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Mobile Technologies& CommunityCase Management——Solving the Last Mile in Health Care Delivery
Contents Introduction 1 — — UnderstandingUnderstanding Community Case Management Mobile phones can change the way healthcare is delivered in the most rural and underserved parts of the world.4 What is Community Case Management? There is now a way to have real-time, two-way communi-5 Community Case Management Challenges cation with communities that are beyond the periphery of Community Case7 What is a Community Health Worker? formal health systems.8 Mobiles & Real-Time Information A child gets sick in a remote village in Malawi. She is10 A framework for leveraging the power of undernourished and there is over a 50 percent chance that mobile phones and real-time information she has either pneumonia, diarrhea or malaria. The nearest Management health clinic is a day’s walk away and her family can barely afford to take her. A Community Health Worker (a volun-Workshop teer member of the community, trained to diagnose, treat and refer) can mean the difference between life and death.14 Workshop Goals Largely unsupported by the formal health system,18 Workshop Process this Community Health Worker is often unable to make a timely and accurate diagnosis. One solution to the disconnectedness, these problems of distance, time, andFocus Areas access to information, exists in the increasingly ubiqui- tous mobile phone.22 Bridging the Gap between Supply Now, the Community Health Worker can use her and Health Groups phone to get information, ask advice, re-order life-saving26 Giving Voice to Demand drugs, and receive feedback from the otherwise-distant30 Building Capacity through Incentives formal health system. Additionally, these interactions34 Solution Highlights provide vital traces, at a national level, of activities and36 Design Principles needs that were previously impossibly far away, creating the ability for realtime monitoring and accountability. To explore this unique solution-space UNICEF and40 Participants frog brought together public health, mobile health and42 About design constituencies to create an adaptable model for how mobile can best support Community Health Work- ers as they diagnose, treat and refer the most common killers of children.
Mobile Technologies & Community Case ManagementWhat is CommunityCase Management?To bridge the access gap to basic healthcare, Ministries Community Case Management Challengesof Health in developing countries increasingly rely on “We do not need a new science or new gadget to address the challenges we faceexisting front-line community health workers to diagnose, today. What we need is to remove the bottlenecks that prevent these populationtreat and refer children from remote communities with groups from sustainably accessing essential services.”common childhood illnesses. Integrated Community Case —Nicholas Alipui, Director of UNICEF ProgrammesManagement is a strategy whereby front-line health workersare trained, supplied, and supervised to deliver treatments Incentives Training Monitoringin the community to children with pneumonia, diarrhea, Motivating community Sharing knowledge and Analyzing and aggregat- health workers and citizens tools to aid Community ing data to trigger feedbackand malaria and sometimes dysentery, newborn sepsis and to participate in Commu- Health Workers and and dialogue.acute malnutrition. nity Case Management increase their capacity to Community Case Management is not a new strategy. services. handle Community Case Supervision Management services. Strengthening linksIt has existed at small scale for decades and at large scale Quality of Care between the communityfor single diseases for years (such as pneumonia control in Fostering successful case Retention health worker and healthNepal). What is new is the priority that global development management through Celebrating and recogniz- system, relying on local effective diagnosis, treat- ing the efforts of Com- solutions as often aspartners and governments have given to large-scale ment, referrals, and munity Health Workers possible.adoption of Community Case Management as a critical link follow-up. to foster high morale andin the healthcare system. engagement.4 5
Mobile Technologies & Community Case Management What is a Community Health Worker? he ty al i un th ca comm Educates Use as Uno cial Community Healthcare Workers re s Give Continuous ystem Gains Respect Healthcare Training Builds Relationships Provide Community Simple Incentives Health Worker A Community Health Worker is a trusted member of the community—a mother or father, a local farmer or business owner—who serves as the primary link in healthcare delivery for many under-served populations. She spends the time she has to spare as a healthcare extension worker, creating a crucial bridge between the community and the healthcare system. She has recognized the suboptimal state of her community’s health, and is motivated by the opportunity to improve it. She gains recognition and respect within the community and is rewarded by small incentives provided by the healthcare system and NGOs in exchange for her extension worker work. Through the minimal training she receives from the clinic, NGOs and the Ministry of Health, she educates the community on healthcare and health-related topics of daily living, like safely preparing food. She sometimes assumes the role of healthcare worker, and often helps out around the understaffed clinic with record keeping, patient intake and a variety of clerical and clinical duties. Through her existing position as a community leader, she is the liaison between the com- munity and the clinic, providing medicine, information and enabling transporta- tion to clinic visits when necessary.6 7
