mHealth

Sankofa mHealth Innovation Brings PTSD Support to War-Impacted Communities

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Monrovia. 3 May 2017 – Second Chance Africa and Code Innovation announce our partnership on the Sankofa project to create a mobile application of an innovative clinical curriculum that helps people recover from trauma in war-impacted communities.

The mHealth curriculum pioneered by Second Chance Africa will be used by the organization’s cohort of mental health facilitators, half of whom are graduates of the program. Since 2008, they have reached more than 7,000 war-impacted Africans on a shoestring, crowdfunded budget. Participants in one of their clinical outreach projects report a 65% reduction in the debilitating symptoms of trauma like intrusive memories, hyper-arousal, and avoidant behavior, a difference that allows them to return to a more stable life in their families and communities.

Post-traumatic stress disorder (PTSD), complex trauma and extreme stress are common outcomes of war and debilitate a person’s ability to function in society. In West Africa, the recent Ebola outbreak worsened existing war-related PTSD, compounding long-lasting community mental health issues that remain unattended. In post-conflict areas, trauma often becomes a silent epidemic and while some people get better with time, many do not.

In some areas, rates of PTSD diagnosis are close to 100% based on the nature and severity of events, and trauma symptoms have been documented in refugee groups decades after traumatic exposure. PTSD may heighten the risk for poverty, aggravating the consequences of war and conflict.

“Approximately 17.6 million people are currently impacted by war and conflict across East, West and Central Africa,” says Second Chance Africa founder and Executive Director Jana V. Pinto. “Yet despite the clear need, trauma relief is not yet a humanitarian priority, as current efforts are expensive and there is no evidence base available to guide treatment choice. We urgently need more scientific research to develop best practices around trauma relief interventions in war-impacted communities.”

“While it may seem secondary to investments in maternal health or child survival, research has shown that communities with a high prevalence of trauma struggle to progress economically,” says Elie Calhoun, Director of Code Innovation. “Trauma becomes a piece of the poverty trap and needs to be addressed before war-impacted communities can make lasting social and economic progress.”

“The Sankofa mHealth app is designed as a tool for civilians and community health workers to lead local trauma relief groups independently and without prior training or experience,” says Calhoun “The 10-hour protocol directly addresses major PTSD symptoms without one-on-one psychotherapy or drug interventions. Digitizing this model on a free mobile app makes the approach accessible to health systems and organizations all over the world. It is a truly game-changing model.”

“Although feature phone handsets still significantly outnumber smart phones in Africa, we expect to see a gradual shift to smartphones as they become increasingly available and affordable. Because the Sankofa mobile app is designed to be used by one facilitator working with many groups over time, the program model leverages what is still a relatively rare technology to harness its impact.”

Field testing of the digital tool will begin in June in Northern Uganda with South Sudanese refugees fleeing current conflict, and in Monrovia, Liberia with a core team of Second Chance Africa facilitators who have been with the organization since its inception in the Buduburam Refugee Camp in Ghana in 2008. As early recipients of the intervention, the facilitators are a testament to the transformative potential of the Second Chance Africa model and have dedicated themselves to ensuring that others in their country receive the same life-changing services.

The Sankofa digital tool will help them and other heroes in the battle against trauma to reach more people and help more people impacted by war regain their lives.

###

Sankofa is crowdfunding to cover its program costs: https://www.razoo.com/story/Sankofa2017

For more information about the Sankofa project, visit http://secondchanceafrica.org/sankofa

Second Chance Africa After six years delivering hands-on clinical services, Second Chance Africa’s team of scientists and health workers now focus on rigorous research and development of innovative, scalable and culturally-adapted intervention tools to advance trauma relief for African communities impacted by war. For more information, visit http://www.secondchanceafrica.org.

Code Innovation’s team of ICT4D experts specialize in helping high-impact development solutions go to scale. Our projects have been supported by UNICEF, the UK Department for International Development and major philanthropic foundations. For more information, visit http://www.codeinnovation.com.

