Archive for the 'Health' Category

Medic Mobile Wins a 2014 Skoll Award

A community health worker featured in Medic Mobile's video at the Skoll Awards
A community health worker featured in Medic Mobile’s video at the Skoll Awards. Click through to see the video and Josh’s short speech about our work.

Earlier this month I had the great pleasure of attending the annual Skoll World Forum with some of the team at Medic Mobile. As my cofounder Josh put it, “The Skoll Award and the $1.25 million investment is rocket fuel for our mission as we embark on the next phase of our work.” While the Skoll selection process is extremely competitive, the awards aren’t given for past accomplishments but for possibilities yet to be realized. In Skoll’s words, they’ve just added us to their “social progress watch list.”

With this award, our team joins a humbling group of change makers. B Lab is among the seven organizations recognized this year. I’ve been following their work with interest since I briefly met a cofounder Jay at the Bus Project’s Rebooting Democracy conference in Portland a few years ago. Awardees of years past include Mothers to Mothers, Tostan, One Acre Fund and Partners in Health.

My work and purpose in life have so many connections to Partners in Health and their example of pragmatic solidarity. Paul Farmer’s scholarship and PIH’s call for Joining Josh and Maeghan for a celebratory photo on the Skoll main stage, just after the awards health delivery research were guiding lights in my decision to pursue a PhD as a Gates Cambridge Scholar. My recent writing about the idea of Preferential Software for the Poor draws heavily on Farmer’s work, and PIH’s influence has also been ever present in Medic Mobile’s approach to partnering with community health workers.

It was fitting that Josh’s short speech revolved around partnering with community health workers like Dickson from St Gabriel’s Hospital in Malawi. I fondly remember working with Dickson as well, and I couldn’t have been more excited for and proud of Josh and our team as he spoke about our work to a packed house. “All of us– you, and me, and Dickson–are working in solidarity. We are all health workers, waking up every day determined to cure an unjust state of affairs.” Bravo Josh.

Joining Josh and Maeghan (Director of Medic Mobile’s programs in Africa) for a celebratory photo on the Skoll main stage, just after the awards ceremony. Read more about the Skoll week on the Medic Mobile blog.

May 1st Update: Skoll has now posted the Medic Mobile 4 minute trailer that is featured in the longer awards video above. I really like Jane Katanu’s role in this video. She is Medic’s team leader on a project that I’m studying as part of my PhD, so I get to work with her often.

Why Can’t You Just Ask People? Tacit Knowledge and mHealth in Malawi

This post was originally featured in Digital Diversity, a series of blog posts curated for National Geographic by anthropologist and innovator Ken Banks. The series discusses how mobile phones and other appropriate technologies are being used throughout the world to improve, enrich, and empower billions of lives.

After driving south to the end of the pavement, we continued on gravel and dirt roads for a few hours, long enough for me to fall asleep and wake up several times before arriving at the district hospital. Temperatures can reach 125 degrees Fahrenheit near the Nsanje River in southern Malawi, so I was grateful to arrive in a milder season when midday temperatures hovered just under 100. For more than a year I had been using mobile phone technology to improve health services and I expected this project to follow the typical routine: discuss the plan with leaders at the local district hospital, install software on phones and computers, and train frontline health workers to deliver routine reports using a mobile phone-based data collection app called FrontlineForms.

In Malawi, government-employed community health workers (CHWs) treat children in rural villages for malaria, pneumonia and diarrhea. Although highly effective medicines exist, these three ancient afflictions remain leading causes of death among children in developing countries, often because medicines are out of stock or only available at distant locations. My goal in Malawi was to improve the flow of information from CHWs to the district hospital, so that these life saving medicines could be resupplied efficiently to remote communities.

Malawi has two major mobile network operators: Airtel and TNM. I had surveyed all 50 health workers about which mobile network had a stronger signal in each of their communities. When the training began, I was bewildered and frustrated to find that there was almost no signal for the network that 8 out of 10 had requested. I had offered to connect them to either network; why would so many choose the one with much poorer coverage? Reluctantly, they explained that although Airtel had weaker signal locally, they sold airtime in units of 25 Malawi Kwacha, while the smallest increment for TNM was 50 Kwacha. These CHWs typically had 25 Kwacha on hand but may not have 50 in their pocket when they wanted to buy airtime for personal use (work related airtime was to be reimbursed). This experience was eye opening, almost unnerving. I was distributing $100 phones to people who considered 25 Kwacha (about 15 cents in US dollars) a greater barrier to access than walking or bicycling several kilometers to reach mobile signal.

