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!

Thanks to Tyler from Ashoka for sending the below synopsis. Great stuff, I’ll try to post more detail when I am back, in the meantime read the full post at Changemakers – Simple Solutions Nudging Extraordinary Change. “A simple piece of cloth or a heap of compost can redirect the course of a community’s health and wellbeing…two winners are demonstrating how everyday items can drastically improve access to wholesome foods and lifesaving hygiene…”

Fact 1: Eleven cent sanitary cloth napkins help 20,000 women in India safely manage their menstruation cycles.

Fact 2: A community-driven waste management in Peru inspires 95% of their community to take control of their garbage and recycling.

Fact 3: 700 Venezuelan children have trained as oral health promoters, providing educational and preventive dentistry programs in their own schools.

What do all these facts have in common?

They are all the winning innovative entries in Ashoka’s Changemakers competition, “Designing for Better Health.” Sponsored by the Robert Wood Johnson Foundation, 335 entrants entered to provide a variety of innovative design solutions to address complex issues in healthcare – how can our choices be shaped to help us make the best ones?  After narrowing down the list to 10 finalists, the public voted for these three as their favorites.

The winners are compelling examples of “nudges” – innovative little pushes – that empower people to make better decisions regarding their own health and the health of others.

I am bouncing for Beijing this Friday, so I thought it would be a good time to do some desktop clearing. Some good links below:

GIS for a changing health landscape, link
Open Source/Science’s Greatest Need Is … Non-Scientists?, link
Interview with Isaac Holeman of FrontlineSMS:Medic, link
New Female Condom Campaign Set for Uganda, link
Sending out a (Google) SMS in Uganda, link
IDEO Ripple Effect at the Water Summit India, link
Africa Could Feed and Fuel the World, link
Web 2.0 Goes Bollywood-for GOOD, link
Brickmakers and Human Rights in Pakistan, link
Debating Which Aid Works Best is to Miss the Point, link
Who’s in charge of global health spending? link
Poverty tourism is getting a lot of attention lately, link

Bonus: Recycling Solutions
In Mali turning plastic bags into paving stones, link
Global recycling efforts, link
Is paper better than plastic? link
For the do it yourself’ers a plastic laptop bag, link

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• Designing useful mobile services for Africa (googleblog.blogspot.com)
• 5 US Cities and States Fighting Plastic Bags, 5 Cents at a Time (treehugger.com)
• Uganda’s Appfrica Labs (whiteafrican.com)
• Location Based Services in Uganda using SMS. (mobilewellbeing.info)

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

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

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.

Just attended session B6 “Not the Usual Suspects: Community Based Low Tech Interventions that Improve Child Health Outcomes”. Copying the description and presenter info from the conference website here:

Presenters Discuss: the value of pictorial representation of integrated management of childhood illness (IMCI) algorithms and child care best practices for the quality of care of illiterate community health workers (CHWs) (Afghanistan); steps to engage religious leaders in health promotion, capitalizing on traditional vehicles to provide funds to increase health-seeking behaviors, and building an effective rotating drug program (Ethiopia); the role of computer based tools for microplanning in routine immunization and the planning process using the tool (Jharkhand and Madhya Pradesh, India); and how introducing new medicines in Tanzania and the Democratic Republic of Congo (DRC) catalyzed policy changes and drove interventions to strengthen pharmaceutical management systems (Democratic Republic of Congo, Tanzania). 

First a quick recap of the presenters and what they talked about – and then what was most interesting.

One theme that weaved through the first three talks – and one of the most important – was that the success of “low-tech” technology in improving child health depended on an improved understanding of the people that use the technology.

From the first talk (Aitken, Afghanistan): The approach relied on a different type of literacy – a specific symbolic literacy making use of fingers and moons for time, and drawn images of children and mothers. During the formative research, the CHWs asked, in reference to a diagram showing a child being held by her mother, “Where’s the rest of the mother?” The next revision of the C-IMCI materials showed the entire mother, not just a cropping suggesting a mother. There’s a very strong analog to the Pull-Ups diaper case from the consumer packaged goods industry in the United States. First-hand design research with Huggies in the late 1980s showed the difference in perspectives between those producing diapers – exemplified by physical model of a baby without head, arms, or legs – and parents – who were concerned not with sanitation, but childhood development. [on short time now because of the conference - can provide reference later] 