Mobile Technologies & Community Case ManagementMobiles & Real-TimeInformationDisparities and inequities are increasing in the world today particularly aroundaccess to health services. How do we remove the bottlenecks that prevent themost underserved population groups from sustainably accessing essential ser-vices? One of the key bottlenecks is the ability to know where disparities are thegreatest so that resources can be targeted more effectively. The expanded reach of mobile devices and wireless networks may prove to bevaluable tools in improving services. However, in order to increase the impactof integrated Community Case Management, they must be used in a way thatmaximizes their capabilities to provide breadth instead of depth and to captureevery interaction in realtime. UNICEF and its partners are beginning to explorenew ways in which mobile technologies can help them answer these questionsin real-time:Are we reaching the right people? How can we get the few key pieces of information we need that can helpWhat are the returns on our programme managers act in time?investments?How can we make mid-term course Can mobiles help us improve program-corrections to our programmes based matic outcomes and increase impact?on feedback from real time data? And how can we engage the people we serve in this process?8 9
Mobile Technologies & Community Case ManagementA framework for leveraging the Conventional Data Flow: Mobile technologies were originally viewed as a more efficient means ofpower of mobile phones and data collection, replacing printed forms. This data was integrated into existing processes in which informa-real time information tion flows in one direction to support oversight and decision-making. Simultaneous Data Flow: Much more powerful results can be achieved when this data is shared simultaneously with participants throughout the ecosystem in a timely Simultaneous Data Flow manner. Tailored views of the infor- mation are essential to ensure that the Conventional Data Flow data is useful to different participants. Reciprocal Communications: Engagement between participants is greatly enhanced by the simple power of conversation, recognizing the personal and social nature of mobile + phones. Simple forms of feedback and acknowledgement have been shown to dramatically increase the use and Measuring Demand Country appeal of these services. + District Measuring Demand: Mobile technologies can open up a dialogue with communities to drive Community demand for services and monitor needs Leaders Clinic across diverse communities allowing service providers to predict as well as react to health needs and creating a positive feedback loop that builds over all trust in the healthcare system. Community Health Metrics as a By-Product: Worker The most effective metrics can be Metrics as By-Product captured as a by-product of human- centered design and increased engage- ment across a range of participants. Services created with a metrics-first are often burdensome and alienat- ing to health workers as they don’t Mother provide any immediate benefits or & Child acknowledgement for their work. Reciprocal Communication Global10 11
2 —— — How can we apply mobile phones and real-time information to strengthen——— — — —— — — community case management?Workshop We brought together a community of international experts in public health and mobile technologies to answer that question.
Mobile Technologies & Community Case ManagementWorkshop GoalsA one-day gathering in New York City which brought together key stakeholdersfrom public health programming and mobile health implementers to build align-ment around how mobile phones can support the tools, processes and systemsof integrated Community Case Management. The workshop was hosted andfacilitated by frog, a global innovation firm and UNICEF partner. The first ordergoal of the workshop was for the two communities to share best practices andexplore innovative ways to integrate mobile technologies into Community CaseManagement. This supported the second order goal: to better support com-munity health workers to serve underserved communities more effectively andimprove key child survival outcomes. In this collaborative and action-orientedworkshop we:Generated a provisional model for Discussed specific local and regionalhow the different layers of healthcare needs in order to integrate theproviders and their user experience appropriate flexibility for location-fits together. specific customization.Identified key opportunities for Generated a set of guiding principlesalignment in the planning and for enhancing Community Caseprioritization process to support this Management and the role of theintegrated user experience. Community Health Worker through mobile technologies.14 15
