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mHEALTHCOMPENDIUMVOLUME THREE | TECHNICAL REPORTNovember 2013This publication was produced for review by the United States Agency for InternationalDevelopment. It was prepared by the African Strategies for Health project.

mHEALTH COMPENDIUMVOLUME THREEDISCLAIMERThe authors’ views expressed in this publication do not necessarily reflect the views of the UnitedStates Agency for International Development or the United States Government

The African Strategies for Health (ASH) project is a five-year contract funded by the United States Agencyfor International Development (USAID). ASH works to improve the health status of populations acrossAfrica through identification of and advocacy for best practices, enhancing technical capacity, and engagingAfrican regional institutions to address health issues in a sustainable manner. ASH provides information ontrends and developments in the continent to USAID and other development partners to enhance decisionmaking regarding investments in health.November 2013For additional copies of this report, please email info@as4h.org.This document was submitted by the African Strategies for Health project to the United States Agency forInternational Development under USAID Contract No. AID-OAA-C-II-0016 .Recommended Citation: Gayle Mendoza, Lungi Okoko, Sarah Konopka and Edna Jonas. November 2013.mHealth Compendium, Volume Three. Arlington, VA: African Strategies for Health project, ManagementSciences for HealthAdditional information can be obtained from:African Strategies for Health4301 N Fairfax Drive, Arlington, VA 22203Telephone: +1-703-524-6575info@as4h.orgThe photographs in this material are used for illustrative purposes only; they do not imply any particular health status, attitudes,behaviors, or actions on the part of any person who appears in the photographs.

ACKNOWLEDGEMENTSThis technical report was produced by the African Strategies for Health (ASH) project in collaboration withthe United States Agency for International Development’s Africa Bureau (USAID/AFR). Funded by USAID/AFR, the overall objective of ASH is to contribute to improving the health status of populations across Africathrough identification of and advocacy for best practices, enhancing technical capacity, and engaging Africanregional institutions to address health issues in a sustainable manner. ASH provides information on trendsand developments across the continent to USAID and other development partners to enhance decisionmaking regarding investments in health.Gayle Mendoza, Sarah Konopka, Lungi Okoko and Edna Jonas all contributed to the production of thisdocument. We extend our thanks to USAID, in particular, Senior Health Adviser Ishrat Z. Husain, andProgram Analyst Kaitlyn Patierno from the Africa Bureau, as well IT/KM Advisor Peggy D’Adamo and AdamSlote from the Global Health Bureau, for their support and inputs.We are grateful for both the mHealth Working Group and the mHealth Alliance and their staff. The mHealthWorking Group provided a readily available platform for engaging with project implementers and forexchanging mHealth project information, and the mHealth Alliance recommended projects to be includedand shared valuable information about mHealth interventions not featured in the first two editions.Our thanks also goes to the people and organizations whose mHealth applications are featured in this paper.They are pioneers in creative and useful mHealth applications that are designed to improve health systemsand achieve health goals. We realize that there are many more people world-wide who are actively involvedin mHealth applications for health. While time and budgetary constraints did not permit a more extensivereview, we would like to acknowledge them for their own contributions to the field.

ACRONYMS AND ABBREVIATIONSAcronym/AbbreviationAIDSANCASHBCCCDCCHWCVDDFIDDHISeHealthGPRSGPSHHSHIPsHISHIVHMISICTIDRCIT/KMK4HMCHMDGsmHealthMNCHMOHNGONMCPRFIDSDSIMSMSUSAIDUSAID/AFRUSSDWHODescriptionAcquired Immunodeficiency SyndromeAntenatal CareAfrican Strategies for HealthBehavior Change CommunicationU.S. Centers for Disease Control and PreventionCommunity Health WorkerCardiovascular DiseaseUK's Department of International DevelopmentDistrict Health Information SystemElectronic healthGeneral Packet Radio ServiceGlobal Positioning SystemU.S. Department of Health and Human ServicesHigh Impact PracticesHealth Information SystemsHuman Immunodeficiency VirusHealth Management Information SystemInformation and Communication TechnologyInternational Development Research Center of CanadaInformation Technology / Knowledge ManagementKnowledge for HealthMaternal and Child HealthMillennium Development GoalsMobile healthMaternal, Neonatal and Child HealthMinistry of HealthNon-Governmental OrganizationNational Malaria Control ProgramRadio Frequency IdentificationSecure DigitalSubscriber Identity ModuleShort Message ServiceUnited States Agency for International DevelopmentUSAID's Africa BureauUnstructured Supplementary Service DataWorld Health Organization

Global Trachoma Mapping Project ..................................................................................... 24Malaria Control Program (MACEPA) ................................................................................ 26Real-Time Biosurveillance Program .................................................................................... 28ZiDi .............................................................................................................................................. 30FINANCE ............................................................................................................................................... 32Interactive Alerts ..................................................................................................................... 34mHealth for Safe Deliveries: Ezy Pesa mobile banking service ................................... 36Pona na Tigo Bima ................................................................................................................... 38LOGISTICS ........................................................................................................................................... 40FoneAstra ................................................................................................................................... 42Project Optimize: Albania ...................................................................................................... 44SMS for Life ............................................................................................................................... 46SERVICE DELIVERY ........................................................................................................................ 48ACT for Birth, Uganda ........................................................................................................... 50Baby Monitor ............................................................................................................................ 52eNUT .......................................................................................................................................... 54Mobile Media Rich Interactive Guidelines ......................................................................... 56MobiUS Ultrasound ................................................................................................................. 58mSakhi ......................................................................................................................................... 60Pre-eclampsia Integrated Estimate of Risk (PIERS) on the Move ............................... 62Sky Social Franchise Network .............................................................................................. 64SMART ........................................................................................................................................ 66ANNEX 1: FIRST AND SECOND VOLUME CASE STUDIES ................................ 68

EXECUTIVE SUMMARYMobile health (mHealth) is the provision of health services and information via mobile and wirelesstechnologies. Within Africa the mobile phone has become ubiquitous, making mHealth applications animportant tool with which to impact the health of Africans. When applied correctly, mHealth can make realcontributions to improved health outcomes. mHealth has the potential to address and overcome: (1)disparities in access to health services; (2) inadequacies of the health infrastructure within countries; (3)shortage of human resources for health; (4) high cost of accessing health; and (5) limitations in the availabilityof financial resources.This third volume of the mHealth compendium contains 24 new case studies which document a range ofmHealth applications being implemented mainly throughout Africa, but also in other regions. A number ofmHealth interventions featured in this compendium seek to contribute to USAID’s two overarchingobjectives of eliminating preventable maternal, newborn and child deaths and achieving an AIDS free generation.Of the 24 case studies, 2 case studies focus on mHealth applications are part of HIV/AIDS programs and 17are part of programs providing maternal, newborn and child health services.In order to help USAID missions access relevant mHealth information, this compendium offers projectdescriptions, publication references and contact information for making further inquiries. Each two-page casestudy includes an introduction to the health area or problem; a description of the mHealth interventionhighlighted; a description of any important results or evaluation findings; lessons learned; and conclusion. Inaddition, the second page includes a summary of the geographic coverage, implementation partners, anddonors, as well as contact information for the implementing partner and donor. The case studies in thiscompendium have been organized within five programmatic areas: Behavior Change Communication, DataCollection, Finance, Logistics, and Service Delivery.The first and second volumes of the mHealth Compendium can be downloaded at http://www.msh.org/resources/infographic-mhealth-compendium-case-studies-volumes-1-2.mHEALTH COMPENDIUM | VOLUME 3 1

WHAT IS mHEALTH?eHealth vs mHealtheHealth is defined by the World Health Organization (WHO) 1 as the cost-effective and secure use ofinformation and communications technologies in support of health and health related fields, including healthcare services, health surveillance, health literature, health education, knowledge and research. eHealth is ageneral term which includes four distinct but related components.Mobile Health (mHealth): Provision of health services and information via mobile and wirelesstechnologies.Health Information Systems (HIS): Systems to gather, aggregate, analyze and synthesize data frommultiple sources to report on health; can include information related to patient records, diseasesurveillance, human resources, management of commodities, financial management, service delivery andother data needed for reporting and planning purposes.Telemedicine: Provision of health care services at a distance; can be used for inter-professionalcommunication, patient communication and remote consultation.Distance Learning (eLearning): Education and training in electronic form for health professionals.This compendium is focused solely on the mHealth component of eHealth. For the purposes of this papermHealth includes mobile phones, Personal Digital Assistants (PDAs), tablets, mobile applications and wirelessmedical devices.WHERE IS THE EVIDENCE FORmHEALTH?With more than 6 billion mobile phone subscribers in the world — including 433 million users in Africa —health sector actors are excited about the opportunities offered by mHealth in terms of improving thequality of care, access to health services and health outcomes. Although still limited, the amount of evidenceabout the effectiveness or efficacy of mHealth interventions has recently begun to increase. In recent years,there has been a significant upsurge in mHealth focused health outcomes research — including a few studiespublished in the Lancet — and reviews aimed at synthesizing the evidence. Some reviews of mHealth studies,such as the February 2013 article by Tomlinson et al. and a 2011 World Bank report, point to the lack ofhigh quality and peer reviewed randomized trials to conclude that little is known about the impacts ofmHealth interventions. 2,3However, the mHealth research landscape is evolving rapidly. Of the 215 unique registered studies found bya recent review of mHealth research projects on the US Government federal clinical trials tracking system, 4“40 new studies were added to this database in the six-month period between May and November 2012alone.” 5 The mHealth Alliance’s mHealth and MNCH: State of the Evidence report concludes that the increasein rigorous mHealth research has been remarkable, calls for greater investment of resources in studying theeffect mHealth interventions have on health outcomes, and emphasizes the need to view gaps in the mHealthevidence as opportunities for future research. 62 mHEALTH COMPENDIUM | VOLUME 3

KEY FACTORS FOR mHEALTHSUCCESSThe potential for mHealth interventions to capitalize on mobile technology for improving the quality ofprograms, extend the reach of services, and strengthen health information systems is great. However, theroll out of mHealth interventions takes time and significant investment in human, technical and physicalinfrastructure. Continuous capacity strengthening at multiple levels in the use of mobile technology devices,information dissemination, data collection, and monitoring and evaluation must be factored into projectdesign. Through compilation of this compendium, a range of factors that are critical to successful mHealthinterventions were identified.Country Ownership and LeadershipNational ownership and full government participation are critical to long term project sustainability. Activeengagement ensures the integration of mHealth into existing national and local health sector plans, strategiesand systems. National governments also play a central role in the creation and maintenance of an enablingenvironment for mHealth to thrive through the development and implementation of mHealth-friendlypolicies. Ensuring that new mHealth interventions align with the country’s national eHealth strategy canprovide opportunities for addressing important organizational development issues, such as governance,infrastructure, architecture, workforce capacity, policy and financing.PartnershipsStrong public-private partnerships are key to the success of mHealth initiatives. Across the projects andproducts profiled in this compendium, prominent partnerships include those with governments, technologysoftware development companies, management consulting firms, international and local non-governmentalorganizations, mobile network service providers, health service providers, and their clients. Partnerships withdifferent actors may vary at each stage of the process in order to leverage and capitalize on the necessaryexpertise.CoordinationThe efforts of all partners need to be properly coordinated, ideally through the leadership of government.One approach is to establish a technical working group consisting of partner representatives. Collaborationat the level of implementing partners is critical, as well, to ensure that systems are interoperable. 7THE IMPORTANCE OF STANDARDS INmHEALTHOne of the most promising aspects of mHealth is its potential for enhancing the smart integration of healthservices and the continuity of care across provider, place and time by making information available at theright place and the right time. Strengthening patient management and health systems in this fashion can onlybe achieved if the various mHealth and HIS platforms have sufficient common ground to reliably exchangemHEALTH COMPENDIUM | VOLUME 3 3

messages in a way that minimizes errors and misunderstandings. Known as interoperability, this ability ofdiverse systems and organizations to communicate and work together (inter-operate) requires theestablishment of and adherence to standards. Much like speaking a common language enablescommunication, using common standards for how data are structured and exchanged enables mHealthplatforms and HIS to share data.mHealth interventions are significantly more powerful when health sector actors make their informationsystems interoperable. Through close cooperation, governments, donors and private healthcare providerscan achieve interoperability by applying the same standards. Donors can champion interoperability byrequiring it as a condition of their funding for mHealth interventions. These actions will maximize the powerof mHealth as a tool for coordinating individual, patient-level services and public health programs. 8,9NATIONAL POLICIES FOR mHEALTHFew countries have initiated the process of regulating the development and use of mHealth applications. Inthe United States, the U.S. Food and Drug Administration, which regulates all medical devices, recentlyannounced it would exercise discretion on lower risk applications, such as applications that disseminate massinformation, but would instead focus its regulation on higher risk mHealth applications—namely applicationsthat turn mobile devices into regulated medical devices, such as an ultrasound machine, and applicationsenabling health care workers to diagnose specific conditions by looking at an image. In addition to issuesrelated to interoperability and the establishment of standards for sharing information, governments will haveto work towards the establishment of mHealth-related policies that strike the balance between allowinginnovation while protecting consumers, especially patients’ rights to privacy.mHEALTH APPLICATIONS AS TOOLSFOR STRENGTHENING HEALTHSYSTEMSIn a technical paper published in the August 2013 issue of the Global Health: Science and Practice journal, agroup of mHealth researchers and implementers from Johns Hopkins University, UNICEF, WHO and frogDesign proposed a new framework for assessing mHealth innovations through a health systems lens. Theframework organizes common mHealth applications into 12 categories: 1) Client education and behaviorchange communication; 2) Sensors and point-of-care diagnostics; 3) Registries and vital events tracking; 4)Data collection and reporting; 5) Electronic health records; 6) Electronic decision support; 7) Provider-toprovidercommunication; 8) Provider work planning and scheduling; 9) Provider training and education; 10)Human resource management; 11) Supply chain management; and 12) Financial transactions and incentives. Italso describes how each of these types of applications can be used to “enhance delivery of life-savinginterventions through improvements in health system performance, such as coverage, quality, equity, orefficiency.” The framework seeks to help mHealth implementers and health program managers select themHealth tools that are most appropriate for addressing specific health systems constraints. By providing acommonly understood conceptual structure that presents the relationship between mHealth applications andhealth systems functions, the framework also aims to facilitate communication between mHealth developers4 mHEALTH COMPENDIUM | VOLUME 3

and health managers. The framework provides a promising tool for evaluating how mHealth systems can beintegrated into existing health systems structures.The full paper can be found at http://www.ghspjournal.org/content/early/2013/08/06/GHSP-D-13-00031.full.pdf.mHELP: A NETWORK FOR mHEALTHTECHNICAL ASSISTANCEThe mHealth Expert Learning Program – mHELP – is an initiative of the mHealth Alliance aimed at buildingthe expertise and capacity of global health stakeholders using mobile technology for health by connectingthem directly to consultations, tools and a network of highly qualified experts in the field. mHELP, which issupported by Johnson & Johnson, seeks to address a persistent gap in the capacity of health programs andservice implementers to design and deploy mobile health (mHealth) and electronic health (eHealth) in lowandmiddle-income countries. mHELP offers a unique set of services to those that wish to use technology toimprove the health and wellbeing of vulnerable populations around the world. In support of MillenniumDevelopment Goals 4, 5 and 6, the initiative has a particular focus on improving reproductive, maternal,newborn and child health, and the diagnosis and treatment of HIV/AIDS.The services offered by mHELP include free tools and resources, an online question answering service, andmore in-depth training, such as university-certified courses in mHealth and eHealth that will launch in 2014.Through mHELP, the mHealth Alliance will also engage in formal assessment and technical assistance bymatching high-level experts with capacity building and technology partners, to address the needs of specificmHealth implementations. Currently, the Alliance has two high-level engagements of this nature: 1) technicalassistance to the Elizabeth Glaser Pediatric AIDS Foundation to establish a decision support and registrationsystem in Tanzania for the elimination of mother to child transmission of HIV and 2) technical assistance tothe South African Government to develop a national maternal and child mHealth implementation.mHELP has an expanding network of quality-assured technical experts in many areas of mHealth andeHealth. These experts are connected to mHealth projects based on their expertise and experience in orderto provide technical support. Areas of expertise include: Implementation of mHealth services at scale Sustainable finance for mHealth projects Monitoring and evaluation for mHealth projects Health system operational research and study design Open standards and interoperability Appropriate technology for mHealth projects Working with Mobile Network Operators Health economics and cost effectiveness studies Social and behavioral change communications Use of communications and social media for mass interaction Gender issues concerning effective mHealth implementation Education and training 11For more information, visit http://www.mhealthalliance.org/our-work/initiatives/mhelp or emailmhelp@mhealthalliance.org.mHEALTH COMPENDIUM | VOLUME 3 5

mPOWERING FRONTLINE HEALTHWORKERSFrontline health workers are the backbone of health systems in resource-constrained environments, yet theyface numerous challenges: inadequate refresher training, weak performance incentives, difficulty reachingremote populations, a lack of supportive supervision, inadequate supply of health products and insufficient real-time access to patient data and reference information.mPowering Frontline Health Workers is an innovative public-private partnership designed to contribute tothe elimination of preventable child and maternal deaths by accelerating the use of mobile technology toimprove the skills and performance of frontline health workers. The partnership will leverage the resourcesand expertise of its founding members: USAID, UNICEF, Qualcomm, Vodafone, Intel, GlaxoSmithKline,Frontline Health Workers Coalition, MDG Health Alliance, Praekelt Foundation, and the mHealth Alliance.The partnership will address multiple barriers to scaling mHealth initiatives for frontline health workers,including issues regarding interoperability, shared standards, terminology, evidence, re-usable tools, sustainablefinancing models, and country ownership.Over the next three years, mPowering Frontline Health Workers will :Build the capacity of governments, organizations and individuals to harness the power of mobiletechnology to strengthen maternal and child health services delivered by frontline health workersSupport the scale up of mHealth applications for frontline health workers through country-basedmulti-stakeholder coalitions in six countries: India, Kenya, Nigeria, Mozambique, Tanzania andUgandaGenerate evidence and information on the use of mobile technology by frontline health workersto mobilize resources and improve the design of mHealth applications.It will achieve these three objectives by undertaking the following activities:1. Crowdsource innovative multi‐media, multilingual health content for use in multipleapplications;2. Create an online library of downloadable digital health content that can be accessed byorganizations in developing countries;3. Accelerate the sustainable expansion of mHealth for frontline health workers in at least twodeveloping countries;4. Rigorously evaluate partnership activities with a focus on cost effectiveness, impact andpotential for sustainability; and5. Share experiences through global learning events, platforms, workshops and webinars.For more information, visit www.mpoweringhealth.org, or contact Lesley-Anne Long, Global Director,mPowering Frontline Health Workers at Lesley-Anne.Long@mpoweringhealth.org, or BethAnne Moskov,Deputy Director, Office of Health, Infectious Diseases and Nutrition, USAID at bmoskov@usaid.gov.6 mHEALTH COMPENDIUM | VOLUME 3

