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Knowledge Exchange Forum: Using m-Health for MNCH

Sharing Knowledge, Inspiring Innovation

March 11, 2016, Ottawa, Canada

Summary Report


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Acknowledgements

This report was prepared by HealthBridge Foundation of Canada. We would like to thank the presenters

who gave their time and shared their expertise with us at the Forum: Amelia Sagoff (Dimagi), Prof.

Daniel Sellen (University of Toronto), Dr. Gail Webber (University of Ottawa), Dr. Githinji Gitahi (Amref

Health Africa), Kristy Hackett (University of Toronto), Lisa MacDonald (HealthBridge Foundation of

Canada), Sian FitzGerald (HealthBridge Foundation of Canada), and Zoe Boutilier (International

Development Research Centre).

Special thanks to the staff at HealthBridge who worked behind the scenes to support the organization of

this event.

The Knowledge Exchange Forum was made possible with funding support from the International

Development Research Centre, Ottawa, Ontario.

Report written by: Lisa MacDonald


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Table of Contents

Introduction ......................................................................................................................................................... 4

Meeting Objectives ............................................................................................................................................. 4

Meeting Format and Content .............................................................................................................................. 4

Main Outcomes ................................................................................................................................................... 8

Conclusions ........................................................................................................................................................ 10

Annex 1: Forum Program

Annex 2: Forum Presentations


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Introduction

The use of mobile health (m-Health) technology has become increasingly popular and is being used in a

variety of ways to support maternal, newborn and child health (MNCH) interventions. Given that mobile

phone ownership is widespread around the world, mobile health (m-Health) has tremendous potential

to reach those living in remote and isolated areas. Despite the popularity of this technology, there has

been relatively little opportunity for cross-sharing of ideas and collaboration amongst Canadian

organizations using m-Health specifically in the realm of MNCH.

On March 11, 2016, HealthBridge Foundation of Canada hosted a half-day Knowledge Exchange Forum

on using m-Health for MNCH with the overall theme of “Sharing Knowledge, Inspiring Innovation”. The

event convened researchers and development practitioners to share about promising practices and

lessons learned in using m-Health to support MNCH in Low and Middle-Income Countries (LMICs).

The event was attended by 30 participants representing government, academia, non-government

organizations, and the mobile technology sector. It was supported by the International Development

Research Centre (IDRC).

Meeting Objectives

The overall purpose of the Forum was to facilitate knowledge exchange between researchers and

development practitioners who have used, or are interested in using, m-Health to support MNCH.

The specific objectives were as follows:

1. To exchange knowledge on different approaches, results and lessons learned from using m-

Health to support MNCH.

2. To identify promising practices, lessons learned and recommendations for implementing and/or

scaling up of m-Health interventions to support MNCH.

Meeting Format and Content

The Forum took place from 9:00 am to 12:00 pm at Novotel Hotel in Ottawa. The program can be found

in Annex 1. The event was facilitated by Sian FitzGerald, Executive Director of HealthBridge. Following

opening remarks, the first half of the morning comprised presentations on emerging findings,

opportunities and challenges from the research and mobile technology sectors. After each presentation,

there was a brief opportunity for questions from the audience. In the second half of the morning, a

panel of 5 speakers presented about “promising practices and lessons learned from the field” based on

experiences from m-Health interventions in India, Tanzania and Kenya. The panel was followed by a


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question and answer period. A brief summary of each presentation is provided below and the

presentations can be found in Annex 2.

Role of Mobile Communications Technology and Social Media in Breastfeeding Support*

Prof. Daniel Sellen, University of Toronto

Professor Sellen spoke about the potential of mobile technology to facilitate counselling and

interpersonal support for breastfeeding mothers. Interpersonal support is key to help mothers

overcome the social and practical barriers to optimal breastfeeding.

He shared some initial findings from a scoping review of m-Health interventions addressing

breastfeeding being conducted with Alison Mildon in his research group at University of

Toronto. This review identified four types of delivery channels through which mobile phones

have been used to provide social support for breastfeeding: job-aid applications for health

workers, interactive media, voice counselling and direct messaging to mothers.

A key point was that there remains a lack of evidence with which to adequately assess whether

m-Health interventions lead to actual changes in behaviour and practice compared to standard

practices. The main reason for this knowledge gap is that while there has been a recent

burgeoning of pilot studies of m-Health interventions, there have been very few rigorously

designed trials conducted on a large scale.

Emerging Results from IDRC’s eHealth Portfolio in 7 Countries

Zoe Boutilier, IDRC (International Development Research Centre)

Ms. Boutilier provided an overview of IDRC’s SEARCH (Strengthening Equity through Applied

Research Capacity Building in e-Health) program, which is a portfolio of 7 thematically linked

research projects led by researchers in developing countries (Peru, Burkina Faso, Kenya,

Ethiopia, Lebanon, Bangladesh and Vietnam).