Money on hand for airtime is one of several important considerations for rural health workers. A few weeks ago I spoke with a volunteer health worker who provides immunization and antenatal care services in coastal Kenya. Mary has a solar panel on the roof of her house and one other volunteer in her community group has grid electricity, but the other 38 volunteers must travel to the market to charge their phones. Charging a phone just once costs 30 to 80 cents. For a volunteer health worker whose cash income may average a few dollars a day, the financial burden of charging a phone this way is similar to filling a car with gasoline in North America or Europe. Walking or paying for public transit to the market are inconvenient, so many volunteers wait a day or two after their phone runs out of battery.

Working in these circumstances for the last three years, I’ve learned that the key to understanding how mobile health services can proliferate is in understanding what technologies these communities are already using. There is wisdom embedded in the observed preferences of ordinary villagers. The technologies that are driving change in society today are, as a rule, already being used at a massive scale. For the urgent change-maker, cutting-edge technologies are hardly relevant, ubiquitous technologies should be captivating.

One such captivating technology is the mobile phone that costs $15 and can last a week or even two on one charge. Clunky nine-button keypads and black and white screens the size of a half-dollar coin can make these phones look second-rate, but they fill an enormous gap in households surrounded by neglected rural roads, with ineffectual postal service, no car and no land-line telephones or internet. The first-generation phone is a quaint memory in developed markets but in Africa, everyman’s phones are referred to with familiar terms such as Kabambe in Kenya and Mosewalelu in Malawi. They have become cultural icons of progress not unlike the early model T Ford, a cultural icon as the first everyman’s car in America. The low cost, long battery life, familiarity and ease of use, being less prone to theft, better supply chains, sales and repair outlets and the promotions put on by mobile network operators all contribute to the statistic that in 2011 there were 32 non-smart phones for every smart phone on the African continent.

During my first design research trip to Kenya in early 2010 I learned something about $15 phones that most Kenyans already knew: every phone can have apps – you don’t need a smartphone. I was talking with ordinary consumers about using mPesa, the wildly successful mobile banking service that lets users send money to and from any phone. I learned that mPesa is available and familiar on any kind of phone, from Android smart phones to ordinary $15 phones. This is possible because mPesa actually sits on the SIM card, not the phone itself. Many North Americans do not even realize that inside of their phone is a small chip called a SIM card that handles the phone’s connections to the mobile network. Throughout Africa, however, people frequently change their phone’s SIM card from one mobile network to another, to take advantage of evening calling rates or other sales promotions. SIM apps are viewed through the phone’s native menu which means that if you know how to check your contacts list or text message inbox on a particular phone, a SIM app on that same phone will look familiar.

The challenge with deploying health related SIM apps is that mobile network operators strictly control which apps are installed on their SIM cards. But I kept tinkering with SIM cards and after several months I discovered that some groups in the financial and security sectors, as well as hackers trying to jailbreak iPhones, use paper-thin parallel SIM cards that slide underneath the mobile network operator’s SIM. Using any standard GSM phone, we’re able to put our SIM apps on the parallel SIM and still use an ordinary SIM card to connect to any GSM mobile network in the world. About a year ago I announced that Medic Mobile would be the first mobile health organization to develop and deploy SIM apps, and since then the Medic Mobile team has started SIM app projects in several African countries.

As we take on larger SIM card projects, our goal is to work closely with mobile network operators so that the apps sit directly on the native SIM card and don’t require parallel SIMs. This will be cheaper and it’s true to the strategy that has served Medic Mobile well: no one understands the communities where we work better than the people who live in them every day. Our best chance of deploying mobile health services that are locally appropriate and manageable at a large scale, is to leverage the phones and other technologies that are already in their hands.

