1. mHealth Consulting Recommendations
A study in the feasibility, design,
development, and implementation of a
new mHealth initiative for Mister Sister
Mobile Clinics
March 21, 2016
Prepared for: PharmAccess
Prepared by: N-6 BUSPH Consulting - Emily Cable, Caitlin Gillespie, Bryan Kirk, Jenna Menefee, Edgar
Pizarro, and Andie Reed

2. LIST OF ACRONYMS
IVR Interactive Voice Response
FAQ Frequently Asked Questions
mHealth Mobile Health
PDSA Plan, Do, Study, Act Cycle
QI Quality Improvement
SMS Short Message Service
VMMC Voluntary Medical Male Circumcision

3. Table of Contents
Executive Summary………………………………………………………………………….…………………………………….……………….1
Overview of Report……………………………………………………………………………………………………………..………..………..2
Feasibility of mHealth in Namibia: A Literature Review……………………………………………………………………………2
Guidelines for the Selection of the Application Platform………………………………………………………………………...7
Description of the Use Case and Prototype of the Application…………………………………………………………….…..9
Guidelines for Application Development and Implementation………………………………………………………………12
Future Recommendations………………………………………………………………………………………………………………..……13
Conclusions……………………………………………………………………………………………………………………………………………14
References…………………………………………………………………………………………………………………………………………….16
VOTO Training Video……………………………………………………………………………………………………….See attached file

4. 1
mHealth Report
Consulting Team: N-6 Consulting
Report Authors: Emily Cable, Caitlin Gillespie, Bryan Kirk, Jenna Menefee, Edgar
Pizarro, and Andie Reed
Executive Summary
PharmAccess Namibia is an organization that runs the Mister Sister Mobile Primary Health Care Clinics, a
program designed to provide primary care to people living in rural Namibia. Currently, Mister Sister
serves multiple rural areas throughout Namibia, and has recently expanded their service area following
a partnership with the University for Science and Technology in Windhoek to deliver mobile health
services to 13,000 students at three different university campus sites. As part of this expansion,
PharmAccess is seeking new and innovate ways to reach their patients.
In line with this goal, N-6 Consulting was asked to explore the feasibility of utilizing mHealth technology
to connect with their patients, particularly the new student population they will be serving.
PharmAccess is interested in exploring mobile solutions to provide information to their patients as well
as to collect information from their patients about cost of services and satisfaction with services, among
others.
N-6 Consulting was asked by PharmAccess to provide the following deliverables for this scope of work: a
feasibility study for using a mobile application in Namibia with this population of patients, guidelines for
selection of the application platform, description of the use case and prototype of the application, and
guidelines for application development and implementation. The report examines available literature
regarding mobile penetration in Namibia, as well as several studies showing the efficacy of mHealth
interventions in developed and developing countries. The application platform VOTO was then selected
for its versatility in using both SMS and voice-based messaging, which will be effective in reaching all
patients despite Namibia’s low literacy rate. Two use cases are then provided, a primary case describing
our proposal for a patient appointment reminder system, and a secondary case utilizing the patient
satisfaction survey created for PharmAccess in our Quality Improvement (QI) report. Guidelines for
development and implementation of the use cases are then described, including a training video on how
to use the VOTO platform attached separately to this document. Finally, we conclude by offering future
recommendations for expansion of our proposal and ventures into new mHealth campaigns.