For more information, contact:

Jana V. Pinto, Executive Director, Second Chance Africa, jana@secondchanceafrica.org

Elie Calhoun, Director of Operations, Code Innovation, elie@codeinnovation.com

Co-Creating a Free Rape Crisis Counseling App

Crowdfunding our Rape Crisis Counseling app for survivors of gender-based violence to receive emergency medical care (www.codeinnovation.com) An estimated one in three women is sexually assaulted over her lifetime. If the woman (or girl) is able to access emergency medical assistance with the support of a rape crisis counselor advocate, the chances of her healing increase exponentially. Without appropriate medical or psychological care, she is more likely to suffer from physical, mental and emotional after-effects that prolong her suffering and impact not just her own quality of life and productivity, but that of her family and community.

For over 40 years, rape crisis centers around the world have provided emergency room advocacy for survivors of sexual violence, ensuring that they receive appropriate treatment and care to begin the healing process. However, in low-resource environments and socio-cultural contexts where the seriousness sexual assault is minimized, survivors are often confronted with hostile or uninformed health care workers who may be unwilling or unable to provide the basic emergency services that help prevent pregnancy, STIs and HIV.

In these cases, which are by far the global majority of rape cases, a rape crisis advocate would make a significant difference in the survivor’s ability to secure adequate care while helping to mitigate the incidence of trauma.

Within the best medical systems, local rape crisis centers offer face-to-face training that prepares new crisis counselors for volunteer service in local hospitals. But in many countries and cities, these trainings are not available and advocates are not present.

We are digitizing the training curriculum of the Pittsburgh Action against Rape coalition and other U.S. rape crisis centers to create a free Rape Crisis Counseling mobile app that will make it easier for women around the world to get the support they require. The app will be released into the Creative Commons and include:

  1. M-learning Rape Crisis Counselor training material for anyone interested in learning the skills to be of volunteer service in their community;
  2. In-hand resources (a script, essentially) that enable a colleague, family member or friend to advocate for a survivor of sexual assault to emergency medical services;
  3. In-hand resources for a survivor herself, so that women without access to advocates can be as empowered as possible on their own.

We are partnering with U.S. rape crisis centers and coalitions to transform their rape crisis counseling training course into an m-learning resource. We also have approval from the U.S. Department of Justice to adapt and use their training resources.

Women’s rights associations and human rights defenders from around the world, as well as a network of aid worker survivors of sexual assault, will review the content for its appropriateness in a variety of challenging use cases and environments.

To date, no mobile resources exist that support survivors and their advocates as they access what can be life-saving medical care. We’re going to change that.

On Sunday 14 February, a global day of action to end violence against women, we’re launching a crowdfunding campaign to raise the funds to develop and translate the first Rape Crisis Counseling app for Android and iOS.

Join us in supporting rape survivors around the world on their road to recovery.

To get involved, email Elie Calhoun at elie@codeinnovation.com.

#rapecrisiscounseling

mHealth for Trauma Intervention Post-Ebola

Our mHealth trauma project is taking one of the most impressive mental health innovations we've seen to scale, digitizing the approach pioneered by Second Chance Africa in post-conflict Monrovia and reaching freshly traumatized communities in the wake of the Ebola outbreak. Our one-pager outlining the project, for which we're actively seeking impact investors, is here. We're pushing the envelope in making low-cost trauma services easily available to low-resource populations where, in most cases, the national health system is still struggling to meet basic needs.

The thousands of Liberians who have graduated from Second Chance Africa’s 8-week program report a 60% decrease in their trauma symptoms -- things like panic attacks, hand tremors and hyperventilation -- and that they're able to return to normal lives thanks to the program. By taking the approach mobile for community health workers, we're helping to network mental health for trauma into the package of basic services.

Now that we're teaching at Singularity University's Graduate Studies Program for the summer, we're feeling challenged to take things a step further. At the moment, we're relying on impact investors for the seed funding that will enable us to create the mobile app for community health workers and test it with implementing partners in Liberia, Sierra Leone, Gaza and Rwanda.

Facilitators who run the app-based program will have, at the end of the 8 weeks, a cohesive and motivated group, ready to join the economy and begin to build their lives back. What if we could reach those people with entrepreneurial training, for those that want it, and vocational training that creates revenue streams to support the project's scale?