OTHER KEY mHEALTH TOOLS ANDRESOURCESThe Knowledge for Health Project (K4Health) and the mHealth Working Group have developed a suite ofnew tools and resources for mHealth to help improve public health around the world. Some of the toolsinclude the following:mHealth Basics: Introduction to Mobile Technology for Health - A new, free, self-pacedeLearning course available on the USAID Global Health eLearning Center that provides anintroduction to mHealth and an overview of best practices for mHealth solution development.An mHealth Planning and Implementation Guide: How to Integrate MobileTechnology into Health Programming - An interactive online guide intended for globalhealth practitioners working to implement mHealth solutions in family planning and reproductivehealth programs and beyond.The mHealth Evidence Database - This new database includes searchable peer-reviewedand gray literature on mHealth effectiveness, cost-effectiveness and program efficiency, enablingresearchers, program managers, funders and other key decision-makers to quickly get up tospeed on the current state-of-the-art. mHealth: Mobile Technology to Strengthen Family Planning Programs –Commissioned by the USAID High Impact Practices (HIPs) in Family Planning series, this briefhighlights evidence about mHealth and family planning programs to date and synthesizes lessonslearned for implementation of mHealth programs. 12For more information, visit: http://www.k4health.org/topics/mobile-technologies-health-mhealthmHEALTH COMPENDIUM | VOLUME 3 7

HOW TO USE THE mHEALTHCOMPENDIUMThis third volume of the mHealth compendium contains 24 case studies which document a range of mHealthapplications being implemented throughout Africa and, in some exceptional cases, in other regions. Whilethere are a number of existing databases with information on the many pilots being undertaken worldwide,these are often cumbersome and sometimes difficult to navigate. The authors envision that a compendiumlike this one is particularly needed where there is a plethora of mHealth activities at the country level—inorder to help USAID missions easily access relevant mHealth information.The case studies included in this compendium do not provide exhaustive descriptions of all aspects of theapplications, however they do include references where the interested reader can seek additionalinformation.In order to highlight the range and versatility of mHealth as a tool for improving health and well-being, thecase studies in this compendium are divided according to five programmatic areas: Behavior ChangeCommunication, Data Collection, Finance, Logistics, and Service Delivery. Each of these five programmaticareas is briefly described below.Behavior Change Communication (BCC)mHealth interventions are frequently utilized for community mobilization, awareness raising, education anddemand creation. It has been reported that mHealth BCC interventions are the most predominant of allmHealth interventions and also the most successful. This is because current interventions center on the useof low-cost SMS texts to reach various audiences. Important short-term changes in behavior have beenobserved, though modest. 10Data CollectionData collection and surveillance can be enhanced by utilizing mobile communication and personal datadevices. Instead of sending paper forms, data can be sent more quickly and reliably through electronicmethods. This has been shown to increase reliability, make data more readily available (especially data fromremote areas), and enhance the quality of the data submitted. Throughout Africa, mHealth applications havebeen used for a variety of data collection activities, from routine reporting to large national surveys.FinanceMobile money applications are increasingly used in Africa to facilitate payment for health services and otherexpenses associated with seeking care for both private patients and clients enrolled in various communityhealth programs. These mobile money applications allow registered users to load money into their accounts,make transfers to other users (whether they are or not), and withdraw money. While registration for theseservices is almost always free, transactions have a predetermined fee which is often covered by the specifichealth program or implementing partner supporting the intervention. Examples of how mHealth applicationshave been utilized include vouchers for family planning clients to access counseling and services, as well asantenatal, delivery and postnatal services at participating hospitals.8 mHEALTH COMPENDIUM | VOLUME 3

LogisticsAvailability of high quality logistics data has been one of the greatest challenges facing the health care system.Without these data, decision makers cannot adequately manage the supply chain, risking the possibility thatpatients won’t receive the medicines they need. Increasingly, mHealth applications are being utilized toaddress this issue. Most of these applications allow a lower-level health facility to transmit informationregarding their supply of essential medicines to the higher-level facility or warehouse which then provides thecommodities. In some cases, these applications have even been utilized by community health workers toensure they have the basic supplies needed.Service DeliveryMobile phones have been used to improve the quality of and access to health care service delivery in amyriad of ways. Applications have been developed that assist health care workers in diagnosing and treatingpatients, such as phone-based treatment algorithms and SMS reminders to follow up on clients’ laboratoryresults and other services. mHealth has been successfully used to train and retrain health workers. Phonebasedapplications have also been developed to promote adherence to medications, provide notification ofresults, and remind patients to keep appointments.———————————————1. Department of Knowledge Management and Sharing (KMS), World Health Organization. Knowledge management and health. , 2012.2. Tomlinson M, Rotheram-Borus MJ, Swartz L, Tsai AC (2013) Scaling Up mHealth: Where Is the Evidence? PLoS Med 10(2): e1001382. doi:10.1371/journal.pmed.10013823. Qiang CZ, Yamamichi M, Hausman V, Altman D (2011) Mobile applications for the health sector. Washington: World Bank.4. http://clinicaltrials.gov5. A. Labrique, et al., H pe for mHealth: More “y” or “o” on the horizon? (in press) Int. J. Med. Inform. (2012), http://dx.doi.org/10.1016/j.ijmedinf.2012.11.0166. Philbrick WC (2013) mHealth and MNCH: State of the Evidence. Trends, Gaps, Stakeholder Needs, and Opportunities For Future Research on theUse of Mobile Technology to Improve Maternal, Newborn, and Child Health. Washington. UN Foundation.7. Adapted from: Evidence to Action Project (2012). Use of Mobile Technology to Improve Family Planning and Reproductive Health Programming:A Synthesis of Evidence.8. Qiang CZ, Yamamichi M, Hausman V, Altman D (2011) Mobile applications for the health sector. Washington: World Bank.9. Payne JD (2013) The State of Standards and Interoperability for mHealth. Washington. UN Foundation. 10. Ibid11. Extracted from: http://www.mhealthalliance.org/our-work/initiatives/mhelp12. mHealth Working Group mailing list, October 28, 2013 posting by Laura KaneymHEALTH COMPENDIUM | VOLUME 3 9

COMPENDIUM CASE STUDIES10 MHEALTH COMPENDIUM | VOLUME 2

BEHAVIOR CHANGECOMMUNICATION (BCC)MHEALTH COMPENDIUM | VOLUME 2

HEART HEALTH MOBILEAn interactive, educational, monitoring and gaming application to improvecardiovascular healthHeart disease and stroke are the first and fourthleading causes of mortality in the United States,making cardiovascular disease (CVD) responsible forone out of every three deaths in the country. Eachyear, over two million people suffer from heartattacks and strokes, while approximately 2,200 peopledie from CVD. The financial implications are alsolarge; over $444 billion is spent in health careexpenditures and lost productivity due to these noncommunicablediseases.To tackle the burden of CVD, the Department of Healthand Human Services (HHS) launched the Million Heartsnational public-private initiative in September 2011, witha goal of preventing one million heart attacks andstrokes in the U.S. over a five-year period. To helpconsumers take charge of their heart health, theinitiative challenged developers to create an applicationto assist consumers in this process. The HHS Office ofthe National Coordinator for Health InformationTechnology, in partnership with Million Hearts,organized the Million Hearts Risk Check Challenge. Inresponse, Marshfield Clinic Research Foundation(MCRF) developed the Heart Health Mobile (HHM)application and won the competition. HHM was firstreleased in February 2013 for Apple products andexpanded to a web-based (HTML5) version in March2013 that works on other devices.Implementation date: February 2013About Heart Health MobileMCRF’s Heart Health Mobile application is designed toachieve the following:1. Reach individuals across the country, taking specialaim at those who may be at risk for CVD and butare unaware of their risk,2. Motivate at-risk individual to obtain an accurate riskassessments, and3. Direct consumers to nearby community pharmaciesand other locations that offer affordable andconvenient blood pressure and cholesterolscreenings.HHM is currently available as a downloadable mobileapplication through the Apple Store or as a web app atwww.HeartHealthMobile.com. Its interface provides theuser with a brief assessment of CVD risk, taking intoaccount self-reported behavioral, familial and biometricrisk factors, including blood pressure and lipids. Basedon the level of CVD risk, users are directed to nearbycommunity pharmacies, clinics and other locations formore advanced CVD risk factor screenings,assessments, and treatments. The app also providesbasic health education materials on key CVD risk factormanagement topics including hypertension, dyslipidemia,12 mHEALTH COMPENDIUM | VOLUME 3

BEHAVIOR CHANGE COMMUNICATIONweight management and tobacco cessation. HHM canbe readily shared via social media links such as Facebookand is also available in a gamified version.Evaluation and ResultsFrom January 28 to August 1, 2013, HHM wasdownloaded 3,225 times from the Apple Store across alliPhone, iPad and iPod Touch devices. During this timeperiod, almost 90% of usage was though iPhones andiPhone users conducted 100% of the shares via emailand Twitter.The mobile app had a global reach even withoutexplicitly promoting it in countries outside the US. FromJanuary 31, 2013 to October 8, 2013, 104 differentcountries logged usage in the app.Lessons LearnedThe number of downloads was somewhat limiteddue to the nature of the Million Hearts Challenge.Concentrated efforts in five major US metro areaswere scheduled to promote the Million HeartsCampaign, of which Heart Health Mobile was thechosen mobile tool available free of charge for usersto download or use at HeartHealthMobile.com.Some campaigns were more effective than others indriving users to the Apple Store or directly to theapp’s website. Chicago saw the largest spike inusers by promoting the app during Heart Month inFebruary, in conjunction with other heart healthyactivities and promotions.Gain of the following valuable market-relatedinsights: 1) traditional media efforts (e.g. newssegments via local television and newspapers) havebeen most effective, 2) feedback is limited throughthe site (

MOBILE INTEGRATED RESOURCES FORAURAT-WOMEN (MIRA) CHANNELProviding critical MNCH services to women at the bottom of the pyramidThe lack of maternal and child health (MCH)information, communication and services reachingwomen in remote and low resource settings is one ofthe main contributors to India’s high maternalmortality rate of 420/100,000 live births, and under-5mortality rate of 72/1,000 live births. Nineteenpercent, or 56,000, of annual global maternal deathsoccur in India. Only 40% of deliveries occur at ahealth facility and less than half are attended by askilled healthcare provider. Additionally, 22% ofbabies in India are born at low birthweight. To reducematernal and infant mortality and morbidity in India,women, especially those in rural and low-incomesettings, must be provided quality health informationand connected to primary health centers and healthinstitutions.The Millennium Alliance – a new partnership betweenUSAID, the Federation of Indian Chambers ofCommerce and Industry, and India’s Department ofScience and Technology – is promoting technologicalinnovations as possible solutions to addressing India’sdevelopment challenges. In response, ZMQDevelopment, a social enterprise, created the MobileIntegrated Resources for Aurat-Women (MIRA)Channel (formerly branded the Women Mobile LifelineChannel) to bridge the information gap among ruralwomen, help them connect with health services, andempower their decision-making abilities related tocritical health issues.Implementation date: March 2012About MIRA ChannelMIRA Channel is an integrated mobile phone-basedapplication using the Global App platform. It provideslifeline sustainable development tools for low-literatewomen at the bottom of the development pyramid. TheWindows compatible application is available on both Javamobile feature phones and Android smartphonesfeaturing an interactive iconic messaging system thatrequires limited audio and text support.MIRA Channel can be downloaded from the applicationsite or through mobile operators. It is also embeddedon new mobile handsets from OEM manufacturers andpromoted through viral marketing mechanisms ofpartner NGOs. Local (village level) mobile rechargekiosks assist women to download the app.Content is delivered based on users’ needs. Educationaltools, iconic messaging kits, mobile games, mobile soapsand other components are available across dedicatedsub-channels geared towards maternal and child health,reproductive health, family planning, home-basedneonatal care and adolescent girls’ health. The MCHchannel features toolkits on prenatal care and universalimmunization. MIRA Channel also contains tools womencan use to track and manage pregnancy, immunizations,menstrual cycles, family planning and infectionprevention.14 mHEALTH COMPENDIUM | VOLUME 3

BEHAVIOR CHANGE COMMUNICATIONTo expand MIRA Channel’s reach, ZMQ developmentutilized Organized Human Networks to identifymicrofinance institutions, self-help groups and frontlinehealthcare networks as possible markets. They are alsoincorporating channels on financial literacy, functionalliteracy, vocational and skills training and women’sentrepreneurship into the application.Evaluation and ResultsWithin the first year, MIRA Channel was utilized by27,600 women in India’s Mewat and Rajasthan regions.To date, over 48,000 Mewat and 22,000 Rajasthanwomen in self-help groups have benefitted from theprogram. Approximately 16,800 pregnancies and 11,800childhood immunizations have been registered. Womenhave downloaded almost 35,000 MCH-related gamesand Value Added Services.When compared with primary health center data from2011 to 2012, there has been an increase in uptake offolic acid during pregnancy, the number of pregnantwomen visiting frontline health workers or AnganwadiWorkers, and deliveries at healthcare facilities.Lessons LearnedUse of iconic messaging with audio support andminimum text is an essential component and hasbeen a successful method to convey messages tosemi-literate and illiterate communities, producingsubstantially better results than SMS.Incorporating training of semi-literate womenenables them to effectively and efficiently use mobilephones and is an essential component of successfulmobile technology initiatives.The program realized that women benefactorsbecame stakeholders rather than clients. They notonly effectively test the messages but essentially actas marketers and peer educators.ConclusionThe MIRA Channel is an innovative response to thehealth needs of low-socioeconomic populations in India.Designed specifically for women in rural and low-incomesettings, the mobile channel provides informationrelated to critical health issues to help manage women’slives. It is important to find innovative and effectivemeans to disseminate the women’s channel and reach alarger audience, as well as to utilize innovative marketingstrategies when working with low promotion andmarketing budgets.--------------------------------------------------------Geographic Coverage: India, Mewat and RajasthanregionsImplementation Partners: ZMQ Development alongwith Mewat Mahila Vikas Society and 6 SHG FederationPartnersFunder: USAID | Federation of Indian Chambers ofCommerce and Industry (FICCI) | TechnologyDevelopment Board (TBD), Department of Science andTechnology, Government of IndiaContact Information:ZMQ Development: Subhi Quraishi, CEO and Mobile 4Development Director (+91-124-4368897, subhi@zmq.in);Hilmi Quriashi (Ashoka Fellow), Co-Founder & DirectorSocial Programs (+91-987-1981960, hilmi@zmq.in)USAID: Anu Rajaraman, Director, Office of Partnershipsfor Innovation, USAID India (arajaraman@usaid.gov)FICCI: Eittee Gupta, Deputy Director, Centre forInnovation, Science & Technology Commercialization(eittee.gupta@ficci.com)References:1. GBCHealth Member ZMQ Wins USAID Award. GBCHealth. 17July 2013. Web.2. Johanna Morden. A mobile lifeline for maternal and child healthin India. Devex. 3 July 2013. Web.3. Women Mobile Lifeline Channel. Fact Sheet. ZMQDevelopment. No Date. Web.mHEALTH COMPENDIUM | VOLUME 3 15

NIGHTWATCH: MOBILECreating a Malaria Mobile Community in TanzaniaIn Tanzania, over 30 million people, or 73% ofthe population, live in areas of high malariatransmission. Nine of mainland Tanzania’s 23regions have more than 100 confirmed malariacases per 1,000 people annually, andapproximately 8.7 million probable andconfirmed cases were reported in 2010 alone.Mass campaigns and a national voucher systemhave contributed to the distribution of 27 millionlong-lasting insecticide-treated nets (LLINs). AZambian study suggested that behavior changecommunications “are necessary to improve use”and could “contribute towards closing the gapbetween ownership and use” of bed nets.Research conducted by Malaria No More alsoindicates there is a general understanding fromTanzanians that sleeping under a net is necessaryyear-round. To preserve malaria as a health priority andprovide continual education on malaria diagnosis andtreatment, Malaria No More, in partnership withTanzania House of Talent (THT), has launchedNightWatch: Mobile. The program uses celebritybrandedmobile communities and features personalizedcommunication by mobile phone to address gaps inmalaria knowledge.Implementation date: April 2012About NightWatch: MobileNightWatch: Mobile builds on the successful nationalmass-media campaign, branded as Zinduka! MalariaHaikubaliki! (“Wake up! Malaria is unacceptable!”),which is endorsed by the National Malaria ControlProgram (NMCP) and the Tanzanian government. TheNMCP approves the content of the malaria messagesand provides overall guidance on national malariacontrol priorities. The Zinduka! campaign is theTanzanian adaptation of the same NightWatch platform(celebrity-driven mass media campaigns for behaviorchange, social mobilization, and advocacy) that MalariaNo More supports in Cameroon, Chad and Senegal.THT celebrities form part of a team of goodwillambassadors who deliver malaria messaging via radio,TV and billboards. President Jakaya Kikwete alsorecorded a public service announcement for thecampaign that aired on national TV in 2012. Through theexpansion of NightWatch via a ‘malaria-mobilecommunity’, the program is able to reach diversepopulation segments via several mobile features,including tools designed to reach the illiterate. Theseinclude a new mZinduka! malaria anthem that is availableas a downloadable ringtone and ringback tone; acelebrity phone tree with on-demand recordedmessages from THT goodwill ambassadors; andinformational messages, quizzes and surveys.The malaria-mobile community (called mZinduka!) alsolinks to malaria-themed, regionally broadcasted radioshows that feature the goodwill ambassadors. Listenersare able to call in and shows feature on-air contests topromote the community and share more complexinformation on malaria. The SMS-based elements of thecampaign are designed to grow in a user-driven way,relying on networks of people to spread malariaknowledge and awareness to their family and friends.Evaluation and ResultsWhile an evaluation of the additional impact of moreinteractive messaging through the “malaria-mobilecommunity” will not be completed until late 2014, initialevidence of the underlying Zinduka! Malaria Haikubaliki!16 mHEALTH COMPENDIUM | VOLUME 3

BEHAVIOR CHANGE COMMUNICATIONcampaign suggested a strong role for mobile phones. Forexample, 3 million Zinduka!-branded malaria messageswere sent via SMS to viewers of the 2011 TanzaniaGospel Music Awards, with 192,000 viewers respondingby SMS to the message to vote for their favorite artistsand receiving additional malaria messages in return (anapproximately 6% response rate).Zinduka! NightWatch community radio programs inTanzania’s Lake Zone in early 2013 also demonstratedan opportunity for more interactive and personalizedprogramming. Over 8 weeks of malaria-themed miniprograms,the community radio stations reported anaverage of 7 listeners calling the station during each 15-minute segment to participate in quizzes and askquestions; these callers used their own mobile phoneswithout any subsidy, highlighting the value they saw.Lessons LearnedUsing trusted and popular spokespeople has beencritical to building a successful behavior changecommunication platform. By using Tanzaniancelebrities and politicians as the faces and voices ofthe campaign, we avoid a common problem: beingviewed as “spam.”The power of music to engage the audience anddeliver key messages is challenging – but worthwhile– to translate from traditional mass media tomobile. The mZinduka! platform is usingdownloadable ringtone/ring-back tones to put ourmalaria anthems in the hands (and ears) ofTanzanians.The additional mobile phone-based elements of theZinduka! campaign are making it possible to harnesssocial networks in a new way. Not only can usersforward messages to their friends, but we are alsolooking at ways to use the social media tools thatare currently growing in popularity in Tanzania tospread malaria messages in a new way.ConclusionThrough developing public-private partnerships and atargeted communications campaign, the NightWatch:Mobile mZinduka! program is able to build a sustainablemobile community for the promotion of malariaprevention and works actively towards the goal of nearzeromalaria deaths in Africa by 2015. Final results fromthe NightWatch mobile expansion will be shared withinthe malaria control community to encourage adoptionof interactive and engaging communication strategies bynational malaria control programs.--------------------------------------------------------Geographic Coverage: TanzaniaImplementation Partners: Malaria No More,Tanzania House of Talent, Vodacom Tanzania, CloudsEntertainmentFunder: mHealth Alliance, Vodacom TanzaniaContact Information:Malaria No More: Hannah Bowen, Director ofResearch & Strategy(Hannah.Bowen@MalariaNoMore.org )Tanzania House of Talent: Ruge Mutahaba, Founderand President (ruge.mutahaba@gmail.com); LillianMadeje, mZinduka! Program consultant(lillian.madeje@gmail.com)mHealth Alliance: Innovation Working GroupCatalytic Grant program, c/o Francis Gonzales, ProgramAssociate (fgonzales@mhealthalliance.org)References: Data from a tracking survey in three regions (Dar es Salaam,Pwani, and Mwanza) conducted in January 2010, March/April2010, July/August 2010, March 2011, and August 2011. Kyagonza P. Workshop Report. Long Lasting Insecticidal NetsProcurement and Supply Management Workshop, held 13–15October 2009 in Geneva, Switzerland. World HealthOrganization, 2009 (http://s3.amazonaws.com/zanran_storage/rbm.who.int/ContentPages/135194378.pdf). Macintyre K, Littrell M, Keating J, Hamainza B, Miller J, Eisele TP:Determinants of hanging and use of ITNs in the context of nearuniversal coverage in Zambia. Health Policy Plan 2012, 27:316–325. World Health Organization. World Malaria Report. Geneva,Switzerland, WHO, 2011. World Health Organization. World Malaria Report. Geneva,Switzerland, WHO, 2012.mHEALTH COMPENDIUM | VOLUME 3 17