From the second talk (Roy, Ethiopia): Working together with the Ethiopian Orthodox Church, CARE has been engaged in a comprehensive community-based program to improve child health in Ethiopia. The EOC priest delivers health messages after Sunday sermon, on significant holidays, and to 20-40 families that he routinely visits as a “confessor”. Within this framework there are a number of innovations that they have developed tailored to this specific program. The booklet that contains health information is a pamphlet in the same form factor as bibles that the priests carry with them (building trust). Yellow “referral tokens” allow the priest on his household visits to refer a sick child to a local clinic (utilizing non-health professionals for services). They also have a “data board” which publicly displays mortality and morbidity statistics (community information sharing) – it’s a chalkboard much like the community board from Ghana that was making the rounds recently. [can't remember where I saw this, but will add the link if I remember, or if someone reminds me] Finally, the program is extending the traditional economic practice of idir (a traditional membership-based funeral insurance scheme with democratically-elected leadership) to childhood health emergencies.

From the third talk (Sagar, India): The Microsoft Excel-based computer microplanning tool had unexpected positive consequences for those using it at district and sub-district levels. Where no microplanning had been present before, these small health organizations in Jharkand, Uttar Pradesh, and Madhya Pradesh have started to incorporate microplanning into routine activities. Technology for positive organizational change. And the innovation is diffusing organically – the speaker said he received word today that Bihar is starting to use a similar tool in planning routine immunizations.

I just discovered this innovative startup aiming to address a need using a low cost technology, produce a product locally and enable local economic development via a franchising model. I plan on having a much more detailed post in a couple of weeks, in the meantime here is the quick blurb:

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

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

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

I was just sent this information (thanks to Becky!) about a new round of funding for microbicides, which comes on the heels of promising results from a trial of the PRO2000 microbicide candidate. We covered this a couple of years ago and at the time I said – the potential of this drug is revolutionary. With microbicides there was great excitement and hope, then there was failure and now there is some maturity. Okay, maybe I am overstating the case, the take home point is that we still don’t have a product and this is not cheap, easy, or quick. Developing a drug is complicated, involves huge risk, can take decades and is highly uncertain. Let’s review the drug development time line again for those of you not familiar – the graph below gives the most simplistic picture:

The early microbicide discussions took place almost 15 years ago (International Working Group on Vaginal Microbicides, source). Over half that amount of time, from 2000-2007, $1.1 Billion has already been invested in microbicide R&D! It takes anywhere from $200M to $1 Billion to bring a single novel drug to market. Let’s hope one of these compounds works and makes it through phase III. But how much will we have spent? $2 Billion, $3 billion? If it works, it will have been worth the money, however, we must ask if we took the most efficient financial route to get to the end point and if there were better financial models – that is a valid question.

Cat Laine over at AIDG alerted me to Maternova…After a little bit of effort I think I finally figured out what they are up to, and the potential is exciting. From what I can tell, Maternova is acting as a clearinghouse and agent to spur the production of low cost life changing technologies in the area of maternal and child health. They are building a portfolio of innovative projects and products. What they are doing is critical for many reasons, one is that they are filling a major gap by coordinating and organizing in one particular area. There are many individuals and groups working globally on similar issues, however attempting to bring some of these ideas together under one umbrella is much more powerful than those projects standing alone.

Here is an introduction to 2 of their several products:

“Embrace is a $25 incubator designed to save premature and low birth weight babies. The product’s mission is to help the 20 million vulnerable babies born every year around the world, who can’t access traditional incubators that cost up to $20,000.  It is not yet on the market.”

“Study findings show the use of a neoprene suit can save the lives of women suffering from obstetrical hemorrhaging due to childbirth. Hemorrhaging accounts for about 30 percent of the more than 500,000 maternal deaths worldwide each year due to childbirth…”

I read on the Maternova website that they are thinking about linking up with mothers in the US as one funding stream. This seems like a great idea, especially if it is to get high volume low cost donations (e.g. <$10-$20). Part of the sales pitch could include an appeal to our global community – today we truly live in a global community and are inextricably linked to one another. Our fates are intertwined like never before. I could see making a pitch like this to appeal to new grandparents, parents, uncles and aunts to make donations in the name of their newborns. I’ll follow up with more information on Maternova…