5. 2
Overview of Report
N-6 Consulting was tasked with researching the feasibility of leveraging mHealth among Mister Sister’s
patient population. mHealth (or mobile health) is the use of tele-platforms to engage patients outside of
a physical healthcare setting, most often through applications, SMS and voice communication. It allows
patients to easily receive information and care in remote and rural settings, but often comes with a
number of limitations, such as cost for the user or patient, technical challenges, and language barriers.
mHealth is not meant to be a catch-all solution, but is meant to supplement existing programs, as it
cannot be used effectively in isolation. We are excited to present our research, findings, and
recommendations for an mHealth application that will be useful in enabling Mister Sister to engage and
serve their patients in a new and innovative way. Our team of consultants has prepared this report to
inform Mister Sister on the feasibility, design, development, and implementation of a new mHealth
initiative for Mister Sister’s mobile clinics.
This report contains the following elements:
1. A feasibility study in using a mobile application in Namibia with the current population of
patients
2. Guidelines for the selection of the application platform
3. Description of the use cases and prototypes of the application
4. Guidelines for application development and implementation
5. Future recommendations
I. Feasibility of mHealth in Namibia: A Literature Review
In assessing the feasibility of using a mobile application in Namibia with Mister Sister’s current patients,
we found that mobile application use in both rural communities and universities was not only feasible,
but would improve service delivery. It is important to note that mobile applications are a tool and
cannot be implemented in isolation meaning it will need to be adapted for the unique needs of the two
patient populations.
Mobile phone use in Namibia is high, with close to 60% of the population being individual mobile
subscribers. Namibia has a population of approximately 2.5 million citizens, but there are over 2.8 active
mobile phone connections. This means mobile phone penetration, or the number of SIM cards being
used, is 114% indicating some users have more than one cell phone or SIM card (GSMA Intelligence,
2016).
The two primary cell phone providers in Namibia are Mobile Telecommunications Limited (MTC) and
Telecom Namibia Mobile (TN-M). Figure 1 and 2 show approximate reported mobile coverage for both
companies. As shown in the figures, MTC has more extensive coverage throughout the country;
however both companies are still utilized (TourBrief, 2013).

6. 3
Figure 1. Reported MTC coverage, 2013 Figure 2. Reported TN-M coverage, 2013
As of 2015, smart phone or data capable phones were relatively few in number throughout the country.
Figure 3 shows the approximate reported MTC data coverage in Namibia, showing that data coverage is
much sparser than basic network coverage (MTC Namibia, 2013). This is one reason a non-smartphone
based mHealth intervention would be more effective.
Figure 3. Reported MTC data coverage, 2013

7. 4
N-6 conducted a literature review to determine if using a mobile application would be effective in reaching the university and rural patients’
needs. N-6 found the following results in Table 1 below.
Table 1. Literature on Feasibility of Using mHealth in Namibia
Author (Year) Title Location Study Design Key Findings Strengths/Limitations
Gilroy, K. E.,
Diedhiou, A., Cox, C.
M., Duncan, L.,
Koumtingue, D.,
Pacque-Margolis, S.,
Fort, A., Settle, D., &
Bailey, R. (2015)
Use of an
Interactive Voice
Response System
to Deliver
Refresher Training
in Senegal
Senegal Pilot program
implementation
in using IVR.
Using Interactive Voice
Response (IVR) mHealth
technology, a refresher
training for family planning
providers in Senegal was
successfully implemented.
The system was feasible,
convenient, well-received,
and all participants
completed the course
successfully.
Strengths:
Easy to implement, successful pilot
program, worked regardless of
provider literacy, well-suited for
rural and remote settings.
Limitations:
Small sample size (20), a few
technological complications
(dropped calls, unable to receive
calls, etc.), expensive for a pilot
program.
Jongbloed, K.,
Parmar, S., van der
Kop, M., Spittal, P.
M., & Lester, R. T.
(2015)
Recent evidence
for emerging
digital
technologies to
support global
HIV engagement
in care
Global Systematic
review of digital
technology
interventions for
engagement in
HIV care after
diagnosis
Mobile phones are the most
feasible and acceptable
digital technology in low-
income settings. Weekly two-
way interactive text
messaging to facilitate
communication between
providers and patients have
the greatest successes in
improving ART adherence.
Strengths:
Wide variety of peer-reviewed
literature in both resource-rich and
resource-limited settings.
Limitations:
Study quality and bias remain an
issue in ART adherence studies using
mHealth technologies. Not enough
targeted interventions among
vulnerable populations: sex workers,
displaced persons, and people who
inject drugs. No identification of
technology interventions for young
people in sub-Saharan Africa.