WIRED MOTHERSIncreasing skilled delivery attendance to reduce maternal and neonatalmorbidity and mortalityEvery year, approximately 270,000 women die duringpregnancy. Moreover, the risk in Sub-Saharan Africa ismuch larger, 50 times greater than indeveloped countries. Seven million childrenalso die before reaching the age of five, agrowing proportion of these (43%) occurs ator around the time of birth. Therefore,antenatal care (ANC), skilled deliveryattendance and access to emergency obstetriccare are essential in improving maternal,neonatal and child health. In Zanzibar, 99% ofpregnant women attend an ANC visit at leastonce, yet only 51% of births are attended by ahealth professional and more than half do notreceive any postnatal care.Wired Mothers is an mHealth project that seeksinnovative ways to ensure access to ANC andskilled attendance at delivery and to examine thebeneficial impact mobile phones can have on maternaland neonatal morbidity and mortality. In 2009/2010, theUniversity of Copenhagen, in collaboration withZanzibar’s Ministry of Health and Social Welfare and theDanida Health Sector Programme Support, conducted astudy to compare differences in service delivery andhealth outcomes between women receiving the WiredMothers mobile phone intervention and those receivingstandard care.Implementation date: March 2009 to March 2010About Wired MothersThe Wired Mothers mobile phone intervention wasdesigned with the aim of linking pregnant women totheir primary health care provider throughout theirpregnancy, childbirth and post-partum period. Wiredmothers, or mama mitandao, received appointmentreminders and educational information via SMS andwere provided with mobile phone vouchers to enablethem to call a primary care provider to discuss anyacute or non-acute issues. Additionally, mobile phoneswere used by health facility workers, ambulance drivers,and referral hospital employees to strengthencommunication between different levels of the healthsystem.The intervention involved all three levels of the healthsystem.Evaluation and ResultsThe Wired Mothers intervention was evaluated in acluster randomized controlled trial. The study involved2,550 pregnant women (1,311 interventions and 1,239controls) receiving care from 24 primary health carefacilities in six districts in Zanzibar. Within each district,two facilities were randomized for intervention and twofor no intervention (standard care). To ensure mobilephone access, the pregnant women in the interventiongroup received a phone credit voucher.The intervention significantly increased the proportionof women receiving four ANC visits during pregnancy asrecommended by WHO and there was a trend towardsmore women receiving preventive health services, morewomen continuing to attend ANC late in pregnancy andmore women with antepartum complications who wereidentified and referred.The majority of intervention women stated that theappointment reminders influenced their health seekingbehavior and felt that the educational messages helpedthem in various areas, including learning about dangersigns in pregnancy and feeling that the health systemcared for them.Results also showed that the mobile phone interventionwas associated with an increase in skilled deliveryattendance. 60% of the women in the intervention18 mHEALTH COMPENDIUM | VOLUME 3

BEHAVIOR CHANGE COMMUNICATIONgroup, versus 47% in the control group, delivered withskilled attendants. While the intervention had asignificant increase in skilled delivery attendance amongurban women (OR, 5.73; 95% CI, 1.51–21.81), it did notinfluence skilled birth attendance among rural womenLessons LearnedThe Wired Mothers intervention was highlyappreciated by women and health workers.The study demonstrates that simple mobile phoneinterventions that involve community and healthworkers can promote the provision and utilizationof essential maternal health interventions such asANC, skilled delivery care and emergency obstetricsservices.The study has proved that supportive supervision,clear job descriptions (responsibilities) and regularprovision of logistics have the potential to improvestaff moral and performanceThe intervention was developed in Tanzania usingsimple technology and at low cost.The collaboration between a government agency, adevelopment organization and an academicinstitution was efficient and increased the evidencebase for policy makers interested in using mHealthapplications.Simple mobile phone solutions such as WiredMothers are a feasible solution for strengtheningaccess to essential maternal and child health (MCH)services in low-resource settings.ConclusionThe Wired Mothers mobile phone interventionsignificantly increased the number of urban womenreceiving the recommended number of ANC visits andskilled delivery attendance. Evidence-based mobilephone solutions may contribute towards improvedMCH and the achievement of Millennium DevelopmentGoals 4 (to reduce child mortality) and 5 (to reducematernal mortality).The policy implication of the Wired Mothers study isthat developing countries should improve public privatepartnership in the area of health education andinformation and use the momentum of informationtechnology in delivering health services. Specifically,mobile phone interventions should be considered as astrategy to improve provision and utilization of ANC,delivery services and emergency obstetric care, whichare essential for maternal and perinatal health. mHealthinterventions for maternal health should howeverconsider the special needs of rural women.--------------------------------------------------------Geographic Coverage: Tanzania (Zanzibar)Implementation Partners: University of Copenhagen;Ministry of Health and Social Welfare, Zanzibar, Tanzania;Health Sector Programme Support Zanzibar; DanidaHealth Sector Programme SupportFunder: Danida Health Sector Program SupportContact Information:University of Copenhagen: Stine Lund, MD(+4522440789, stine_lund@dadlnet.dk);Danida Health Sector Program Support: BoudewijnPeters, MD (boudewijn.peters@gmail.com)Zanzibar Ministry of Health: Maryam Hemed, MD(+251927361823, hemed32@yahoo.com)References:1. Wired mothers - use of mobile phones to improve maternal andneonatal health in Zanzibar. Danida Research Portal. 12 March2013. Web.2. mHealth Info. Wired Mothers. November 2010. Web.3. Lund, S. 2009, Wired Mothers - Use of Mobile Phones toImprove Maternal and Neonatal Health in Zanzibar,Presentation, Institute of International Health of the Universityof Copenhagen.4. Lund S, Hemed M, Nielsen B, Said A, Said K, Makungu M, RaschV. Mobile phones as a health communication tool to improveskilled attendance at delivery in Zanzibar: a cluster-randomisedcontrolled trial. BJOG 2012;119:1256–1264.5. Wired Mothers Project Team 2009, Wired Mothers - Use ofMobile Phones to Improve Maternal and Neonatal Health inZanzibar, FFU Application.mHEALTH COMPENDIUM | VOLUME 3 19

DATA COLLECTION

CHILD PROFILING SURVEYProviding critical MNCH services to women at the bottom of the pyramidCivil society groups play a critical role in the fightagainst HIV and AIDS, especially in countries such asSwaziland where the HIV prevalence is 31% amongadults 18 to 49 years old. However, weaknessesamong these groups, including challenges with time,staff, funds, knowledge and systems to effectivelycollect and report data, have led to a critical need forcapacity building. One of the key capacity challengesPact Swaziland identified in local organizations is theirlimited ability to use their data for effective programplanning and budgeting. Since 2010, Pact Swaziland hasbeen implementing the Community REACH programto provide capacity building services to civil societyorganizations to help them deliver effective HIVprevention, care, treatment and impact mitigationservices. Additionally, they are focusing oncapacitating local organizations to use improvedmonitoring and evaluation strategies for evidencebasedservice deliveryIn reviewing a variety of mHealth platforms, PactSwaziland noted that the costs of mHealth technologieswere generally less expensive, less time consuming andless prone to data entry errorsthan traditional methods of datacollection, entry and analysis. Thecountry’s mobile phone networkcoverage of over 80% and 73%penetration would allow thesetechnologies to reach even themost marginalized and ruralbeneficiaries. Pact Swaziland,therefore, began building thecapacity of six civil societyorganizations to use mHealth toenhance service delivery and datacollection procedures as a way toimprove their monitoring andevaluation systems and strengthenthe evidence behind their programimplementation. They supportedthese organizations in developingconcept notes around sixstrategies for mobile phones usagein specific programs. This wasfollowed by tailored technicalassistance to implement each strategy, including assistingorganizations in selecting appropriate mobile platforms,developing cost-analyses comparing paper-based surveysand mobile phone data collection, conducting training onplatforms, helping to troubleshoot any issues that aroseduring implementation, and supporting use of data fordecision making. The focus of this case study is on twoof the six organizations, Save the Children Swaziland(SCSWD) and the Coordinating Assembly of NGOs(CANGO).Implementation date: May 2013About Child Profiling SurveyIn May 2013, Pact Swaziland began piloting mobile datacollection technologies in partnership with SCSWD andCANGO. The Mobenzi platform was selected for use ina child profiling exercise of 10,244 orphans andvulnerable children (OVC). The survey looked at fourkey service needs: child protection, education, childabuse and psychosocial support needs. Through thissurvey, SCSWD, with support from Pact Swaziland and22 mHEALTH COMPENDIUM | VOLUME 3

DATA COLLECTIONCANGO, gathered data for key programmatic andbudgetary decisions to improve and provide targeted,quality services to OVCs throughout Swaziland. Thepilot project used Android phones to collect data. GPScoordinates were also collected to map servicecoverage and target areas with the highest needs.Evaluation and ResultsOf the 10,244 children surveyed, nearly 3,000 childrenwere orphans, while 7,284 were determined to bevulnerable. Additionally, 2,993 children did not havebirth certificates or national IDs. The survey alsoassessed school attendance, showing 331 children haddropped out of school primarily because they could notpay school fees or became pregnant or ill. The surveyalso found that 386 children had been abused, of which224 had not yet reported the abuse.As a result of these data, SCSWD realigned its budgetto cover the programmatic and administrative costs ofproviding targeted services to the children identified inthe survey. Having GPS data at the household levelallowed for budgeting of staff time and fuel costs forproviding the services, as well as key programmaticcosts such as assisting children to obtain their necessarynational documents. SCSWD was also able to redesignits program to provide specialized support for school re-entry of children who dropped out due to lack ofschool fees or pregnancy. Lastly, they developed a planto provide health care linkages and home visit supportfor children who reported dropping out of school dueto illness.Lessons LearnedTraining and on-going mentorship of civil societyorganizations during the start-up phase is essentialto ensure that staff are fully capacitated to integratethe mHealth technologies into their routine datacollection and monitoring activitiesReal time data allows civil society organizations tomake quick, evidence-based programmaticadjustments without having to wait for the end of along data collection period where summary data andtrends are not available until several months laterMost mHealth platforms have built in data securitysystems to ensure that lost mobile phones do notcompromise confidentiality of the dataConclusionCivil society organizations often do not have systems inplace to track data that will demonstrate the outcomesof their community and household level interventions.These organizations can be capacitated to use innovativemHealth technologies to solve their data collection,reporting, and usage challenges in such a way thatprogram evaluation becomes integrated with programdelivery. As a result, the body of evidence supportingthe important and unique role that civil societyorganizations play in the HIV response will grow andbecome better understood.--------------------------------------------------------Geographic Coverage: SwazilandImplementation Partners: Pact Swaziland, Save theChildren Swaziland, Coordinating Assembly of NGOsFunder: USAIDContact Information:Pact Swaziland: Nicole Miller, Country Director(+26824045579, nmiller@pactworld.org)Save the Children Swaziland: Dumisani Mnisi,Executive Director (+26824047731,dmnisi@savethechildren.org.sz)CANGO: Emmanuel Ndlangamandla, Executive Director(+26824044721, director@cango.org.sz)USAID: Natalie Kruse-Levy, Country Director, USAIDSwaziland (+26824043100, nkruse-levy@usaid.gov)References:1. Skovdal et al: Community Groups as Critical Enablers of the HIVResponse in Zimbabwe. BMC Health Services Research 2013,13: 195.2. Swaziland HIV Incidence Measurement Survey (SHIMS) FirstFindings Report, November 2012.mHEALTH COMPENDIUM | VOLUME 3 23

GLOBAL TRACHOMA MAPPING PROJECTGIS mapping to achieve the Global Elimination of Blinding Trachoma by 2020Trachoma is a neglected tropical disease (NTD) thataffects over 21 million people and is endemic in 53countries. While it has been eliminated in mostdeveloped countries, it is still the world’s leadinginfectious cause of blindness and affects the poorestcommunities. Women and children living in hot, dryand dusty areas with poor access to water andsanitation are especially susceptible. An estimated 229million people worldwide live in highly trachomaprevalent areas and are at risk of going blind ifrepeated infections are left untreated. Ethiopia is themost adversely affected country by Trachoma. InOromia and Tigray regions alone, over 30 millionpeople are at risk.To aid in identifying, treating and eliminating trachoma inEthiopia and worldwide, the International TrachomaInitiative (ITI), NGOs and academic institutions, led bythe UK non-profit Sightsavers, launched the GlobalTrachoma Mapping Project (GTMP). The GTMP is thelargest disease-mapping project ever attempted. In twoand one half years, up to 4 million people will besurveyed in over 1,200 suspected-endemic districts inmore than 30 countries, including more than one-thirdof African countries. Mapping will be completed byMarch 2015 to facilitate countries implementation of theSAFE Strategy (Surgery, Antibiotics, Facial cleanliness,Environmental improvement) to treat and preventtrachoma and reach the WHO-endorsed GlobalElimination of Blinding Trachoma by 2020 (GET2020)target.Data from household surveys are collected onsmartphones via the LINKS System. ITI is the stewardfor the data, which are made available in categoricalform on open-access disease maps on the TrachomaAtlas website (www.trachomaatlas.org).Implementation date: December 2012About Global Trachoma MappingOver 300 survey teams have already been trained togather prevalence data. Each team is comprised of onegrader and one data recorder who are supported bycoordinators, drivers, field supervisors, local guides, andlogistics and finance personnel.Field data are collected using the ArcGIS mappingplatform and Open Data Kit-based software, a flexiblesmart phone-based tool that runs on devices using theAndroid operating system. Global Positioning System(GPS) readings are also taken for every householdsurveyed. Data are then securely transferred from thefield to a central web-based reporting and datamanagement tool, where they are quickly analyzed,approved and shared by Ministries of Health, using adynamic web-interface. WASH (waster, sanitation andhygiene) and other NTD mapping is also conducted togain a broader picture of poverty and developmentissues affecting trachoma endemic populations. If there islimited cellular connection, data are stored in the mobiledevice’s micro SD card and uploaded when the surveyteam can access the internet or a cellular connection.Data will be available in-country through the country’sown Health Management Information System. Onceapproved by the MOH, data are published, shared andupdated through the open-access Trachoma Atlaswebsite which contains free country maps withpopulation-based trachoma prevalence data at thedistrict level.Evaluation and ResultsIn June of 2013, trachoma prevalence data collected by40 survey teams as part of the project's first phase inEthiopia’s Oromia (252 districts) and Tigray (48districts ) regions was approved by the Regional HealthBureaus and the Ethiopian Federal Ministry of Health.This gives health officials the ability to plan trachomaelimination programs for over 30 million people at riskin these areas.As of September, 1 million people in Ethiopia, Nigeria,Malawi, Mozambique, Solomon Islands and Yemen havebeen checked for trachoma.Lessons Learned Standardization is key to scale-upExternal support is welcomed by countries andcommunities24 mHEALTH COMPENDIUM | VOLUME 3

DATA COLLECTIONGeographic Coverage:WorldwideElectronic data capture and web-based review offersignificant advantages over paper-based data captureand discussion via emailTraining teams in new (not home) environmentsallows them to learn more effectivelyConclusionThe Global Trachoma Mapping Project is providingaccurate, rapid and robust data. It will aid partners,MOHs, and other organizations in tailoring trachomaelimination programs to produce a more integrated,efficient and evidence-based global response totrachoma and reduce the devastating personal andeconomic impact on those affected by the NTD. Theproject will assist endemic countries in establishing theSAFE strategy by 2015, thereby allowing time to achievethe World Health Assembly’s goal of Global Eliminationof Blinding Trachoma by 2020 (GET2020)----------------------------------------ImplementationPartners: InternationalCoalition for TrachomaControl, African Medicaland Research Foundation,CBM, Blantyre Institutefor CommunityOphthalmology, FredHollows Foundation,Helen KellerInternational,International TrachomaInitiative, Johns HopkinsUniversity, KilimanjaroCentre for CommunityOphthalmology, Light forthe World, LondonSchool of Hygiene &Tropical Medicine,Mission to save theHelpless, Orbis,Organisation pour la Prévention de la Cécité, Sightsavers,The Carter CenterFunder: UK Department of International Development(DFID)Contact Information:Sightsavers: Freya Paleit, Global Media Manager(fpaleit@sightsavers.org)DFID: Iain Jones, Economic Adviser, Health ServicesTeam, Human Development Department (I-Jones@dfid.gov.uk)References:1. Sightsavers. Ethiopia completes trachoma mapping in tworegions. June 24, 2013. Press Release.2. Sightsavers. Global survey to identify 180 million at risk ofblinding disease begins in Ethiopia. Date unknown. Press Release.3. Sightsavers. Trachoma. No date. Web.4. Mapping the world’s trachoma hotspots. IRIN Global. 2013.Web.5. ArcNews. Winter 2012/2013. GIS Helps fight world’s leadingcause of preventable blindness.mHEALTH COMPENDIUM | VOLUME 3 25

