scaling up mobile health: developing mhealth … · scaling up mobile health: h developing mhealth...

SCALING UP MOBILE HEALTH:

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DEVELOPING MHEALTH PARTNERSHIPS FOR SCALE

AUTHOrEd By JEANNINE LEMAIrESECOND REPORT IN A SERIES OF SPECIAL REPORTS ON SCALING UP MOBILE HEALTH

COMMISSIONEd By AdvANCEd dEvELOPMENT fOr AfrICA

CASE STUDIES: CroSS-CoUnTry SCAlE Up

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CASE STUDIES: In-CoUnTry SCAlE Up

Scaling Up mobile Health: Elements necessary for the Successful Scale Up of mHealth in Developing Countries

Disease Surveillance & mapping project kimmnCHipmDiabetesmHealth Tanzania public-private partnershipmTrac

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Background: mobile HealthOverview: partnerships & Scale Up

mobile Alliance for maternal Actionmobile Technology for Community Healthprogramme mwanaSmS for lifeSwitchboard

PARTNERSHIP EXPERTSOVERVIEW

building the partnershipImplementing the partnership Sustaining the partnershipEnsuring partnership-Driven Scale Up

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I would like to convey my deepest gratitude to Coumba Touré, the Founder and president of Advanced Development for Africa, who commissioned this impor-tant report. This report would not have been possible without her commitment to

addressing the challenges in applying ICTs for health in developing country contexts through knowledge sharing, empowerment and capacity-building.

I would like to express my sincere thanks and appreciation to the experts who com-mitted their time to sharing invaluable insights, perspectives and expertise from different sectors through interviews: Sean blaschke, Health Systems Strengthening Coordinator at UnICEF Uganda; Awa marie Coll-Seck, minister of Health for Senegal; Amir Dossal, Founder and Chairman of the Global partnerships Forum; Sarah Em-erson, Country Director of the mHealth Tanzania public-private partnership; kirsten Gagnaire, Global Director of the mobile Alliance for maternal Action (mAmA); patri-cia mechael, Executive Director of the mHealth Alliance; and Judy njogu, product manager for eHealth and elearning at Safaricom.

I would like to extend my gratitude and appreciation to our Expert review panel who provided careful, in-depth reviews and important feedback to the report, ensuring realities and various experiences are reflected: yunkap kwankam, CEo of Global eHealth Consultants; Chris locke, managing Director of GSmA mobile for Development; Carole presern, Executive Director of The partnership for maternal, newborn and Child Health (pmnCH); Sandhya rao, Senior Advisor for private Sec-tor partnerships in the office of Health, Infectious Diseases and nutrition at USAID; and Véronique Thouvenot, Head of the International women and eHealth working Group at millennia2015.

Special thanks to Soumya Alva, Senior Technical Specialist at the International Health & Development Division of ICF International, and Vaibhav Gupta, Technical officer in the private Sector and Innovation Division of the world Health organi-zation, who contributed important concepts and feedback to this report. Several insights were also drawn from speakers at the 2012 mHealth Summit Global Health Track convened by the mHealth Alliance. I would therefore like to convey acknowl-edgement and appreciation to the individuals that put the Global Health track together and the mHealth Alliance for its leadership in this space.

Jeannine LemaireAdvanced Development for [email protected]

ACKNOWLEDGEMENTS

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Advanced Development for Africa

base of the pyramid

Community Health worker

Corporate Social responsibility

District Health Information Software 2

Early Infant Diagnosis of HIV

GSm Association

Health management Information System

Information and Communications Technology

Information Technology

International Telecommunication Union

Interactive Voice response

monitoring and Evaluation

USAID’s maternal & Child Health Integrated program

millennium Development Goals

mobile network operator

maternal, newborn and Child Health

ministry of Health

memorandum of Understanding

non-Governmental organization

prevention of mother to Child Transmission of HIV

public-private partnership

Short message Service

United nations Children Fund

United States Agency for International Development

Unstructured Supplementary Service Data

world Health organization

ADA

BOP

CHW

CSR

DHIS2

EID

GSMA

HMIS

ICT

IT

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IVR

M&E

MCHIP

MDGs

MNO

MNCH

MOH

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PMTCT

PPP

SMS

UNICEF

USAID

USSD

WHO

ACRONYMS

Scaling up Mobile Healthfirst report

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Policy environments, business models and funding schemes around mobile health (mHealth) have fueled the proliferation of pilot projects. Therefore in 2011, Advanced Development for Africa (ADA) commissioned the first report in a series of special reports on scaling up mHealth to assess various implementations of mHealth programs in developing country contexts that were either scaled up or in the process of achieving this. The objective was to iden-tify the important elements necessary for achieving scale.

This report profiled select mHealth programs that had been piloted and were in the scale up phase, having proven enough success that they should be considered as potential models for other initiatives. Using the identified success fac-tors and interviews with experts in the field of mobile health, the report generated a set of best practices and specific pro-grammatic, operational, policy and global strategy recom-mendations to create an enabling environment for mHealth and support organizations in achieving scale.

mobile health can directly support policy-making and plan-ning within healthcare systems and improve the health of local communities, particularly remote populations, through the dissemination of health information, more accurate and timely data for disease surveillance, decision support for health workers and health information management. The primary goal of ADA’s first report is to provide recommenda-tions and best practices that will allow mHealth initiatives to better plan their own scale up beyond successful pilot phases. To download the first report, click on the image.

The following report is the second in a series of special reports, focused specifically on partnership-driven scale up of mHealth containing sets of recommendations for building effective partnerships to achieve scale in mHealth.

FIRST REPORT: Scaling Up Mobile Health: Elements Necessary for the Successful Scale Up of mHealth in Developing Countries

SCAL ING UPMOB ILE HEALTHELEMENTS NECESSARY FOR THE SUCCESSFUL SCALE UP OF mHEALTH IN DEVELOPING COUNTRIES

WHITE PAPER COMMISSIONED BY ADVANCED DEVELOPMENT FOR AFRICAPrepared by Actevis Consulting Group

Researched and Written by Jeannine Lemaire

December 2011

First report in a series of special reports on scaling up mHealth.To download the First Report, click on the image above.

http://adaorganization.org/docs/ADA_mHealth_FV_singlepages.pdf

Scaling up Mobile Healthfirst report

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Image Credit: mTrac, Sean Blascke, UNICEF Uganda.

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01 Background & Overviewintroduction

INTRODuCTION

In a world of 7 billion people and over 6 billion mobile phone subscriptions, this remarkable adoption of mobile phones presents concrete opportunities for increased access to health care, thanks to the growing field of mobile health. mobile health, or mHealth, is the use of mobile technology in health and can be a powerful tool in improving health, particularly in places where health care is unavail-able or access is limited. According to the International Telecom-munication Union (ITU), mobile phone networks cover 90% of the world’s population today, with just over 75% of mobile subscriptions held by nearly 80% of the population in low- and middle-income countries.1 while there is still a need for a stronger evidence-base of mHealth health impacts and cost-effectiveness, some studies have already demonstrated the positive effects of mHealth. one study showed that two daily text messages to health care workers in kenya improved pediatric malaria care by 24.5%.2 Another trial identified significantly improved ArT adherence and rates of viral suppression thanks to weekly mobile text messaging and follow-up improving HIV drug adherence.3

Interest from NGOs, companies, government institutions, and donors in mHealth is rapidly expanding. To illustrate the current global landscape:• The mHealth Alliance’s HealthUnbound mobile health directory

lists over 300 mHealth programs around the world, while the mHealth working Group Inventory of projects lists 400 mHealth projects in 79 countries.