8. 5
Green, E. (2013) Baby
Monitor: Preventin
g maternal and
newborn deaths
through mobile
phone-based
screening
Kenya IVR program
implementation
IVR screening tool proved to
be a valid assessment of
medical need for nursing
mothers.
Strengths:
Demonstrates the feasibility of using
IVR-based screening in rural and
remote regions, reliable and
accurate measure that is cheap and
easy to implement.
Limitations:
Limited studies on use, this was a
pilot study and more testing needs
to be done.
Gurol-Urganci, I., de
Jongh, T., Vodopivec-
Jamsek, V., Atun, R.,
& Car, J. (2013)
Mobile phone
messaging
reminders for
attendance at
healthcare
appointments
Global Systematic
literature review
mHealth text reminders are
shown to improve
attendance rates at
healthcare appointments
compared to no reminders.
SMS reminders are also
inexpensive.
Strengths:
Only included RCTs, quasi-RCTs, or
interrupted time series studies with
at least 3 before and after- time
points.
Limitations:
Few studies on mHealth, the
literature is global literature (though
some are from S. Africa) so maybe
not specific enough to Namibia.
NID & UNICEF
(2011)
Improving Civic
Participation of the
Youth in Namibia
Through the Use of
Mobile Phones and
Engagement
Through a Study
Circle Program in
Schools.
Namibia IVR program
implementation
used to gather
information
IVR is a feasible and
successful way to gather
information from students
Strengths:
Large sample size, successful
implementation, study received a
large amount of data from use.
Limitations:
Requires extensive promotion for
adoption to occur successfully, as
participation got underway slowly.

9. 6
Akter, S., & Ray, P.
(2010)
mHealth - an
Ultimate Platform
to Serve the
Underserved
Global Summary of
major current
developments
and research in
the field of
mobile health
mHealth offers an
unprecedented opportunity
to serve the underserved by
providing right time medical
information services, and is
particularly useful in low
resource settings due to its
low cost, high reach and
versatility.
Strengths:
Growing evidence that mHealth
works in low resource areas.
Applicable to a wide variety of
increasingly of locations, formats,
and populations.
Limitations:
Difficult to develop customer-centric
solutions. Challenges: Delivering
quality services consumers can
effectively utilize, and regulation of
use.
Analysis of Literature Review
Our key findings from the literature revealed mobile health applications are feasible and effective tools to use in low resource settings due to
their high reach and versatility. A variety of options exist to contact patients from SMS messaging to interactive voice response (IVR) messages.
In Kenya, an IVR-based system called Baby Monitor calls pregnant and postpartum women to screen for maternal and neonatal risk factors and
refers them to necessary care (Green, 2013). It has begun showing promising results in reducing maternal and infant mortality. IVR is easily
adaptable as messages can be recorded and delivered in any language or dialect. In 2009 and 2011, Namibia conducted an IVR project to gather
views on educational priorities of children and youth as well as their opinions on how to encourage students to stay in school. In 2011, almost
7,000 students participated in the three-week survey. IVR use was declared usable in other studies by The Namibian Institute for Democracy
indicating it would benefit the needs of Mister Sister (NID and UNICEF, 2011)