MALARIA CONTROL PROGRAMA mobile rapid reporting system to strengthen surveillance in support of malariaeliminationIn Zambia, malaria affects over 4 million people eachyear, accounting for 30% of outpatient visits and 8,000annual deaths. Over 50% of these deaths are childrenunder five years of age and about 20% of maternalmortality is attributable to malaria. However, in thelast several years, advances in prevention andtreatment have resulted in marked reductions inillness and deaths from malaria. The National MalariaControl Program set a goal of malaria elimination infive zones.Through the use of both new and existing tools and amore focused strategy, The Malaria Control andEvaluation Partnership in Africa (MACEPA), a programat PATH, is partnering with the Government of Zambiato chart its way toward this goal. MACEPA hassupported the Ministry of Health in designing andintroducing a rapid reporting system that recordsspecific points of malaria burden and commodity dataeach week and sends the data to a central server bymobile phone. The information is immediately availableto program managers at district, provincial, and nationallevels, allowing them to monitor and respond faster toprevailing conditions on the ground, avoid stock outs,and better target interventions.Implementation date: January 2011About MACEPAUsing District Health InformationSystem (DHIS2) open sourcesoftware and its Java-based MobileClient, staff at the clinics reportweekly on small carefully chosendata sets that includes the numberof tests done, number of positivetests, number of people givenmalaria treatment and stockinformation. Low-cost mobilephones and prepaid SIM cards aresupplied to the health workers.The system also extendssurveillance into the communitieswithin the health facility’scatchment area through a networkof community health workers (CHWs). A speciallytrained Data Community Health Worker (DCHW) isgiven the responsibility for reporting data into theDHIS2 server for groups of CHWs to improve on thedisaggregation of focal transmission sites. The DCHWreceives reports from the other CHWs on a monthlybasis, concentrating data entry training to a smallergroup of health workers and creating a cluster of datacollectors around one reporter.Only the DCHW is given a reporting mobile phone atthe start of the project, but by consistently reportingtimely data over a period of time, the other CHWs areable to work towards a cheaper non-Java-enabledphone. Both the DCHW and CHW receive an incentivein the form of airtime to mobile phones, improvingcommunication channels locally for responding tomalaria infections and the ability to report by DCHW.The phone and credits earned are used as a work tool,making it easier for clinic staff to reach individual healthworkers to alert them to malaria cases that requiretheir attention. The DCHW and CHWs are also given asmall financial incentive for completing the reportingwork, based on timely reporting.Evaluation and ResultsOver 800 mobile phones in 23 southern Zambiandistricts have been equipped with DHIS2 software.Nearly 600 facilities have been trained, and an additional1,200 CHWs report data through their catchment area’sDCHW. Interactive dashboards of malaria surveillanceand commodity data are available online. Data auditswere conducted against the national health managementinformation system (HMIS) and the malaria system alsorunning on DHIS2 to identify process barriers to betterdata. An assessment was done on the use of these data.It revealed that the Rapid Report system to be a goodmonitoring tool for acquisition of timely data being usedby district managers to improve malaria control in theirareas, including identification of mentorship needs,indoor residual spraying and insecticide-treated netsdistribution, focal testing and treating, as well as stockmanagement.26 mHEALTH COMPENDIUM | VOLUME 3

DATA COLLECTIONProviding low-end phones with ‘justenough’ capabilities reduces costs andrisks of investments in the phonesprovided.Training is critical for supportingDHIS2 nationally and requires finding atraining partner for the system.Tying reporting of data to talk timeallocations encourages reporting andaccountability at the end user level.ConclusionThe malaria surveillance system deliversreal time data for monitoring the diseaseburden and can be used as an evidencebaseddecision-making tool for eliminatingmalaria in Zambia’s five targeted zones.--------------------------------------------------------Lessons LearnedIntegrating within the national HMIS system allowswider stakeholder buy-in. Rolling out the mobileplatform helped leverage additional developmentson the main HMIS system, including establishing thecommunity level HMIS system.DHIS2 is a complex system. Having a large andconsistent user base in-country is the best way todevelop communities of practice for data sharing,problem solving and learningThe cost of hosting a local server can be expensiveand may require dedicated technical skills that alsoare expensive. A hosted server option, such asAmazon Web Services or Linode.com, minimizesserver deployment and maintenance costs andworks well for these efforts.Using a platform such as DHIS2 that works acrosscellular network providers allows local users to usethe network with the best local coverage.Geographic Coverage: Southern half ofZambiaImplementation Partners: PATH MACEPA, ZambiaMinistry of Health, Akros Research, Inc.Funder: The Bill & Melinda Gates FoundationContact Information:PATH: John Miller, Senior Malaria Technical Advisor,MACEPA (jmiller@path.org)References:1. Unicef. Zambia Fact Sheets: Malaria. No Date. Web.2. DHIS2. Mobile community reporting. Using DHIS2 Java clientsfor Malaria community reporting in Zambia. No Date. Web.Photo credits: Anne Jennings (opposite page); Todd Jennings (samepage)mHEALTH COMPENDIUM | VOLUME 3 27

REAL-TIME BIOSURVEILLANCE PROGRAMUtilizing information and communication technologies to improve early detectionand notification of infectious disease outbreaksEpidemiology Unit Officials in India and Sri Lankaface problems in receiving health information in atimely manner which would enable the preventionof diseases from reaching epidemic states.Statistics on a priority list of infectiousdisease data, from regional and community healthcenters, continue to be gathered and analyzedlargely through paper-based forms andprocedures, and notifications are issued from theregional health administrations to local authoritiesusing paper-based reporting. Experts in the field ofbiosurveillance and health informatics have arguedthat improvements in disease detection andnotification can be achieved by introducing moreefficient means of gathering, analyzing, and reportingof data from multiple locations as well as on a largerset of disease and syndromic information. NewInformation and Communication Technologies (ICTs)are regarded as an important means to achieve theseefficiency gains.The Real-Time Biosurveillance Program (RTBP) was amulti-partner research initiative that studied thepotential for new ICTs to improve early detection andnotification of disease outbreaks in Sri Lanka and India.RTBP established a pilot project involving village-levelnurses in select districts, and an attempt to scale up theproject began in March 2011 based on evaluation of thepilot.Implementation date: June 2008 to December2010About RTBPRTBP provides the ability to detect and monitor a widevariety of health events involving communicable, noncommunicable,reportable and non-reportable diseases,and follows WHO’s general recommendations fordisease surveillance systems. The RTBP infrastructure iscomposed of an interconnected network betweenhealthcare workers via a mHealthSurvey mobile phone(J2ME) application, T-Cube web interface (TCWI) andSahana Messaging/Alerting Module. Village level nursesare provided mobile phones with the mHealthSurveycustom software installed to message individual outpatientdata in a prescribed format that is transmitted toa centralized database. The ICT system utilizes GeneralPacket Radio Service (GPRS), while also storing recordson the phone during times of limited or no connectivity.Health facility health records, such as demographicinformation, symptoms, suspected and diagnoseddiseases are collected through the mHealthSurvey thatfeeds into the TCWI, a browser-based statistical analysissoftware tool that uses cutting edge algorithms todetect adverse events. Health officials are notified of theadverse events using the Sahana Alerting modulethrough SMS, email and web. Sahana is a free and opensource software collection of disaster managementmodules that work as a platform for integrating multiorganizationresponse efforts that provide criticalinformation to responders’ communication needs.Evaluation and ResultsInitial findings show significant efficiency gains in terms ofdisease reporting, outbreak detection, and healthalerting. Over the 15-month study, the project’s threecomponents were successfully integrated into anoperational system, which collected more than 450,000and 130,000 patient records in Sri Lanka and India,respectively. A cost analysis also identified 35% savingsin both countries when compared to the existingsystems. Public Health Inspectors in Sri Lanka were ableto detect a Chickenpox outbreak well in advance sothey were able to notify the regional healthcareworkers, enabling them to be better prepared. Similarly,28 mHEALTH COMPENDIUM | VOLUME 3

DATA COLLECTIONNurses in India detected diarrhea outbreaks andidentified the source of origin, which was a religiousfestival gathering. The value of collecting data on noncommunicablediseases and non-priority communicablediseases were evident when TCWI revealed trends andpopulation segments in specific geographic locations thatwere vulnerable to life-style-associated and respiratorydiseases. Central healthcare workers were takingadvantage of the Sahana Alerting tool to shareinvestigation information with field-level healthinspectors through SMS. Previously, the inspectorswould have had to make a long journey to the centraloffice to collect this paper-based information, and then,return to their village to conduct the investigation.Lessons LearnedFrontline health workers found the standard mobilephone numeric keypad difficult to use, particularlywhen entering large numbers of recordsMany records entered into the system containederrors that could likely be eliminated throughimproved user interface design and a mobile phoneapplicationWhile desktop computers, provided by thegovernment, were harder to maintain and not oftenused, healthcare workers took it upon themselvesto maintain the mobile phones as they served a dualpurpose for both official and personal use.TCWI was able to apply statistical methods todetect data inconsistencies and entry errors; whichthe project verified as a result of occasional falsereporting to maintain statistics to implicate jobsecurityConclusionThe project demonstrated that new ICTs candramatically reduce turnaround time for outbreakdetection and alerting from weeks to a matter of daysor even hours. It also demonstrated the feasibility ofusing low-cost mobile phones and existing commercialcellular infrastructure and services to enable affordable,real-time reporting of patient records from communityhealth centers. However, further research is needed tobetter understand the challenges associated with scalingsuch a system up to a regional or national level. Furtherwork needs to be done to optimize data entry over lowcost mobile devices, to address usability and trainingrequirements for the analytics platform, and to continueto enhance and integrate health notification into nationaland regional systems and practices.--------------------------------------------------------Geographic Coverage: India, Sri LankaImplementation Partners: Carnegie Mellon University'sAuton Lab, USA; Epidemiology Unit, Ministry of Health andNutrition, Sri Lanka; Indian Institute of Technology-Madras;LIRNEasia; National Center for Biological Science,Bangalore, India; National Institute of CommunicableDiseases, Ministry of Family and Welfare, Tamil Nadu,India; Sarvodaya Shramadana Movement; University ofAlbertaFunder: Canada’s International Development ResearchCenter (IDRC)Contact Information:Partner Name: Nuwan Waidyanatha, Senior ResearchFellow (nuwan@lirneasia.net)IDRC: Laurent Elder, Program Officer (lelder@idrc.ca)References:1. Sampath, W.G.C. et al. 2010, Real-time Bio-surveillance PilotProgramme in Sri Lanka: Lessons Learned, Sri-Lanka Journal ofBio-Medical Informatics 1(3): 139-1542. Gow G.A. et al. 2010, Using Mobile Phones in a Real-TimeBiosurveillance Program: Lessons from the Frontlines in SriLanka and India, 2010 IEEE International Symposium onTechnology and Society (ISTAS ’10), Wollongong, New SouthWales, Australia3. Waidyanatha, N.2010, Evaluation of an InformationCommuniation Technology Pilot in Support of Public Health inSouth Asia, International Development Research Center4. Waidyanatha, N. 2008, Real-Time Biosurveillance Program: AResearch Proposal, LIRNEasiaPhoto credits: LIRNEasiamHEALTH COMPENDIUM | VOLUME 3 29

ZIDISolution design, testing and national scale-up of an enterprise healthmanagement systemGathering reliable, retrievable and timely informationon service delivery and other key indicators is animportant step in improving health outcomes. MobileHealth Management Information Systems (HMIS) canhelp with this process. Additionally, the private sectorcan play a key role in the design, development andtesting of such systems, especially when it is not heldto the scope and scale-related constraints that comewith grant-funded projects.ZiDi is an innovative cloud-based enterprise healthmanagement system developed by MicroClinicTechnology, Ltd., a Nairobi HMIS company. ZiDi’srobust, easy-to-use and integrated design has primed itfor large scale use in the public and private sectors. Totest the system, a pilot of the ZiDi was undertaken inKisumu County in September 2012. The successful 12-month pilot led to ZiDi’s approval for use in publichealth facilities by the Government of Kenya.Implementation date: September 2012About ZiDiZiDi is a cloud-based software service that iscurrently optimized for use in dispensaries, healthcenters and out-patient departments. It allows healthworkers to record and access patient data at any timewith web-enabled devices, preferably tablets. Regardlessof connectivity, a health worker can enter a patient’sdemographic information, health parameters, symptoms,tests, diagnosis and prescribed drugs when offline.ZiDi automatically uploads the data to the cloud onceconnectivity is reestablished. ZiDi also assists healthworkers to adhere to clinical protocols, tracksprocedures and services performed, lab tests orderedand results in a manner that facilitates supportivesupervision, monitoring and evaluation of the quality ofcare offered. Drug inventory and facility revenues andexpenses are also tracked. Patients who default on visitscan be easily identified and contacted via outboundtargeted or generic text messages. Data archived inZiDi can be easily retrieved and exported as an Excelfile for offline analytics. Auto-generated serviceutilization, financial and inventory reports facilitatedecision-making by the health workers and districtmanagement teams. Through tracking the productivity ofhealth workers, it enables the MOH, in collaborationwith the county governments, to correlate resourceallocation with productivity in a health facility.ZiDi is also interoperable with multiple existinginformation systems. Service utilization data areexportable into a District Health Information System(DHIS2). Consumption data on all essential medicinesand medical supplies are exportable into the KenyaMedical Supplies Authority’s (KEMSA) logisticmanagement information systems. Lastly, data from themaster facility list can be uploaded into ZiDi toupdate facility profiles.Evaluation and ResultsZiDi has been successfully piloted in dispensaries andhealth centers in Kisumu County. Frequent andconsistent feedback from health workers and districthealth management teams has been incorporated intoZiDi to improve the system. More than 95% ofreports generated in ZiDi matched those housed inthe facility. Fifteen health workers are currently usingZiDi and have fully adopted the system within theirpractice. Patients also report enhanced service deliveryand quality of care at the pilot sites. ZiDi has alsoeliminated the need for health workers in the pilot sitesto manually quantify and forecast their 90-day supplies.Instead, this information is readily available from ZiDi.The system also allows the Kenya Medical SuppliesAuthority (KEMSA) to monitor consumption, rationaluse and stock levels in real-time. Benefits such asimproved health worker efficiency, enhanceddecentralized decision-making, and improved clinicaldecision-making are invaluable attributes of ZiDi. It isalso easy to adopt and use.Lessons LearnedIt is important to incorporate end user feedbackinto the design of mHealth technology.Government entities should be active partnersthroughout the entire development and pilotingprocess.30 mHEALTH COMPENDIUM | VOLUME 3

DATA COLLECTIONPlan ahead for various scenarios to better anticipateadverse situations that may impact scale up of theproduct and program.When thinking about sustainability, keep in mind therole of different stakeholders, including those inheadquarters and those in the field.While open source systems are often preferred, it isimportant to note any limitations they may haveregarding integrated needs of the health systems.ConclusionZiDi’s offers an integrated approach to data collectionthat ensures health workers have constant access topatient data even in remote rural health settings, andprovides access to real-time monitoring of diseasetrends and inventory, thereby, preventing drug stockouts.Designed to streamline reporting, it accords theMOH and other health officials access to up-to-date,web-based reports in real time, serving as a valuableresource for future decision-making and supportivesupervision. By incorporating accountability into ruralhealthcare, it provides the necessary foundation toimprove health outcomes in Kenya.--------------------------------------------------------Geographic Coverage: KenyaImplementation Partners: Government of Kenya |Kenya Medical Supplies Authority | MicroClinicTechnologies | OGRA Foundation | Microsoft 4 Africa |Yahclick – SimbaNet, Kenya | Samsung/SafaricomFunder: Public-private partnership between private equitypartners and Government of KenyaContact Information:MicroClinic Technology: H. Moka Lantum, MD. PhD,SM, Managing Partner (+1585 820 6403, +254715459584,moka.lantum@microclinictech.coml)Kenya Medical Supplies Authority: Dr. John Munyu,MBS, Chief Executive Officer (+254(20)3922000, +254719033000, john.munyu@kemsa.co.ke)References:1. Com World Series. Find out more about ZiDi, the mHealthapplication winner of the Top App award at East Africa Com2013. 11 July 2013. Web.2. ZiDi -- An Enterprise Management System for Rural HealthCenters by MicroClinic Technologies. 3 October 2012. Video.mHEALTH COMPENDIUM | VOLUME 3 31

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INTERACTIVE ALERTSImproving vaccine coverage through small incentivesAn estimated 17% of the 8.8 million deaths worldwideeach year in children under five are attributed tovaccine-preventable illnesses. Despite majorimmunization coverage efforts through Pakistan’sExpanded Program on Immunization (EPI), low ratesof uptake and delayed immunization leave childrenvulnerable to diseases that are vaccine-preventable.Provinces report full immunization coverage ratesfrom 40% to 80%. Additionally, there are limited dataidentifying whether vaccines were administered at age-appropriate times during infancy.Through education and small incentives, InteractiveResearch & Development (IRD) hopes to decrease theburden of vaccine-preventable diseases by increasing theimmunization coverage and timeliness among Pakistanichildren. IRD, in collaboration with the Government ofPakistan and the Department of Health in SindhProvince, implemented Interactive Alerts, a mobilephone-based vaccine registry system that uses SMSreminders to caregivers and conditional cash transfersto care givers and health workers to improveimmunization coverage among children in and aroundKarachi, Pakistan.Implementation date: June 2012About Interactive AlertsInteractive Alerts offers child tracking and referral viageneral packet radio service (GPRS) using near fieldcommunication (NFC) mobile phones and radiofrequency identification (RFID) tags. It provides a J2MEmobile client application for data collection and a webbased server side application for data monitoring andstorage. Plans are to release the android version of theapplication in November 2013.A child’s caregiver first enrolls in a lottery system duringan EPI center visit and then receives SMS remindersabout vaccination appointments. To assure each childcompletes the scheduled vaccines on time, healthworkers also individually track enrolled children usingthe mobile phone-based RFID system. The amount ofcash the caregiver is eligible to win increases with eachsubsequent vaccine their child completes. Caregiversreceive higher cash amounts for vaccinations that areadministered at the recommended age. After winningthe lottery, the caregiver is sent a winning lottery codevia SMS. The lottery winnings can be used at theparticipating stores offering groceries and medicineslocated in close vicinity to each EPI center, and codescannot be exchanged for cash. Each time a lottery prizeis won, the health worker who administered thevaccination also receives a mobile money transferpayment through Easypaisa, equivalent to 40% of thelottery prize. Easypaisa is a mobile banking serviceoffered through Telenor Pakistan cellularcommunications, in partnership with Tameer BankMicroFinance.Evaluation and ResultsThe pilot phase started in June 2012 and has enrolledmore than 14,000 infants from 12 public and privatesector EPI centers in Karachi.Interim data analysis suggests improved immunizationcoverage and timeliness. Currently, an impact evaluationstudy is underway to determine the effectiveness ofInteractive Alerts in improving immunization coverageand timeliness in children, performance of vaccinators,and the accessibility and quality of program data.Scale-up of the project will begin in January 2014 with atarget of reaching another 100,000 children fromKarachi over the period of one year.Lessons LearnedVaccinators are enthusiastic about using a cell phonedata entry system for recording immunizationevents. mHealth Innovation leverages existingresources and personnel and increases theirefficiency compared to the existing paper-basedrecord keeping system.Lottery-based conditional cash transfers incur lowcosts and have the potential to induce positivebehavior change in caregivers for improvingimmunization and improve performance ofvaccinators34 mHEALTH COMPENDIUM | VOLUME 3