• The GSmA’s mobile for Development Intelligence portal maps 376 organizations from a wide variety of sectors working on mHealth.

• USAID funds more than 100 mHealth activities across the globe.

Background: Mobile Health

Overview: Partnerships & Scale Up

1 ITU World Telecommunication, ICT Indicators Database 2011.2 Zurovac D et al. (2011). “The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: a cluster randomised trial.” The Lancet.3 Lester, R. T., Ritvo, P., Mills, E. J., Kariri, A., Karanja, S., Chung, M. H., Jack, W., et al. (2010). “Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya

(WelTel Kenya1): a randomised trial.” The Lancet.4 Leon, N., Schneider, H., and Daviaud, E. (1 January 2012). “Applying a framework for assessing the health system challenges to scaling up mHealth in South Africa.” BMC Medical Informatics and Decision Making.

Scale up related to mHealth has been defined in various ways, in-cluding technology replication in multiple contexts, or an expansion or national scale of a project, platform or organization. Although increasing organizational scale and scaling up the diffusion of mHealth platforms and strategies is a great achievement for organ-izations, such as Text to Change (which has delivered 70 mHealth projects in 17 countries), this report focuses on program or project scale at a national or cross-country level. Achieving scale may not be required or appropriate for all projects, particularly those that prove a particular concept does not work. However, governments in developing countries are increasingly frustrated with the prolifera-tion of pilots and fragmentation within their borders. This has re-sulted in the South African national Department of Health and the Ugandan ministry of Health placing moratoriums on the implemen-tation of new telemedicine and electronic health (eHealth) projects, respectively, until national strategies are in place.4 The movement away from pilots presents a common objective for mHealth initia-tives today: scale up.

players from the public, private and non-profit sectors are now ac-tively seeking partners to collaborate with in order to increase the capacity, reach and impact of their projects. A concrete example of this was shared by Judy njogu, product manager for eHealth and elearning at kenya’s leading mobile network operator, Safaricom. She identified partnerships with partners from different sectors as a key factor for enabling Safaricom to go beyond their limits as a mobile network operator. “without partnering with organizations from different sectors, Safaricom would just be focused on m-vouchers and mobile money transfers in the healthcare space. now

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5 Research by Dalberg Global Development Advisors. 2012.6 Useem, A. (11 December 2012). “Mobile health initiatives look to service providers for scale.” DevexImpact. Available: https://www.devex.com/en/news/mobile-health-intitia-tives-look-to-service-providers-for-scale/79932 (Cited on 10 January 2013)

7 Sturchio, J. (8 January 2013). “The Evolving Role of the Private Sector in Global Health.” The Huffington Post. Available: http://www.huffingtonpost.com/jeffrey-l-sturchio/the-evolving-role-health_b_2432823.html (Cited on 10 January 2013)

that we’ve partnered with different organizations with different expertise areas, we are able to go much further,” says njogu as she describes Safaricom’s partnership initiatives on mHealth micro-insurance and maternal health messaging.

Historically, 85% of funding for mHealth was dedicated primar-ily to early-stage r&D or pilot programs.5 Although funding for pilots can be important for rationalizing the mHealth field, fund-ing towards growth, coordination and scale up is also needed. Dr. Esther ogara, Head of eHealth at kenya’s ministry of medical Services, says there are many projects launched in kenya with-out an idea of who will fund them in the long run, highlighting the fact that donors are reluctant to underwrite on-going pro-grams, and that host governments cannot be a catch-all funding mechanism for every pilot. Therefore, ogara conveys that part-nerships offer the best hope for bringing mHealth projects to scale.”6 The landscape described by ogara is a strong incentive for the emergence of partnerships to bring together alternative methods of financing projects. Today, partnerships are employing new methods of cooperation, new business models, and demonstrating greater measurable results. A realization is emerging that the fragmentation of efforts is a big barrier to achieving large-scale impact, and that the right

partnerships can bring about scale through joining distinct sets of core capabilities and collaboration directed towards common goals. Diversity in partners can bring together new ways of think-ing, technology, methods, best practices, lessons learned, markets, innovative ideas and more to support the scale up of a project. The USAID alone has formed nearly 700 public-private partner-ships (ppps), a huge increase from the 50 ppps that existed in the 1980s.7 partnerships with the private sector have evolved over time — moving beyond simple philanthropic and charitable models towards collaborations based on business models and sharing risks, rewards, responsibilities and investment.

There is consensus that partnerships hold the key to scaling up successful projects. Therefore, Advanced Development for Africa (ADA) commissioned this report to determine how to best build and sustain partnerships between public, private and non-profit sector players, and how to ensure partnership-driven scale up of mHealth, with three main objectives in mind. Through a thorough examination of the landscape of partnerships in the field of mHealth, the report’s first objective is to provide an as-sessment of a set of partnerships that have demonstrated or are in the process of achieving regional, national or cross-country scale, through a series of case studies. The second objective is

GSMA Mobile for Development Intelligence map of 376 organizations working on mHealth

© www.mobiledevelopmentintelligence.com mobile for Development Intelligence organisations map, 30/5/13

https://www.devex.com/en/news/mobile-health-intitiatives-look-to-service-providers-for-scale/79932


http://www.huffingtonpost.com/jeffrey-l-sturchio/the-evolving-role-health_b_2432823.html


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to determine how they have achieved this scale, by identifying key success factors that other budding partnerships could draw from. The final objective is to present the expertise and experiences of brokers, stakeholders, and key decision-makers within large-scale cross-sector partnerships through concise sets of recommendations focused on the different phases of partnership development.

The intended audience for this report is the international develop-ment sector in emerging markets and stakeholders working with this sector on mHealth. our goal is to amalgamate and share the knowledge and perspectives of experts from various sectors in order to support the international development sector in devel-

oping partnership initiatives geared towards greater impact and scale. In-depth research and interviews, as well as a full review of the report by an Expert review panel, was performed with stakeholders and representatives from different partnerships that demonstrate strong cross-sector collaborations. As partnerships typically bring together individuals and organizations from differ-ent sectors and fields, this report will carefully present the varying needs, challenges and recommendations from various sectors. we hope this report will be valuable to organizations from all sec-tors seeking to partner with others as it presents diverse perspec-tives that are critical to understanding how to build successful, scalable and sustainable partnerships.

Our goal is to amalgamate and share the knowledge and perspectives of experts from various sectors in order to support the international development sector in developing partnership initiatives geared towards greater impact and scale.

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IN-COUNTRY SCALE UP

8The information presented in these case studies, including project data, is sourced from online research, project docu-ments, communications, and interviews with personnel involved in the management of these initiatives.