10. 7
II. Guidelines for the Selection of the Application Platform
N-6 Consulting considered a number of needs from Mister Sister and the patient population before
selecting an application platform to use to accomplish the goals outlined by Mister Sister. In considering
which mobile application platform to select, it was essential to consider cost. Cost is an important factor
for Mister Sister due to their extremely limited budget for mHealth - they are therefore seeking an open
source software. Mister Sister is also aiming to collect information from their patients regarding cost of
services and satisfaction with the clinic experience. Additionally, Mister Sister requested an application
that does not require internet at all times, as connection is not always available, and the ability to keep
information collected secure and private. Lastly, Mister Sister requested an mHealth tool to be used for
an appointment reminder mechanism for patients.
In selecting the application, it was also critical for our team to consider the characteristics of the users of
such an application - the patients themselves. Among the rural population that Mister Sister serves,
there are very low literacy rates. Therefore, it was essential to choose an application with an audio
feature. The majority of Mister Sister patients have access to cellphones but not smart phones, so an
SMS-based application is needed. Internet and data coverage are unreliable and scarce in Namibia
therefore, an offline-capable application is needed as well.
Description of IVR
Interactive voice response (IVR) is a technology that can be used with any type of cell phone to deliver
information through audio recordings. IVR allows users to provide feedback by pressing a number key
on their cellphone, allowing IVR to deliver more complex information than SMS text. IVR does not
require a smartphone, connection to the Internet, and does not require users to be fully literate. Public
health programs are increasingly using IVR in mHealth applications to reach populations with high
penetration of mobile phone ownership, but with low levels of literacy and Internet connectivity. IVR is
the recommended technology to use for the audio component of the mHealth application for Mister
Sister.
Platform Selection
Digital technology tools should be developed with context-appropriate solutions informed by user
needs, employ a systems approach to design, use open data and functionalities, and mitigate risks to the
security of users and their data in order to be the most effective (Waugaman, 2016). Therefore, taking
into consideration Mister Sister’s hopes for an mHealth application and the patient and student
population they serve, we recommend Mister Sister adopt an mHealth tool that uses VOTO Mobile, a
Ghana based social enterprise.
The VOTO platform is a mobile phone notification and survey system with the following features:
1. Send and receive voice (IVR) and SMS
2. Real-time, two-way communication
3. Conduct surveys
4. Scheduling timely reminders

11. 8
VOTO enables NGOs, businesses, and governments to easily collect from and share information with
their clients. VOTO allows users to interact with the organization through SMS or voice calls in any
language. Organizations using the VOTO cloud service pay only for the call-time minutes they actually
use.
Table 2 below depicts four mobile platforms in comparison to VOTO Mobile. While there are strengths
and limitations among each of the platforms, N-6 concluded that VOTO Mobile is the superior choice for
Mister Sister due to its low cost, offline support, and dual SMS and IVR functionalities.
Table 2. Mobile Platform Comparison
Phone
Requirements
Any Any Any Android or
Internet Access
Android or Java
Enabled device
Offline
Support
Yes No No No Yes
Cellular
Function
SMS, IVR SMS SMS, IVR in beta SMS, IVR Yes
Pricing Pay as you go
(with 30 day
free trial)
Subscription
of
$10/month
Subscription Varies by usage
($10-$125/month)
Subscription and
charges for incoming
and outgoing
messages
Strengths Bi-directional,
offline
functionality,
Audio surveys
are free
API access,
send
messages
offline
API access, real-
time analytics,
Three- step simple
design for all
users, multi-
language
API access, two way
SMS, multi-language
IVR
Limitations Charges for
incoming and
outgoing SMS
Only SMS No offline
support and does
not officially
support dual SIM
phones
Need Android or
Internet enabled
phone, charges for
incoming and
outgoing
messages
Charges for incoming
and outgoing
messages, software
price based on
number of users-
could get expensive