FINANCEFigure 1. Participant flowConclusionSmall incentives can prove beneficial in public healthprograms. Through SMS reminders and a lottery system,caregivers are encouraged to bring in their children fortimely vaccinations and health workers are incentivizedto provide efficient vaccination services. Together, theseinnovative strategies help prevent needless childhooddeaths and illnesses associated with vaccine-preventablediseases.--------------------------------------------------------Geographic Coverage: PakistanImplementation Partners: Interactive Research &Development (IRD) | Expanded Program on Immunization(EPI), Sindh Province, Government of Pakistan |openXdata.org; Indus Hospital | Johns Hopkins BloombergSchool of Public HealthFunder: mHealth Alliance, Community Health SolutionsContact Information:IRD Pakistan: Subhash Chandir, Director of VaccinesProgram (subhash.chandir@irdresearch.org) | Asad Zaidi,Medical Epidemiologist (asad.zaidi@irdresearch.org) | SairaKhowaja, Director of Program Development(saira.khowaja@irdresearch.org)mHealth Alliance: Francis Gonzales, Program Associate(Fgonzales@mHealthAlliance.org)References:1. eHealth. Interactive Research & Development. No date. Web.2. Global immunization data. WHO and UNICEF, October 2012.Web.3. Hasan Q, Bosan AH, Bile KM. A review of EPI progress inPakistan towards achieving coverage targets: present situationand the way forward. East Mediterranean Health Journal, 2010,16 Supplement:S31–S38. Web.4. Pakistan Demographic and Health Survey 2006–2007. Islamabad,Pakistan, National Institute of Population Studies and MacroInternational Inc., 2008.5. World Health Organization. IRD – Interactive Alerts for VaccineCoverage (Pakistan). Project Profile. 2013.mHEALTH COMPENDIUM | VOLUME 3 35

mHEALTH FOR SAFER DELIVERIES: EZYPESA MOBILE BANKING SERVICEA mobile money transfer service for traditional birth attendantsIn response D-tree International, in collaboration withEtisalat Group telecommunications and their localmobile service provider, Zantel, is utilizing mobiletechnology to meet this challenge through thecombination of mobile decision support, data storage,on-line banking and communications on a single deviceat the point of care. mHealth for Safer Deliveries is acomplete suite of services enabling traditional birthattendants (TBAs) and midwives to ensure saferpregnancies and deliveries. It not only enables healthworkers to quickly and accurately identify obstetricemergencies, but also features Ezy Pesa, a mobilebanking service that assists them in arranging obstetricrelatedtransportation for the pregnantwoman to a health facility where shecan receive appropriate care.Implementation date: October2011 to December 2014About Ezy PesaThe application provides a step-by-stepprotocol for the following: identifyingdangers signs during labor and delivery,the phone number of vehicle ownerswho can transport the patient on anemergency basis, access to money onthe phone to pay the vehicle owner fortransportation, a record of permissionsneeded from the family or localdecision makers to transport motherand infant in case of emergency, andthe ability to contact the referralfacility so they can be prepared for thepatient’s arrival.Most women, especially in low-income countries,continue to deliver at home for a variety of reasons,including cost, preference, culture and lack ofinformation. In Zanzibar, half of all pregnant womendeliver from home and only one-third of mothers andnewborns receive timely postnatal checkups. Homedeliveries can, in part, be made safer by assuring theprovision of adequate care.Mobile banking accounts were established for the TBAsworking with the project. After registering them withtheir mobile banking accounts, Zantel assisted with theproject by opening pay points in the project areas andby providing training to the TBAs on Ezy Pesa.Additionally, D-tree worked with the health facilities andthe villages to identify appropriate transport providers,enroll them in the program and pre-negotiate rates.Once a month, D-tree calculated cost estimates basedon the TBAs’ total expected delivery estimates for themonth. This was transferred to the D-tree Ezy Pesaaccount, and then using either a mobile phone or theInternet, the money was transferred to the TBAs’mobile banking accounts.Evaluation and ResultsThe Zanzibar Ministry of Health and Social Welfare(MoHSW) helped develop the project and select twopilot areas, the North A District of Unguja and theMicheweni District of Pemba, based on their low facility36 mHEALTH COMPENDIUM | VOLUME 3

FINANCEdelivery rates. Twenty-four TBAs were also trained touse the mHealth application.During the first phase, which ran until April 2012, theseTBAs successfully registered 682 pregnant mothers, ofwhich 211 delivered during the implementation period.Health facilities and hospitals in the project areas alsosaw their in-facility delivery rates more than double onaverage, and there were no maternal deaths recordedamong the registered mothers.In the second phase, the project is now being used byover 200 TBAs and CHWs who have registered nearly7,000 women, and the facility delivery rate stands atover 70%.As referrals and post-partum visits are made, the TBAswithdraw funds from the pay points and pay themselvesand/or the drivers. Timely transfers of the money leadto smooth transactions and fast turnaround ofpayments. Lastly, the average cost per deliveryamounted to $22.26, a minimal expense for ensuring thesafety of a mother during her pregnancy.Lessons LearnedIt is important to take into account local culturalpreferences and sensitivities during the applicationdevelopment process.When possible, provide a vertical integration ofvarious mobile services, such as mHealth and mobilemoney, to enhance program impact.mHealth program models should be scalable andsustainable, creating incentive and/or revenue for allparties involved.There should be an educational and trainingcomponent, as well as opportunities for end-usersto provide feedback which can be applied toongoing application optimization.Closely collaborate with various stakeholders andengage the government from the early stages ofproduct development.Investment in systems to reconcile the mobilemoney (financial) and mobile health (programmatic)data, while time consuming, can greatly facilitatescale up.ConclusionThe combination of mobile decision support, datastorage, on-line banking and communications on a singledevice at the point of care will lead to more successfulmaternal health outcomes and a greater potential formeeting MDG5.--------------------------------------------------------Geographic Coverage: Zanzibar, United Republic ofTanzaniaImplementation Partners: D-tree International, Etisalat,Ministry of Health, ZanzibarFunder: The Bill & Melinda Gates FoundationContact Information:D-tree International: Marc Mitchell, President (+1-617-432-6322, mmitchel@hsph.harvard.edu)Etisalat: George Held, Vice President – Commerce,(+971506171225, gheld@etisalat.ae)The Bill & Melinda Gates Foundation: Ken Warman,(+1-206-369-9083, Ken.Warman@gatesfoundation.org)References:1. Etisalat. Mobile Baby: Building Scalable Sustainable BusinessTogether. No Date. PowerPoint Presentation.2. Group Corporate Communications. Etisalat CSR & SustainabilityReport 2012.3. International Business Awards: Etisalat Group CSR Program.Stevie Awards. 2013. Web.4. Joan Justice. Mobile Health Around the Globe: mHealth andSocial Networking in Rural Tanzania. Healthworks Collective. 16April 2012. Web.5. Mojca Cargo. What is the role for Mobile Operators in MDG 4?A look at Etisalat’s Mobile Baby service. GSMA: mHealth. 20September 2012.mHEALTH COMPENDIUM | VOLUME 3 37

PONA NA TIGO BIMAHealth microinsurance utilizing mobile phone-based claim paymentsWorld Bank studies have found that poor health andthe inability to access health care are key factorsleading to, and resulting from, poverty. Healthmicroinsurance can offer financial protection to thepoor as well as increase access to medically neededhealthcare services.In October 2012, the social business MicroEnsure, inpartnership with mobile network provider Tigo, salesand technology facilitator Bima and insurer GoldenCrescent, piloted the Pona na Tigo Bima (“Get Well withTigo Insurance”) health insurance product in Dar esSalaam, Tanzania, offering life insurance and hospital cashfor hospital care at a defined network of hospitals.Implementation date: October 2012About Pona Na Tigo BimaMicroEnsure designed the insurance product andprocesses to manage and deliver it to consumers. Theyperform daily overall administration and oversight,including claims processing and customer service. Bimadeveloped the technical platform for enrollment andmanages the agent network, and Tigo distributes theproduct under its local brand.The health insurance product offers six tiers of life andhospitalization coverage paid via three monthlyinstallments that are deducted from the customer’sairtime balance. From a technical perspective, Pona naTigo Bima utilizes a USSD application for productenrollment, which provides an efficient service as well ashigh-quality product information at low cost to theentire Tigo Tanzania subscriber base. The claimsprocess is handled via a call center and most documentsare submitted digitally in Tigo shops. MicroEnsureassists claimants throughout the claims process, helpingthem to find and submit the documents required toreceive their claim payments. Once the claim isapproved by MicroEnsure and Golden CrescentAssurance, the claim is paid immediately via mobilemoney transfer using the Tigo Cash service. Tigo Cashoffers a safe, transparent and reliable means forMicroEnsure and its partners to pay claims whereverthere is a Tigo network signal. As a result of thisprocess, the vast majority of claimants can submit claimsand receive money without travelling to an insuranceoffice.Evaluation and ResultsBy switching from paper to mobile claims payments,MicroEnsure reduced claims processing time from 11 to3.2 days. Claimants were willing to register for mobilemoney payments and expressed interest in learningabout the details of the payment process. The timelyand reliable nature of the payment has built client trustin both mobile payments and MicroEnsure’s healthproduct. Based on its experience, MicroEnsure isimplementing new mobile health insurance products forlaunch in 2014 in six new markets across sub-SaharanAfrica and Asia.Lessons LearnedMicroEnsure and Tigo built a successful partnershipby clearly defining their roles and responsibilitiesand ensuring that all parties were in agreement fromthe outset and benefitted from the arrangement.A network of sales agents was essential in educatingconsumers about the Pona na Tigo Bima program.By bundling health insurance in a package of Tigoservices and automatically deducting premiums viaairtime, MicroEnsure established a convenientpayment mechanism for its clients that ensuresregular and timely contributions for premiums.Mobile money’s potential continues to increase;however, current low utilization rates in Tanzanialimit opportunities for expansion into other areas.such as premium payments.Client understanding of MicroEnsure’s healthproducts is lower than for its life products. Thecompany is continuing to address this challengethrough its product development, messaging andunderwriting work.38 mHEALTH COMPENDIUM | VOLUME 3

FINANCEConclusionWhile challenging, health microinsurance has thepotential to increase access to needed healthcareservices, mitigate the risks of disease and ill health, andaddress the need for new methods of health financing.Insurance practitioners, researchers, policy makers andthe global health community should continue to seekevidence towards the benefits, as well as shortcomings,of mobile health microinsurance for the poor.--------------------------------------------------------Geographic Coverage: TanzaniaContact Information:MicroEnsure UK Ltd: Richard Leftley, CEO MicroEnsure& MicroEnsure Asia (+44 (0)1242 526836,richard.leftley@microensure.com), Peter Gross, RegionalDirector - Africa (+254-786-499-100,peter.gross@microensure.com)References:1. MicroEnsure Case Study. USAID, Health Finance & Governance.No Date.2. Micro Insurance Matters. Issue No. 10. MicroEnsure. No Date.Implementation Partners: MicroEnsure, Tigo, Bima,Golden Crescent AssuranceFunders: MicroEnsure, Tigo, Bima, Golden CrescentAssurancemHEALTH COMPENDIUM | VOLUME 3 39

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FONEASTRAA safety management system for human milk bankingBreast milk is considered a pillar of child survival; ithas unique immunological and nutritional propertiesthat help infants get a healthy start to life. Infants whoreceive breast milk are less likely to become seriouslyill or die from infections, compared to those who donot receive breast milk. This is especially true ofvulnerable infants in developing countries who mayface continual exposure to pathogens through unsafewater or unhygienic conditions. For infants whosemothers’ milk is unavailable, the World HealthOrganization supports human milk banks (HMB) as acritical intervention for guaranteeing access.To ensure safe pasteurization in resource-limited healthcare facilities, PATH is advancing a pasteurizationmanagement system based on a platform developed byUniversity of Washington called FoneAstra. This systemleverages the use of mobile phones to precisely monitorpasteurization of donor breast milk.Implementation date: October 2011 to June 2013About FoneAstraTo address the challenge of ensuring safe pasteurizationin homes andresource-limitedhealth care facilities,PATH is advancing asafety managementsystem based on aplatform calledFoneAstra.FoneAstra is a realtimetemperaturemonitoring deviceand remote datarecording tool. Thissystem leveragesmobile phones toprecisely monitorflash-heatpasteurization ofdonor breast milk. FoneAstra components include amobile phone, a USB cable and bridge, a glass jar and atemperature sensor probe. These are paired with simplepasteurization equipment: a freezer, a pot and a heatsource. A novel USB bridge connects the phone andtemperature probe, allowing the phone to act as theCPU walking users through the pasteurization processthrough simple audio and visual instructions. The phonethen transmits the data wirelessly to a central servicerfor review, reports and archiving.Evaluation and ResultsIn early 2012 , PATH, in collaboration with the HumanMilk Banking Association of South Africa, managed a one-year pilot study of FoneAstra. This included a field testto evaluate the use of FoneAstra as a low-cost HMBsystem compared to routine flash-heat. Userassessments were performed with milk bank staff tovalidate they were able to correctly operate the system.A cost analysis was also conducted to guide scalability ofHMB systems in South Africa.None of the 100 samples pasteurized with the newFoneAstra system showed any bacterial growth. Thisfinding confirmed the safety of this pasteurizationmethod, since it was effective in completely destroyingthe bacteria present in 86 of the pre-pasteurizedsamples.Lessons LearnedHuman milk bank technicians can successfullyoperate the FoneAstra devices.The ability to provide remote monitoring, as well aspush updates remotely, is a key advantage of theplatform and allows for off-site supervising andtracking.Some challenges that continue are the cost of thephones and the risk that they could be lost orstolen.Small-scale human milk banks can be fullyoperational even with limited staff using withsimplified systems such as FoneAstra.42 mHEALTH COMPENDIUM | VOLUME 3

LOGISTICSConclusionFoneAstra has undergone significant development andrefinement, making the technology well-integrated withexisting organizational workflows. It is a feasible, safe,and affordable tool, costing about US$600, for resourcelimitedsettings to ensure the safety and enhance theacceptability of donor breast milk. With its establishedquality measures, the pasteurization management systemhas the potential to prevent significant infant morbidityand mortality through increased access to contaminantfreedonor milk, a critical step toward expanding HMBadoption.--------------------------------------------------------Geographic Coverage: South AfricaImplementation Partners: PATH, University ofWashingtondonations from private foundations and individuals to thePATH Health innovation Portfolio, and the NationalScience Foundation Research Grant No. 11S-1111433.Contact Information:PATH: Kiersten Israel-Ballard, Technical Officer, Maternaland Child Health and Nutrition Program, (kisraelballard@path.org),Noah Perin, Commercialization Officer(nperin@path.org)References:1. PATH. Technology Solutions for Global Health: SafetyManagement System for Human Milk Banks. June 2012. FactSheet.Photo credits: c. PATH, Steffanie ChritzFunder: Funding was provided from a grant from the Bill& Melinda Gates Foundation through the Grand ChallengeExplorations Initiative, the University of WashingtonDepartment of Computer Science and Engineering,mHEALTH COMPENDIUM | VOLUME 3 43

PROJECT OPTIMIZE: ALBANIARemote temperature monitoring for vaccine qualityProper monitoring of temperatures is crucial toensuring the quality of vaccines. As vaccine efficacycan be affected by exposure to excessive heat andcold, it is important that vaccines are correctlytransported and stored from the point ofmanufacture to the point of use. Temperaturemonitoring, usually conducted by health workers,helps ensure the quality with which vaccines arehandled, detects malfunctioning equipment andprevents temperature fluctuations that can negativelyimpact vaccine potency and safety. In Albania, 30-daytemperature recording devices, such as Berlinger’sFridge-tag®, are used in most health centers wherevaccines are stored. However, health workers cannotrespond to an alarm during nonworking hours, andwithout supervisors’ assistance, they cannot alwaystake the appropriate remedial actions.Project Optimize designed and implemented a study inAlbania to evaluate the potential benefits of remotelyconnected monitoring devices. Optimize was a five-yearpartnership between WHO and PATH to identify waysin which supply chains can be optimized to meet thedemands of an increasingly large and costly portfolio ofvaccines. The project tested an SMS-based system tomonitor and log temperature conditions in peripheralcold chain equipment. The aim was to assess whetherthese remote alarm systems facilitate better vaccine andcold chain management than non-connectedtemperature loggers.Implementation date: March 2010About Project Optimize: AlbaniaIn collaboration with the National ImmunizationProgram (NIP) and Berlinger, Optimize installed an SMSbasedsystem that monitors and logs temperatureconditions in peripheral cold chain equipment. InAlbania’s Shkoder District, 24 health centers storingvaccines were equipped with remote temperaturemonitoring devices that included sensors, monitors andSMS gateways. When an alarm is activated due toexceeded temperature limits, an SMS text message isimmediately sent to a central server that logs the issueand sends a notification to health workers andsupervisors in charge of the storage location. Once theproblem is addressed, its status is reset on the centralserver.To analyze temperature curves for the working status ofrefrigeration equipment, mobile phones were also usedto transmit frequent temperature measurements. TheFoneAstra system was used for this process andinstalled at six sites. Temperature probes were placedinside equipment and the mobile phone and accessorymounted externally, which sampled and aggregated datafrom the temperature sensors every few minutes.Detailed temperature logs are periodically sent to thecentral server via SMS, which also stores alarmnotification data. All data can be easily viewed using astandard web browser.Evaluation and ResultsOver a 10-month period, 136 alarm incidents weredetected, including 22 low- and 114 high-temperaturealarms. The system also demonstrated certainmanagerial benefits. For example, supervisors phonedhealth workers or storekeepers in 41% of incidents toconfirm detection of the problem and assisted in takingappropriate follow-up measures in 15% of these.In focus group discussions, nurses and supervisorsreported that the technology was beneficial for theirwork. However, while the study highlighted somequalitative benefits of the technology, it did not find anysituation in which remote monitoring saved a vaccinefrom freezing or excessive temperature exposure.Therefore, a case for positive cost-benefits could not bemade.Lessons LearnedThe study increased awareness of the importance oftemperature monitoring, improved collaborationbetween vaccinators and supervisors to resolvealarm events and cold chain problems, and served toimprove the entire cold chain system in ShkoderdistrictThere was a sense that this technology provided a“best-in-class” level of quality control.44 mHEALTH COMPENDIUM | VOLUME 3

LOGISTICSSince the study was designed to establish thepotential benefits of the concept, there was noattempt to produce the devices at low cost, therebymaking scalability and sustainability unknown. AtUSD$1,000 per monitoring device, the Fridge-tag®–based system is unaffordable for limited-resourcelocations. However, a prior FoneAstra projectsuggests costs may drop to about $100 per device. Ongoing communication costs of almost $1,500each year may also present a barrier to projectadoption.ConclusionThe adoption of non-connected recording devices hasdemonstrated willingness to invest in temperaturemonitoring equipment to safeguard expensive vaccines.The prospects for adoption of remote monitoringsystems will likely be driven by their costs. Theexperience in Albania suggests it may become a nicheproduct, mostly suitable for places where high vaccinestock values are at stake or for remote storage pointswith unreliable storage conditions.The demonstration was a partial success. Furtherresearch is needed to quantify potential benefits, such asthe number of vaccines saved, and to produce lowercostdevices.--------------------------------------------------------Geographic Coverage: AlbaniaImplementation Partners: Ministry of Health, Albania |Institute of Public Health, Albania | Health InsuranceInstitute, Albania | PATH | Shkoder Directorate of PublicHealth, Shkoder, Albania | Albania Country Office, WorldHealth OrganizationFunder: The Bill & Melinda Gates FoundationContact Information:World Health Organization: Jan Grevendonk,Technical Officer (grevendonkj@who.int)References:1. World Health Organization, PATH. Optimize: Albania Report.Seattle: PATH; 2013.2. Temperature monitoring for vaccine quality. Optimize FactSheet. World Health Organization, PATH. July 2012.mHEALTH COMPENDIUM | VOLUME 3 45