We're in the early stages of trying to bring in a social business component to our mHealth trauma app, . After all, while we need seed funding to get this started, we don't want to create a system that constantly needs external funding. Lucky for us, Singularity University is now partners with Yunus Social Business, so we've got some of the best support and thinking on this available.

If you'd like to learn more about how your impact investing could improve the lives of people affected by emergencies and disasters, including Ebola, get in touch (info@codeinnovation.com) to continue the conversation.

Our Singularity Hub article, "How Mobile Technology Can Bring Trauma Relief After Ebola"

Code Innovation founder Nathaniel Calhoun and I co-wrote an article for Singularity Hub about how mobile technology can be used to bring relief to people living with complex trauma in communities affected by the recent Ebola outbreak. You can read the piece here. It explores recent donor-funded projects that seeks to ameliorate the mental health of affected communities and profiles our own Community Mental Health app project, for which we're actively seeking funding.

Please get in touch if you'd like more information by emailing us at info@codeinnovation.com.

Teach Yourself mHealth, Part 3

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This post is the third part of a three-part series, 'Teach Yourself mHealth.' In Part 1, we focused on what mHealth is and what mHealth projects look like. In Part 2, we mapped out exactly how mHealth can strengthen communities and information systems, step-by-step. In this post, we'll explore some common design challenges in mHealth projects and review the best online resources for bringing your mHealth knowledge up to speed.

Now that you're familiar with some mHealth basics, it's worth looking closer at what we've learned about how to implement solid, scalable and sustainable mHealth systems. One benefit of the myriad mHealth pilots that are out there is a wealth of lessons learned on everything from project design to better monitoring and evaluation. Many of these challenges exist for other, less technology-focused aid projects as well, of course, but they're nonetheless a good reminder of where to pay special attention.

Design Hurdles in mHealth Projects

The following summary of design hurdles that mHealth projects commonly face is assembled from lessons learned from my own research and interviews. This is by no means a comprehensive list, merely some interesting things to think about if you're considering adding an mHealth component to your international health work.

1. Human-centered design: Designing with people in mind puts the service back into development work. mHealth systems improve communications and information systems when they meet a need better than traditional systems. To meet this need, a thorough understanding of the problem you're trying to solve and the multidimensional context it exists within is essential. Testing and improving ideas and designs with the stakeholders you're trying to serve ensures that their needs are more adequately met by your project, and that means a better and more sustainable system

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2. Interoperability: Customizing and deploying an mHealth platform that interoperates with the Ministry of Health's electronic information system is key to avoiding parallel information systems that can duplicate work and deplete motivation. For example, current iterations of RapidSMS can be customized to interoperate with DHIS2, the open source health information system used by many government ministries throughout Africa.

Creating standalone platforms is often unnecessary and can get especially confusing in a Ministry running multiple mHealth projects. Ensuring interoperability from the start means your SMS platform can be more easily scaled and will likely have an easier time getting Ministry and staff buy-in. After all, your system needs to be useful to the stakeholders that the project is for, otherwise, what's the point? If you're using SMS for health behavior change communications, interoperability may be less important.

3. M&E: Many mHealth projects have been

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criticized for not developing a solid monitoring and evaluation framework to collect baseline and project data and accurately report on project effectiveness. Don't let this happen to you.

4. Map the tech4dev and telecommunications landscape: Any good project idea starts with a solid understanding of the current landscape and technology projects are no different. Before you start sketching out your mHealth idea, it's a good idea to map the landscape of your country and region for other mHealth projects, which could be using software platforms that you can piggyback on. Who else is working in your region? What have they found challenging? Reaching out to colleagues creates an atmosphere of shared collaboration and healthy competition, plus the benefit of shared lessons learned.

The same goes for understanding the mobile phone and telecommunications infrastructure in your country. What does cell phone ownership look like in your country? Is there anywhere where the signal is unreliable? Who are the main mobile network operators? Have they previously partnered on any mHealth projects? Understanding the landscape lets you know what your options and constraints are, so you can proceed with clarity.