Mobile Technologies & Community Case Management16 17
Mobile Technologies & Community Case Management Workshop Process 4 1 Concept Generation From the provocation exercise, each Knowledge Shareout group created 2 to 4 new concept ideas A workshop’s success is driven by the related to their specific focus area, and collective expertise and knowledge presented them to everyone. Focus available in the room. Our first areas included supply chain, demand step was to share successes and generation and incentives. failures from our varied perspectives and experiences in healthcare, government and technology (and their intersections). 2 5 Scenario Building Solution Voting Scenarios help envision people using UNICEF country representatives used a future tool or service in a specific dots to select the concepts they found situation. Divided into groups, we most compelling. The top 6 concepts imagined an ideal service or process were then used as the focus for further centered around a specific Community refinement in the Data Flow Exercise. Case Management focus area. 3 6 Provocation Exercise Data Flow Exercise Building on our scenarios, we The goal of this exercise was to overlayed perspectives and potential illustrate the ways in which data flows practices inspired by global companies. back, forth, and between users in the How would DHL or Nokia handle chain of communication. Identifying Community Case Management users goals, actions and feedback challenges? illustrated good opportunities for mobile technologies — as well as opportunities where other methods were more appropriate.18 19
3 —— ———— — — —— Bridging the Gap Between Supply and Health Groups As Community Health Workers take on responsibility for more front-line care and case management, it is critical that they have adequate supplies to support their — — expanded activities. How can we use communication technology to ensure that the necessary supplies are available to respond to needs?Focus Areas Giving Voice to Demand Much of the effort in program planning goes toward the delivery of products and services. Community Health Workers are embedded in the communities they support, driving program awareness and responding to demands. How can we use communication technologies to give a stronger voice to community demand — — for Community Case Management services through Community Health Workers on the front line of care? Building Capacity through Incentives The policies and organizations that support Community Health Workers vary tremendously from region to region. Yet in almost every case there is a huge challenge in building capacity and rewarding performance in meaningful ways. How can communication technologies help us test different forms of recognition and reward to improve performance and engagement, particularly as Community Health Workers take on more responsibilities for case management?
Mobile Technologies & Community Case ManagementBridging the gap 1 Community Health Worker Florence is with a mother and herbetween supply child. Florence diagnoses the child with malaria and gives the mother anti-malarial drugs. She inputs this transaction and other patientand health groups information (name, sex, age, address, symptoms) into her mobile phone and sends it to the database. Patient + Transaction Information 2 FloREnCE: + Infant female diagnosed w/early Immediately following the input of the stage malaria transaction into her phone, Florence receives an instant follow-up message ClInIC: Please give ACTs (dosage that states “Thank you for the update. x for 7 days) and Please give ACTs (dosage x for 7 days) then follow up in and then follow up in 3 days and check Stock Levels 3 days and check District symptoms.” Oct - Nov symptoms. Manager + F J T Clinic Supervisor Mother & Child 3 Community Health Worker This transaction data is received and aggregated through a database engine that reports real-time supply stock information back to the District, Replenish Community Leaders Regional, and National offices. An administrator reviews a dashboard showing stock supplies of various Vaccination Stock drugs and vaccines by region. He can easily troubleshoot stock overages and deficiencies, and send action requestsIllustrates Challenges: back to regional offices to reallocate stock between their clinics.Quality of Care / Monitoring / Supervision / Training22 23
Mobile Technologies & Community Case Management 4 7 ClInIC: Hi Florence, how is female infant This transaction data is simultaneously doing with anti-malaria One week later, Florence receives an received and incrementally reported to treatment? SMS message prompting her to give the NGO and public/private sectors to an update on the baby to whom she FloREnCE: inform them of stock usages. Healthy baby :) prescribed the anti-malarial drug. Did the treatment work? ClInIC: Great news! Florence inputs a follow-up response, which is again cycled back into the system and she receives a friendly message back acknowledging receipt of the information and thanking her for her continued work in the community. 