The SEARCH program aims to answer two main research questions: 1) Can e-Health make health

systems more equitable? and 2) Can e-Health improve health governance?

Details of the Bangladesh project were discussed. Findings indicate that there has been a “rapid

explosion” of m-Health interventions in Bangladesh, however few have gone to scale, and there

has been a lack of rigorous evaluations demonstrating improvements in health outcomes. In

addition, there is a general lack of coordination and formal regulation of e-Health, particularly

amongst the private sector.

Two important lessons with respect to grant-making were described: 1) Need to provide

dedicated expertise with gender analysis at the project start, and 2) Networking and

collaboration amongst grant recipients will not happen organically; it needs to be driven by

IDRC.

* Presentation not included in Annex at request of presenter.


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Opportunities and Challenges in m-Health: Perspectives from the Technology Sector

Medic Mobile (presented by Dr. Gail Webber)

Dr. Webber provided an overview of Medic Mobile’s services. Medic Mobile leverages mobile

technology to support Community Health Workers in disconnected communities.

Medic Mobile uses a Human Centred Design in which, as part of their technology design, they

spend time with Community Health Workers to understand their workflows and activities.

They have projects in multiple countries, on basic and Smartphones, and support disease

surveillance, drug stock monitoring, childhood immunizations and antenatal care.

Amelia Sagoff, Dimagi

Ms. Sagoff provided an overview of Dimagi’s services. Dimagi delivers open and innovative

technology to help underserved communities around the world.

The core of their work involves using technology to support Community Health Workers.

There are currently over 20 peer-reviewed publications on the impact of their CommCare

application, which supports Community Health Workers. Results show that when used

correctly, CommCare can lead to improved quality and utilization of care.

Dimagi is currently scaling up CommCare to national scale in several countries, which creates

new challenges on both the technology and implementation side. They are currently working to

develop new guidelines (the “Maturity Model”) and an interoperability system (“MOTECH”) to

address these challenges.

Interactive Panel “Promising Practices and Lessons Learned from the Field”

Using m-Health to engage men and maternal health in India

Lisa MacDonald, HealthBridge Foundation of Canada

Ms. MacDonald presented on a pilot project in rural India, in which educational voice messages

were sent to husbands of pregnant women to engage them in their wife’s maternal health care.

Results on the impact on behaviour change are still pending. Preliminary results indicated that

69% of husbands listened to at least one of the voice messages.

The main challenges were logistical issues that prevented husbands from receiving the

messages: some phone numbers were on a “Do not Disturb” list to avoid spam advertising, and

some husbands migrated for work and changed their phone number when out of state.

Lessons learned highlighted the need for regular follow-up with husbands to reduce drop-out

from migration and address any problems in receiving messages. The importance of technical

training and support to field staff was also emphasized.

Community health workers using m-Health in rural Tanzania

Dr. Gail Webber, University of Ottawa

Dr. Webber discussed the use of m-Health with Community Health Workers in Tanzania to

register pregnant women, monitor stock in dispensaries (birth kits, misoprostol, oxytocin), and

monitor workflows of Community Health Workers.


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The main challenges related to training a large number of Community Health Workers at once,

input errors and missing data, and technical problems with the system.

Lessons learned were the need for more training and a large budget. To reduce input errors, Dr.

Webber’s next project will use a system that prompts Community Health Workers for each

response rather than inputting a code, and will use m-Health to collect baseline and intervention

data.

Smartphone support for frontline health workers to improve uptake of maternal health services in

Tanzania*

Kristy Hackett, University of Toronto

Ms. Hackett presented on a study that investigated the impact of smartphone support for

frontline health workers on women’s use of facility-based delivery. This study was conducted

within the context of World Vision’s SUSTAIN program in Singida, Tanzania.

Findings indicated that the intervention, called “SP+” strengthened health care delivery through

improving Community Health Workers’ job satisfaction, data management, client referral and

follow-up, perceived quality of care and workflow.

Women visited prenatally by smartphone-assisted health workers were twice as likely to deliver

at a health facility. One likely mechanism for this impact is that women in intervention villages

were more likely to receive two or more home visits from a Community Health Worker

compared to those in control villages.

Challenges included lack of formal compensation, transportation and ongoing support for

Community Health Workers, concerns from clients about data privacy and from Community

Health Workers about personal safety and security, and logistical issues with phone charging

and maintenance.

Empowering community health workers with HELP in Kenya

Dr. Githinji Gitahi, Amref Health Africa

Dr. Githinji shared about the Health Enablement and Learning Platform (HELP), a mobile learning

platform to train and support Community Health Workers in Kenya.

In Kenya, the Community Health Workers are not formally paid for their work. Consequently,

they often have other employment and are unable to attend training.