SMS FOR LIFEPreventing malaria and other medicine stock-outs at the remote health facility levelin sub-Saharan AfricaMalaria is a preventable and treatable mosquito-bornedisease whose main victims are children under fiveyears of age in Africa. Although highly effectiveantimalarial drugs are available, countries continue toexperience stock-outs due to systematicshortcomings. It is essential to have adequate suppliesof drugs when and where they are needed. However,this continues to be a major challenge, especially inremote rural communitieswhere widespreadantimalarial stock-outsfrequently prevent patientsfrom receiving treatment.In response, Novartis,utilizing public-privatepartnerships, has led thedevelopment of the SMS forLife system. Leveraging theavailability of mobile phonesin remote areas, the internetand mapping technologies,the solution increases thevisibility of antimalarial stocklevels at remote healthfacilities, thereby ensuringdistrict medical officers havethe information they need toadequately manageantimalarial commodities ateach and every facility.Implementation date:2010AboutEach country’s system provider, guided by the Ministryof Health (MOH), the National Malaria Control Program(NMCP) and the SMS for Life Team, configures the SMSfor Life system to national needs. It can flexibly addressthe priorities of the local MOH, including betteravailability of commodities, prevention of stock-outs andbetter forecasting of drug needs, and provide timelysurveillance information to support best practices indisease management.Each week, automatic SMS text messages are sent tomobile phones at health facilities requesting informationon current stock levels and disease surveillance.Responses are reported via SMS, centrally stored in adatabase and made accessible to key health-care staff viathe internet and email. The website provides thefollowing: current and historical data on stock levels ofantimalaria medicines, antibiotics and rapid diagnostictests at the health facility anddistrict level. The system alsoprovides disease surveillancecurrent and historicalinformation, in addition tocalculated indices such aspercentage of confirmed casesunder and over the age of five.The system also tracks andreports on system usagestatistics, such as numbers ofreceived messages, errors andsystem accesses, and has adata extraction function.Reports are created and canbe delivered by mobile phone,email or the internet to staff atall system levels. Districtmedical officers can utilizereporting data for decisionsabout transferringcommodities between facilitiesin response to stock-outs ormake emergency orders toreplenish stocks that arerunning low. National healthauthorities can view diseasesurveillance and various datasuch as numbers of patients, testing rates and testpositivity rates, by facility, District, Region or Country.Any mobile phone can be used at the health facility levelfor data reporting, with district managers using smartphones or internet to access email and web-basedinformation. District medical officers and regional- andnational-level authorized users can use any personalcomputer with Internet access to view the website.46 mHEALTH COMPENDIUM | VOLUME 3

LOGISTICSEvaluation and ResultsSMS for Life has been rolled out nationally in Tanzaniaand pilots have been completed in Ghana and Kenya.Both countries have indicated interest in national scaleups.Cameroon has begun nationwide implementationand the program has also been implemented in fiveprovinces in Democratic Republic of the Congo. Inaddition, the system is being used to track bloodsupplies in all blood stocking locations in one region ofGhana and countrywide scale-up is planned for 2014.Lessons LearnedThe key to long-term sustainability lies with localministries of health. They should commit at earlystages to taking over the system after successful roll-out and to running it for an extended period, untilit is integrated into the mainstream health systemand can continue to evolve in that context.It can be a challenging and time consuming, albeitworthwhile process to establish and managepartnerships between ministries of health andmobile phone companies.An in-country presence would be very helpful andearly discussion on funding and funding sources isessential.It would be beneficial to find evidence-basedsolutions through publications and pilots, as well asa cost analysis of necessary full country scale-upprior to implementing the pilotConclusionThe improved visibility of medicine stock levels atremote health facilities allows better management ofessential commodities and increased availability andaccess. Sustainability of the SMS for Life intervention isincreasingly attainable because of productive publicprivatepartnerships among local authorities andtelecommunications companies, the system provider,major funders and NGOs, and their goal of eliminatingalmost all malaria deaths in Africa by 2015.--------------------------------------------------------Geographic Coverage: Cameroon, Ghana, Kenya,United Republic of Tanzania, Democratic Republic of theCongoImplementation Partners and Funders: Novartis,Ministry of Health United Republic of Tanzania, Medicinefor Malaria Ventures (MMV), Swiss Agency forDevelopment and Cooperation, Vodacom Tanzania, IBM,Google, Vodafone, Ghana Health Service, Swiss Tropicaland Public Health Institute, Ministry of Public HealthCameroon, Malaria No More, Ministry of Public Health andSanitation Kenya, Safaricom Kenya, Management Sciencesfor Health, PSI/PMI, NoradContact Information:Novartis: Rene Ziegler, Project Manager, SMS for Life(rene.ziegler@novartis.com), Jim Barrington, ProgramDirector, SMS for Life (jim.barrington@novartis.com)References:1. Githinji S, Kigen S, Memusi D, Nyandigisi A, Mbithi AM, et al.(2013) Reducing Stock-Outs of Life Saving Malaria CommoditiesUsing Mobile Phone Text-Messaging: SMS for Life Study inKenya. PLoS ONE 8(1): e54066. doi:10.1371/journal.pone.00540662. Guidelines for the treatment of malaria, 2nd ed. Geneva, WorldHealth Organization, 2010. Web.3. Novartis - SMS for Life (Cameroon, Ghana, Tanzania, Kenya).Project Profile. World Health Organization. 2013.4. SMS for Life: a pilot project to improve anti-malarial drug supplymanagement in rural Tanzania using standard technology; JimBarrington, Olympia Wereko-Brobby, Peter Ward, WinfredMwafongo, Seif Kungulwe Malaria Journal 2010, 9:298 (27October 2010).mHEALTH COMPENDIUM | VOLUME 3 47

SERVICE DELIVERY

ACT FOR BIRTH, UGANDAEnsuring safe delivery through fetal heart rate monitoring and a mobile phonebasedmortality audit systemIn Uganda, almost half of births takeplace in facilities. However, evenwhen emergency care is available,many opportunities for saving livesare missed. In 2010, there were anestimated 6,000 maternal deaths,39,000 neonatal deaths and 38,000stillbirths. Poor quality care at thetime of birth, including the lack offetal monitoring during labor, hasbeen highlighted as a key gapthrough Uganda’s maternal andperinatal mortality audit process.The baby’s heart rate is one of themost important markers of distressin labor and a key indicator of theneed for prompt intervention. Current devices formonitoring labor in high-income countries can beexpensive, complex, electricity-dependent andunreliable in resource-limited settings ,where theymay be ill-suited for use.ACT for Birth, Uganda is an initiative to improve qualityof care at birth using high-impact, low-cost technologyto promote timely decision-making for safe andsuccessful delivery. The project involved testing aninnovative fetal heart rate monitor (FHRM) and anaction-oriented mobile phone-based mortality auditsystem. The integrated pilot was implemented in Ugandaby Save the Children’s Saving Newborn Lives Programand partners from 2011-2013.Implementation date: April 2011 to 2013About ACT for BirthACT for Birth comprises three components:A = Audit and Accountability: Uganda’s national paperbasedmortality audit forms were adapted to a mobilephone platform to capture and input information onmaternal and neonatal deaths and stillbirths in real timeby midwives that is the fed into a central database. Itcaptures information on causes of deaths and missedopportunities for care. Data is analyzed on-site and usedto inform decision-making for improved quality of care.c. Ian P. Hurley, Save the ChildrenC = Connecting Communities: VillageHealth Team (VHT) members equippedwith mobile phones and maternal andnewborn health training are directlyconnected to referral facilities. VHTsassist with referral of mothers andnewborns with danger signs, reportbirths and deaths at the community level,and conduct pre- and postnatal visits topromote best maternal and newborncare practices, including care seeking,facility based deliveries and theidentification of danger signs.T = Technology and Training: Theinnovative wind-up Doppler FHRM ispowered by human energy and designedby South African non-profit medical device companyPowerfree Education Technology. It is paired withtraining on intra-partum care, and thus, empowershealth workers to provide better care.Evaluation and ResultsACT for Birth consisted of four phases. The year-longstartup phase included meetings with stakeholders,feasibility assessments, baseline data collection usingmaternity register data and protocol development.During Phase Two, health workers and VHTs weretrained and facilities equipped with FHRMs and mobilephones. Project implementation (Phase 3) occurredfrom July 2012 – July 2013. Regular support andsupervision meetings were held to assess progress andevaluate implementation. The final phase includeddocumentation and dissemination of findings.Audit and Accountability: Mortality audits can reducedeaths by up to 30% if data are used effectively andclearly linked to action. Working with the Ministry ofHealth (MOH), the project simplified the MOH deathaudit form and adapted it for use on cell phones tomake it more user-friendly. Twenty-five health workersinvolved in service delivery were trained to capture datausing the adapted audit software which allows midwivesto code the direct cause of death, as well as theavoidable factors linked to each death. During the50 mHEALTH COMPENDIUM | VOLUME 3

SERVICE DELIVERYproject period, all five maternal deaths were audited. Inaddition, 75% (121/162) of all newborn deaths wereaudited, compared to 7% (9/123) during the baseline.Connecting Communities: The intervention to link womento health facilities through VHT also proved successful.As a result of the training provided, VHTs were highlymotivated to perform their work, health workers knewand respected them and honored the referrals theymade, and the communities developed trust in them.Technology and Training: In the endline evaluation, 17 ofthe 25 health workers interviewed indicated that theyhad recently received in-service training on intrapartumcare. All who attended thought that the trainings wereeffective. However, training alone is not sufficient tomaintain skills; ongoing supervision and mentorship arealso essential. Correct use and completion ofpartographs during deliveries was also monitored andmarkedly improved during the course of the project.The Doppler FHRM registered high levels of success inNakaseke in terms of acceptability, usefulness, andappropriateness. Health workers and mothers found thedevices effective in monitoring the fetal heart ratebefore, during and after contractions. However, therewere noted challenges related to the inability of thedevice to display the remaining battery life.Lessons LearnedACT for Birth functioned as an integrated wholeresulting in a sustainable package ready for scale up.The level of quality improvement would not havebeen reached if any of the three interventions wereimplemented as a stand-alone solution.At the health facility level, quality of care andaccountability improved through the training,technology and frequent audit meetings.The use of an electronic audit platform wassuccessful and is promising even in sites with limitedconnectivity due to cell phone adaptation.Improved knowledge and skills of VHTs improvedaccountability.ConclusionIn light of ACT for Birth’s findings and engagement ofthe National Newborn Steering Committee with theproject, the Ugandan MOH is currently updating theMaternal and Perinatal Death Review strategic plan andguidelines. There is strong governmentcommitment and high potential for uptake of thewhole package, including audit and the FHRMand Helping Babies Survive Labor training, aswell as the connection between the district,VHTs and health facilities. Additionally, the trainingpackage is being adapted for pre-service training fornurses and midwives in partnership with the Ministry ofEducation and Academic Institutions, and the UgandaAssociation of Ob/Gyn.--------------------------------------------------------Geographic Coverage: Nakaseke District, UgandaImplementation Partners: Save the Children, inpartnership with the Ugandan Ministry of Health, theAssociation of Obstetrics and Gynaecology of Uganda,Powerfree Education Technology, MTNFunder: Saving Lives at Birth Grand Challenge partners,including USAID, the Government of Norway, the Bill &Melinda Gates Foundation, Grand Challenges Canada, andthe World BankContact Information:Save the Children: Hanifah Sengendo, Chief of Party,Saving Newborn Lives (+256-414-510-582,hanifah.sengendo@savethechildren.org)USAID: Rachel Gordon, Presidential Management Fellow/Program Manager, Saving Lives at Birth (+1-202-712-4361,rgordon@usaid.gov)References:1. ACT For Birth Final Report, Save the Children2. http://savinglivesatbirth.net/blog/13/04/30/act-birth-improvingquality-care-uganda3. http://savinglivesatbirth.net/summaries/534. Mbonye AK, Sentongo M, Mukasa GK, Byaruhanga R,Sentumbwe-Mugisa O, Waiswa P, et al. Newborn survival inUganda: a decade of change and future implications. HealthPolicy and Planning 2012,27 Suppl 3:iii104-117.mHEALTH COMPENDIUM | VOLUME 3 51

BABY MONITORPreventing maternal and newborn deaths through mobile phone-based screeningDespite significant global progress in reducingmaternal and infant mortality rates, nearly 300,000maternal deaths and an estimated 5 million infantdeaths occur each year. Prenatal care and a series ofproven interventions delivered by a skilled attendantcould prevent nearly 80% of maternal deaths and 66%of newborn deaths. However, many women andinfants are never assessed and connected tohealthcare. Baby Monitor, a new mHealth platformthat takes clinical screening directly to pregnantwomen, aims to change this.The goal of Baby Monitor is to save lives, improve healthoutcomes, and optimize the use of community healthworkers (CHWs) in rural and remote regions whereaccess to health systems is limited and clinicalassessment often occurs too late or not at all. Withseed funding from the Saving Lives at Birth GrandChallenge, Population Council and its partnersdeveloped and tested a beta version of Baby Monitor, amobile-phone based screening, referral and patientmanagement service that targets hard-to-reach pregnantwomen as end-users. The formative study wasconducted in a periurban catchment area in Nairobi,Kenya in 2012. Baby Monitor is currently being furtherrefined and tested in a second study in Bungoma EastDistrict, Kenya.Implementation date: October 2011About Baby MonitorBaby Monitor is an open source mobile phoneapplication that uses interactive voice response (IVR)technology to offer free mobile screenings to pregnantwomen and new mothers. When it is time for a prenatalor postnatal exam, a registered user receives a textmessage with a code that can be redeemed by “flashing”the Baby Monitor phone number to trigger a free callback. The woman selects her preferred language, listensto recorded audio prompts asking her how she and herbaby are feeling, and presses keys on her phone’snumber pad to respond. All of her responses are loggedin an electronic medical record. The analysis enginedetermines whether the woman is likely to need referralto a medical facility or more immediate assistance.When fully operational, Baby Monitor will include an“action” component that uses screening results totrigger automated referrals and emergency dispatch.Baby Monitor uses Verboice, a free IVR platform,installed on an Amazon Elastic Compute Cloud (EC2)server connected to a Voice over IP (VOIP) provider inKenya. Each call costs Baby Monitor USD $0.04 perminute, which could be reduced through bulk pricing.Evaluation and ResultsThe initial study conducted in Nairobi in 2012 allowedBaby Monitor developers to:1. evaluate the feasibility and acceptability of BabyMonitor through interviews and focus groupdiscussions with study participants and consultationswith our clinical partner and2. assess reliability and accuracy of the mobilescreening protocols by comparing results frommobile screenings to follow-up, in-person clinicalassessments.Four health screening protocols were developed fordifferent stages of the birth continuum. The antenatalprotocol included screening questions about maternalphysical and mental health. The postnatal protocol, usedone and three days after delivery, assessed maternal andinfant physical health (but not mental health or infantdevelopment). The postnatal protocol, used seven daysafter delivery, assessed maternal physical health,perinatal depression and infant physical health, and thepostnatal screenings, delivered at 6, 10 and 14 weeks,assessed maternal physical health, perinatal depression,infant physical health and infant development.Ninety-five (95) women in their second trimester wereenrolled for the study. Women completed automatedscreenings and, one day later, completed the samescreening with a nurse.In the prenatal period, Baby Monitor correctly identified88.5% of positive cases—those classified by the nurse ashaving “any problems”. The screening tool was lesssuccessful in the postnatal period, only correctly52 mHEALTH COMPENDIUM | VOLUME 3

SERVICE DELIVERYintegration with existing electronic medical recordssystems, the developers of Baby Monitor will be able tobuild an interoperable service that encourages womento seek healthcare, optimizes the use of health systemresources, tracks outcomes and offers women a morepersonalized health experience.--------------------------------------------------------Geographic Coverage: Kenya (initial study in Nairobi,current study in Bungoma East District)Implementation Partners: Population Council, inpartnership with InSTEDD, Jacaranda Health and MoiUniversityidentifying 23.8% of positive cases. The tooldemonstrated high specificity, positive predictive valueand negative predictive value in both periods.Overall, the screening tool proved to be a validassessment of medical need. It also had acceptable initialmeasures of reliability, meaning that the women largelyprovided the same responses to the automated serviceas they did to the live nurse. Reliability can be improvedas the system moves to production by increasing thestability of the platform and enhancing the audio qualityof the phone connection.Lessons LearnedThe Baby Monitor system is feasible to implementand acceptable to users.Automated screening can be used as a tool toidentify women and infants with medical needs.Funder: Saving Lives at Birth Grand Challenge partners,including USAID, the Government of Norway, the Bill &Melinda Gates Foundation, Grand Challenges Canada, andthe World BankContact Information:Population Council: Eric Green, Principal Investigator,Population Council (+1919-666-7111,eric.green@duke.edu)References:1. Green, Bellows, di Tada and Pearson (2013). “Baby Monitor:Developing and testing a mHealth screening service for pregnantwomen and new mothers in Kenya.” Preliminary WorkingDraft.2. Baby Monitor Slide Deck, Tech’n’Talk session, Women Deliver2013.3. http://www.babymonitor.coConclusionFor many women in rural and remote settings, a mobilephone signal is more likely to reach their home than acommunity health worker. The formative study of BabyMonitor demonstrates the potential of using anautomated IVR screening on mobile phones to identifywomen and infants with medical needs. ThroughmHEALTH COMPENDIUM | VOLUME 3 53

eNUTSupporting the diagnosis and treatment of childhood malnutritionNearly 12% of children in Zanzibarsuffer from acute malnutrition.However, when this entirelytreatable condition progresses tosevere acute malnutrition (SAM), itbecomes life threatening andrequires urgent treatment. Prior to2009, 20% to 30% of children whowere admitted with SAM dieddespite receiving treatment, butthis number could be reduced toas low as 5% if children with SAMwere treated according to theWHO-UNICEF standardtreatment guidelines. In response,the Government of Zanzibar isworking to nationally eradicatemalnutrition, especially amongyoung children, by collaboratingwith UNICEF on a comprehensiveprogram for the identification andtreatment of malnourished children in the communityusing national standards of care.D-tree International designed the nutrition software,eNUT to facilitate implementation of these guidelinesand standards. eNUT was built to streamline themanagement of information and support the decisionmakingneeds of health workers, helping them toimplement the national guidelines for providing effectivetreatment to children suffering from malnutrition.Launched in November of 2010 and continuing to scalethrough December of 2013, eNUT is an integralcomponent of Zanzibar’s national nutrition program andis fully supported by the Ministry of Health and SocialWelfare.Implementation date: 2010 to 013About eNUTThe eNUT software provides an interactive mobileversion of the government-approved treatmentguidelines for acutely malnourished children. Used bygovernment health workers, primarily nurses, theapplication takes them step-by-step through theguidelines using data from past and current visits toassess the child’s progress and determine the next stepsfor effective treatment. Nurses can access patient data,enter new data and schedule appointments. Thesoftware captures the data that the nurse enters duringthe patient visit, providing the health serviceadministrators with real-time access to program dataand improving overall decision-making abilities.The software runs on the Android operating systemand combines on-device electronic medical records withprotocol execution, using a password-protected loginprocedure for data security. Information is drawn fromseveral major parts of the electronic protocol tocontribute to the patient record, including screening andregistration, physical examinations, treatment,counseling for the caregiver and appointment scheduling.D-tree’s private-sector partner, Zantel, is currentlysupporting the project with reduced fees for datatransfers and technical support, helping to keep programcosts low.c. 2013/Mark Leong54 mHEALTH COMPENDIUM | VOLUME 3