5 8 DISTRICT MGR: Administered Meanwhile, Florence’s local clinic is The data is fed back from the District AMM Oct-Nov – low on malarial drugs. They receive Manager to the community. He sends Florence 16; a proactive update via SMS that a an SMS message to the Village Health Joe 37; Tom 6; Fennis 21 new shipment is on its way. They Committee Leader with positive stats: also receive a report that Joe has been “76 children got healthier from seeing administering a higher percentage of a Community Health Worker or clinic anti-malarial drugs compared to the in your village this month.” other Community Health Workers in the district. Joe receives the same message with positive affirmation of his work to help the children in his community. 6 9 The clinic Supervisor goes to meet The Village Health Committee in turn with Joe in person. He intervenes by relays this information back to their reviewing diagnostic steps to ensure community via word of mouth. that he is not overlooking other DISTRICT MGR: 76 children got conditions. better after seeing CHW in He also proactively brings with him your village! new supplies based on reporting of his other drug supply levels.24 25
Mobile Technologies & Community Case ManagementGiving voice to 1 In Village X, members of the Village Health Committee hear from a localdemand woman that a Community Health Worker referred her child to the nearest clinic, but it is too far and expensive for her to travel. The Village Health Committee members note that this is a continuing problem that has prevented the children in the village from receiving “Lack of proper treatment. Transportation” 2 HoTlInE: Community Issues with access Leaders to healthcare? Periodically, the leader of the Village  None Health Committee receives an SMS  No education  Transportation text stating they can report concerns to clinic or issues to the district manager  No supplies Hotline. He is provided a series of “Low Referral Attendance” prompts via SMS to rapidly record the VIllAGE: Community concern.  Transportation Health Workers to clinic + The prompt provides a list of common problems that reduce the quality of care. He selects “#3 Transportation to clinic” as a major issue.CLINIC 10km HO TLI NE Clinic Nurse + 3 HoTlInE: nURSE: How are things at your clinic?  Low referrals  Okay Meanwhile at the nearest clinic, a  Too busy Nurse is also prompted via SMS  Low referrals message to take a poll survey on “How District are things at the clinic?” Manager Subsidized She selects “#3 Low referrals” from a Clinic Transporation list of common or recurring issues.Illustrates Challenges:Incentives / Quality of Care / Monitoring26 27
Mobile Technologies & Community Case Management 4 7 The Village Health Committee leader A text is sent to the Village Health VIllAGE: nURSE: and Nurse both receive an SMS Committee in Village X letting them Transportation Low referrals message immediately thanking them know that transportation to the clinic to clinic for using the Hotline. It also explains will now be supported through the that their concerns will be reviewed new taxi program. and a status update will be provided in one week. HoTlInE: Looking for a solution for your problems 5 8 Administrators at District and The Village Health Committee shares National levels view aggregated the news of transportation to the clinic hotline and poll data to troubleshoot with their village via word of mouth. areas. They review top unmet needs, HoTlInE: such as clinic access, and quality of We will provide service trending data for Community your village Health Workers. with low-cost alternative transportation They pinpoint a problem with high to the clinic referrals reported, but patient atten- dance in clinics and hospitals is low across the region. 6 At the national level they realize that the root of many problems for Village X, including perceived quality of health services, is lack of access to the clinic. They send a note to the Regional Manager to work with local taxi drivers in Village X to help with transportation issues.28 29
Mobile Technologies & Community Case ManagementBuilding capacity 1 Community Health Worker transactions with villagers arethrough incentives being recorded and tracked by the Community Case Management database engine. Florence, a Community Health Worker, is directly linked with the percentage of increasing demand for regular checkups and treatments in her community. “Florence is great!” 76 malaria 29 pneumonia patients treated Florence 2 Citizens of Village X are able to rate the performance of their Community Mother + Aug Sep Oct Health Workers via SMS, providing qualitative information about the & Child responsiveness and quality of care they are receiving. District Manager $ $ $ Community RewardsHealth Worker “Florence is doing a great job.” 3 Florence is noted as being a high- performing Community Health Worker from both number of Community transactions and feedback from actual Praise patients. The clinic and district office Community Members gets a report on these high performing Community Health Workers on a regular basis.Illustrates Challenges:Incentives / Training / Retention / Monitoring30 31
