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.

Related articles by Zemanta

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

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 sixth and final in a series of posts from the conference.

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.

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.

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

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

Power to the People: Stop the Stockouts

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

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

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

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

“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).

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

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

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

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

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

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

Read the rest of this entry »

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).

Cross-posted from Design Research for Global Health:

Atul Gawande’s recent New Yorker article about the super-high costs of healthcare in McAllen, Texas has gotten lots of people talking. (If you haven’t read it, you need to.) In the White House, President Obama made the article White House required reading, as reported by the New York Times:

President Obama recently summoned aides to the Oval Office to discuss a magazine article investigating why the border town of McAllen, Tex., was the country’s most expensive place for health care. The article became required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators.

Data show that increased healthcare spending does not necessarily result in better health outcomes, and that the spending varies widely within the US. The Gawande article begins to answer the question of why this is the case, but there is a counterpoint (also from the NYTimes):

In his blog last month, Mr. [Peter] Orszag wrote, “The higher-cost areas and hospitals don’t generate better outcomes than the lower-cost ones.” But other researchers and politicians are not so sure. They say it would be a mistake to cut or cap Medicare payments without knowing why spending in some places far exceeds the national average.

What’s as interesting about Gawande’s article as the story is the fact that the national discussion has been altered by a quick case study of a single town in Texas. (Aside: this is why extreme case sampling is so valuable.) What else can we learn by studying individual systems, sitting down with real providers, and talking to actual patients?

They brought the x-ray machine to me this time. I told the people from Social Services, “There’s no way I can pay for all this”. The doctor came and told me it was a pulled muscle, and to go home, elevate it, and rest. I did just as the doctor said and four days later - four days - I got a call saying “We made a mistake”. Then he said “They made a mistake”. I went to Highland – no Summit – and they showed me two x-rays side-by-side. In the last one my bone was out of its socket and my kneecap was broken in two places. I was in rehab for 12 months!

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.

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

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

The cast:

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

Presenters and talk titles:

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

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

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

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