SERVICE DELIVERYEvaluation and ResultsAn independent evaluation carried out on the first sixsites of the project concluded that the intervention siteswere 20% more accurate in diagnosis than the nonprojectsites. A qualitative survey of the health workers’perceptions about the application was also completed.The majority of the users reported an improved abilityto register and screen children, an easing of workload,and improved skills and capacity.Currently, the scale up has reached 3 districts and 12health facilities. It is now focused on integrating theexisting application with the Integrated Management ofChildhood Illness (IMCI) strategy, developed by WHOand UNICEF, to better incorporate the use of theapplication into the routine clinical workflow.Lessons LearnedSuccess in the clinics where D-tree has beenworking can be attributed to close follow-up,flexibility, and an understanding of the environmentand needs that stem from user feedback.Underpinning its ability to scale-up, D-tree hasfound that the key factor influencing the level ofgrassroots support among patients and FWHs isintegration of the mobile service into the flow ofcare. For the mobile service to be integratedeffectively into the health system, it must be seen aslessening the burden on FHWs and improving thequality of health services for clients.mHealth interventions are not a panacea – theycannot be viewed as a quick fix to an underlyingpublic health problem. By working with thegovernment at multiple levels, D-tree has learnedhow to integrate its mobile solution into broaderpublic health initiatives and into the health system.Though effective scale-up depends on successfullyengaging with government partners, D-tree hasfound that engaging with the right governmentactors is challenging, as these actors are scatteredacross multiple levels and departments.An additional challenge for D-tree has been a lownumber of patients reached. Although the TanzaniaDHS survey indicated high levels of SAM, D-tree hasnot seen a corresponding high number of patients.ConclusioneNUT provides an innovative delivery mechanism anddecision support system for Zanzibar’s nationalstandards of care for the identification and treatment ofmalnourished children. This component of the nationalnutrition program is integral in aiding the Governmentof Zanzibar eradicate malnutrition as a public healthproblem, and thus reduce overall morbidity andmortality in the population, especially among youngchildren.--------------------------------------------------------Geographic Coverage: Zanzibar, United Republic ofTanzaniaImplementation Partners: D-tree International,Zanzibar Ministry of Health and Social Welfare, Zantel,Edesia, UNICEFFunder: UNICEF, mHealth AllianceContact Information:D-tree International: Marc Mitchell, President (+1-617-875-5143, mmitchel@hsph.harvard.edu)mHealth Alliance: Patty Mechael, Executive Director(+1-202-419-6414, pmechael@mhealthalliance.org)References:1. mHealth Alliance. IWG Round 1 Grant Winners. D-treeInternational – Mobile Technology to Support the Diagnosis andTreatment of Malnutrition (Zanzibar) Project Profile. The WorldHealth Organization, 2013. Web.2. Francis Gonzales. IWG Grantee Year 1 Update: D-treeInternational. Health UnBound, May 7, 2013. Web.3. Tanzania Demographic and Health Survey 2010. Dar es Salaam,Tanzania, National Bureau of Statistics and ICF Macro, 2011.4. Collins S et al. Management of severe acute malnutrition inchildren. The Lancet, 2006, 368:1992-2000mHEALTH COMPENDIUM | VOLUME 3 55

MOBILE MEDIA RICH INTERACTIVEGUIDELINESMobile-phone based media-rich clinical guidelines to improve community healthworker performanceimproving and maintaining theirknowledge and performance. Onestrategy is the use of job aids thatprovide just-in-time knowledge andinformation. However, paper-basedversions have not produced idealresults due to poor design, incompleteexplanations and lack of explicitworkflow, all leading to a possibleincrease in the user’s workload.One solution is the development ofmobile phone-based job aids enhanced byrich media such as text, audio and visualaids. These tools can provide CHWs withthe point-of-care clinical information anddecision support they need to improvetheir performance and subsequentlyhealth outcomes within theircommunities.Implementation date: 2008 to 2009Community health workers (CHWs) play a vital rolein developing countries, often serving as the primaryand sometimes sole providers of healthcare to manypeople, especially in areas where there is a shortageof physicians and nurses. Since the educationalbackground, literacy and clinical training of CHWsvaries, it is important to provide means towardsAbout Media RichInteractive GuidelinesA study funded Microsoft Research andperformed by the University of Texas andUniversity of Antioquia in Medellin,Colombia investigated and analyzed thepossible benefits on CHWs’ performanceof point-of-care clinical guidelines (MRIGs,also known as Interactive structured m-rich media guidelines) presented asinteractive rich media job aids on smallformatmobile platforms. The MRIGswere used to diagnose and treat pediatricand adult medical conditions in asimulated setting. Fifty CHWs weredivided into an intervention (rich media job aids) orcontrol (traditional paper-based job aids) group. EachCHW treated a total of 30 standardized cases usingboth methods in a randomized cross-over design.The Spanish version of the WHO’s Integral Managementof Childhood Illnesses, and two common Colombian56 mHEALTH COMPENDIUM | VOLUME 3

SERVICE DELIVERYevidence-based, peer-reviewed, published guidelineswere presented in both paper and mobile phone format.HTC Tilt cell phones running Windows Mobile 6.1 useda system called GuideVue® to present the guidelinesinteractively, step by step. Guidelines were also loadedinto cell-phone memory or micro-SD cards so CHWscould access the tool during times of poor connectivity.The instructions of each step were presentedsimultaneously with voice/audio, text and/or images/video. Video was used if the step was an instruction forperforming a task. Otherwise, a static image of therelevant medication, supply item, or other object waspresented. Each step provides up to five options that theCHW can select, leading to the next step in the clinicalpractice guideline, based on information provided in thecurrent step. Each executed step was saved into a timestampedhistory log in the phone for later upload into adatabase and analysis.An additional report analyzed the perceived workloadand usability aspects of the interactive, structured media-rich clinical guidelines by the health workers.Evaluation and ResultsA total of 1,394 cases were evaluated. The interventionreduced errors by an average of 33% and increasedprotocol compliance with approved guidelines by 30%.CHWs using the mobile phone MRIGs also reportedstatistically significant decreases in mental demand(cognitive load), frustration and overall workload ascompared to using paper-based job-aids.Lessons LearnedPresenting clinical guidelines in an interactive richmedia structured format on small phones candecrease error rates and enhance protocolcompliance, indicating significant potential benefitsfor health outcomes and standardization of care.Acceptance of new technologies can be inhibited ifthe ensuing workload is perceived as excessivecompared to existing methods.Medical cases were presented on human patientsimulators in a laboratory setting, not on realpatients. Further research using human patients,rather than patient simulators, and with CHWs andpatients across a spectrum of educational levels isneeded.ConclusionThe use of MRIGs on mobile phones by CHWs indeveloping countries has the potential to decrease theirperceived workload, fatigue, and enhance their ability toprovide better care for more patients. These resultsindicate encouraging prospects for mHealth technologiesin general, and for the use of rich media clinicalguidelines on cell phones, for improving CHWperformance. Future work could include enhancing theuser interface, adding features such as GPS location, andrepeating the study with human patients in Colombiaand elsewhere.--------------------------------------------------------Geographic Coverage: ColombiaImplementation Partners: University of Texas,University of AntioquiaFunder: Microsoft ResearchContact Information:University of Texas: M. Sriram Iyengar, AssociateProfessor of Biomedical Informatics, University of TexasHealth Science Center at Houston (+1-281-793-4733,M.Sriram.Iyengar@uth.tmc.edu)References:1. Florez-Arango JF, Iyengar MS, Dunn K, et al. PerformanceFactors of Mobile Rich Media Job Aids for Community HealthWorkers. J Am Med Inform Assoc. 2011; 18(2), 131-137.2. Iyengar MS, Florez-Arango JF. Decreasing workload amongcommunity health workers. Technology and Health Care. 2013;21, 113-123.mHEALTH COMPENDIUM | VOLUME 3 57

MOBIUS ULTRASOUND IMAGING SYSTEMSPoint of care ultrasound diagnostic imaging on a smartphone or tabletMobile ultrasound imaging is a non-invasive diagnostictool that has the potential to greatly improve accessto quality health care in more remote areas. InZambia, ultrasound findings from a focused maternalultrasound-training program for midwives had apositive effect on clinical decision-making.Additionally, findings from a study in Senegal pointtowards the utility of a mobile ultrasonographyservice in managing health problems for both ruralcommunities and healthcare structures.MobiSante, a company based in Washington State, hasdeveloped a mobile diagnostic system that allows healthprofessionals to conduct ultrasound assessment at thepoint of care. After receiving FDA clearance in 2011,MobiSante launched the MobiUS SP1 smartphonesystem, followed by a tablet version entitled the MobiUSTC2 system.Implementation date: 2011c. Lydia Zibincalls, however, the patient exam can be emailed forarchive or second opinion. The system’s versatileperformance for diagnosis include routine screenings,abdominal and pelvic examinations to determine causeof pain, monitoring women throughout their pregnancy,determining extent of trauma, and various ultrasoundguidedprocedures. Multiple probe types are availablefor different clinical applications, and customers haveaccess to training videos and manuals.There is a five-step process to scanning with theMobiUS: select exam type, optimize image (optional),add annotations (optional), save image or video, andreview the images and send directly from the system.Images are readily stored and quickly shared via cellularor Wi-Fi networks. In areas without networkconnectivity, patient data can be stored on the deviceand transmitted at a later point. All data transfer isencrypted when the device is password protected.Users have the option of sending emails securely orstripping data out of non-encrypted emails, as well astransmitting data to a cloud server for archive and offsiteanalysis by trained health professionals.About MobiUSThe complete ultrasound imaging system includes asmartphone (SP1 System) or tablet (TC2 System),transducer probe and pre-installed software. Devicesare both battery powered and rechargeable and theentire system can either be purchased or leased.Currently, SP1 capabilities are limited to ultrasoundimaging and cannot be used for text messaging or phonec. Lydia Zibin58 mHEALTH COMPENDIUM | VOLUME 3

SERVICE DELIVERYEvaluation and ResultsSeveral studies have been done or are in process withthe MobiUS systems. Studies have been done inRochester, NY where the systems were successfullyused for thoracic ultrasound to help identifypneumothorax and congestive heart failure. In anotherstudy, users compared field trauma evaluations using theMobiUS SP1 system and a Sonosite device. Equalsuccess rates were obtained by identifying intraabdominalfluid in the pre-hospital environment.Additionally, this study demonstrated that images couldbe created, then pushed to a remote location to be readby the ultrasound fellowship director with similarsuccess rates. A wilderness medicine study was alsoconducted on Denali. Pulmonary edema and IVCvolumes were observed in climbers using the MobiUSSP1 system. Finally, broad screening of 100+ patients inSierra Leone were conducted with over-read servicesprovided by a radiologist in Seattle. Short studies werealso conducted with the MobiUS SP1 system in Nepal,Philippines and India.A study in progress is looking at post-operative woundsto identify small amounts of fluid accumulation, whichcan indicate early stages of infection. Ongoing studiesinclude a residency program conducting a central venousaccess project with the MobiUS SP1system.Lessons LearnedWhile MobiUS systems cost only a fraction ofconventional ultrasound machines, the current pricemay still keep this product out of reach forfinancially constrained health facilities and lowresourcesettings. However, MobiSante is offeringspecial discounts for NGOs and not-for-profitorganizations.The current system only works with a MobiSanteprovided smartphone or tablet which all featureUSB 2.0 host support to connect the ultrasoundprobes. However, future applications are expectedto be compatible with other platforms, includingAndroid, Apple iPhones and iPads, thus expandingits reach.Ultrasound education is a critical component inplanning a successful implementation. Severalresources and partners are available to users forbecoming competent in acquiring and interpretingimages.ConclusionData captured from the MobiUS system provides pointof-carediagnostic capabilities in a wide range of settings,including more remote locations. These data can becombined with electronic medical records therebyimproving clinical decision-making capabilities. Futureiterations should involve lower cost models andexpanded platform compatibility to aid in expandedmarket usage. Lastly, additional research will needed todetermine whether ultrasound ultimately improveshealth outcomes in rural areas and if the benefitsoutweigh the costs of such devices.--------------------------------------------------------Geographic Coverage: United States of AmericaImplementation Partners: MobiSanteFunder: WRF Capital, W Fund, Alliance of AngelsContact Information:MobiSante: Sailesh Chutani, CEO/Co-Founder (+1-425-605-0600, sailesh.chutani@MobiSante.com)References:1. Brian Dolan. Smartphone ultrasound device launchescommercially. MobiHealthNews. Oct 10, 2011. Web.2. The Economist. The dream of the medical tricorder. TechnologyQuarterly: Q4 2012. Dec 1, 2012.3. Gianni Truzzi and Hayley Young. 2013 Leaders in Health Care,Innovation in Medical Devices: MobiSante Inc. brings remotecontrol to health care. Seattle Business. March 2013. Web.4. MobiSante. Products: Product Brochure. Web.5. Ndiaye P, et al. Annual assessment of a mobile ultrasonographyservice in the region of Ziguinchor, Senegal. Medecine tropicale :revue du Corps de sante colonial. February 2007. 67(1):38-42.6. World Federation for Ultrasound in Medicine & Biology.Focused maternal ultrasound by midwives in rural Zambia.August 2010. (8):1267-72.mHEALTH COMPENDIUM | VOLUME 3 59

mSAKHIAn interactive mobile phone-based job aid for accredited social health activists(ASHAs)operations research (OR) studies were carried outbetween April 2012 and June 2013 in Uttar Pradesh.Implementation date: April 2012 to June 2013With 56,0001 maternal and 876,0002 newborn deathseach year, India accounts for 19% of all maternal and29% of newborn deaths globally. Accredited socialhealth activists (ASHAs), instituted as part of India'sNational Rural Health Mission (NRHM)3, can preventmany of these deaths by helping women and theirfamilies recognize maternal and neonatal danger signsand promptly seek care. However, a majority of thesecommunity health workers (CHWs) are low-literatevillage women and face significant operationalchallenges in conducting routine maternal, newborn,and child health (MNCH) activities and in keepingtheir skills updated. In particular, ASHAs' lack ofaccess to healthcare information, refresher training,supportive supervision and user-friendly job aidscompromise their ability to contribute to improvematernal and newborn health outcomes4,5.c IntraHealth International, Inc._NahidThe near ubiquity of mobile phones throughout thedeveloping world, including India, has led to theemergence of mHealth applications that are potentiallyeffective tools for supporting CHWs across a range ofactivities. The Manthan Project, funded by the Bill &Melinda Gates Foundation and led by IntraHealthInternational, developed and tested mSakhi, a mobilephone-based multimedia job aid for ASHAs. TwoAbout mSakhimSakhi, ('a friend' in Hindi) is an interactive audio/videoguidedapplication that provides support to ASHAs inconducting routine activities across the continuum ofMNCH care. It combines the functions of existing paperbasedtools, thereby eliminating the need for difficult-touse-and-carryflipbooks, manuals, registers, and otherjob aids. mSakhi content is based on the NRHM ASHAmanuals and home-based newborn care (HBNC)guidelines and formats.The Manthan Project initially developed mSakhi on theopen-source CommCare platform using Java-enabled,keypad-based mobile phones. Based on ASHA andbeneficiary feedback for more intuitive and multimediaenabledapplications, the Project modified mSakhi fortouch phones using an open-source Android platformavailable on Google Play.ASHAs register pregnant women and/or newborns intomSakhi during home visits. Upon registration, mSakhigenerates a home visit schedule for each beneficiary andprovides a set of audio-video guided instructions forcounseling, assessment and referral specific to each visit.Auxiliary nurse midwife (ANM) supervisors receive thedata, which is stored in the mSakhi central database,allowing for real-time tracking of both ASHAs andbeneficiaries. The database is designed for seamlessintegration with existing government information andcommunication technology (ICT) systems such as theMother-Child Tracking System (MCTS) and the HealthManagement Information System (HMIS), saving timeand reducing delays.Evaluation and ResultsThe Manthan Project conducted two OR studies, incollaboration with the Government of Uttar Pradesh(GOUP), to compare the feasibility and effectiveness ofmSakhi against existing paper-based tools. The pre-test/60 mHEALTH COMPENDIUM | VOLUME 3

SERVICE DELIVERYpost-test quasi-experimental design involved a total of143 ASHAs. The first study was conducted from Aprilto December 2012 in Bahraich District. The feasibilityand effectiveness of mSakhi was tested as a self-learningand counseling tool. A total of 86 ASHAs (46experimental, 40 comparison) participated, covering apopulation of 46,000. The second study was conductedfrom November 2012 to June 2013 in Jhansi District.IntraHealth evaluated the effectiveness of mSakhi as anintegrated tool (self-learning, beneficiary registration,counseling, decision-support and real-time monitoring)for the postnatal period. Fifty-seven ASHAs (29experimental, 28 comparison) participated, covering apopulation of 39,000.ASHAs reported that mSakhi enabled them to articulatecorrect and complete counseling messages due to thevoice-enabled and video-supported guided instructions,without having to carry manuals and flipbooks duringhome visits. Beneficiaries found mSakhi to be engagingand also reported other family members' interest in thecounseling messages because of the multimedia mobilecontent.mSakhi users also demonstrated greater recall of at leastsix critical newborn conditions warranting referralcompared to paper-based ASHAs. mSakhi users in thefirst study delivered complete messages for severalMNCH topics significantly better than those not usingthe application. Lastly, observations of ASHAs usingmSakhi showed them to have significantly betternewborn assessment skills while also being able toregister more births and identify more sick newbornsneeding referral for both immediate and home-basedtreatment.Lessons LearnedmSakhi can help ASHAs identify and make correctreferrals of sick newborns.mHealth applications can improve CHW knowledgeand skills, but require periodic refresher training andsupervision to support acquisition and retention.A simple, intuitive and voice navigated user interfaceis important for uptake of mHealth applications.ICT support is critical for sustained support onmobile maintenance and application updates toCHWs. ASHAs also need regular supervisoryfeedback to ensure high and effective use of theapplication.mHealth interventions require initial and recurringcosts, with the mSakhi program costing INR 10,280and INR 4,680 per ASHA, respectively. This outlayneeds to be compared with the benefit ofpotentially improved newborn health outcomes.ConclusionThe two operational research studies demonstratedthat, compared with existing paper-based job aids,mSakhi is a more user-friendly and effective ASHA toolfor a range of activities, including self-learning,counseling, and newborn assessment. Although the twostudies' limited sample size and short duration do notpermit measurement of mSakhi's effect on communitylevelhealth outcomes, these promising data suggest thatmobile applications may be an important tool to supportASHAs in improving MNCH outcomes and forimplementing and evaluating mSakhi at scale.--------------------------------------------------------Geographic Coverage: Bahraich and Jhansi districts inUttar Pradesh, IndiaImplementation Partners: IntraHealth International |Government of Uttar Pradesh, IndiaFunder: Bill & Melinda Gates FoundationContact Information:IntraHealth International: Madhuri Narayanan,Country Representative (+91(11)4601-9999,mnarayanan@intrahealth.org)Bill & Melinda Gates Foundation: France Donnay, MD,MPH, Senior Program Officer, Maternal, Neonatal andChild Health on the Family Health team (206-709-3100,France.Donnay@gatesfoundation.org)mHEALTH COMPENDIUM | VOLUME 3 61