Mobile Technologies & Community Case Management 4 7 The district office sends a message to At incremental periods throughout the Village Health Committee, and the year, they reward a set of high directly to Florence, with positive performing Community Health feedback and her stats: “Florence has Workers delivered in the form treated 29 cases of pneumonia and her of money, new mobile phones, or patients have given her a 99% approval resources for training. rating.” DISTRICT MGR: DISTRICT MGR: Great job Florence! Your CHW, Florence You have helped 29 has helped 29 pneumonia patients pneumonia patients this year in your community 5 8 The Village Health Committee puts Florence is empowered to train together a local ceremony and provides another village member as a her with a Community Health Worker Community Health Worker to badge of excellence. This in turn builds assist her in her duties. She acts as a more trust for Community Case mentor and now both of them can Management among the villagers. handle the increasing number of cases in their village. 6 Meanwhile, the District office tracking high-performance Community Health Workers in their villages. They have a special fund set aside for incentivizing the highest performers.32 33
Mobile Technologies & Community Case ManagementSolution Highlights1: Bridging the gap between 2: Giving voice to demand 3: Building capacity through incentivessupply and health groups Instant SMS feedback collected Performance tracking enabled atSMS data collection at point of at the community and clinic levels individual and district levelstransaction to increase accuracy of leading to increased demand andstock level reporting quality reporting Capturing and tracking data at point of transactions that link CommunityReal-time feedback to clinics, Aggregation of demand-based data Health Workers with patient outcomesCommunity Health Workers, village from clinics and community, enablingleaders and community on status quicker troubleshooting from Enabling 2-way communications andof actions program management ratings directly from citizensDistributed reporting of supply Real-time feedback to clinics, Real-time feedback that promptslevels and drug efficacy, allowing Community Health Workers, village motivation and behavior change forfor proactive planning and local and leaders and community on status Community Health Workersnational levels of actions Accelerated Community HealthReduced restock supply cycles based Faster reporting of concerns and Worker improvement and mentorshipon real demand issues that might not have otherwise enablement been identified Improving community trust for Com- munity Health Workers through better alliance with Village Health Committee34 35
Mobile Technologies & Community Case ManagementDesign PrinciplesThese principles emerged as a result Design for the Person Consider that Technology Changes Motivate the Private Sectorof the exercises and workshop. Design for people, rather than for the Much Faster than the Health Domain Private sector partners are great, but system. Designing for people and Design for the ideal, and trust the consider their incentives to invest.Set Boundaries and Scope their everyday interactions assures technology to fill in. Technology What is there to gain in the healthWhen choosing areas for mobile that you will uncover and solve for the changes rapidly, while the health domain or technology sector? Whotechnology application, focus on the right problems. sector is much more slow to change. might the big partners be?interactions that will be best enabled When designing for mobile, you haveand enhanced with mobile. Setting Consider Value of Efficiencies to remember that by the time you Embrace Collaborationboundaries for the solution prevents Create communications efficiencies in design a system, features or capabili- Foster “communities of practice” orovercomplicating or overburdening and across your organization. Rather ties might have already changed in ad hoc sharing networks within UNI-the system. than forcing hierarchical, linear chains the market. CEF and its partners. Share knowl- of communications, look for overlaps edge of initiatives and pilots, what’sApply Mobile Where Appropriate in data that can be distilled for differ- Design for Flexibility and Reciprocity working or not, build on and leverageMobile is not a panacea—it has big ent points in the system. Design for 2-way communications. existing systems, bundle differentbenefits for some interactions, but in Keep in mind the need for flexibility pilots together in larger rollouts.some cases analog might actually Consider Scale from the Outset and reciprocity of communicationsstill be best. Mobile is a tool, not the Think about creating solutions that (e.g. if you pull knowledge from atotal solution. can be used elsewhere, that can grow community, you should push back with technology, that can take on information to that same community). more participants. In other words, Mobile is great at both of these. don’t design yourself into a corner36 37