02CASE STuDIES

1. disease surveillance & Mapping project

2. KimMncHip

3. mdiabetes

4. mHealtH tanzania public-private partnersHip

5. mtrac

The following set of case studies present mHealth partner-ship initiatives that have achieved or are working towards scale within a country and present concrete elements of success that can be incorporated in other partnership initiatives looking to achieve regional or national scale.8

02 In-country scale upcase studies

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Disease Surveillance & Mapping Project� LOCATION: BOTSWANA, KENYA (PLANNED), MOZAMBIQUE (PLANNED) � STATUS: SCALING UP

1The Disease Surveillance and mapping project is an initia-tive of the public-private partnership formed between Hp, Clinton Health Access Initiative (CHAI), botswana ministry of Health (moH), CDC botswana, mobile network operator mascom, and positive Innovation for the next Generation (pInG), a local botswana non-profit organization. It covers the implementation of a mobile disease surveillance and mapping project to aid botswana’s fight against malaria with the use of mobile phone technology. The program equips health workers with mobile devices that collect malaria data and can be viewed in a geographic map of disease trans-mission to generate more context-aware information about outbreaks in order for workers to respond accordingly. This allows health workers to report real-time disease outbreak data, tag the data with GpS coordinates, and send out SmS disease outbreak alerts to all other healthcare workers in the district, and allows facilities to submit regular reports back to the moH. The data is then aggregated in real-time on the backend and graphs and reports are generated in a matter of seconds. This enables moH officials to promptly collect and analyze context-aware data on malarial outbreaks, track developments in real-time and quickly dispatch medicines and mosquito nets, and monitor treatments using GpS coordinates.

Results since the program rolled out in June 2011 in Botswana’s Chobe region: • Improved response times to notify authorities of malaria

outbreaks from four weeks to three minutes in the first year of the program.

• 1,068 real-time notifications and updates on disease pat-terns to moH officials and health workers.

• 93% of facilities now reporting on time, compared to 20% previously.

OBJECTIvES & GOAlSThe long-term vision of this project is to move away from paper-based reports by equipping health workers at clinics across botswana with mobile phones, enabling them to sub-mit real-time reports to the moH. The objective is to shorten the outbreak identification process and improve response times of medical intervention to outbreaks using mobile-based disease surveillance solutions.

SCAlE UP ACHIEvEDThe project expanded its scope to cover tuberculosis and was rolled out to an additional 100 facilities in botswana.

FURTHER SCAlE UP PlANNEDThe botswana moH, pInG, Hp and mascom are currently planning a full national scale up of the current system (cover-ing malaria and tuberculosis) that will cover 100% of all health districts across the country. botswana’s government aims to add another 16 diseases to the project, and increas-ing the scope to all notifiable diseases. pInG is also looking to adapt the program to improve the broader health system, including the national Cancer registry and blood supply logistics.

Hp and CHAI have started working with kenya’s moH and are in talks with mozambique’s government to expand the program to these countries. kenya’s government is already using the platform to track the spread of 11 diseases, includ-ing malaria.

CASE STUDy

PARTNERS ROlES

Botswana MOH, CDC Botswana, Clinton Health Access Initiative (CHAI)

Implementers

HP, Mascom (leading MNO in Botswana) Providing technology, funding, and technical expertise (HP provided smartphones and cloud solutions, MASCOM provided free data transmission)

Positive Innovation Next Generation (PING) Initially only technology provider (mobile application platform), now directly supporting implementation

In-country scale upcase studies02

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The objective is to shorten the outbreak identification process and improve response times of medical intervention to out-breaks using mobile-based disease surveillance solutions.”“

Technology partners play an active role in implementation:• pInG was initially a technology partner, but has since evolved into a hands-on implementation partner by leading train-

ings, support and maintenance, as well as interacting regularly with health worker end-users and performing site visits with the moH.

• Hp and mascom, who are private sector partners, were actively engaged in the program by sharing skills and expertise in project implementation, instead of simply donating technology and resources.

The partnership project presented strong value propositions to its private sector partners. For example, by providing free data transmission for the project, mascom sees an opportunity to build market share while fulfilling its strong commitment to social responsibility.

The moH was directly involved in project design and implementation from the beginning, ensuring country ownership of the program and, based on the success of the pilot, is now supporting scale up of the program.

Success factors

93% of facilities now reporting ontime, compared to 20% previously.


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KimMNCHip� LOCATION: KENYA � STATUS: ONGOING, WITh NATIONAL SCALE AS A TArGET

2The kenyan integrated mobile maternal and newborn Child Health (mnCH) information platform, or kimmnCHip, is a national-scale mHealth initiative for maternal and child health run by a cross-sector partnership between the Gov-ernment of kenya, Safaricom, world Vision, Care, AmrEF, and netHope.

kimmnCHip aims to support kenya’s efforts in meeting mDGs 4 and 5 focusing on reducing child mortality and improving maternal health by offering three complementary services:

1. Public information via an mHealth advisory service for pregnant women who register and provide their due date. They receive a mix of “push” SmS and voice messag-es, and access to call-in advisory hotlines and information databases for mnCH issues. These messages provide the women with timely health information scheduled in ac-cordance with the national mnCH plan. SmS/voice charges are being covered by private partners (funded via text or voice message advertising).

2. Mobile financial (mFinancial) services for health that provide pregnant women with electronic vouchers to

redeem in a collaborating clinic of their choice. The vouch-ers act as an incentive for clinics to enhance the quality of their services and attract more pregnant women, through a results-based payment system. The voucher also includes a social protection cash transfer to support the women with the costs of delivery. kimmnCHip is exploring other uses of mpayments to support maternal and new-born care. Funding of the vouchers is being sourced from social protection funds and contributions from donors and the private sector.

3. Primary care via mobile support (mSupport) services along the continuum of care, for mothers and for primary health care workers. These will be based on access to electronic medical records, appointments, reminders, and checklists to deliver better community health services, and monitor and respond to mnCH indicators.

OBJECTIvES & GOAlSkimmnCHip aims to support kenya’s commitment to the Un Global Strategy for women’s and Children’s Health through one integrated system, providing women with mHealth support along the continuum of care from pre-pregnancy to post-natal stages.

CASE STUDy

PARTNERS ROlES

World Vision Partnership broker

Safaricom, Mezzanine Private sector partners providing the technology (cloud-based application and technical architectures), mServices and business models

CARE International, Aga Khan University Hospital, AMREF Non-profit implementing partners

NetHope, mHealth Alliance Global platform partners providing expertise and supporting information sharing

Ministry of Public Health and Sanitation (MOPHS) Supporting implementation and scale up


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kimmnCHip is designed from the beginning to be implemented at national scale.

kimmnCHip focuses on the brokering and partnership processes necessary to develop a national service through implement-ing a partner brokering monitoring framework.

Safaricom, world Vision, Care, AmrEF, the ministry of medical Services, and the mopHS have formed a taskforce to define kimmnCHip’s requirements. This taskforce includes representatives from the Division of reproductive Health, the Divi-sion of Child and Adolescent Health, the Division of E-health, the Division of Community promotional Services, and other nGos. kimmnCHip members also actively engage in key committees responsible for family planning, maternal and child health, and community health indicators. Efforts are ongoing to form focus groups of mothers to provide feedback on kimmnCHip.