12. 9
III. Description of the Use Cases and Prototypes of the Selected Applications
Primary Use Case
Patient Appointment Scheduling System via Phone
In order to facilitate Mister Sister’s appointment reminder and confirmation process, N-6 Consulting
created an appointment notification system using the VOTO Mobile platform to generate standard SMS
or IVR reminders. Prior to the day of service, PharmAccess can send out appointment reminders to all
registered and eligible candidates who may wish to utilize their services.
Figure 4 below depicts a use case scenario showing the logic behind a patient selecting and confirming a
time block he or she may want to participate in, or opt out from. The image illustrates a VOTO message
tree with step-by-step logic for the chain of messages.
The first message in the SMS tree would be the ‘Welcome’ message asking patients if they would like to
receive messages from Mister Sister regarding appointments, schedules and educational reminders. If
the user wishes to opt into the service, they will press 1, if they wish to opt out of the service reminder,
they will press 2. For those users wishing to opt out from receiving future reminders, a notification
message will prompt them with Mister Sister’s contact information if ever they wish to enroll in the
notification process in the future, or have any questions about services.
For patients that press 1, they will next be sent a message informing them of Mister Sister’s upcoming
clinic days in their area. This message will prompt them to pick an option: to either attend an
appointment in the morning, afternoon, or not attend one at all. This allows the user to choose which
time block works best with their schedule and lessens patient dissatisfaction and wait times on-site for
the clinic. All users wishing to attend in the morning will press 1, users who wish to attend in the
afternoon will press 2, and users who are not planning to attend at all will press 3.
Mister Sister informed our consulting team that on average, they see 19 patients a day. Taking this
information into account, conditional logic was built into the SMS application chain to minimize over
selection of times. A quota of ten responses per time block was selected as the maximum number
before the user is prompted to select an alternative time. For example, if the quota of ten patients for
the afternoon block has not yet been met, the system will accept their selection and remind them of any
additional resources they may need to bring along with them to the clinic (such as their Health
Passport). If the maximum quota of ten users has been reached for that time slot, the system will notify
the user that there is no longer any availability for that selection and prompt them to either select an
alternative time block or not attend at all.

13. 10
Figure 4. VOTO Tree Diagram, Patient Appointment Scheduling System

14. 11
The VOTO Mobile platform will allow PharmAccess to generate in-house reports on the number of
patients that utilized this service, what time blocks were most popular, and whether a high number of
users declined to participate. The platform has a robust capability to create subgroups based on
location, specific services, activity or inactivity and would give PharmAccess the capacity to deactivate
phone numbers for those users who wish to opt out from receiving future notifications. Location
subgroups will be helpful to restrict sending out appointment schedule requests only to the next clinic
location. These reports will also enable Mister Sister to differentiate between different user needs
based on their location. The deactivation feature may be also be of particular interest to PharmAccess
as they may be able to reactivate these numbers in the future when new campaigns are initiated.
Secondary Use Case
Patient Satisfaction Survey via Tablet
N-6 Consulting has also created a secondary mHealth use case designed with the clinic nurses as the
user. This use case will fulfill Mister Sister’s request for data on patient perception of services. N-6
Consulting has therefore recommended a way to incorporate digital health applications into soliciting
patient feedback on the quality of Mister Sister services. In the last set of recommendations on Quality
Improvement, N-6 consulting developed a “Patient Satisfaction Survey” to be filled out by patients and
give Mister Sister this feedback. This survey can be used as a digital version via KoboToolbox, an easy to
use online survey platform. Patients can fill out the survey on the nurse’s tablets after their
appointments, and the information will be uploaded and aggregated once there is internet service
available.
N-6 Consulting has created an updated Patient Satisfaction Survey using KoboToolbox software for
Mister Sister to use. This software presents questions on a computer, tablet, or phone in a bubble
format that the user can touch to select their answer to each question. The survey asks questions
regarding patient perspective on cost of services, quality of services, and other opinions. The survey will
be downloaded onto tablet computers that Mister Sister nurses already have for their job. Once the
survey is downloaded onto the tablets, it is ready for use offline.
Patients will fill out the survey when coming into the Mister Sister clinic for their visit. After the nurse
completes their treatment, the nurse will hand the patient the tablet and give a brief explanation how to
use the touchscreen if patients are unfamiliar with the technology. Next, the nurse will turn away to give
the patient some privacy while the patient selects their answers on the screen. After completing the
survey, the patients are free to leave. The answers are automatically stored in the KoboToolbox
software, and will be uploaded to a central database by one of the clinic nurses or driver at the end of
the day. The data will then be accessible for anyone with secure access, such as the project manager,
who can use the data for monitoring of quality and patient needs.
In case the patients are illiterate, individuals will have the option to complete the survey using IVR
technology on the VOTO platform. Illiterate patients will be offered this option at the end of their clinic
visit if they decline the tablet survey form. In this situation, patients will be called by an automatic

