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.

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.

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).

From The Economist (link):
“Using an elaborate system of colour-coded boxes to convey over 170,000 meals to their destinations each day, the 5,000-strong dabbawala collective has built up an extraordinary reputation for the speed and accuracy of its deliveries. Word of their legendary efficiency and almost flawless logistics is now spreading through the rarefied world of management consulting. Impressed by the dabbawalas’ “six-sigma” certified error rate—reportedly on the order of one mistake per 6m deliveries—management gurus and bosses are queuing up to find out how they do it.” Full story link here.

Hat tip Intangible Economy.

This headline in Wharton’s newsletter intrigued me, only time for a quick posting, but this is certainly food for thought. Wal Mart is expanding operations in India and there are two quotes of note that we should think about in the context of culture; delivery and distribution of medical/health goods to those in need; and in the context of refrigeration of medication and/or vaccinations:

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“The biggest challenge is that there is no organized supply chain in India. We’ve even been surprised by some of the leading manufacturers in India like Unilever, Procter & Gamble, and some other big names, who are actually welcoming the arrival of organized supply chains in India and Wal-Mart pioneering that effort. Because of the lack of that supply chain today, there is no forecasting, there is no understanding of how demand is. It’s largely a push based system. So, I think, getting that transparency across the supply chain will be very unique.”

“The other thing is, there is no refrigerated cold chain for fresh produce in India, so therefore a lot gets wasted. By McKinsey’s own work, which the consulting firm has done, almost 40% of fresh produce in India gets wasted from farmland to the time it reaches the consumer.”

“India is very unique. In fact, I have lived in China, so maybe I can say it with a little bit more liberty that the only thing common between India and China is the one billion people. If you really operate in the two countries, I think, there are very different consumers, very different kinds of legislation, very different levels of economic development, social infrastructure, and governmental management of the economy.”

 
Read the full interview here.

Fast Company and Monitor Group Recognize Innovative Non-Profits for Applying Business Savvy to the World’s Toughest Social Problems

“New York, NY (November 14, 2006) — Scojo Foundation, a non-profit social enterprise that works to improve the economic condition of families in the developing world by broadening access to affordable reading glasses, is honored to be among the 43 winners of the 2007 Social Capitalist Award…

Employing market-based solutions to address this crucial public health issue, Scojo Foundation trains microfranchisees, or “Vision Entrepreneurs,” to run profitable businesses conducting vision screenings within their communities, selling affordable reading glasses, and referring those requiring advanced eye care to reputable clinics.” The full press release can be found on the Scojo Foundation website.

From Fast Company: The amazing organizations that received the Fast Company/Monitor Group Social Capitalist Awards have found a better way to do good: They’re using the disciplines of the corporate world to tackle daunting social problems. In our third exclusive ranking, we used a similarly hard-nosed approach to find the 25 best social entrepreneurs.

The theme of this year’s conference is “Public Health and Human Rights”, and as it is in one of Paul Farmer’s backyards (Boston), he was a well-suited speaker. The overall message was an extension of his 1999 article “Pathologies of power: rethinking health and human rights” (American Journal of Public Health, Vol 89, Issue 10 1486-1496). In short, he argued “prevailing orthodoxies” in public health center around the “crude” concepts of sustainability and cost-effectiveness, while the focus should be on social and economic rights. “[Sustainability and cost-effectiveness] are tools we need, not religion.”

The more practical message was that we need to address more immediate, material concerns, such as food, clean water, drugs, and medical supplies – much of which can be considered “wrap around services”.

“There should be a right to sutures. There should be a right to sterile drapes. There should be a right to anesthesia … We will need gloves, sutures, drapes, and hot, clean water. This is uncharted territory for human rights groups. We here are ready to talk about gender inequality, but to few of us are ready to buy generators, sutures, or [operating room] lamps … [This] may not seem sexy to people commenting on health and human rights.”

I was delighted to hear his talk touch on such “unglamorous” issues as supply chain and procurement.

He is still very committed to his ideology of providing equivalent technology to poor people. While this is certainly the most effective and ethical approach in many cases – as he has demonstrated to the rest of the world – it is unclear that this is always in the best interests of poor people. I argue not from the point of “cost-effectiveness”, but rather of “effectiveness”. Take for example his advocacy for clean water and infant formula in Rwanda. A colleague who is an expert on breastfeeding reported that people at this year’s International AIDS Conference were highly critical of this approach because of the increased potential for infant deaths from diarrheal diseases. Significant, comparative research over the last few years has shown that while formula is effective for PMTCT (prevention of mother to child transmission) of HIV, breastfeeding results in fewer overall infant deaths. One key is the lack of access to clean water, which results in diarrheal disease, while another is the protective nature of the breastmilk itself. Farmer’s response, no doubt, would be that Partners in Health will provide all the clean water necessary. Achieving this for small communities will be difficult, but not impossible – achieving it at a large scale will take considerable time. In the short-term, breastfeeding seems to be a much safer bet.

Several nursing colleagues and I went to dinner in Chinatown, where we discussed Farmer’s talk. The consensus was that Farmer often makes it seem as if nothing positive is being done in the sphere of international health.

Despite some concerns about his ideology, he provided a strong, persuasive, and needed message. His quote from a young Kenyan doctor, lamenting about working conditions and supplies, sums it up best: “I did not go to medical school to become a mortuary attendant.”