High-level commitment from the partners was secured, resulting in the initiative being recently endorsed as the principal maternal newborn and Child Health initiative in the country at an mHealth and eHealth Stakeholders Conference hosted by the mopHS.

Success factors

KimMNCHip will be implemented at all health facilities across the country (over 8,000). The initiative plans to achieve national scale to reach 6-10 million mothers and 200,000 community health workers in 200 districts.

Its objectives are to: 1. Strengthen kenya’s community health system/referral

services by linking households, community health workers, and health facilities in a real-time health information system that tracks pregnancies, births, and maternal deaths and provides updates and reminders for timely interventions;

2. provide push and pull target-based health messaging for mothers and household members; and

3. promote and popularize mSavings and eVouchers for mothers and related family members. kimmnCHip will link the end-to-end process from mother, community health worker, health facility and back with data aggregation at a national level.

SCAlE UP ACHIEvEDkimmnCHip is in the process of national roll out. Initially, there was a CHw component through which Safaricom equipped CHws with 650 mobile devices. now kimmnCHip is being scaled to a national level covering all health facilities, at the request of the mopHS.

FURTHER SCAlE UP PlANNEDkimmnCHip will be implemented at all health facilities coun-trywide (over 8,000). The initiative plans to achieve national scale to reach 6-10 million mothers and 200,000 community health workers in 200 districts.

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mDiabetes� LOCATION: INDIA � STATUS: ONGOING, WITh PrOjECT TArGET SCALE Of ONE MILLION rEAChED ONE YEAr EArLY.

3mDiabetes is a large-scale diabetes prevention mHealth initiative being implemented in India using text messaging to increase awareness and prevention of diabetes among the Indian population. This nationwide mHealth project is implemented by the US non-profit Arogya world in partner-ship with nokia, and supported by a consortium of partners in the US and India.

Arogya world is providing free access to mDiabetes content for an initial period of six months to both current and new nokia customers in India who have the nokia life applica-tion on their mobile phones and subscribe to nokia’s health channels. Their business model is based on user fees - once the six-month trial is over, customers will have the opportu-nity to opt-in to receive the diabetes awareness and preven-tion messages at a nominal fee.

The content of the project was developed in partnership with Emory University and consists of 56 diabetes aware-ness and prevention text messages in 12 regional languages. The messages have been reviewed for cultural relevancy and technical accuracy, and potential for behavior change, through Arogya world’s behavior Change Task Force made up of medical, health promotion and consumer communica-tions experts.

mDiabetes implementation activities were launched in January 2012. The project considers measurement and evaluation critical to project success, and therefore is im-plementing a rigorous effectiveness evaluation plan. Initial consumer testing of messages with 750 consumers and analysis of feedback was performed; the results revealed that the messages were found to be clear, useful and com-pelling. Effectiveness studies and evaluation of behavior change is currently underway.

OBJECTIvES & GOAlSThe goal of mDiabetes is to educate Indians on diabetes prevention and to bring about behavior changes proven to prevent diabetes in 50,000 people in India. The initial aim was to enroll one million consumers in the program over a period of two years. This initial enrollment target has already been met, one year ahead of time.

SCAlE UP ACHIEvEDbetween January 2012 and January 2013, 1.05 million consumers from across India opted in and were enrolled in mDiabetes through the nokia life platform. As of April 2013, mDiabetes has sent out over 45.9 million text mes-sages through the program, with over 185,000 people hav-ing already completed the initial six-month program.9

CASE STUDy

9 Data is not available on what percentage of the 185,000+ have continued to subscribe to mDiabetes by paying a nominal fee.


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mDiabetes creates a value-added service for nokia presenting a strong investment case, and uses their existing large-scale network of consumers on the nokia life platform to deliver diabetes awareness and prevention messaging. over 95 million consumers in India, China, Indonesia and nigeria have experienced nokia life services, which also recently launched in kenya in march 2013.

mDiabetes launched with a business model built into the project, whereby consumers can access the content for free for the first six months, after which they have to pay a nominal fee to continue receiving diabetes messaging. According to Arogya world, the marginal cost of enrollment is about 40 cents per person, thereby presenting a potentially cost-effective model for chronic disease prevention.

Arogya world is employing a strong monitoring and evaluation strategy with multiple phases, particularly to evaluate the effectiveness of the intervention in changing behavior in both urban and rural areas. Coupled with this, Arogya world is maintaining a flexible and adaptable approach to mDiabetes, allowing for corrective changes informed by interim results to be applied to improve program effectiveness throughout the implementation period.

Success factors

9 Data is not available on what percentage of the 185,000+ have continued to subscribe to mDiabetes by paying a nominal fee.

PARTNERS ROlES

Arogya World Implementer and evaluator providing strategic leadership

Nokia Implementer and technology provider: providing Nokia Life platform, translation and transmission infrastructure, and ac-cess to consumer network. Nokia is also providing funding by subsidizing program costs.

Synovate (now Ipsos) Providing market research

Biocon, Johnson & Johnson (LifeScan Inc.) and Aetna Providing financial support for the program and measurement and evaluation insights

Emory University Providing support on content development

FURTHER SCAlE UP PlANNEDmDiabetes aims to send 58 million text messages over a two-year implementation of the program and scale up the program to reach more of India’s mobile subscribers, depending on re-

sults. Through a rigorous effectiveness evaluation of mDiabe-tes, Arogya world aims to establish a scalable, cost-effective model for chronic disease prevention to be replicated in other countries.


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mHealth Tanzania Public-Private Partnership� LOCATION: TANZANIA � STATUS: SCALING UP

4The ministry of Health and Social welfare of Tanzania (moHSw) leads the mHealth Tanzania public-private partnership (ppp), with support from the US Government Center for Disease Control and prevention (CDC), as well as numerous Tanzanian and international public and private sector partners. The ppp focuses on addressing ministry-defined public health priorities by convening partners and supporting national-scale solutions that work in concert with initiatives underway at the ministry.

The ppp supports several active mHealth programs includ-ing the blood Donor SmS messaging Service (led by the moHSw national blood Transfusion Services), as well as the scale-up of the Electronic Integrated Disease Surveil-lance and response system (led by the Epidemiology and HmIS sections). This case study focuses on the national launch of the ‘healthy pregnancy’ free text messaging service of the ‘wazazi nipendeni’ campaign.

A key commitment of the ppp and the moHSw is to improve maternal and child health during pregnancy, delivery, and newborn babies’ first part of life. This com-mitment is part of the Campaign on Accelerated reduc-tion of maternal mortality in Africa in Tanzania (CArm-mAT).10 Therefore, the moHSw launched the “wazazi nipendeni”, or “parents love me”, countrywide multi-media campaign in late november 2012 with the support of several key partners, to operationalize CArmmAT. The campaign is supported by providing free healthy pregnancy SmS messages in Swahili to pregnant women and mothers of newborn babies (up to 16 weeks of age), as well as her supporters, including the husband, friends and family. The ppp and moHSw developed official Government of Tanzania-sanctioned SmS messages, in close collaboration with several departments at the moHSw, and leveraging ‘fetal development’ messages from the global mAmA program. wazazi nipendeni involves a multi-media campaign that includes promo-tion of the free (reverse-billed) SmS messaging service by listing the short-code 15001 on campaign materials and instructs anyone interested in more information on healthy pregnancy for free to text the word ‘mToTo’ (‘baby’) to the short-code.