15. 12
system and take the survey by answering pre-recorded voice questions. Patients can submit answers by
speaking into the phone or by pressing a number key, and these answers are recorded into a database.
Please see the “References” section of this report for the URL link to the KoboToolbox “Patient
Satisfaction Survey” ready for use.
IV. Guidelines for Application Development and Implementation
Based on the recommendation to utilize the mobile platform VOTO and the appointment reminder use
case above, N-6 has developed basic guidelines for its development and implementation by the Mister
Sister program. Below is a step-by-step guide laying out how to create programs within VOTO, deploy
programs to phones, and steps for implementation of the initiative. Implementation steps for the
patient satisfaction survey use case are included as well.
Application Development
Patient Satisfaction Survey
N-6 Consulting had previously developed a patient satisfaction survey for use by PharmAccess in the
Mister Sister Mobile Clinics. This survey was adapted to the digital tool KoboToolbox, so that surveys
could be initiated both on and offline. Details for implementation are below, instructions and links for
access and editing can be found in the references section.
Appointment Reminder System
Using VOTO, N-6 has created the prototype use case shown above to aid in sending appointment
reminders and schedule requests to Mister Sister patients. A training video has been created to instruct
PharmAccess employees in the basic functionality of VOTO, including how to create subscribers, groups,
messages and surveys to send to patients. The VOTO platform allows for the import of collected patient
data into Microsoft Access, Excel, or the VOTO API. Individual patient information can be entered as
well, and patients can be assigned to specific groups as needed (e.g. region-based groups). Patients can
receive either voice messages, SMS messages, or both, depending on how they are setup in the system
as subscribers. Please see the separately attached video file for instructions on how to use the VOTO
platform.
Application Implementation
Patient Satisfaction Survey
The patient satisfaction survey created for PharmAccess in our QI report has been adapted for use via
KoboToolbox (see references for Patient Satisfaction Survey link). Included in our references is a link to
instructions for using KoboToolbox offline, which would allow the survey to be taken offline via the
tablets Mister Sister already uses for wellness screening in the clinics. This survey was designed to be
quick, so it could be done at the end of a patient’s appointment while the Mister Sister nurse is finishing
the consultation. For patients that are not able to read, a backup voice survey could easily be created via
VOTO that the patient could either call in to take, or Mister Sister could have VOTO automatically send a
call at a pre-specified time.

16. 13
Appointment Reminder System
For the appointment reminder system, application implementation is recommended to take place in
three stages, similar to a quality improvement style Plan, Do, Study, Act cycle:
1. Preparation
2. Enrollment and Pilot Study
3. Reflect and React
Preparation
The preparation phase would begin with PharmAccess’ decision to undertake a new mHealth initiative,
including the type of application to create, platform of development, use case, and creation of the
application. The first three steps of this process have been modeled in this report for use by
PharmAccess. Once the application has been developed, it would need to be tested to ensure that it
works as intended, and will be able to reach the desired patient population effectively. Based on the
application proposed by N-6, preparation would also involve compiling and auditing patient information
in Microsoft Excel to upload into the VOTO platform. Once this is done, patients should be assigned to
groups according to their region, and a pilot region should be selected for implementation.
Enrollment and Pilot Study
Once a pilot region has been selected, enrollment for existing patients in that area would occur in a
fashion similar to Mister Sister’s current practice of bulk SMS to patients informing them when a mobile
clinic will be in their area. In lieu of this bulk message, N-6 recommends the use of VOTO to begin the
message tree shown in the use case for application rollout. This way, patients would be informed of
Mister Sister’s impending visit, and can choose to opt-in to appointment reminders as well as setup a
time to visit the clinic. For new patients, this can be included in the existing registration process that
takes place with the Mister Sister drivers by asking additional questions about a patient’s desire to opt-
in to the system, which type of messages they would like to receive, and their language and literacy
status would be noted. New patients would need to be entered into the VOTO database, which can be
done individually or uploaded via Excel file. Each time a new message is sent out for an appointment
reminder, a Mister Sister employee would need to edit the text to update the appointment dates. Stock
messages can be created within VOTO and easily altered to include new dates and times for
appointment reminders.
Reflect and React
Once the pilot study has been implemented, PharmAccess can informally assess the impact of the
program and decide on any alterations necessary to the program before scaling up to the remaining
Mister Sister regions. Changes can easily be made to the VOTO application, and a new pilot study can be
run either in the same area or a new region. Once all Mister Sister regions are under the new system,
future recommendations can be taken into account to incorporate new mHealth initiatives.
V. Future Recommendations
Using the VOTO platform, N-6 has also identified a number of future recommendations and areas of
expansion both based on the current recommendations, as well as potential new mHealth campaigns.