HELP utilizes the government training curriculum that has been converted into mobile modules.

Community Health Workers also communicate with each other and supervisors via SMS and

group chats, reducing their isolation.

The main challenge is how to scale up and absorb costs into the health care system.

Recent trials of cell phone based breastfeeding support*


* Presentation not included in Annex at request of presenter.


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Prof. Sellen outlined the context of a recent trial of cell phone based breastfeeding support

conducted with collaborators at Egerton University in Kenya.

He described the design of a Randomized Controlled Trial that investigated if cell phone based

peer counselling beginning prenatally to 3 months postpartum led to increased exclusive

breastfeeding rates. The trial design compared the impact of cell phone based support with

hospital messaging and monthly peer support groups.

Preliminary results indicated that exclusive breastfeeding rates at three months of age were

significantly higher amongst mothers who receive the cell phone based support compared to

the hospital messaging and monthly support groups.

Main Outcomes

The main themes that emerged from the presentations and discussion at the Forum are described

below.

Promising Practices and the Need for Evidence

Promising practices identified in the forum included:

m-Health as a job-aid support Community Health Workers with counselling, tracking client

information, training, peer support and supervision.

m-Health as an engagement tool through sending voice messages to husbands of pregnant

women to educate them about maternal health care.

m-Health to strengthen social support for breastfeeding mothers through peer counselling.

Three of the presenters shared study results on the impact of m-Health on health behaviour and health

care delivery. Ms. Hackett and Ms. Sagoff presented results that demonstrated mobile phone support to

Community Health Workers led to improvements in the quality of health counselling and women’s

utilization of maternal health care. Additionally, Prof. Sellen’s research found that cell phone based peer

counselling for mothers led to increased rates of exclusive breastfeeding.

Despite the high expectations of m-Health, the overall message emerging from the Forum was that

there is a lack of evidence that it leads to behaviour change and strengthened health systems. There

have been numerous pilot projects, but few were rigorously evaluated. Thus, there is a need for well-

designed, longer-term studies to assess if m-Health actually leads to improved health outcomes.

Is there a Real Need/Demand for m-Health?

In addition to the need for more evidence on the impact of m-Health, questions were raised about

whether there is a real need or demand for m-Health interventions in low and middle income countries.

Has the explosion of m-Health initiatives been driven by the research and technology sectors, and the

push for “innovation”? Are we developing the tools that local beneficiaries want and need? For


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example, Community Health Workers still lack formal compensation in many countries and in some

cases, take on additional forms of work to earn a living. Although m-Health may help them with some

aspects of their work, there are concerns that the task of learning a new technology may add an extra

burden to these workers who are already overstretched. It was also mentioned that local beneficiaries

expressed concern about the confidentiality of information being entered into the mobile system. These

concerns not only emphasize the need to involve local beneficiaries in the design of m-Health

interventions, but also suggest that we need to better understand the needs, barriers and gaps within

local health systems before assuming that m-Health is the appropriate solution.

Sustainability and Scale-up

Logistical issues and technical support

Many of the lessons learned and challenges raised were logistical issues related to implementing the m-

Health intervention in the local context. For example, having places to charge mobile phones in rural

areas, and the existence of network regulations that block user access. Scale-up models should stress

the importance of understanding and tailoring m-Health interventions to the local context. Several

presenters also emphasized the need to provide on-going training and technical support to users, which

should be built into the budget and intervention design.

Government ownership and affordability

Government ownership was acknowledged as a critical factor for scale-up and sustainability of m-Health

interventions. Few m-Health interventions have been scaled-up at a national level. Developing a viable

business model to sustainably cover the costs of m-Health interventions was recognized as a major

barrier. Ms. Sagoff from Dimagi was the only presenter who shared experiences about trying to take m-

Health interventions to scale and transfer them to government ownership. She indicated that the cases

that have successfully transitioned to scale have had strong government interest and involvement;

without this, scale-up does not happen.

Regulation of m-Health interventions

Along with the need to increase government ownership of m-Health interventions, it was recognized

that there is a need to formally regulate m-Health, particularly in the private sector. This is also relevant

to addressing concerns about data privacy and security, mentioned above. Ms. Boutilier, of IDRC,

described how a regulatory framework and guidelines have been developed in Bangladesh but have not

yet been formally approved or adopted. Overall, developing regulatory frameworks for low and middle

income countries is an issue that requires more attention.


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Conclusions

The Knowledge Exchange Forum provided an excellent opportunity for Canadian researchers and

practitioners to gather and discuss experiences and challenges with implementing m-Health

interventions for MNCH in low and middle income countries. Many participants expressed the desire to

have similar meetings in the future to further discuss this topic. In addition to identifying promising

practices, the Forum identified key gaps in m-Health research including the call for more evidence on

the impact of m-Health on health outcomes and evidence that m-Health interventions are addressing

the real needs of local beneficiaries.

www.healthbridge.ca

Knowledge Exchange Forum:

Using m-Health for MNCH

Sharing Knowledge, Inspiring Innovation

An event to share promising practices and lessons learned in using mobile

health (m-Health) technology to support maternal, newborn and child

health.