OBJECTIvES & GOAlSThe objectives of the ppp are to improve the flow of infor-mation across and between levels of the health system and community, reduce the response time of providing critical ser-vices, increase evidence-based planning and decision-mak-ing, and improve public awareness on key health priorities. The ppp works on leveraging the rapid expansion of mobile networks and technologies by exploring numerous applica-tions of mHealth technology, such as increasing direct patient care, rapid lab results communication, health worker training, and drug supply-level information management. The ppp aims to strengthen Tanzania’s public health systems by sup-porting a scalable, cost-effective and sustainable foundation for enhanced national health information systems. This will

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10 Campaign on Accelerated Reduction in Maternal, Child and Newborn Mortality: http://www.carmma.org


http://www.carmma.org

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All projects are performed through major partnerships, including wazazi nipendeni. The ppp convenes multiple partners from different sectors, combining expertise and resources to implement sustainable and scalable public health programs that leverage the rapidly expanding mobile phone and network infrastructure in Tanzania and existing activities of local partners. These partners were selected based on their core strengths and complementary abilities that could be leveraged for the campaign. For example, EGpAF contributed their technical expertise in pmTCT to support the development of SmS content on this topic, as well as utilized their extensive on-the-ground experience in supporting over 1,300 health facilities in Tanzania to help orient health facility workers to assist women enrolling in wazazi nipendeni.

The wazazi nipendeni free SmS service utilizes the multi-media campaign to reinforce awareness of the service and the shortcode, while employing a reverse-billing approach to enable pregnant women and their supporters to access the SmS service for free.

The ppp works across departments, sections, units, programs and projects at the ministry, under the leadership of the ministry’s mHealth Coordinator who is in the Department of policy and planning. The ppp supports the ministry in developing a national mHealth Strategy that will link with the eHealth Strategy and other Government of Tanzania and moHSw strategic plans. It also works in concert with initiatives underway in the moHSw, including integration with the national enterprise architecture.

Success factors

PARTNERS ROlES

Tanzania Ministry of Health and Social Welfare Strategic leadership

US Government Centers for Disease Control and Prevention (CDC)

Funding and technical assistance support

CDC Foundation Partnership Administration and Management Support

Text to Change Provider of technical assistance and SMS Text Messaging Technology Platform

Johns Hopkins Bloomberg School of Public Health, USAID, Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), Aga Khan Health Services

Technical, implementation and financial support

involve leveraging private sector interest in mHealth and related areas of ICT to develop long-term public-private partnerships, while continuing collaboration with other governmental and non-governmental implementing partners.

SCAlE UP ACHIEvEDwazazi nipendeni was launched as the moHSw’s national healthy pregnancy campaign in late november 2012. The SmS component of the multi-media campaign has proven to be the most successful (measured by volume) national-scale mHealth program in Tanzania to date, with 100,000 active, unique sub-scribers within the first 15 weeks of the campaign.

FURTHER SCAlE UP PlANNEDnational scale of the wazazi nipendeni healthy pregnancy campaign.


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mTrac� LOCATION: UGANDA � STATUS: SCALING UP, WITh NATIONAL SCALE PrOjECTED WIThIN 2013

5mTrac11 is part of a nationwide health systems strengthen-ing initiative launched by the Ugandan ministry of Health (moH), the national medical Stores and the president’s monitoring Unit, with support from UnICEF, wHo and DFID. It consists of a mobile-based disease surveillance and medicine tracking system that provides real-time data for response while monitoring health service deliv-ery performance.

mTrac achieves this by digitizing the transfer of Health management Information System (HmIS) data via mobile phones. The initial focus of mTrac is to speed up the transfer of HmIS weekly Surveillance reports (covering disease outbreaks and medicines). powered by rap-idSmS, mTrac collects the weekly surveillance reports from Health Facility workers who use their own basic handsets to send the data using SmS and USSD. This data is then amassed and presented on an online dashboard for moH officials to observe the data in real-time. All mTrac data is also automatically fed into the national District Health Information Software 2 (DHIS2) database. Using mTrac, the ministry of Health is receiving real-time information on medicine stocks, and district health of-fices are able to successfully lobby the national medical Stores for resupply based on their ability to present reli-able and timely data.

mTrac also focuses on providing a mechanism for commu-nity members to report on service delivery challenges by implementing a toll-free SmS Anonymous Health Service Delivery Complaints Hotline, supported by an initiative called ureport - UnICEF’s social monitoring network with almost 200,000 registered reporters in Uganda alone. Data from

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11 mTrac was featured in the first ADA report on mHealth focused on scale up. It has been included again here, with significant updates, given the national scale up of the program as of the first quarter of 2013.

PARTNERS ROlES

UNICEF Technical partner focusing on community management, negotiations brokering with private sector, and providing technical assistance to the MOH

WHO Technical partner focusing on national training curriculum, national data usage and analysis, and providing technical assistance to facilities

DFID Funder

USAID and local Implementing Partners Supporting implementation by requiring USAID implementing partners to include DHIS2 and mTrac in program plans

Local NGOs and Community Service Organizations Supporting implementation, advocacy and community mobilization

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both Health Facilities and community members is available on mTrac’s web-based dashboard, where District Health Teams are expected to follow up on incoming reports (such as drug stock-outs and health worker absenteeism). The aim is to empower District Health Teams by providing timely information for action. national level government stakeholders also monitor this, ensur-ing accountability and action.

OBJECTIvES & GOAlSThe goal of mTrac is to tackle the challenge of access to disag-gregated health data, identification of bottlenecks and timely follow-up, by strengthening Uganda’s health management information systems. The objective of mTrac is to avoid unneces-sary stock-outs and to improve transparency and accountability within the healthcare system.

SCAlE UP ACHIEvEDFollowing an 18-month pilot program, mTrac is now taken over and operated by the moH and has sustained a 90% response

rate for weekly reports via SmS. At district-level, mTrac is fully rolled out. mTrac is also serving as the moH’s national communications tool, with over 15,000 registered and trained CHws already in the database. mTrac was used to send out alerts and refresher training information during the 2012 Ebola outbreaks. UnICEF Uganda’s related initiative, ureport, has 190,000 people registered, while their anonymous hotline receives 1,200 to 1,500 reports per month. As part of the mTrac roll-out, UnICEF has put in place computers and access to the Internet at all 112 district offices and set up an online dashboard to allow them to validate and review the official data that comes in, as well as receive SmS alerts when certain notifiable diseases are identified.