17. 14
Expansion of Current Recommendations
The proposed implementation plan has the new mHealth initiative piloting in one area that Mister Sister
serves. Once the pilot has been successfully tested, this application can be expanded to cover the
remaining areas that Mister Sisters serves over time. While the ideal starting implementation cycle for
the new mHealth initiative would be the one of the new partnership sites followed by expansion to the
existing rural areas that Mister Sister serves, this could easily be used in the rural sites first and
expanded to the university sites next. Based on the nature of the application platform, this use case
would be able to reach any patient population regardless of literacy rate.
New mHealth Campaigns
N-6 has selected three specific initiatives that the VOTO platform could be adapted to use in different,
but beneficial ways: (1) implement a referral system to follow-up care, (2) begin a “question line” where
patients could ask Mister Sister nurses questions outside of mobile clinic visits, (3) health education
campaign where patients could opt-in to receive SMS texts about basic health education information.
Referral System
This would allow for Mister Sister to send patients information on referral services for any needed
follow-up appointments at facilities outside the mobile clinics that Mister Sister could not provide.
Appointment reminders could also be adapted for this use in order to follow up with patients regarding
the referral Mister Sister provided them with.
Question Line
A question line would help reduce wait times at mobile clinics by allowing patients to contact Mister
Sister nurses with health questions, allowing them to receive services outside the mobile clinics
themselves.
Health Education
PharmAccess has expressed interest in being able to communicate information effectively with patients,
and these messages would allow them to do so with beneficial health tips for patients. These could be
centered on themes (i.e. maternal and child health, sexual education, etc.) that patients could opt in to
receive messages about. Additionally, VOTO could be used to create FAQ trees where patients could
inquire about preset questions in given categories to see if their questions could be answered without
using the question line or visiting the clinic.
Conclusion
With the Mister Sister program experiencing great success in Namibia, PharmAccess has begun
branching out to increase their service area. In doing so, they are seeking to leverage mHealth
technology to reach their patients in new and innovate ways. In line with this goal, N-6 Consulting
researched the feasibility of launching an mHealth application with Mister Sister’s population of
patients. We then selected an application platform, created two use cases, and provided prototype
information on the development and implementation of these use cases. We have also included
recommendations for future mHealth campaigns beyond the proposed use cases.

18. 15
We hope that our recommendations align with PharmAccess’ vision for their new mHealth initiative, and
look forward to working with PharmAccess in their supply chain management sector.