Annex 1: Forum Program


Friday, 11 March 2016

9:00 am – 12:00 pm

Time Activity

9:00 - 9:15 am Arrival of Participants – Continental Breakfast & Coffee

9:15 - 9:20 am Welcoming remarks

9:20- 9:35 am “Role of Mobile Communications Technology and Social Media in

Breastfeeding Support”


9:35 - 9:55 am “Emerging Results from IDRC’s eHealth Portfolio in 7 countries”

Zoe Boutilier, IDRC

9:55–10:15 am “Opportunities and Challenges in m-Health: Perspectives from the

Technology Sector”


Medic Mobile

10:15– 10:30 am Coffee Break

10:30 – 11:55 am Interactive Panel: “Promising Practices and Lessons Learned from the Field”

1. “Using m-Health to engage men in maternal health in India”


2. “Community health workers using m-Health in rural Tanzania”


3. “Smartphone support for frontline health workers to improve uptake of

maternal health services in Tanzania”


4. “Empowering community health workers with HELP in Kenya”


5. “Recent trials of cell phone based breastfeeding support”


11:55-12:00 pm Closing Remarks

Speakers


Amelia Sagoff is a Product Manager at Dimagi, where she oversees the development of Dimagi’s

software products. Amelia plays an active role mapping out upcoming software features for

Dimagi’s products and providing technical support to Dimagi’s partners and field staff. In her first

role at Dimagi, Amelia worked in Tanzania as one of Dimagi’s first Field Managers, where she

field-tested the earliest version of CommCare.


Prof. Dan Sellen is Professor of Anthropology, Nutritional Sciences and Social and Behavioural

Health Sciences at the University of Toronto. He joined the Dalla Lana School of Public Health at

the University of Toronto as its first Associate Dean of Research in 2014. He currently leads teams

using cluster-randomized trials to assess the usefulness of cell phones to provide vulnerable

women with pre- and post-partum counseling to support healthy breastfeeding, infant care and

health system access, and smart phones to improve community health worker outreach to

pregnant women (principally in urban Kenya and rural Tanzania).


Dr. Gail Webber is a family physician and researcher, based in Ottawa. Her current research is focussed on access to health services for pregnant women in rural Tanzania, in collaboration with her Tanzanian and NGO colleagues.


Dr. Githinji Gitahi is Global Chief Executive Officer at Amref Health Africa. Until his appointment

as Group CEO at Amref Health Africa, Dr. Gitahi was the Vice-President and Regional Director for

Africa at Smile Train International, where he successfully established partnerships for long-term

sustainability with various African governments. Prior to that, he worked with the Nation Media

Group where he was the Managing Director for Monitor Publications in Uganda as well as

General Manager for Marketing and Circulation in East Africa. He also held progressively senior

positions at GlaxoSmithKline, Avenue Group and in the insurance industry.


Kristy is a PhD Candidate in the Health & Behavioural Sciences Program at the Dalla Lana School

of Public Health at the University of Toronto. Drawing on her training in medical anthropology

and global health, Kristy's research aims to enhance the capacity of health systems to improve

maternal, newborn and child health (MNCH) outcomes in hard-to-reach populations. She has led

and/or contributed to MNCH research projects based in Tanzania, Ghana, Kenya, Vietnam,

Bangladesh and Canada. Her doctoral work investigates the impact of a smart phone application

for community health workers on maternal health services uptake in rural Tanzania.


Lisa is a Project Manager at HealthBridge where she currently leads the development and

management of projects in the area of Gender, Reproductive, Maternal, Newborn and Child

Health (GRMNCH). She holds a Masters in Health Studies and Gerontology from the University of

Waterloo, and has over 7 years of experience working to improve the health of vulnerable

populations in Canada and internationally.

Sian FitzGerald, HealthBridge Foundation of Canada

Sian is the Executive Director of HealthBridge, where she oversees health and development

programs at HealthBridge, including nutrition and maternal and child health. Her role includes

building capacity, and designing, implementing and monitoring programs, as well as governance.

Sian has a Master of Science degree in international nutrition for which she conducted research

in Guatemala, and a Bachelor of Science degree in Chemistry. She has worked in international

development since 1992, when she joined the Food and Agriculture Organization of the UN´s

program to eliminate vitamin A deficiency. Based in Rome, she worked on programs in

francophone Africa, specifically Mali, Burkina Faso, and Niger, and in Vietnam, where she lived

from 1993 to 1995. Following her return to Canada in late 1995, she worked as a consultant for

CIDA and the Micronutrient Initiative, before joining HealthBridge (then PATH Canada) in 1996.