FURTHER SCAlE UP PlANNEDmTrac is being scaled up nationally in Uganda, with all 5,000 government Health Facilities expected to be using the system by may 2013 (as of march 2013, mTrac is already being used in 70% of all Health Facilities).

ownership and operation of mTrac has shifted to the moH.

mTrac has secured high-level government involvement through the appointment of an inclusive steering committee by the permanent Secretary, which comprised the moH, the national medical Stores (in charge of distribution of all drugs to govern-ment facilities and includes state houses monitoring unit for accountability issues, transparency and corruption), along with a number of other external stakeholders. A technical working group has also been put in place by the permanent Secretary with representatives from each of the program divisions, including the users of the national malaria Control program, surveillance division, pharmacy unit and moH resource center.

mTrac employs strategies, such as avoiding heavy hardware or software costs, that enable the initiative to both scale very quickly as well as put in place a system that the government is comfortable taking on by not imposing a huge hardware burden that other systems may have required. For example, Health workers use their personal mobile phones to send in the data, addressing issues of sustainability by eliminating the need for the government to manage and support tens of thousands of electronic devices while keeping recurrent costs at a minimum.

Success factors

Sustainability and scale up of mTrac has been achieved thanks to several factors:

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12 The information presented in these case studies, including project data, is sourced from online research, project documents, communications, and interviews with personnel involved in the management of these initiatives.

03CASE STuDIES

1. Mobile alliance for Maternal action

2. Mobile tecHnologY for coMMunitY HealtH

3. prograMMe MWana

4. sMs for life

5. sWitcHboard

The follow set of case studies present mHealth partnership initiatives that have achieved or are working towards scale across different countries and present concrete elements of success that can be incorporated in other partnership initia-tives looking to achieve cross-country or global scale.12

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Mobile Alliance for Maternal Action� LOCATION: BANGLADESh, SOUTh AfrICA, INDIA � STATUS: MAMA BANGLADESh: SCALING UP. MAMA SOUTh AfrICA: SCALING UP. MAMA INDIA: PLANNING PhASE.

The mobile Alliance for maternal Action (mAmA) is a global mHealth public-private partnership that is initially mobilizing US$10 million over the course of three years to improve maternal and child health. The partnership will implement and support mHealth projects in three initial countries - bangladesh, India and South Africa - that will deliver culturally-sensitive, evidence-based health informa-tion to pregnant women and new mothers. Subscribers to the service register by indicating their expected due date or the birthday of their recently born child and receive weekly messages and reminders during the pregnancy and up to the child’s first birthday. messages include everything from proper nutrition, breastfeeding, vaccinations and referrals to local health resources.

Each country program is different as they are tailored to local contexts. For example, in bangladesh a high percent-age of the target beneficiary group is illiterate, therefore voice messaging via Interactive Voice response (IVr) is a major delivery method. A smaller percentage of the popula-tion receives push SmS. In South Africa, literacy rates are much higher but SmS messages are very expensive at scale. Thanks to the high penetration of data-enabled feature phones, this then allowed the use of mobile web (mo-bisites). The program also uses USSD, a text-based interac-tive platform that works on the lowest-end phones but is cheaper than SmS. mAmA South Africa offers specialized support to mothers enrolled in prevention of mother-to-child transmission of HIV (pmTCT) programs. mAmA India is currently performing a landscape analysis and mapping effort using cross-sectoral partners to assess how to best design the program.

mAmA also provides a library of free, adaptable mHealth messages for programs that are using mobile phones to inform and empower new and expectant mothers. These health messages and reminders are comprehensive, stage-based and available for use in SmS and audio (IVr) programs. The messages are based on wHo and UnICEF guidelines and can be adapted to different languages, cul-tures, regions, and to address specific needs.

OBJECTIvES & GOAlSmAmA is a global partnership that seeks to accelerate the use of mobile technology to improve the lives of expect-ant and new mothers in developing nations by engaging an innovative global community to deliver vital health informa-

tion through mobile phones. mAmA’s objectives are to help coordinate and increase the impact of existing mHealth mes-saging programs, provide resources and technical assistance to promising new business models, and build the evidence base on the effective application of mobile technology to im-prove maternal health. lessons learned from these and other initiatives will be shared globally in a coordinated exchange of information.

SCAlE UP ACHIEvEDmAmA bangladesh was the first country program to launch a national mHealth service, called Aponjon, after complet-ing an 11-month pilot phase. Aponjon is delivering critical stage-based information to new and expectant mothers and their families. Since launching, Aponjon already has 40,000

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PARTNERS ROlES

USAID Providing funding, strategic leadership, access to local USAID missions and expertise through MCHIP

Johnson & Johnson Providing funding, technical expertise in communications and branding

UN Foundation Providing support for communications, advocacy and public outreach, and linkages to UN organizations

mHealth Alliance Serving as MAMA Secretariat, and providing technical mHealth expertise and a forum to exchange knowledge and share best practices

BabyCenter LLC Providing adaptable messages library (both text and audio messages) and expertise

MAMA BANGlADESH113

D.Net MAMA Bangladesh partnership coordinator and primary implement-ing agency, with its own consortium of partners, including BRAC

Bangladesh Ministry of Health and Family Welfare (MOHFW)

Providing health content review and approval; leadership of the MAMA Bangladesh Advisory Board; promotion through state media and public sector health system

Local partners Providing in-cash and in-kind support

MAMA SOUTH AFRICA

Praekelt Foundation, Main local implementation and service design

Cell-Life, WRHI partners

Vodacom Foundation Provision and promotion of free access to MAMA South Africa for Vodacom subscribers

13 There are over 30 partners in Bangladesh, including five mobile network operators, over five outreach (NGO) partners including BRAC, Smiling Sun Franchises, and Mamoni (Save the Children), as well as the MOHFW and corporate sponsors such as Multimode and Beximco.

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subscribers registered for the service thanks to the 1,500 community health workers coordinating this process, trained by key local partner D.net, a social enterprise in bangladesh and lead project implementer. Aponjon is a service where most (about 80%) of the subscribers opt-in and pay for the service at a subsidized rate. only about 20% of the sub-scribers who meet the criteria for being the poorest get the service entirely for free.

mAmA South Africa was launched nationally in may 2013 and announced its first partnership with a mobile network operator, Vodacom (via the Vodacom Foundation), one of the country’s leading telecommunications companies. The partnership will give all 25 million Vodacom subscribers free access to mAmA’s mobile website (askmama.mobi) and will support a free SmS program offered through two inner-city clinics in Hillbrow, one of the lowest-income areas of Johannesburg.

mAmA’s adaptive messaging library has been accessed by more than 120 organizations in 50 countries14. The library is constantly being expanded with new content, including messages on pmTCT, post-partum family planning, breast-feeding, immunization, as well as messages for husbands and mothers-in-law. These adaptable messages have reached 200,000 new and expectant mothers and have been translated in 10 languages.

FURTHER SCAlE UP PlANNEDmAmA bangladesh aims to reach two million new and expectant mothers, as well as household decision-makers, by 2015.

mAmA South Africa aims to reach 500,000 women and household decision-makers over two years. The program uses multiple channels of message delivery: they are cur-rently rolling out SmS, USSD, and mobisite services and aim to add voice and mXit services in 2013.

Aponjon is a service where most (about 80%) of the subscrib-ers opt-in and pay for the service at a subsidized rate. Only about 20% of the subscribers who meet the criteria for being the poorest get the service entirely for free.”