5. Sustainability: mHealth systems can

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be extremely cost effective, but implementation costs for SMS air time, server maintenance, and other needs can add up in the long term, especially as the program reaches a national scale. Taking these costs into consideration

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early on will encourage you to design a system that is self-sustaining. The importance of including Ministry of Health and other Ministries' staff from the very start was discussed in my previous post, but suffice to say that their level of ownership over the project is directly related to the system's likelihood of long-term success.

Developing mHealth Expertise

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programs and projects, check out the links to documents and mHealth communities of practice below. mHealth, like all technology for development innovations, is a field that's changing rapidly. For those of us who want to further develop mHealth expertise, subscribing to regular email updates with the latest research findings and new projects is very useful. So are posting questions and design challenges you're facing on mHealth forums online, where an experienced community of practice is often very willing to offer guidance by sharing their own experiences.

For those eager to incorporate mHealth into their international health work, I recommend two online documents that summarize best practices to date and lessons learned. Both can be read in about an hour and offer pragmatic, no-nonsense guidance on the ins and outs of mHealth programming and implementation.

The first is "How to RapidSMS", written by a friend and former UNICEF colleague, Evan Wheeler. RapidSMS is a customizable mHealth platform that requires technical programming skills to install, but this how-to document is a great primer on the basics of a good mHealth project. The review of different SMS shortcode options offered by mobile network providers is especially helpful for thinking about how to best set up a scalable and financially sustainable system.

The second resource is a white paper written by Jeannine Lemaire for Advanced Development for Africa, "Scaling Up Mobile Health: Elements Necessary for the Successful Scale Up of mHealth in Developing Countries." Lemaire interviewed leading mHealth experts to mine their knowledge and experiences for a concise and thoroughly-researched list of best practices and programmatic, operational, policy and strategic recommendations. This might take you a bit longer than an hour, but is well worth the read.

As with learning any new thing, you're bound to have questions, especially technical ones. In that case, it can be helpful to reach out to a community of mHealth practitioners on one of the many mHealth forums online. I've found that RapidSMS and FrontlineSMS have particularly active communities.

Of course, the best way to teach yourself mHealth is to do it. Design, set up and implement a simple SMS-based project to apply what you've learned, and see what happens.

Teach Yourself mHealth, Part 2

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This post is the second of a three-part series, 'Teach Yourself mHealth.' In the first post, we focused on what mHealth is and what mHealth projects look like. In this post, we'll map how mHealth can strengthen information systems to build better health services, step-by-step. In Part 3, we'll explore some common design challenges in mHealth projects and review the best online resources for bringing your mHealth knowledge up

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to speed.

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We'll focus particularly on how an mHealth information system works on a detailed and practical level. Of course, SMS can improve other health services and plays an active role in communications for behavior change. My interest lies in systems strengthening, particularly in resource-poor settings, so that is the mHealth example I'll choose to focus on here.

 

mHealth Data: How It Works

Information for decision-making can be divided into two main categories: quantitative, to do with numbers, and qualitative, to do with language. Quantitative data, in public health and most social sciences, involves getting the results of random clinical trials or demographic surveys,

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or perhaps the routine information systems that Ministries of Health use to assess their population's disease burden. Qualitative data involves someone telling a story. For example, what does your new community health worker think about her level of supervision by the District Health Team?

By SMS, mHealth coordinators can gather both types of data, quantitative and

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qualitative. For the purposes of national level public health decision-making, numbers are a much easier information source to scale. In the example of outbreak early warning systems, a simple text message can specify the number of deaths, location and suspected diagnosis of a priority disease under surveillance, alerting District Health teams and central level Ministry staff to the need to respond.

Such a system's mHealth information system could look like this:

Of course, whenever gathering and analyzing data is involved, things can get complicated. As with any health information system, we need to identify exactly what we want to know, and trim off extraneous steps to simplify data reporting protocols as much as possible. Smart phones running mHealth apps can lead health facility staff through step-by-step reporting in greater detail than basic mobile phones (though they may be more vulnerable to theft and rough treatment).

