mobile network operators

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

If you'd like to

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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 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.