts
2. TropIKA.net comprehensive coverage of Forum 2009, including daily reports and session reports

On my Cancún-bound flight out of Havana, on the morning of the 20th, the woman sitting next to me asked me for help with her Mexican immigration forms. As I was helping her, I asked what she did. “Terapista”. She asked what I was doing in Cuba. Attending “un congreso de investigaciones de salud pública”. She was a Cuban physical therapist going on a three month medical mission to Tecate in the Mexican state of Baja California, via Cancún, Mexico City, and Tijuana. I spent most of the short flight asking about her experiences on previous missions, all to Mexico, and probing for more details about the Cuban health system. Most memorably, she was quite proud of a unique surgical treatment the Cubans have developed for Parkinson’s disease.

I spoke about the medical assistance Cuba lends to other countries in an earlier post. The photo below of the 20 convertible peso note reinforces this. It touts Operación Milagro (Wikipedia link in Spanish), a joint program between Cuba and Venezuela with official aims similar to Cuba’s other medical mission efforts.

While I was speaking to this terapista on the plane, it occurred to me how important the setting of the conference was given the innovation theme. I don’t think that this was lost on many of the conference participants given external interest in the Cuban system, Cuban participation on panels, and various site visits. Still, there were three circumstances that limited knowledge exchange between the visitors and the Cubans:

1. Language barriers. There wasn’t very much communication between the several hundred Cuban participants and the external participants, especially those from outside Latin America. This was due in no small part to language barriers. Simultaneous translation took place during the larger sessions (UN-style headsets), but the smaller sessions didn’t have any and the informal exchange was visibly limited between the two groups.
2. An apparently flawless system. The Cuban health system may have been the talk of the week, but it was presented without fault. Even though it may be one of the best systems on the planet, it is not immune to needing improvement. Without a realistic understanding of the challenges, it was hard to understand the true effectiveness of the system. (In comparison, Minister of Health Chen Zhu was frank in talking about elements of the Chinese health system that need improvement, for example indicating in his plenary talk that many public clinics in China operate like private clinics.)
3. No U.S. government employees in attendance. There were certainly Americans at Forum 2009, but because of the restrictions associated with the U.S. embargo – it’s a bloqueo the Cubans said, since an embargo implies wrongdoing – there were almost no representatives of U.S. government institutions. I didn’t realize this myself until a colleague from the WHO pointed it out to me. He cited the example of his colleagues from the CDC who were not permitted to attend. Looking through the participant list, I only spotted one, someone from USAID. It’s unfortunate because there was a big opportunity for learning in both directions. In any case there were strong suggestions that we are months away from ending the embargo/bloqueo. Time will tell.

And here’s a post Aman wrote for Global Health Ideas about the Cuban health system two years ago: Lessons from Cuba: Healthcare Infrastructure and Information Systems.

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.

NEW DELHI: Think out of the box. It pays. This is what 15-year-old Sarojini Mahajan is happy to realise after her idea of using human pulse to charge a cellphone was picked up by Stanford University on Wednesday. Sarojini had sent her idea as an entry to IGNITE 2009 — a nationwide contest of innovative ideas. Though she won a consolation prize in the contest , Stanford University will now work on her idea.

Anil Gupta, vice-chairperson , National Innovation Foundation (NIF), which conducts IGNITE every year, Stanford University has already given a token amount of $1,000 to develop a prototype if feasible. ‘‘ The girl has provided the idea. But we need technical assistance to make it work. Stanford University has come forward to try out if human pulse can be used to charge an e-book they have developed.’’

‘‘ I can’t believe it’s true. I had thought of this idea last year but never told anyone till Neena ma’m once asked for crazy ideas in the class. It was just an idea which has become so big now.’’ Sarojini recalled that she was just sitting once when she thought of watches that run on the human pulse. ‘‘ I wondered if mobiles could be charged using the pulse too.’’