Zoe Boutilier, International Development Research Centre

Zoe is a Senior Program Officer in the Maternal and Child Health program at IDRC. Zoe has been

working with IDRC since 2007 and in that time she has also served as a Program Officer for the

Global Health Research Initiative (GHRI), Governance for Equity in Health Systems (GEHS), and

Policy and Evaluation. Before coming to IDRC she worked for the Micronutrient Initiative in

Ottawa, Oxfam Quebec in Bolivia, Canada World Youth in Costa Rica, and CUSO in Lao PDR. Zoe

holds an undergraduate degree in Biology and a Master’s degree in International

Development. With more than a decade of experience managing health programs in developing

countries, her technical expertise lies in North-South partnerships for global health , research for

health systems strengthening, and programming to address micronutrient malnutrition.

SEARCH (Strengthening Equity through Applied Research Capacity Building in e-Health)

2011 - 2017

Emerging Results

Zoe Boutilier March 11th 2016

Annex 2: Forum Presentations

Pre-SEARCH Groundwork, 2011 / 2012

• Evaluation of IDRC e-Health projects 2005-2010

• Literature review of e-Health research and research gaps

• Joint work with WHO to interview international stakeholders

• Regional experts roundtables

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Conclusions of the groundwork

Evaluation: support capacity, research for evidence based policy, more for national e-health frameworks, more national e-health planning committees

Lit review: lots of potential l to improve health systems, lack empirical evidence

Stakeholder interviews & Expert roundtables: Not an end. A tool within system.

E-health: Much potential. High expectations. Lack of evidence.

3

SEARCH research questions

4

2. SHAREPOINT (IC)

In low and middle income countries:

Can e-health make health systems more equitable?

Can e-health improve health governance?

5

2. SHAREPOINT (IC)

2012

• 1 Call • 134 CNs received • 13 shortlisted for full

proposal • 13 full proposals

reviewed by committee

• 7 projects selected

2013

• 7 projects begin • 7 countries • 3 working languages • 3.5 year duration • 2013 - 2017 • ~ $425,000 each

SEARCH: A cohort of 7 e-Health Projects

PERU: Is our integrated maternal health information model feasible, and is it improving health governance and maternal health outcomes in Ventanilla?

BURKINA FASO: Using m-health for MCH and HIV/AIDS services, can we improve health governance and equity in access to care in Nouna district?

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SEARCH Cohort: The Research Questions

KENYA: What e-health interventions have been implemented in Kenya to date, and how have these influenced progress towards health equity and good health system governance in Kenya?

ETHIOPIA: What is the feasibility and effectiveness of using eHealth to strengthen equitable health systems and related governance processes through inter-package linking and integration into the existing HMIS in Southern Ethiopia?

LEBANON: Can our community-based eHealth intervention enhance equity in demand for and access to chronic care services in rural settings and refugee camps?

BANGLADESH: What are the equity and accountability implications of the eHealth landscape in Bangladesh?

VIETNAM: Will the implementation of an integrated mHealth intervention improve access to MCH services for ethnic minority women living in mountainous and difficult-to-reach areas?

Emerging research results from Bangladesh

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2. SHAREPOINT (IC) Household cell phone ownership in rural Bangladesh, Khatun et al 2014

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Program-level answers?

In low and middle income countries:

Can e-health make health systems more equitable?

Can e-health improve health governance?

Grant-making lesson #1: gender analysis

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2.

(IC) Consultancy to Strengthen Gender Component of SEARCH Grants

Rosemary Morgan, Elizabeth Larson, Asha George

Grant-making lesson #1: gender analysis

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2.

(IC)

• Overall, the SEARCH teams are receptive to strengthening the gender component of their projects.

• Most projects are women-centred, without a framing of gender power relations that explain gender differences in access to health care; engagement of gate keepers; inequities in the health workforce; issues of confidentiality/ privacy.

Implementation

• Gender considerations are mainly siloed within the gender and equity sections of proposals and reports, and often not linked to project research objectives, activities or outcomes.

• Gender analysis is not consistently demonstrably used, with a few exceptions.

Overview of cohort-wide findings

Grant-making lesson #2: cohort networking

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2. (IC) SEARCH Online Sharing and Networking Platform

Grant-making lesson #2: cohort networking

13

2. (IC)

World Development Report 2016

14

2. (IC)

Digital technologies can

be transformational

By promoting inclusion, efficiency, and innovation Benefits often remain

unrealized

Development impacts have fallen short The digital divide is

still wide

Both in access and in capability

Thank you!

1

Dimagi

Started ~10 years ago out of MIT media lab

Socially-conscious technology company (“B Corp”)

HQ in the US with regional offices in India, South Africa, Mozambique, Senegal, permanent staff in Guatemala, Myanmar, Kenya and Zambia.

