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.

Just happened upon a great discussion about making data make sense quickly on the Innovation in Evaluation Blog over at good.is

What happens when we put people at the center of evaluation (as Jocelyn Wyatt puts it)? In this context, it means recognizing that people are preoccupied with more important tasks than spending long amounts of time in front of dashboards and data visualizations.

This is true in any setting, and in our case it was driving. The role of visualization should not be to demand full attention, but to support the priority task and improve it through feedback loops. The challenge is not just to display how you are doing right now, but also to figure out how you could do better. So, what does this mean for the visualization itself?

Every form of visualization should tell a story. Unfortunately there is limited attention and time to process all the stories. So the gist of the story, or its immediate impact, should be visible right away. The term I like to use for this principle is “glanceability.” What does a visualization tell us before we take time to analyze it? I invite you to look at the following chart and image for 10 seconds each and compare. What did you see? What did you feel?

Modified from Azar Askin’s reproduction of a poster by Muenster Planning Office, Germany

A followup post talks about understanding how data is presented. How can you tell what is fact and what is fiction? What basic questions should you ask of the graph? How do you know if you are being taken for a ride?

Super-cool. Now, if you’ll excuse me, I’m going to go curl up with some of the other posts here – How Can We Measure What’s Most Meaningful? and In Non-Profit World, Numbers Don’t Tell the Full Story.. (something a friend of mine always used to tell me).

Read all about it! @ Innovation in Evaluation.

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”

Cross-posted from Design Research for Global Health.

Giving talks is not one of my strong suits, but it seems to be a part of the job requirement.  Earlier this month, I had the opportunity (even though I’m no good, I do consider it an opportunity), to give a couple talks, one to the Interdisciplinary MPH Program at Berkeley and one to a group of undergraduate design students, also at Berkeley.  Despite the difference in focus, age, and experience of the two groups, the topic was roughly the same: How do we effectively use design thinking as an approach in public health?

The first session was so-so, and I suspect that the few people who were excited about it were probably excited in spite of the talk.  It started well, but about halfway through, something began to feel very wrong and that feeling didn’t go away until some time later that evening.  Afterwards, I received direct feedback from the instructor and from the students in the form of an evaluation.  I recommend this if it is ever presented as an option.  Like any “accident”, this one was a “confluence of factors”: lack of clarity and specificity, allowing the discussion to get sidetracked, poor posture, and a tone that conveyed a lack of excitement for the topic.

It’s one thing to get feedback like this, another to act on it.

The second session went much better, gauging by the student feedback, the comments from the instructor, and my own observations.  This in spite of a larger group (60 vs. 20) that would be harder to motivate (undergraduates with midterms vs. professionals working on applied problems in public health).  I chalk it all up to preparation and planning.  Certainly there are people that are capable of doing a great job without preparation – I just don’t think I’m one of those people.

Most of that preparation by the way was not on slides.  I did use slides, but only had five for an hour session and that still proved to be too many.  Most of the time that I spent on slides, I spent developing a single custom visual to convey precisely the information that was relevant to the students during this session (see image).  The rest of the preparation was spent understanding the audience needs by speaking to those running the class; developing a detailed plan for the hour, focusing on how to make the session a highly interactive learning experience; designing quality handouts to support the interactive exercise; and doing my necessary homework.  For this last one, I spent 20 minutes on the phone with a surgeon friend, since the session was built around a case study discussing surgical complications and design.

Three resources I found really useful:

1. Why Bad Presentations Happen to Good Causes, Andy Goodman, 2006. This commissioned report was developed to help NGOs with their presentations, but I think there is value here for anyone whose work involves presentations. It is evidence-based and provides practical guidance on session design, delivery, slides (PowerPoint), and logistics.  Most importantly, it is available as a free download. I was fortunate enough to pick up a used copy of the print edition for US$9 at my local bookstore, which was worth the investment for me because of the design of the physical book.  It’s out-of-print now and it looks like the online used copies are quite expensive – at least 3x what I paid – so I recommend the PDF.
2. Envisioning Information, Edward Tufte, 1990. I read this when I was writing my dissertation. Folks in design all know about Tufte, but I still recommend a periodic refresher.  This is the sort of book that will stay on my shelf.  Also potentially useful is The Visual Display of Quantitative Information. For those working in global health, don’t forget how important the display of information can be: (a) Bill Gates and the NYTimes, (b) Hans Rosling at TED.
3. Software for creating quality graphics.  The drawing tools built into typical office applications, though they have improved in recent years, are still limited in their capability and flexibility, especially if you’re looking at #2 above.  In the past 10 days, three people in my socio-professional network have solicited advice on such standalone tools, OmniGraffle (for Mac) and Visio (Windows): a graphic designer in New York, an energy research scientist in California, and a healthcare researcher in DC.  Both are great options.  I use OmniGraffle these days, though I used to use Visio a few years back.  If cost is an issue, there are open-source alternatives available, though I’m not at all familiar with them (e.g., the Pencil plug-in for Firefox).

This piece is cross-posted from the Uganda output-based aid (OBA) site which just got a major under-the-hood overhaul in its move to a blog format. The Uganda OBA project contracts private clinics to see qualified patients for complaints of suspected sexually transmitted infections (STIs). Patients who buy a subsidized voucher from local drug shops and pharmacies are entitled to seek care for themselves and their partner at any of the contracted clinics. Clinics are reimbursed on a negotiated fee-for-service schedule.

The following report (“VSHD, 2007, Assessment of OBA Clinic Utilization”) is an evaluation of the OBA program’s first year impact on utilization at participating clinics (July 2006 to June 2007).  The study, led by Berkeley graduate students Richard Lowe and Ben Bellows, was undertaken June to August 2007 and required an extensive review of thousands of handwritten lab and outpatient entries at OBA facilities. Records were kept differently at many of the clinics and,at several clinics, data were simply not available. However, we have information from 7 of the 16 clinics and they indicate a strong patient uptake and program improvement in the first year of OBA. One of the more dramatic findings is that the total number of patient visits at contracted clinics increased 226% in the first year of OBA compared to the year before OBA.

It does not appear that patients who have attended OBA clinics simply substituted the OBA voucher for their own out-of-pocket spending. Taking all seven clinics together, the number of non-OBA patients seeking STI treatment actually increased in the first year of OBA. One likely reason is that social marketing stimulated greater demand for STI treatment beyond the voucher-using population.

Program adherence also appears to be improving over the first year of OBA as the number of fully paid claims increased from 30% of all submitted claims in July/August 2006 to 70% of all claims in June 2007. Although it should be stressed that claims quality varied significantly between providers.

There is some concern about the quality of lab testing at participating clinics. Lab technicians could benefit from better on-site follow-up and incentives for high quality diagnoses. However, the percent of positive gonorrhea tests more than doubled, indicating increased awareness of this infection in the community and at provider clinics.

The report paints a detailed picture of the participating clinics in their first year of OBA and it is hoped that findings can be used for program improvement as the expansion is planned.

Our many thanks go to both Microcare and MSI who graciously assisted with our many requests for supplemental data and assistance reaching clinic providers. Many thanks as well to the KfW Development Bank and the Bixby Program at UC Berkeley for funding the research.