 

Isolating Variables

During one of my consultancies, I had the opportunity to interview Dr. Theo Lippeveld, President of the Routine Health Information Network, who quite literally wrote the textbook on the Design and Implementation of Health Information Systems. I was a bit star-struck during the interview, but I remember his emphasis on "data for decision-making".

mHealth projects interface

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directly with health information systems to strengthen the flow of accurate information for improved decision-making. To present information effectively, they must be as simple as possible for the health facility, for the team sending the information, and for the Ministry of Health decision-makers to analyze and take action on.

Breaking down a system to look in detail at the part each reporter and each variable plays helps us identify where systems can be simplified and where the most important information can be prioritized. For example, if I want to use an mHealth SMS platform to gather real-time information about coverage for routine immunization, I will want to identify who will be sending and analyzing what kind of data, when they will

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send it and how it will be received--and ideally, I want to know why:

 

Sending data by SMS is important to keep simple and to the point. At the level of Ministry decision-makers, however, there is a bit more room for visual interpretation.

 

Visualizing Data

When displaying quantitative information and communicating about numbers at scale, design becomes important. In the international development world, many tools use crowd-sourced information and mapping to create real-time displays that shape emergency response (as in the case of Ushahidi in Haiti). In public health, we are used to seeing demographic data on maps and graphs.

The SMS platform (the one that ideally interfaces with

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the Ministry's electronic information system, complementing rather than duplicating the flow of data) selected for an mHealth project will often interpret that data graphically for easier analysis, enabling decision-makers to manipulate and customize the system to tell them exactly what they need to know. I'm currently reading 'The Visual Display of Quantitative Information' by Edward Tufte, who shows a lot of interesting historical examples of how large data sets can be creatively and meaningfully portrayed.

 

mHealth Applications for Developing Country Health Systems

As we see with each new post about an mHealth project in the developing world, using mobile systems to improve information flow can play a large role in systems strengthening. Routine reporting can be distilled into a text message that communicates priority data to government decision-makers. Qualitative information gathering through polls and SMS or radio outreach provides health campaigns with data to develop better communications for behavior change.

In the next post, we'll explore some common challenges that mHealth projects face and review the best online resources for keeping your new mHealth knowledge up to speed.

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Teach Yourself mHealth, Part 1

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This post is the first of a three-part series, 'Teach Yourself mHealth.' Here, we focus on what mHealth is and what mHealth projects look like. In Part 2, we'll map out in detail how mHealth can strengthen health information systems. In Part 3, we'll explore some common design challenges that mHealth projects face and review the best online resources for keeping your mHealth knowledge up to speed.

Subscribe by email to get Parts 2 and 3 delivered straight to your Inbox.

Early last year, I became interested in the intersection of mobile phone technology and health information systems, or 'mHealth,' which is short for 'mobile health.' A project I was working on required a high degree of mHealth knowledge in addition to my public health expertise, so I put my time in. I spoke with experts and friends who design and implement mHealth projects in sub-Saharan Africa. I spoke with government ministers who were eager to improve existing health management information systems and NGO coordinators who want to include mHealth in their program scope.

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Throughout my discussions, mHealth's mystique as the next big thing gave me the feeling that people want an mHealth project the same way you might want a new hand bag--because it looks good and everyone else has one. To many program people I spoke with, the specifics of what mHealth is--and what it is not--were often unclear.

Without doubt, mHealth and eHealth projects are now a part of the international health landscape. mHealth's ability to strengthen systems is increasingly quantified in peer-reviewed literature and best practices are becoming more standardized by the month.

Despite the ability of technology-based projects to become intimidatingly technical, mHealth knowledge is straightforward and easy to learn. If you work in international health, it's smart to acquaint yourself with the basics, even if you're not interested in including mHealth components in your current project portfolio just yet.

 

Starting with the Big Picture

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straight and explore what we mean by mHealth in the first place.

eHealth refers to electronic technology that improves or automates a health system. It's the broader category under which mHealth falls.

mHealth refers to health systems that include a mobile component, most often the use of mobile phones. The mobile phone can be the basic indestructible Nokia or a higher-end smart phone. Smart phones and tablets are becoming increasingly available in sub-Saharan Africa, where I work, and so the hardware landscape is constantly changing.