“

14 To request access to use MAMA’s adaptable mobile messages library, visit this page: http://www.mobilemamaalliance.org/mobile-messages.

http://www.mobilemamaalliance.org/mobile-messages

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mAmA carefully selected its partners based on their added value. Engaging and working closely with diverse global, regional and local partners enabled mAmA to tailor each country program to local contexts and use different mechanisms for message delivery that best suit local market structures and target populations to ensure uptake.

mAmA identified different types of business models, such as variable pricing, to ensure sustainability of the service. For exam-ple, Aponjon engages local community health agents from different partner organizations in order to assess eligibility of users for different price tiers, thereby targeting different segments of the bop. Aponjon is available for free for the poorest, while the other 80% pay a small user fee, consistent with prices charged for other mobile information services. A benefit of applying user charges is that implementers can assess whether users value the content, as they would unsubscribe if not. mAmA bangladesh is currently exploring the use of sponsorship tags on IVr services to generate an additional revenue stream to ensure long-term sustainability.

mAmA country programs are employing a comprehensive approach in program design and implementation. mAmA is working with a wide variety of local partners in each country, including nGos, mobile network operators and government institutions, to inform the program design, perform direct implementation and drive scale up.

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Mobile Technology for Community Health � LOCATION: GhANA, INDIA � STATUS: SCALING UP IN GhANA AND rOLLING OUT TO NEW A GEOGrAPhIC ArEA IN INDIA.

The mobile Technology for Community Health, or moTECH, project is a joint initiative between the Grameen Foundation, the Ghana Health Service, and Columbia’s mailman School of public Health, that addresses maternal and neonatal health and mortality among the rural poor using mobile technology. Through its “mobile midwife” information service, moTECH sends targeted, time-specific, evidence-based voice and text messages with vital health care information to pregnant women and new parents in their local language throughout the pregnancy and during the first year of their child’s life. These messages contain advice on pregnancy-related issues, important facts about fetal development and reminders about upcoming clinic check-ups and care visits.

A complimentary service called mobile nurse enables rural community health workers to record and track the care pro-vided to women and newborns in their area. Using a basic mobile phone, community health workers enter data from patients’ clinic visits and upload the records to moTECH servers for authentication. patient records are analyzed to establish personalized care schedules, and notifications are sent to nurses about care visits. This information is also used to personalize the mobile midwife alerts, reminders and information sent to the pregnant woman. The system also sends weekly notifications to nurses on various patient updates, such as new defaulters (patients who miss appoint-ments) and upcoming and recent deliveries. mobile nurse enables nurses to automate the generation of their monthly reports, which used to take 4-6 days per month of their

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time, thereby helping the nurses save valuable time as well as improve the accuracy of their reports. mobile nurse also facilitates the identification of patients who have missed certain care visits. The system also sends detailed data on health service delivery and outcomes to the Ghana Health Service, giving policymakers an accurate and detailed pic-ture of health conditions in the country.

OBJECTIvES & GOAlSThe objectives are to enable the delivery of maternal health information over mobile phones to pregnant women in rural areas, while helping nurses record and track care delivered to women and newborns in their area. moTECH aims to use mobile phones to increase the quantity and quality of an-tenatal, postnatal and neonatal care in rural Ghana, as well as the demand for such services, with a goal of improving health outcomes for mothers and their newborns.

SCAlE UP ACHIEvEDIn Ghana, there are now over 25,000 people registered for the service and almost 300 community health workers us-ing mobile phones to track their patients. The Ghana Health Service is expanding the service to additional districts to

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15 Available at: http://www.grameenfoundation.org/sites/default/files/MOTECH-Lessons-Learned-Sept-2012.pdf

Grameen Foundation designed moTECH for long-term scale and replication from the outset by building components that could be reused in other geographies and other health domains.

Grameen Foundation worked with organizations such as Dimagi and InSTEDD that had complimentary technologies to make their services interoperable, resulting in the moTECH Suite.

much value is placed by the Grameen Foundation in developing strong partnerships and working collaboratively to address the myriad operational details required to build a successful mHealth intervention.

Grameen Foundation employs a strong monitoring and evaluation approach, and has publicly shared their documented their lessons learned and experiences from Ghana in documents available online.15

Success factors

PARTNERS ROlES

Grameen Foundation Program implementer and manager

Columbia Mailman School of Public Health Providing program support

Bill & Melinda Gates Foundation (for Ghana), Johnson & Johnson (for India)

Funders

Ghana Health Services Supporting scale up and implementation

help meet its top-priority goals: increasing the number of women who receive four antenatal care visits, the number of deliveries that happen with a skilled birth attendant, and the number of newborns who are seen by a health worker within the first 48 hours of life.

FURTHER SCAlE UP PlANNEDmoTECH is now being expanded to a new geography and health prior-ity with Grameen Foundation’s HIV/AIDS program in India. moTECH is enabling organizations to send messages to HIV-positive patients reminding them to take their antiretroviral medication. It is working to provide tools and training to 200,000 health workers reaching the poorest communities in bihar, India. moTECH is also helping health workers track their clients in world Vision programs in seven countries, such as Afghanistan and zambia.

http://www.grameenfoundation.org/sites/default/files/MOTECH-Lessons-Learned-Sept-2012.pdf

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Programme Mwana � LOCATION: ZAMBIA, MALAWI � STATUS: SCALING UP

programme mwana is a mobile health initiative implemented by the zambian moH with support from UnICEF and col-laborating partners to strengthen health services for moth-ers and infants in rural health clinics, with particular focus on improving Early Infant Diagnosis (EID) of HIV and improving post-natal care for mothers and their children.

In zambia, delivery of paper-based infant HIV test results typically averages 6.2 weeks given poor road infrastruc-ture and far distances between clinics and labs processing the results, thereby presenting long delays for EID. Such delays contribute to loss of follow-up and possible death of 30% of affected children if no interventions are provided. programme mwana launched a pilot in April 2010 to reduce these delays in results transmission from the HIV test labo-ratories to rural health facilities via SmS message. The pilot had two main SmS components: results160 and remindmi. results160 was used by staff to securely deliver infant HIV results from the lab to the health clinics, while remindmi was used by CHws to remind the mothers to return to the clinics to receive their infant’s results.

The following results were identified through a program evaluation:• over 5,000 infant HIV test results have been delivered (as

of September 2012).• The time between when the samples were collected and

when the mother received the results was reduced by 56%.• 30% more results were successfully delivered to mothers

thanks to the digitization of the results (as the paper cop-ies were often getting lost).

A national scale-up plan was developed and is now being implemented, which commenced with a preparation phase and followed by shifting to an iterative phase where clinics

are trained and added to the system and problems and suc-cesses are evaluated. Throughout the scale-up process, the project will be closely monitored to ensure the systems are having a positive effect on the targeted health challenges.

OBJECTIvES & GOAlSThe primary goal of programme mwana is to use mobile technology to strengthen health services for mothers and infants in rural clinics, particularly EID as it is a significant problem for countries trying to improve prevention of maternal to child transmission of HIV (pmTCT). The limited amount of technology available to perform infant HIV diagnosis combined with very poor road infrastructure for delivery of results present major bottlenecks for EID. programme mwana was designed to reduce infant mortality by addressing these particular bottlenecks using mHealth, SmS-based interventions.