CommCare: Data, workforce, and beneficiary management tool for community-based programs

Software (as a service) & Services

Core work is with CHWs in MNCH

Delivering open & innovative technology to help underserved communities everywhere.

2

Snapshot of our work

Our experience 300 active projects 20,000 active users

1,000,000 forms/month submitted 100,000 SMS sent

Example of partners

4

Implemented India, 2012 Partners Bill & Melinda Gates Foundation, Government of Bihar, CARE India, BBC Media Action, Grameen Foundation, Dimagi Features Decision support, client management, data collection & sharing, mobile reports, home visit scheduler, call center, referral system, EDD & BMI calculators, multimedia, & performance dashboards Scale 500 FLWs

5

Impact Results show that higher levels of CommCare adoption are significantly associated with higher quality and experience of care. Highlight Over 50% increase in number of women visited by a FLW within 24 hours after delivery

6

Dimagi has partnered with several top-tier research groups to evaluate CommCare’s impact and over 20 peer-reviewed publications about CommCare, making CommCare the most evidence-based mobile platform for FLWs*

CommCare is the most evidence-based platform for FLWs

20% more protocol steps completed during home visits

85% increase in home visit timeliness

34% more likely to encourage women

to use health services

28-45%.increase in institutional delivery rates

Reduction in average time to

submit data from 45 days to 8

hours

Example of our research outcome:

* Front-line workers

Our full evidence base is available for download on www.dimagi.com

7

Wherewework

Ghana India Guatemala Myanmar Tanzania Mozambique

Createinfographics

Guatemala: Scaling maternal health,

malaria, & nutrition app to 9,000 users

Ghana: Supply Chain, IVR, CHW Expansion

India: Scaling app to 90,000 CHWs in 8 states Myanmar: Potential

national scale CHW deployment Senegal: National Informed

Push for Supply Chain

Burkina Faso: Clinical tools for IMCI used in 25% of all

national clinics

Mozambique: National CHW app

rollout

Tanzania: Nationally scaling supply chain project

… and is scaling-up to national scale in several countries

8

New Question: How Do We Scale?

Tech

Implementation

Hosting Requirements

Scaling Architecture

System Integration

Troubleshooting & Support

Training of Trainers

Supervision

Top-down design

Complex Features

Pace of Scale

Reporting

9

Addressing Implementation Challenges: Maturity Model

Hosting Requirements

Scaling Architecture

System Integration

Troubleshooting & Support

Training of Trainers

Supervision

Top-down design

Complex Features

Pace of Scale

Reporting Maturity Model

Program Design Data-driven Management Technical Support

Training & Implementation Scale Sustainability & Strategic Alignment

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

Stabilized and field-tested

system

Proof of concept use of system

Validated system for delivering

value to frontline workers

Packaged, repeatable

system for scale up

Ongoing, stable use of system

providing value at scale

10

Addressing Tech Challenges: MOTECH

Client Registry (CR) Shared list of patients with demographic data.

Facility Registry (FR) Shared list of facilities, districts, blocks, etc. in a country.

Health Management Information System (HMIS) Data and analytics for aggregate health data. Ex. DHIS2.

Point of Service App Provide health services (ex. CommCare or OpenMRS)

Interoperability Coordinate all the different systems

11

Future Challenge: Sustainability

How do we sustain impact at scale?

12

Thank you!

For more information on CommCare, please visit www.commcarehq.org For more information on Dimagi, please visit www.dimagi.com

Questions? Email [email protected]

All logos are shared under open source licenses from “thenounproject.com"

http://www.commcarehq.org

http://www.dimagi.com

mailto:[email protected]

We are all health workers

Problem: 1 billion people will never receive care from a health professional. Community

health workers (CHWs) could have significant impact, but they are disconnected from health

systems and lack support.

Core Idea: Mobile and web tools help a new wave of health workers improve access,

adherence, and quality in health systems. We envision a world where CHWs are supported

as they provide equitable care for their neighbors.

Structure: 501(c)(3) nonprofit organization with 55 staff. Offices in Nairobi, Kathmandu, and

San Francisco. Over 60 partners in 21 countries in Africa and Asia.

Medic Mobile’s mission and

purpose is to improve health in

hard-to-reach communities.

96% of the global population is covered by a mobile signal

We are connecting the dots in response to …

We don’t know who

needs emergency

care.

We can’t monitor

danger signs during

pregnancy

We don’t know who has

tuberculosis

Our Approach

We start with people

Our Partnerships

Working together

We have worked with more than 55 partners in 23 countries.