Managing airtime with community health workers


Throughout Africa the vast majority of phone subscriptions are pre-pay. Usually that means you buy a voucher like the one pictured above and enter the voucher PIN into your phone to redeem units of airtime (rather than using a certain amount of airtime and paying at the end of the month). One of the big challenges in my work is figuring out how we can let our community health workers continue to use their phones in this way, while also reimbursing them for work or hospital related airtime. A week or two ago I posed these questions to the ICT4CHW mailing list:

Option 1: has anyone come across a telecom that offers zero-rated SMS or data lines – analogous to a 1-800 number in the USA – as a standard service? This approach is very appealing but for the fact that usually you need to negotiate this on a special basis with the telecom which can take time, requires clout, etc. Is there any way we could collaborate to make negotiation for this service easier and/or convince more telecoms to offer it as a standard service?

Option 2: Brian of ComCare mentioned bulk buying data for their program and fortunately the CHWs weren’t using data services personally so they didn’t use program airtime for personal use – clever! Has anyone else tried this approach?

Option 3: At one of Medic’s projects in Malawi we set up an automated top-up system where CHWs could text in their ID and have airtime sent automatically to their phone. It was easy to manage and was very infrequently abused, in retrospect this was due to the strong relationship between the hospital we were working with and their CHW program, and because we had explained to the CHWs that their airtime requests were monitored after the fact – if they requested more airtime than they should have needed based on the number of messages they were sending to the hospital, they would be removed from the program.

This approach isn’t foolproof though. Here are some issues:
You may send enough airtime for 10 SMS and find that CHWs only use 1 or 2 SMS for program use and spend the rest on their own stuff, then request more airtime. You could switch to a system where a CHWs is initially given enough airtime for say 10 SMS, and they are automatically credited 10 more SMS (via USSD) as soon as the tenth SMS is received by the system. This does prevent abuse… but it also just halts your program if CHWs spend their initial airtime on personal stuff and it is beyond their means/will to buy more so that they can keep sending SMS to the hospital.

Another option is to send smaller amounts of airtime each time you request a CHW activity that will require them to respond to you, and say they can have for personal use whatever they don’t use in responding to that specific task. This has a high transaction cost though; in places like Malawi where the transaction cost for a USSD airtime transfer is the same as the cost of one SMS, you can basically doubles the cost of your program’s SMS.

Have others encountered similar circumstances? In the long run we should probably invest more time in figuring out Option 1, but we are really trying to develop models that can be replicated by normal health care folks – people who aren’t professional mHealth practitioners like us – and so we’d like to find a solution that doesn’t involve negotiating with a telecom. I feel like a human and work flow solution is may be necessary here, it’s hard to replace basic health worker trust and discipline, but I’d love to hear ideas any others have!

Other mHealth practitioners seem to be dealing with these issues as well – we had a lively discussion over 32 posts to the list. Here’s my summary of a few key points:

    Reverse billing, short codes etc are possible, and usually the best option if your project is large and you have staff who can make a good business pitch to the local telcos.

    Smaller projects, those that need to get up and running quickly, or project that lacks the savvy to pitch to/negotiate with a telecom will usually want to reimburse their health workers manually. The key to success here may be in creating proper incentive structures. For example, allowing some extra airtime for personal use, making airtime a collective resource so that peers in the community enforce prudent airtime use, or modifying salaries (bonuses or salary deductions) according to whether airtime use was appropriate.

    To “reimburse manually” could mean handing out paper scratch-off airtime vouchers, sending airtime directly from facility SIM to CHW SIM, distributing voucher pins via SMS, or having a telco or kiosk vender send out airtime for you. The most appropriate method may depend on your incentive structure.

    There are also technical hacks – for example only buying data bundles among CHWs who don’t use data, getting smart phones that can restrict which numbers may be called/SMSed, or working with a telco to restrict sms/voice/gprs services and outgoing numbers (the reality may not live up to the expectation with some telcos).

    Long term, I’m excited to continue conversations about working with individual telcos and the GSMA ‘union’ to make available the services that will be most useful to us. Based on the broad issues we’re discussing here I think there is a profit incentive for telcos to offer these services. Eduardo offered some useful insight on how to go about making the pitch to various telcos.

The ICT4CHW list has a new discussion about once a week, you are welcome to join us.

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