On October 27th, 2014 JSI hosted the third in a series of interactive sessions the Principles for Digital Development. This meeting focused on the Principle 3: Design to Scale. It began with a discussion of how to design for scale from the very start, transitioned to a discussion of the importance of considering the implications of design beyond the immediate project, and then concentrated on designing solutions that are replicable and customizable in other countries and contexts. Joy Kamunyori (JSI) facilitated the meeting. Kate Wilson (PATH), Marion McNabb (Pathfinder International) and Sarah Andersson (JSI) presented. More information about the principles can be found here: http://ict4dprinciples.org/

1. Designing mHealth for Scale:
Lessons Learned from Pathfinder
Marion McNabb, MPH, DrPH(c), Senior Technical Advisor, mHealth
ICT4D Principles #3 Meeting - October 27, 2014

2. ENHANCING SERVICE DELIVERY
AND QUALITY IMPROVEMENT
THROUGH MOBILE TECHNOLOGY

3. PATHFINDER mHEALTH AND MOBILE MONEY PROGRAMS
Community Health
Worker Mobile
Applications and
Mobile Money
Behavior Change
using SMS
Mozambique – mCenas! - Youth Focused SMS for FP and SRH
Ethiopia – m4Youth - Youth Focused SMS for FP and SRH
Tanzania – EngageTB – TB Client Self Screening and Referral
Kenya - MNCH and OVC Application, Pay for Performance
Nigeria - MNCH Application, Mobile Conditional Cash Transfer
Haiti – Integrated CHW application, Stipends with mMoney
Tanzania – MNCH, FP, HIV and Client Feedback mobile money
for maternal emergencies
Vietnam – NIH RCT – SMS for Continuing Medical Education

4. Pathfinder’s
Approach

5. HEALTH SYSTEM STRENGTHENING AND mHEALTH

6. PATHFINDER APPROACH TO MHEALTH AND MOBILE $
Scale Evidence Based Interventions
Drive Quality and Performance Improvement
Integrated Service Delivery at Community and Facility Levels
-Through-
Public Private Partnerships
Engaging Youth
Building the Capacity of Local Partners
Generating Evidence
A mobile phone is just a means to an end, not the end in itself

7. MHEALTH AT PATHFINDER, CONT.
• A does not deliver a
• Ensuring sexual and reproductive health
services are available and of quality is key
–What are we driving clients to?
• Mobile money implementation depends on
infrastructure, adoption, users needs
• Choosing simple technologies in tech nascent
environments is key to scaling

8. DIFFUSION OF INNOVATIONS…HOW DOES THIS
TRANSLATE TO SCALE?

9. IF YOU WANT TO INSTITUTIONALIZE AND SCALE
mHEALTH, UNDERSTAND YOUR AUDIENCE….

10. KEY CONSIDERATIONS FOR SCALING mHEALTH TOOLS
• Employ user centered design techniques
• Retrofit tools to the actual needs on the ground
• Who is your audience, what is the goal of scale?
– Vertical and horizontal scale – ideally both to achieve
impact
• Analyze technology solutions through the lens of national and
regional needs: integration, collaboration and coordination
• Establish public private partnerships; its essential
• Demonstrate impact before scaling interventions

11. CONSIDERATIONS FOR SCALING, CONT.
• Business models: MNO, Bank, Clients, Government
• No “one size fits all” scalable solution or framework. Client
focused verses health workforce/systems focused mHealth
interventions
– They are different!
– Who pays for scale, who OWNs the scaling process, is it
holistic and framed within a health systems strengthening
framework?

12. WHICH TECHNOLOGY SOLUTIONS FOR SCALE?
• Simple is best, go too far and you may lose interest
• Technology is 10% of the problem, the issues are rooted in
health systems and governance
• Local innovators versus global tech solutions
• Open source, building on pilots, coordination among partners
• Data Storage: how and where? Cloud or local? Laws….
• Government capacity, IT/MNO infrastructure, is mHealth the
top priority of the government?
• Mobile money: complex and different
– Kenya mPesa vs. Nigeria vs. Haiti

13. PUBLIC PRIVATE PARTNERSHIPS
• Essential and necessary. What is the motive for private sector,
clients and governments? How do motives align?
• Mobile network operators and mobile money operators
(banks and MNOs) have different monetary incentives. Each
country is different.
• When to engage, who should engage private sector:
Pathfinder/Implementers, GSMA, Banks, Donors?
• Who pays? What is the business model? What do you need to
prove its worth it for governments, business and NGOs to be
sustainable? Where are the international and local
implementers in the scaling process?