The Medic Mobile toolkit

Easily gather information

Communicate with your contacts

Use analytics to guide decisions

Our Use Cases

Antenatal Care

Childhood Immunization

Disease Surveillance

Stock Monitoring

100 million people 200,000 health workers

Our goals for 2020

@medic

medicmobile.org

[email protected]

Get Involved

Medic Mobile @Medic

Lisa MacDonald, HealthBridge

March 11, 2016

Knowledge Sharing Forum: Using m-Health for MNCH

The 3M Project: Men using Mobile phones to

improve Maternal health

www.healthbridge.ca

The 3M Project

www.healthbridge.ca

Collaborative partnership between:

The 3M Project What: Pilot tested sending educational voice messages

to men’s mobile phones during their wives’ pregnancy in rural India.

Purpose: To educate husbands and engage them in their wives’ maternal health care.

www.healthbridge.ca

Why Engage Men with m-Health? • Baseline research – women more likely to give birth in a

health facility if supported or encouraged by their husband.

• Literature: Engaging husbands may lead to reduced workload, improved birth preparedness, post-natal care attendance & emotional support1

• Men are hard to engage: time constraints, lack of appropriate clinic space, stigma from becoming involved in “women’s issues”

www.healthbridge.ca

1. Davis, Luchters & Holmes. (2013). Men and maternal and newborn health: Benefits, harms, challenges and potential strategies for engaging men. Compass: Women’s and Children’s Health Knowledge Hub.

The 3M Project: Jharkhand State, India Hiranpur Block, Pakur district

84,062 population

www.healthbridge.ca

Main Objectives Process:

1. To investigate the feasibility of sending mobile voice messages to husbands of pregnant women in rural India.

Impact:

2. To increase men’s knowledge & supportive behaviour regarding maternal health.

3. To increase women’s use of maternal health care.

www.healthbridge.ca

The 3M Intervention

• Weekly voice messages sent to husbands of pregnant women, with health information and recommended actions to take.

• Timed Messages – provided targeted advice from week 12 to week 40 (29 messages in total)

• Messages adapted from MAMA (Mobile Alliance for Maternal Health)

• Recorded in 3 local languages (Hindi, Santhali, Bengali)

www.healthbridge.ca

The 3M Intervention

• Examples:

• Week 12: ANC – 4 visits required

• Week 13: IFA supplements

• Week 17: Danger signs during pregnancy

• Week 24: Planning for place of delivery & costs

• Week 27: ANC – going for second visit

• Week 34: Signs of Labour

www.healthbridge.ca

The 3M Intervention • Husbands identified by

Community Health Workers (CHWs) during home visits to pregnant mothers.

• Mother’s pregnancy stage and husband’s mobile number recorded on a smart phone.

www.healthbridge.ca

www.healthbridge.ca

Inclusion Criteria: 1. Wife 12-20 weeks pregnant

2. Husband owns mobile phone

25 Intervention Villages

Target: 115 Husbands

25 Control Villages

Target: 115 Husbands

Baseline

Baseline

Women: Counselling from ASHA using

CommCare

Men: m-Health Voice Messages

Women: Counselling

from ASHA using CommCare

End line (4 weeks after birth)

End line (4 weeks after birth)

Inclusion Criteria: 1. Wife 12-20 weeks pregnant

2. Husband owns mobile phone

Preliminary Results

On Average: Husbands listened to 33% of messages - 9 out of 29

(Range: 1 – 23 messages)

www.healthbridge.ca

Preliminary Results

www.healthbridge.ca

Challenges

• Network “Do not Disturb List” – blocked phone numbers.

• Unable to discern “spam calls ” from the 3M calls.

• Labourers: Work during day, home late at night = missed calls.

31% of calls were missed due to restrictions on calls from

9pm – 9am

www.healthbridge.ca

Challenges • Migration for work – phone left at home or number changed

when out of state = no longer received messages.

• Trouble shooting CHW’s smart phones took a lot staff time.

www.healthbridge.ca

Lessons Learned – This Project

• Select only husbands who do not migrate for work. Or choose another family member.

• SMS + voice message to discern 3M calls from spam

• Schedule weekly follow-up with husbands to monitor problems and resolve right away.

www.healthbridge.ca

Lesson Learned - General

• Try only one m-Health intervention at a time.

• Build enough time into budget and work plan for on-going technical training and support.

• Have at least one field staff who is technically savvy.

www.healthbridge.ca

Thank You

www.healthbridge.ca

“Saving Mothers Project”: Preventing Maternal Deaths in

Rural Tanzania Dr. Bwire Chirangi, Shirati Hospital, Tanzania and Dr. Gail Webber, Bruyere Research

Institute, Canada

Funded by HDIF, UK Aid: 2015 to 2017

Bunda and Tarime Districts, Mara Region, Tanzania

Maternal Mortality: Context

• MMR for Tanzania 454/100,000 (2010)

• Almost 1 woman dies hourly in childbirth

• Mara Region > 60% of women have non-facility delivery

• Priority of National and Regional Governments to address this

• Globally the causes of Maternal Mortality are bleeding (25%) and infection (10%)

Maternal Mortality: Part of the Solution? Hemorrhage Prevention: Misoprostol effective for PPH prevention (heat stable, tablets can be self-administered).