Sarojini teamed up with her teacher to develop her idea further who had by then decided to send her entry to IGNITE this year. They both worked for nearly four months and conceived a charging system in which sensors would be placed on the cellphone. Holding it in hand in a particular way would charge it using the heat of the palm. Sarojini’s recognition has got other students thinking too.

‘‘ Students have a lot of ideas some of which are absolutely crazy. Many of them will be motivated to share them now. I have already started getting new ideas from students,’’ said Punj. Agreed principal Anjali Agarwal. ‘‘ The fact that a 15-year-old student’s idea is being taken up by Stanford University will definitely inspire other students.

Full article here.

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. Celia Dugger of The New York Times reported that the new health minister, Dr. Aaron Motsoaledi, had accepted the strong critique of South African HIV policy reported in this Lancet series: Health in South Africa. He is a brave man, and needs all of our support as he tackles the challenge of rebuilding the healthcare system.

Gap in Treatment Access and Re-estimating the Need

One of the most daunting challenges Dr. Motsoaledi faces is that less than 50% of people who need ARVs in South Africa have access to treatment. And this may be an understatement of the actual need. Why? The government uses the Actuarial Society of South Africa ASSA model to project need, but ASSA uses 10 years from seroconversion to the time of first AIDS definining illness, whereas research evidence now supports 7 years. Dr. Francois Venter and Dr. Pierre Barker created the HAART calculator which uses 7 year period to AIDS, and estimates a higher patient need for HAART at this point in the epidemic than that projected by the National Strategic Plan. So, the gap is even bigger than reported.

Budgeting Failures threaten HAART program

This week, the Treatment Action Campaign released a press release on the creation of the Budget and Expenditure Monitoring Forum. Read the IRIN report here.

The Forum plans to put pressure on the national departments of health and finance to provide better budgeting and oversight of health expenditure in the country’s nine provinces, and ensure that there are no further moratoriums on ARV treatment. Last year, the most visible of budget cut decisions was the moratorium on the initiation of patients onto HAART in the Free State from November 2008 through March 2009. The Southern African HIV Clinicians Society estimated that at least 30 lives a day were lost as a result of this decision.

Here’s an excerpt (with some editing by me) of the press release from TAC:

A further problem is that the quality of financial and programmatic information about the HAART and PMTCT programmes is poor. This makes it difficult to assess implementation progress and leaves civil society largely dependent on what we can find out from our own investigations and anecdotal reports. For example, there is no publicly available information of the volumes purchased against the antiretroviral tender. We have received a report that the volumes being purchased are substantially less than predicted. If this is correct, then the treatment target set in the HIV & AIDS and STI Strategic Plan for South African, 2007 – 2011 (NSP) is not being met.

The Minister of Health, Dr. Aaron Motsoaledi, has already confirmed that nationally, there is a billion rand shortfall ($135 million USD) in HIV programme budgets for the current financial year. We have received reports indicating that provinces are facing financial constraints which could lead to a cut-off or slow-down in putting patients onto HAART. This will lead to more avoidable deaths.

If I can get a .pdf of the TAC press release, I’ll post it.

My PictureRx is designed for the domestic US market, but I thought I would post it on the off chance that it might stir up some ideas for situations in low resource settings. Not clear if they have gone mobile with this. While there are a slew of SMS pill reminders (first used in a widespread way in the “South”) it is important to think about this in development context due to the coming wave of chronic diseases – how well do SMS only medication remdiners work for people with co-morbidities and complex drug regimines? Also important to note – this is just one type of tool among many, and doesn’t seem like it helps with remembering whether you took your pill or not (have you ever looked at your watch for the time and then forgotten the time 10 mintues later?). The design looks slick and you can sign up for email reminders, however I am not sure what the efficacy is. Other issue to keep in mind with SMS reminders or something like this – while you can improve pill popping rates (adherence), there are many situations where people don’t want to take their meds (side effects or getting plan fed up with the polypharmacy).

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