19. 16
References
Akter, S., & Ray, P. (2010). mHealth - an Ultimate Platform to Serve the Unserved. Yearbook of Medical
Informatics, (November), 94–100. doi:me10010094
Catalani, C., Philbrick, W., Fraser, H., Mechael, Patricia, & Israelski, D. M. (2013). mHealth for HIV
Treatment & Prevention: A Systematic Review of the Literature. The Open AIDS Journal, 7, 17–
41. http://doi.org/10.2174/1874613620130812003
Gilroy, K. E., Diedhiou, A., Cox, C. M., Duncan, L., Koumtingue, D., Pacque-Margolis, S., Fort, A., Settle, D.,
& Bailey, R. (2015). Use of an Interactive Voice Response System to Deliver Refresher Training in
Senegal. CapacityPlus IntraHealth Report.
http://www.capacityplus.org/files/resources/ivr-system-refresher-training-senegal.pdf
GSMA Intelligence. (2016). GSMA Intelligence — Markets — Africa — Namibia.
https://gsmaintelligence.com/markets/2456/dashboard/
Green, E. (2013). Baby Monitor: Preventing maternal and newborn deaths
through mobile phone-based screening. mHealth Compendium, 3, 52-53.
http://www.africanstrategies4health.org/uploads/1/3/5/3/13538666/baby_monitor.pdf
Gurol-Urganci, I., de Jongh, T., Vodopivec-Jamsek, V., Atun, R., & Car, J. (2013) Mobile phone messaging
reminders for attendance at healthcare appointments. Cochrane Database of Systematic
Reviews 2013, Issue 12. Art. No.: CD007458. DOI:10.1002/14651858.CD007458.pub3.
Hightow-Weidman, L., Muessig, K., Bauermeister, J. & Chen Zhang, C. (2015). Youth, Technology, and
HIV: Recent Advances and Future Directions. Current HIV/AIDS Reports, 12(4), 500-515.
Jongbloed, K., Parmar, S., van der Kop, M., Spittal, P. M., & Lester, R. T. (2015). Recent Evidence for
Emerging Digital Technologies to Support Global HIV Engagement in Care. Current HIV/AIDS
Reports, 12(4), 451–461. doi:10.1007/s11904-015-0291-7
KoboToolbox (2015). Using KoboToolbox Offline.
http://support.kobotoolbox.org/customer/portal/articles/1691105-using-kobotoolbox-offline
Mbuagbaw, L., Mursleen, S., Lytvyn, L., Smieja, M., Dolovich, L., & Thabane, L. (2015). Mobile phone text
messaging interventions for HIV and other chronic diseases: an overview of systematic reviews
and framework for evidence transfer. BMC Health Services Research, 15, 33.
http://doi.org.ezproxy.bu.edu/10.1186/s12913-014-0654-6
MTC Namibia. (2013). Coverage - | MTC - Make the Connection. Retrieved March 19, 2016, from
http://www.mtc.com.na/coverage
NID & UNICEF. (2011). Improving Civic Participation of the Youth in Namibia Through the Use of
Mobile Phones and Engagement Through a Study Circle Program in Schools.

20. 17
http://www.unicef.org/namibia/NID-UNICEF_2011_Listen_Loud_Final_Report.pdf
N-6 Consulting (2016). Patient Satisfaction Survey. https://jq7c6.enketo.kobotoolbox.org/webform
Piette, J. D., Datwani, H., Gaudioso, S., Foster, S. M., Westphal, J., Perry, W., … Marinec, N. (2012).
Hypertension management using mobile technology and home blood pressure monitoring:
results of a randomized trial in two low/middle-income countries. Telemedicine Journal and E-
Health : The Official Journal of the American Telemedicine Association, 18(8), 613–20.
http://doi.org/10.1089/tmj.2011.0271
TourBrief. (2013). Mobile Phone Coverage. Retrieved March 19, 2016, from
http://www.tourbrief.com/cms/index.php?option=com_content&task=view&id=919
Waugaman, A. (2016) From Principle to Practice: Implementing the Principles for Digital Development.
Washington, DC: The Principles for Digital Development Working Group.
http://digitalprinciples.org/wp-content/uploads/2016/03/From_Principle_to_Practice_v4.pdf
VOTO Mobile. What is VOTO? https://www.votomobile.org/files/WhatIsVOTO7.pdf