Basic mobile phones send and receive data through SMS text messages, usually sent to a specific number, or shortcode, that the project team arranges with a mobile network provider. Usually, project participants already have mobile phones and there is sufficient mobile network coverage in or near their area to allow them to send and receive text messages on a consistent basis.

It's worth noting that many mHealth project stakeholders--by which I mean the people the project is created to serve--may not be fully literate, may not know how to send and receive SMS, may not be able to charge their phones easily, and may not

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have good enough eyesight to read the small screen even if everything else is working (this last lesson from a pilot project in rural Liberia). Using a Human Centered Design approach and some solid common sense can encourage mHealth teams to anticipate these hurdles in the design phase and to keep adjusting and improving during project implementation.

mHealth projects that use smart phones have the distinct advantage of being able to use phone-based applications, or apps, that can gather, send and process mHealth data, behaving like a very small computer. Smart phones that run on open source operating systems, like Android, encourage software developers to create customized mHealth applications that operate from the phone.

Whatever phone is being used ultimately connects to a central server. Some SMS platforms, like EpiSurveyor, have a server online that you access from an Internet browser. Others, like Medic Mobile, run off of a mobile phone connected to a computer. Others are physically installed and need 24-hour electricity and a cool, dry environment. Setting up these servers can be tricky and, depending on the

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platform, can require technical expertise. Key mHealth Project Areas

For now, mHealth projects are often communications or information based, used for behavior change communications or to gather health information. Diagnostic applications for mHealth are very cool, like the mobile phone that could scan a blood slide to

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test for malaria, but still in pilot phases for the moment and not ready for field use.

Let's look for a moment at these two program focuses of current mHealth projects: communications and information. Obviously, mobile phones are great communication tools and using text messages to send targeted behavior change communications is an obvious application of the technology. Reproductive health messages and other potentially sensitive health messages can be easily adapted to the anonymity of text messages. These projects work especially well when there is two-way communication between the person receiving the message and the system sending it.

Information systems stand to gain a lot from mHealth applications, gathering data for accurate and timely decision-making that can save lives. Community health workers or primary health facilities have huge opportunities, using mHealth technology, to collect information that helps health officials make day-to-day decisions, especially around stock management and disease surveillance. Conversely, mHealth information systems can prompt primary care providers and assist with patient tracking, providing an automated structure for supportive supervision.

 

Key Players in mHealth Teams

Bringing together a good team, assembled from a diverse range of stakeholders, is key to a mHealth project's long-term success. Including the right people on the project team can help to ensure that the mHealth project meets the needs of its stakeholders and improves, rather than duplicates, existing systems. In addition to a good project coordinator, the following stakeholders are important to include in a mHealth team:

The Ministry of Health is the key stakeholder in mHealth projects, and early buy-in and ongoing Ministry guidance is essential to ensure that the project is owned and operated by Ministry staff in the long-term future.

The mobile network operator, or mobile phone company, is a key player in mHealth projects, especially as they attempt to scale. Demonstrating the value of a private-public partnership to a for-profit company demands both strategy and patience, with a long-term vision of how the mHealth system will go to scale.

Having a good software developer customize and install the SMS platform is obviously crucial, and if at all possible, hiring local developers builds technical capacity in-country and improves sustainability down the road, since you won't need to fly in technical help from someplace else. If you do bring someone in from outside, try to pair them with a local developer who can learn how to maintain the system.

Innovations projects can often feel competitive, and implementing organizations may be reluctant to involve or include sister organizations or NGOs in their design and implementation. I always feel this is a shame, as successful projects require a diverse team, and local NGOs in particular have a lot to offer in terms of specialized local or regional knowledge and of the cultural attitudes that can influence appropriate project design.

When you get right down to it, designing and implementing mHealth projects are no different than designing and implementing good aid projects. The basics, like designing for and with your stakeholders, and planning for long-term sustainability, remain the same no matter what hardware or technological innovations we apply.

In the next post, we'll map

out in detail how mHealth can strengthen communications and information systems. Subscribe by email to get Parts 2 and 3 delivered straight to your Inbox.