14. DEMONSTRATING THE mHEALTH CHAIN OF EVIDENCE

15. DEMONSTRATING IMPACT WITH FRONTLINE WORKER
SUPPORT TOOLS
• Generate evidence chain through the log frame
– Feasibility, acceptability, effectiveness, health outcomes
– Cost effectiveness
• Follow the chain of evidence to continually build to the base
• Research studies ongoing in Nigeria, Ethiopia, Mozambique,
Haiti, Tanzania, Vietnam – CHW tools, SMS program impact
• Cost effectiveness studies: Nigeria with Brandeis and Abt,
Vietnam for SMS based continuing medical education (CME)

16. Z
Country
Case Studies

17. PATHFINDER SSQH CENTRAL AND SOUTH: HAITI
Integrate mobile tools to strengthen the work of 2,500 CHWs in Haiti
through the implementation of an integrated client enumeration and
case management tool across all major health domains of CHW work
Objectives:
• Strengthen the quality of CHW community services
• Improve quality of community to facility referral systems and
improve documentation
• Reduce reporting burden
• Strengthen ability for supervisors to conduct CHW mentoring and
supervision to improve performance
• Integrate the use of Tcho Tcho mobile payments within the health
sector

18. • Built-in care protocols
• Priority scheduling of visits
driven by client needs
• Targeted SMS/IVR reminders to
improve care retention
• Community commodity tracking
• Mapping community services
• Information feeds into
HMIS
• GIS mapping of services
• Data security and
confidentiality
• Reports per MSPP needs
• Client referral and counter
referral between ASCP and
facility
• ASCP performance monitoring:
driving quality improvement
ASCPs Decision Support Tool Data and Information
Facility Tool
mSante Implementation Model

19. HAITI, CONT.
• First Lady of Haiti committed to nationally scaling mHealth
• Pathfinder opened all apps: no need to reinvent the wheel
• Pushing technology to the edge, can it scale? Its complex
when you build in referrals
• Building local capacity through NGOs – decentralize
management, build supervision app, dashboard
• Human resource capacity? Can we teach local public health
and technologists to manage deployments? Where does
government step in? Who owns what?

20. NIGERIA
• Innovation Working Group/UN Foundation Award (2014-
2016)
– Pilot test the use of CommCare to track beneficiaries of
government-led conditional cash transfer (CCT) program
and deliver payments via mobile money (mCCT)
– Co-Lead National mCCT technical working group – goal is
to design and pilot for scaling nationwide
– Develop plan to expand from 5 to 1,250 sites post-award!
• Two cost effectiveness studies, dissertation research to
develop costed scale up plan post pilot phase

21. mCCT PAYMENT WORKFLOW (3 OUT OF 9 STEPS)
Client Registration of
SIM, Create mobile
wallet
1 2
State SURE-P
review of eligible
women in
CommCareHQ
3
National SURE-P
approval for
payment in
CommCareHQ
Immediately
Health facility
client registration
in CommCare

22. NIGERIA
• Under the overall ICT4 Saving One Million Lives Initiative led
by Government
• Health worker/Facility application (linking primary health
centers to hospitals for referrals), client education and receipt
of mobile payments and government administration through
dashboard
• Government has the money for CCT implementation: delays
and need for capacity building
• Mobile money at scale in Nigeria (over 18 mobile money
operators) – issuing client sim cards a challange
• HMIS Reporting on the app itself

23. LEARNING TO TAKE COMPLEX MHEALTH SOLUTIONS
TO SCALE
• Nigeria: Costed scale up plan by mid next year, what
frameworks and tools to use to support government
• Haiti: Real life deployment of complex solutions,
decentralized ownership and management; supporting local
NGOs and International NGOs to use the tools
• Pushing the edge of innovation; simple solutions vs complex
solutions at scale
• Importance of PPPs and government ownership of scaling and
maintaining

24. Thank you!

25. twitter.com/PathfinderInt
facebook.com/PathfinderInternational
Youtube/user/PathfinderInt
For more information contact Marion
McNabb - mmcnabb@pathfinder.org