Infection Prevention: use of clean birth kits to reduce postpartum sepsis (gloves, cord clamps, razor, soap, plastic sheet).

NEED FOR ACCURATE DATA and EDUCATION OF WOMEN using community health workers (CHWs)

Research Purpose

• Research Purpose: Demonstrate the feasibility and effectiveness of distributing delivery kits with misoprostol to women for self-administration.*

• *Note the implications on facility birth rate.

Role of M-Health

• Use m-health to:

• 1. Engage community health workers in registering pregnant women, educating them and reporting on danger signs

• 2. Monitor stock in dispensaries (Birth kits, misoprostol, and oxytocin)

• 3. Monitor work flows of CHWs

Structure of Saving Mothers Project Team

Dr. Bwire Chirangi Dr. Gail Webber Co- investigators

Financial administrator

Program Team Research Team

Research Coordinator

Tarime Medic Mobile

Bunda

Tarime RAs Bunda RAs

AMREF CPAR

CHWs &

DNs

CHWs &

DNs Research Team Roles - to collect data from women,

CHWs and DN’s

Medic Mobile Roles - to develop m-health apps

for 1. Pregnant women registration 2. Stock monitoring, and

3. CHW work flows

Program Teams Roles - to train and supervise CHWs and DNs distributing BKs and using m-

health applications

Medic Mobile Data: Oct 2015 to Feb 2016*

*Preliminary Data

Topic Bunda District Tarime District Total

Number of women registered

3,602 2,102 5,704

Number of birth kits

distributed

522 207 729

Number of deliveries 591 281 872

Number of Home

Deliveries

193 (32.7%) 129 (45.9%) -

Number of Facility

Deliveries

294 (49.7%) 141 (50.2%) -

Unspecified Site of

Delivery

104 (17.6%) 11 (3.9%) -

M-health Challenges

• Training large numbers of CHWs at once

• Field Issues: Input errors or missing data by CHWs leading to erroneous reports to Medic Mobile.

• Medic Mobile technical problems/changes to the system caused some delays for CHWs receiving acknowledgement.

What would we do differently next time?

• More time for training/larger budget.

• For our next project (IMCHA), the m-health data will be used for baseline and intervention data in a trial:

• - we will use a different system where the CHWs are prompted for each response (rather than inputting with a code).

• - we will have one list of questions for baseline.

• - we will add new questions during the intervention phase.

Acknowledgements

• Funders HDIF, UK Aid

• Our program partners, Canadian Physicians for Aid and Relief, AMREF Health Africa and Medic Mobile and their staff

• The dispensary nurses and community health workers

• RMO Mara, Dr. Samson Winani, DMOs of Bunda and Tarime Districts

• Our research team Nyamusi Magatti (coordinator), Simon Songe (administrator) and our research assistants (Bunda: Erick and Mapesa; Tarime: Mary and Brian)

Asante Sana!

Health Enablement and Learning Platform (HELP)

A mobile learning platform to train and support Community

Health Workers

Confidential – not to be shared or disseminated without explicit permission from Accenture & Amref Health Africa

Meet George.George is a Community Health

Worker (CHW) in Kenya’s Samburu District.

TRUSTED.

TRAINED.

RESPONSIBLE.

by his community to operationalise the community health strategy

with basic health curriculum defined by the ministry of health

for specific households in his community unit – governed by a community health committee


Full utilisation of CHWs could save 3.6 million children’s lives each year…however, today we face a severe shortage and skill gap…

Kenya needs

80,000+Community Health Workers

Africa needs

1,000,000+Community Health Workers


…and there is a pressing need for a more effective, sustainable, scalable approach to CHW training

Need for ongoing training

Increasing demand for CHWs

Strengthen supervision

1

2

3


Introducing

HELP.

Built on the partnership of many:

How HELP workshttps://www.youtube.com/watch?v=97l6OsPdRAw

Confidential – not to be shared or disseminated without explicit permission from Accenture & AMREF

Some Learning Outcomes

7

• 3000 CHWs trained in Kenya

• 31 mLearning topics rolled out

• Over 12Million content andpeer collaboration SMSeshave been sent between CHWs and CHEWs

• ~170,000 minutes of IVR audio shared (1,800 feature length movies)

• Enhance learning and higher knowledge retention and recall

• Improve health worker practice

• Reduce health worker isolation and enhance peer collaboration

• Increase interaction with supervisors and leadership

For the latest project news visit http://ehealth.amref.org

or contact:

Dr Githinji [email protected]

We want to collaborate!

knowledge exchange forum: using m-health for mnch · knowledge exchange forum: using m-health for...

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