Mobile Technologies & Community Case Management“The work you are doing gives us the opportunity to answer these important questions in real-time. Fast enough to impact how we manage our programmes, report to our donors, and have a direct effect on the lives of children.”— Nicholas Alipui, Director of UNICEF Programmes“We have taken for granted that [because the problems are complicated,] the solutions are going to be complicated. But simple things can go a long way. ”— Bernard Kasawa, UNICEF Coordinator MNCH/PMTCTInitiative Luapula Province, ZambiaThe principles and recommendations improve the quality of outcomes andin this report serve as guidance for 190 empower communities health workersUNICEF country offices as they inte- around the world.grate real-time monitoring and mobiletechnologies into their programming to38 39
Mobile Technologies & Community Case ManagementParticipantsAaltje Camielle noordam Denise Gershbein Gabriele Fontana Julia Kim Merrick Schaefer Sarah AndersonHealth Officer, Health Section Creative Director Health Specialist, Health Section Knowledge Management, Health Tech 4 Dev Specialist Country Technical ManagerUNICEF New York frog UNICEF New York UNICEF New York UNICEF Zambia and World Bank JSIAlex Harsha Donna Espeut Garrett Mehl Julianna lindsey neal lesh Scott RatzanField Project Manager Deputy Director Scientist, Department of Chief Advocacy Communication, Chief Strategy Officer Vice President, Global HealthMedic Mobile Concern Worldwide Reproductive Health and Research Monitoring and Analysis Dimagi Johnson and Johnson WHO UNICEF GhanaAlicia lin Fabiano Dyness Kasungami nicolas oliphant Sean BlaschkeJohnson and Johnson Technical Team Leader, Child Health Heather laGarde Kajsa Westman Health Specialist, Health Section Tech4Dev Specialist Maternal and Child Health Integrated Director, Special Programs Industrial Designer UNICEF New York UNICEF UgandaAllison Green Program (MCHIP) IntraHealth frogSenior Strategist nicolas osbert Stephanie Dolanfrog Eric Swedberg J F Grossen Khassoum Diallo Chief, WASH Program Manager, Malaria and Senior Director, Child Health Creative Director UNICEF WCARO UNICEF Mali Child Survival DepartmentAlyssa Sharkey and Nutrition frog PSIHealth Specialist Save the Children, USA Kumanan Rasanathan Patricia MechaelUNICEF New York Jaleen Francois Knowledge Management, Health Executive Director Texas Zamisiya Erica Kochi Marketing Manager UNICEF New York mHealth Alliance UNICEF MalawiAmy Ginsburg Tech Innovation Specialist frogPATH UNICEF New York Marc Mitchell Robert Johnston Tom Manning Jonathan Payne CEO Regional Advisor, Nutrition, WCARO Principal DesignerAnirban Chatterjee Esther Ahn Partners in Health D-Tree UNICEF Western and Central Africa frogChief of Health and Nutrition Associate Creative Director Regional OfficeUNICEF Ghana frog Jorge Just Mariame Sylla Troy Jacobs RapidFTR coordinator Regional Health Specialist, WCARO Robert Fabricant Child Health & PediatricBrigitte Pedro Flavia Mpanga Kaggwa UNICEF Protection UNICEF Western and Central Africa Vice President, Creative HIV/AIDS AdvisorWASH E&M Specialist ICCM Health Specialist Regional Office frog USAIDUNICEF DRC UNICEF Uganda Joshua Harvey Senior Associate, Integrated Mark Young Sandhya RaoCatherine Sun Friday nwaigwe Partnerships Senior Health Specialist, Senior Advisor for Private SectorAssociate Creative Director UNICEF Rwanda U.S. Fund for UNICEF Health Section Partnershipsfrog UNICEF New York USAID40 41
Mobile Technologies & Community Case ManagementAbout UnICEF About Mobile MandateUNICEF works in 190 countries and territories to help Mobile Mandate is a collaborative platform that amplifieschildren survive and thrive, from early childhood through the positive social impact of mobile technologies throughadolescence. The world’s largest provider of vaccines for the transformative power of design. Mobile Mandatedeveloping countries, UNICEF supports child health leverages the skills, talents, and capabilities of frog andand nutrition, good water and sanitation, quality basic Aricent to bring about positive change in the worldeducation for all boys and girls, and the protection of through the exploration of innovative models for servicechildren from violence, exploitation, and AIDS. UNICEF delivery. UNICEF’s Tech4Dev organization is a signatureis funded entirely by the voluntary contributions of Mobile Mandate partner on a number of programsindividuals, businesses, foundations and governments. including Project Mwana, an mHealth initiative to strengthen health services for mothers and infants in Eastwww.unicef.org Africa. Other Mobile Mandate programs include Project Masiluleke, an mHealth initiative to battle AIDS in South Africa; Movirtu, a phone-sharing system in Kenya; asAbout frog well as Mobile Money Afghanistan, a research project that investigates the use of mobile phones for noninstitutionalfrog works with the world’s leading companies, helping banking in Afghanistan.them to design, engineer, and bring to market meaningfulproducts and services. With an interdisciplinary team mobilemandate.frogdesign.comof more than 1,600 designers, strategists, and softwareengineers, frog delivers connected experiences thatspan multiple technologies, platforms, and media.Clients include Disney, GE, HP, Intel, Microsoft, MTV,Qualcomm, Siemens, and many other Fortune 500brands. Founded in 1969, frog is headquartered in SanFrancisco, with locations in Amsterdam, Austin, Boston,Chennai, Bangalore, Gurgaon, Johannesburg, Kiev, Milan,Munich, New York, Seattle, Shanghai, and Vinnitsa. frogis a company of the Aricent Group, a global innovationand technology services firm.www.frogdesign.com42