PRE-ECLAMPSIA INTEGRATED ESTIMATEOF RISK ON THE MOVEPreventing the deadly complications of pre-eclampsia using a mobile phonePre-eclampsia is the second-leading cause of maternaldeath in childbirth globally, killing 76,000 pregnantwomen and 500,000 fetuses and infants each year.Over 99% of the women and babies who die or suffercomplications related to pre-eclampsia live in middleand low income countries. Pre-eclampsia, a rapidlyprogressive condition characterized by high bloodpressure and the presence of protein in the urine,arises during pregnancy and following delivery, andaffects both the mother and the unborn baby. Deathsrelated to pre-eclampsia are often preventable andtypically due to delays in diagnosis and treatment.The Child & Family Research Institute (CFRI) at theUniversity of British Columbia developed a groundbreakingsolution to this global health challenge withSaving Lives at Birth seed funding in 2011. Thetechnological solution integrates two separate previouslysuccessful innovations: the miniPIERS (Pre-eclampsiaIntegrated Estimate of Risk) predictive model and aPhone Oximeter. By combining these innovations in amobile phone application, they can be made immediatelyavailable in rural, low-resource community settings.Together they produce a cutting-edge mHealthapplication that empowers community healthcareproviders in rural, low-resource settings to rapidly andreliably assess risks to mothers and children, and to savelives by providing appropriate treatment and/or referralto higher level health centers.Implementation date: September 2012 toOctober 2013About PIERS on the Move"PIERS on the Move" integrates the miniPIERS (PreeclampsiaIntegrated Estimate of RiSk) predictive model,which can accurately stratify women into risk categoriesup to one week before complications arise and withoutlaboratory tests with a Phone Oximeter, a cellphonebased pulse oximeter (a non-invasive device which canmeasure blood oxygen saturation levels). The mobilephone application assists community health workers inrural, low-resource settings to provide local, rapid andaccurate risk assessment, referral, and treatment advicefor pre-eclampsia, and transmits information to referralcenters for coordination of triage, transportation andtreatment.Development of the user interface for the PIERS on theMove application involved three phases of usabilitytesting with target end-users in South Africa. Userswere asked to complete clinical scenarios, speakingaloud to give feedback on the interface and then tocomplete a questionnaire to rate all aspects of the tool.A final stage in development included piloting the tool inTygerberg Hospital, Cape Town, South Africa toconfirm accuracy of the decision algorithm.Evaluation and ResultsThirty-seven nurses and midwives (15: TygerbergHospital; 22: Frère Maternity) evaluated the userinterface between November 2011 – January 2013.During the first round of usability testing, major issues inthe functionality of the touch-screen keyboard and datescroll wheels were identified; during the second, majorimprovements in navigation of the application weresuggested; and finally during the third round, thefeedback was satisfactory and only minor improvementsto navigation were required. Overall, users felt theapplication was pleasant and would improve their abilityto care for hypertensive women.Pilot clinical evaluation at Tygerberg Hospital occurredfrom September 2012 -October 2013. During this time,165 inpatient women with a hypertensive disorder ofpregnancy were evaluated. Among them, three had anadverse maternal pregnancy outcome, two of whomwere correctly classified as high-risk by the PIERS on theMove tool.The next step is a larger clinical evaluation when thedevelopers will seek to leverage the existing researchframework and collaborations in Mozambique andPakistan to provide clear evidence of the innovation’simpact and develop a sustainable economic model for itsimplementation through local demand, value and supplychain creation in Mozambique.62 mHEALTH COMPENDIUM | VOLUME 3

SERVICE DELIVERY--------------------------------------------------------Geographic Coverage: SouthAfrica; planned for Mozambique andPakistanImplementation Partners: Child& Family Research Institute (CFRI) atthe University of British ColumbiaFunder: Saving Lives at Birth GrandChallenge partners, including USAID,the Government of Norway, the Bill& Melinda Gates Foundation, GrandChallenges Canada, and the WorldBankLessons LearnedUsability evaluation with target end-users leads to auser friendly, intuitive application even for thosewho have little familiarity or training withsmartphone technologyLarger scale evaluation is required to determine thefull scope and breadth of the possibility of globalapplicationBy using ubiquitous smartphone technology, healthcare workers in low-resource settings areempowered to make decision that can save livesContact Information:CFRI: Mark Ansermino, SeniorAssociate Clinician Scientist andDirector of the Innovations in AcuteCare & Technology (iACT),Research Cluster (+1-604-875-2000x6669, part@cw.bc.ca), Peter vonDadelszen, Senior Clinician Scientist, Reproduction &Healthy Pregnancy Cluster (+1-604-875-2424 x5545, preempt@cw.bc.ca)Grand Challenges Canada: Kristen Yee, AssociateProgram Manager (+1-416-673-6536,Kristen.yee@grandchallenges.ca)References:1. http://cfri.ca/news/news/2013/07/25/vote-for-piers-on-the-movefor-a-people-s-choice-award-at-saving-lives-at-birth2. http://savinglivesatbirth.net/summaries/2763. http://savinglivesatbirth.net/summaries/37ConclusionIn low-resource settings, referrals for pregnant anddelivering women typically occur only when lifethreateningevents have occurred. By harnessing theprocessing and battery power of mobile phones, andleveraging the widespread availability of cellular servicesin Africa and South Asia, "PIERS on the Move"overcomes the barriers of skill, distance and resources.mHEALTH COMPENDIUM | VOLUME 3 63

SKY SOCIAL FRANCHISE NETWORKUsing mobile technology to improve a multi-tiered health and family planningtelemedicine networkIn India, one in 170 women die from pregnancyrelatedcomplications and 47 out of 1,000 infants diewithin the first five years of life. Over 85% of thesewomen and children live in remote locations and donot travel far outside of their village, making access toquality health services and essential medicines achallenge. While only 32% of women own mobilephones, 83% have access to one. Mobile phones arealso ubiquitous among healthcare providers, includingthe 200,000 informally trained first-line providers thatserve people in rural areas.World Health Partners (WHP) launched a multi-tieredtelemedicine network of mutually beneficial franchiseproviders drawing on private sector capacity throughsocial franchising, innovations in labor management, andlow-cost technologies to develop a scalable andsustainable health care service delivery model thatincludes reproductive health, family planning, maternalhealth, childhood diseases and TB care. WHP beganincorporating the use of simple voice and text-basedfunctions to extend the reach of their services and havemade these mobile tools an essential component of theirrural health infrastructure.WHP currently operates its telemedicine-enabledfranchise in eight districts of Uttar Pradesh, focused ondemand generation and service provision of familyplanning and maternal health services. A larger scaleprogram operates in 13 districts of Bihar and is gearedtowards improving the detection and treatment of fourdiseases: tuberculosis, visceral leishmaniasis, childhoodpneumonia, and diarrhea.Implementation date: 2011About Sky Social Franchise NetworkThe social franchise consists of a tiered health and familyplanning service delivery network, bringing togethertrained urban doctors and informally trained ruralprivate providers, all earning revenue for providingpatient services. Mobile devices are used for multiplefunctions allowing increased value and cost-effectivenessfor both WHP programs and network providers.Each village’s mobile-based SkyCare Provider diagnosesand treats minor ailments, initiates tele-consultationsfor more complex cases, and refers the most difficultcases to entrepreneur-run telemedicine SkyHealthHealth Centers equipped with additional telediagnostictechnologies for measuring vital signs. A last-mile supplychain delivers a range of medicines and family planningproducts, and collects lab samples, all the way down tothe village level. If needed, patients may be referred toWHP-approved urban clinics for further examination bydoctors. The costs of tele-consultations vary fromUSD$0.20 for patients below the poverty line toUSD$2.00.Providers and the community are supported by variousIVR and SMS-based mobile applications that enableefficient data collection, helplines for franchisees, andhealth information lines for the community. mHealthtools are also used for franchise management – field staffare equipped with tablets loaded with simpleapplications for survey data collection, lab sampletracking, and product inventory management. Most ofthese tools are IVR-based, with the program returningcalls after a missed call is registered.Evaluation and ResultsAs of October 2013, the service has provided over93,000 telemedicine consultations. Most consultationsfocus on common ailments such as fever, gastroenteritis,infections and various reproductive health issues.Electronic data collection by field staff improved dataintegrity. A newly launched community health line thatprovides basic health information aimed at clientempowerment received over 11,000 authentic calls in itsfirst two months.Sky Health Centers are able to provide care at moreaffordable rates. For example, IUD insertion costsUSD$2.40 compared to USD$10 to $18 at an urbanclinic. Unit costs of WHP’s mHealth tools are decreasingwith an increase in number of applications being hostedon the same platform. WHP’s programs in UP andBihar are making close to 45,000 calls per month at lessthan USD$0.20 per call to WHP.64 mHEALTH COMPENDIUM | VOLUME 3

SERVICE DELIVERYtechnology platforms, there are fewer challengeswith videoconferencing and other technical issuesConclusionPatients are connected with remote, qualified doctorsthrough internet and mobile-based consultation anddiagnostic systems. Using simple forms and interactivevoice response application improve patient tracking,provide alerts and reminders, and improve dataintegrity. WHP will continue to develop appropriatemobile phone-based solutions to bring telemedicineservices to even lower level providers/remote areas andto improve provider capabilities, monitoring and datacollection.--------------------------------------------------------Geographic Coverage: IndiaLessons LearnedIn Uttar Pradesh, rural clients are willing to adoptfamily planning if quality services are provided closeto homeIn Bihar, there is a need for mobile phone-basedapplications (IVR preferred over SMS) for datacollection to monitor patient adherence, alerts andreminders, and mobile training.A large set of mHealth applications that leveragesthe same platform can reduce per call costs greatlyand enable quicker addition of new tools.WHP is piloting the use of simple mobile and webcommunications and applications to boost clientawareness of quality standards – the demand isstrong with over 11,000 calls received in the firsttwo months.Additional efforts must be put towards recruitingenough medical specialists to see patients in remotelocations and having patients trust the opinion ofvirtual doctorsWith the addition and stabilization of variousImplementation Partners: World Health Partners,Partners Consulting (communications), Government ofBihar, WayGeNext, MOTECHFunder: Bill and Melinda Gates Foundation, anonymousdonorContact Information:World Health Partners: Gobi Gopalakrishnan,President & Founder (gopi@worldhealthpartners)Bill and Melinda Gates Foundation: Tim Wood, SeniorProgram Officer (tim.wood@gatesfoundation.org)References:1. Center for Health Market Innovations. World Health Partners(WHP). 2012. Web.2. Gopi Gopalakrishnan, Karen Pak Oppenheimer, & Prachi Shukla.mHealth: Not a Standalone Solution. Stanford Social InnovationReview. 20 February 2013. Web.3. The World Bank. Data: Mortality rate, infant (per 1,000 livebirths). 2013. Web.4. World Health Partners. Bihar Infectious Diseases Program. July2012. Print.5. World Health Partners. UP Family Planning Program. July 2012.Print.6. World Health Partners. The World Health Model. July 2012.Print.mHEALTH COMPENDIUM | VOLUME 3 65

SMARTSMS printer technology for early infant diagnosis of HIV/AIDSIn Nigeria, approximately 230,000 HIV-positivepregnant women are at risk of infecting their babiesdue to the absence of adequate care. Early infantdiagnosis (EID) and immediate treatment withantiretroviral therapy (ART) are necessary measuresto reduce this burden. However, almost 50% ofinfants tested for HIV across sub-Saharan Africa neverreceive their test results. Moreover, EID of HIVrequires sophisticated virologic testing using PCR,which can only be performed at a handful oflaboratories in Nigeria. This creates challenges forcommunicating the results back to the health facilities,and thus, contributes to delays in providing timelytreatment. To address these challenges, theGovernment of Nigeria, in collaboration with a rangeof partners, has coordinated an aggressive responseby scaling up prevention of maternal-to-childtransmission (PMTCT) programs from 2010 to 2015.The Clinton Health Access Initiative (CHAI) chose toaddress one of the primary objectives of Nigeria’sPMTCT scale-up plan: to ensure that at least 90% of allHIV-exposed infants have access to EID services. CHAIpartnered with two engineering companies to develop anew technology, SMS printers, to strengthen EIDservices by reducing the turnaround time for test resultsby more than half. These SMS Printers to AccelerateReturn of Test Results for Early Infant Diagnosis of HIV/AIDS became known as the SMART Program. To keeppace with the rapid expansion of EID, CHAI, inpartnership with the Federal Ministry of Health andImplementing Partners (IPs), scaled up SMART in January2010, integrating the program into local and nationalmanagement structures.Implementation date: January 2010About SMARTNearly every district in Nigeria has network coveragefor mobile telecommunications, even in remote areaslacking roads and electricity. SMS printers combinemobile SMS technology and small, battery-operatedprinters, allowing health facilities to receive and printEID test results without the need for computers andinternet access or waiting for hard copies to bedelivered. The only consumable involved is thermalpaper for printing.When an infant is tested at a remote health facility, thesample is sent to the lab. HIV test results areimmediately reported back to the health facility via SMStechnology, received and printed by the SMS printer,and shared with the baby’s caregiver. Unskilled healthworkers are easily trained on operating the printers andminimal maintenance requirements.CHAI works closely with the Federal Ministry of Health,the PCR lab units and the IPs from both the President’sEmergency Plan for AIDS Relief (PEPFAR )and theGlobal Fund to Fight AIDS, Tuberculosis and Malaria todevelop management and technical expertise, bothlocally and nationally. The Hewlett-Packard Companyalso works with local universities to provide acentralized computing infrastructure as well as softwareapplications for labs to enable real-time management andmonitoring of program data.Evaluation and ResultsSince scale-up in January 2010, a total of 203 SMSprinters have been installed in health facilities across all6 geopolitical zones of Nigeria and over 500 skilled andunskilled health workers have been trained on printeroperation. In 2012, a large scale, national impact66 mHEALTH COMPENDIUM | VOLUME 3

SERVICE DELIVERYassessment of the SMS printer program to evaluate itsimpact on the National EID Program and generaterobust evidence on its benefits was carried out in 33study sites.The impact assessment report was disseminated in 2013to serve as an advocacy tool for partner buy-in on thetechnological innovation. Analysis of results showedsignificant reduction in turnaround time byapproximately 21 days when compared to traditionalpaper-based methods, and the SMS printer system was4.6 times cheaper than the paper-based method. Furtheranalysis suggested that infant loss-to-follow-up wasreduced through the use of SMS printers to facilitatereturn of results.The report highlighted key recommendations to addressprogrammatic and operational challenges with theSMART program. One recommendation was todemonstrate the needed support from all IPs for thesuccessful operation of SMS printers on the field. Thusfar, CHAI has secured buy-in from 50% of IPs who carryout routine monitoring and evaluation of health facilitiesand the SMS printers in the field, and providetroubleshooting assistance when required. Somepartners have also procured SMS printers for use attheir EID sites. CHAI continues to partner with theFederal Ministry of Health to provide technical supportto IPs on SMS printer-related matters, when needed.Lessons LearnedThe ability to instantly transfer results from the labto the health facility via SMS has been demonstratedto reduce turnaround time significantly, therebyhelping caregivers and clinicians to promptly initiatelife-saving ART, resulting in fewer infants being lostto follow-up.IPs lacked a sense of ownership over the technologybecause they were not involved in the initial stagesof design. To resolve this issue, CHAI adjusted itsinstallation approach by adopting a “train-thetrainer”model in order to foster a greater sense ofownership among partners.CHAI created and disseminated a troubleshootingguide in response to many sites that failed to reportif printers were not functioning properlyConclusionThe SMART program addresses a critical barrier to EIDby leveraging simple mobile technology and design tomore rapidly communicate HIV test results from thelaboratories back to the health facilities. By providingaggregated data across all SMART-implemented sites,the government is then able to track PMTCTperformance indicators nationally, thereby tailoringprevention and treatment efforts.--------------------------------------------------------Geographic Coverage: NigeriaImplementation Partners: Clinton Health AccessInitiative (CHAI), Federal Ministry of Health of Nigeria,HIV/AIDS Division; Hewlett-Packard Company; Institute ofHuman Virology, Nigeria; PEPFAR Implementing Partners;Global Fund Implementing PartnersFunder: mHealth Alliance, WHO’s Department ofReproductive Health and ResearchContact Information:CHAI Nigeria: Rosemary Archibong, Senior ProgramOfficer, Laboratory (rarchibong@clintonhealthaccess.org)CHAI: Zachary Katz, Director of Diagnostic Services(zkatz@clintonhealthaccess.org)mHealth Alliance: Francis Gonzales, Program Associate(202.419.6412, fgonzales@mhealthalliance.org)References:1. Children and AIDS: fourth stocktaking report, 2009. UNICEF,UNAIDS, WHO, UNFPA, 2009.2. Federal Ministry of Health of Nigeria. National scale-up plantowards elimination of mother-to-child transmission of HIV inNigeria 2010-2015. Government of Nigeria, 2011.3. Francis Gonzales. IWG Grantee Year 1 Update: CHAI Nigeria.Health UnBound, May 3, 2013. Web.4. mHealth Alliance. IWG Round 1 Grant Winners. CHAI –SMART (Nigeria) Project Profile. The World HealthOrganization, 2013. Web.5. SMART Impact Assessment Report 2013mHEALTH COMPENDIUM | VOLUME 3 67

ANNEX 1mHEALTH COMPENDIUM EDITION ONE CASE STUDIESBEHAVIOR CHANGE COMMUNICATIONChakruok Interactive Radio ProgramCycleTeliCycleBeads Smartphone AppsLa Ligne Verte Family Planning HotlineMobile 4 Reproductive Health (m4RH)SMS and IVR to Improve Family Planning ServicesText Me! Flash Me! Call me!Workplace-based SMS Awareness CampaignDATA COLLECTIONAutomating Data Collection for HIV ServicesChild Status Index (CSI) Mobile AppEpiSurveyor/MagpiIntegrated Health Systems Strengthening Project – IHSSP: RapidSMSJSI Early Warning SystemFINANCEChangamka Maternal Health SmartcardMobile Finance to Reimburse Sexual and Reproductive VoucherscStockDelivery Team Topping Up SystemIntegrated Logistic System – ILSGatewayLOGISTICSInternational Quality Short Message Services (IQSMS)Mobile Product Authentication MPAmTrac: Monitoring Essential Medicine SupplyTupange SMS Community Tracking SystemSERVICE DELIVERYCommCare for Home-Based CareCommunity IMCI (cIMCI)eFamily Planning (e-FP)eNutritionMaternal Health (Antenatal and Postnatal Care)mHealth for Safe Deliveries in ZanzibarMobiles for Quality Improvement (m4QI) – SHOPS ProjectMOTECH SuiteProject Mwana – SMS for Early Infant Diagnosis of HIVSIMpill® Medication Adherences SolutionSupportive Supervision (SS) for TB in NigeriaThe Malawi K4Health Mobile Learning Pilot68 mHEALTH COMPENDIUM | VOLUME 3

mHEALTH COMPENDIUM VOLUME TWO CASE STUDIESBEHAVIOR CHANGE COMMUNICATIONCommCare for Antenatal Care Services in NigeriaJustTested: SMS-Based Support and Information for HIV Testing and Counseling ClientsMAMA BangladeshMAMA South AfricaTobacco Kills: Say No & Save LivesWazazi Nipendeni (Parents, Love Me): mHealth Initiative to Support Maternal Care in TanzaniaDATA COLLECTIONCommunity-based Health Promotion for Safe Motherhood using mHealthDataWinners PlatformiHRIS and Mobile Reference DictionaryiPhones for Malaria Indicator SurveyThe Last 10 Kilometers: What it Takes to Improve Health Outcomes in Rural EthiopiaMobile Phone Microscopy for the diagnosis of Parasitic Worm InfectionsOpenHDSFINANCEHeartfile Health Financing - an mHealth enabled innovation in health social protectionJamii Smart | KimMNCHip—referrals, mSavings and eVouchersTanzania National eVoucher SchemetransportMYpatient: Facilitating access to treatment for obstetric fistulaeEnat Messenger for Maternal Health in EthiopiaMobile Phone Survey Software for End-UsemPedigreemTRAC Stop Malaria Program (SMP)LOGISTICSSERVICE DELIVERYAliveCor Heart Monitor - Mobile ECGFioNet: Mobile Diagnostics Integrated with Cloud Information ServicesGxAlertMarieTXT: A Mobile Powered Management Information SystemmCARE: Enhancing Neonatal Survival in Rural South AsiatxtAlert for Patient RemindersThe First and Second Volumes of the Compendium are available at www.as4h.org/ash-publications.html.mHEALTH COMPENDIUM | VOLUME 3 69

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