SCAlE UP ACHIEvEDprogramme mwana was first piloted by the zambia moH in 13 districts in six provinces from 2010 with a goal of reaching nationwide coverage by 2014. programme mwana is now currently in more than 364 facilities and full national scale up is underway in zambia.

In malawi, the program was adopted at national level in 2012 and rapidSmS has been rolled out to tackle other issues as well, including pre- and post-natal care, immunization, growth monitoring and nutrition promotion.

FURTHER SCAlE UP PlANNEDIn 2011, the zambian moH officially decided to scale pro-gramme mwana to 414 health facilities that provide EID ser-vices. The scale-up is taking place over three years, assisted by a wide range of government and nGo partners.

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PARTNERS ROlES

Zambia MOH / Malawi MOH Implementer providing strategic leadership

UNICEF Innovation, UNICEF Zambia / UNICEF Malawi Providing implementation support, technical expertise and technology/systems development.

Boston University affiliate the Zambia Centre for Applied Heath Research and Development (ZCHARD), Clinton Health Access Initiative (CHAI), and other implementing and technical partners

Implementing partners

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16 For more information on the project design of Programme Mwana, see the Case Example on page 59.

Success factors

The mobile solutions developed for programme mwana were designed with specific health objectives that were aligned with the national health strategies of zambia.16

Upon completion of the pilot, all computer hardware, system software, partnerships with telecom companies and software developers were in place to simplify the scaling up of the system to a matter of training.

The entire system and supporting processes and materials were designed in a way to make a single package that can be easily replicated in other countries.

The team invested significant effort and time in understanding and strengthening the existing health interventions, rather than replace them with a new intervention. This was done in close partnership with the government and partner nGos.

MWANA INITIATIVE, ZAMBIA & MALAWI

MOTHER

CHILD 1ST TRIMESTER

2ND & 3RD

TRIMESTERS

CHW

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DISTRICT

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CHW registers birth

6/6/6 visit reminder 6/6/6 visit reminder 6/6/6 visit reminder

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Mother asked to visit clinic

Mother receives results at clinic

Results registered at national lab

SMS results received

Sample shipped and tracked

KEY SYSTEMCOMPONENTS

PREGNANCY BIRTH &POSTPARTUM

BIRTH &POSTNATAL

MATERNAL HEALTH

INFANCY CHILDHOOD

USER REGISTRATION PATIENT REGISTRATION LOGISTICAL TRACKING REMINDER

LOGISTICAL TRACKING RESULTS NOTIFICATION CONFIRMATION

CONFIRMATION REQUEST FOR ACTION

CONFIRMATION

A national scale-up plan was developed and is now being implemented, which commenced with a preparation phase and followed by shifting to an iterative phase where clinics are trained and added to the system and problems and successes are evaluated.

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Programme Mwana mapped on the continuum of care. Credit: UNICEF Innovation

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SmS for life is an innovative public-private partnership ini-tially led by novartis and supported by the Tanzanian minis-try of Health and Social welfare (moHSw), Ibm, medicines for malaria Venture (mmV), the Swiss Agency for Develop-ment and Cooperation (SDC), Vodacom and Vodafone. The project comes under the umbrella of the global roll back malaria partnership.

SmS for life harnesses everyday technology to improve ac-cess to essential malaria medicines in rural areas of devel-oping countries. It uses a combination of mobile phones, SmS messages and electronic mapping technology to track weekly stock levels at public health facilities in order to: eliminate stock-outs, increase access to essential medicines, and reduce the number of deaths from malaria.

Every Thursday, the system sends a stock request message to the mobile phones of all registered health facility work-ers. They then count how much stock they have and send the information back to the system via a free text message. If they have not done this by Friday, the system sends them a reminder. on monday the system would send information about stock levels and non-reports to the district manage-ment officer, who can then monitor stock levels and order or redistribute medicine between sites accordingly.

OBJECTIvES & GOAlSThe SmS for life project was originally conceived to harness mobile resource management technology in eliminating stock-outs and improve access to malarial medicines in Tanzania. The partnership’s objectives are to bring weekly visibility to medi-cine stock levels at the remote Health Facility level, improve access to life saving medicines at the point of care by eliminat-ing medicine stock-outs at the health facility level, and provide an infrastructure to allow weekly collection of surveillance information. It tackles these by enabling real-time reporting of stocks using mobile phones and two-way text messaging.

SCAlE UP ACHIEvEDSmS for life has been rolled out nationally across Tanzania, with the staff of over 5,000 facilities trained and reporting on a weekly basis. ownership of the initiative has been officially transferred to the Tanzanian moHSw. The post-pilot partner-ship includes the Tanzanian ministry of Health, the medicines for malaria Venture (nGo), novartis Foundation, Vodacom, and the Swiss Agency for Development and Cooperation.

FURTHER SCAlE UP PlANNEDnovartis is now planning to expand SmS for life to several African countries. In Ghana, following a successful pilot in six districts sponsored by the Swiss Tropical and public Health Institute (Swiss TpH), novartis is working with the Ghana Health Service on planning a full country scale up. In kenya, another successful and extensive pilot has been completed and novartis is working with the national malaria Control program (nmCp) on a plan for a full country scale up. In Cameroon, with support from the norwegian Agency for Development Cooperation (norAD), novartis and its partners are in the planning phase for a full country scale up of malaria medicine tracking, in addition to collecting patient surveillance data on the use of rapid diagnostic tests.

In addition to Tanzania, kenya, Ghana and Cameroon, there is interest in exploring SmS for life integration in zimbabwe, madagascar, Chad and the Democratic republic of Congo.

SMS for Life� LOCATION: TANZANIA, KENYA, GhANA, CAMErOON � STATUS: TANZANIA: National scale achieved. Additional African Countries: Scale up and implementation ongoing or planned.

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Extract from SMS for Life Poster. Credit: RBM Partnership

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Sustainability has been achieved through securing government buy-in and ensuring ownership of SmS for life programs by country governments, as well as sustainable funding as partners fund the initial systems cost associated with the pro-ject while the in-country training and implementation costs are typically covered by the country government itself. SmS for life brings together a broad consortium of partners from a variety of sectors. A strong steering committee has been set up to manage the partnership and the initiative via the roll back malaria partnership, including representatives from government, the private sector and non-profit partners (including Vodafone, novartis and the Swiss Tropical Institute).

Success factors

PARTNERS ROlES

Novartis Providing funding, technical expertise and strategic leadership

Roll Back Malaria partnership (RBM) Providing strategic support and guidance by facilitating a steering committee and advocacy efforts

Swiss Agency for Development and Cooperation, Medicines for Malaria Venture

Initial funders

IBM, Google, Vodacom, Vodafone Technical supporting partners providing technology and other support

Country Governments Supporting implementation and national scale

Extract from SMS for Life Poster. Credit: RBM Partnership

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In partnership with mobile network operators Vodafone and mTn, Switchboard has created a free calling network for every doctor in Ghana and liberia, and is now creating a free calling network for all health workers in Tanzania. Since 2008, physicians have been collaborating using the Switch-board network to improve patient care with over four million calls made.

physicians in Ghana were spending upwards of US$70 per month on calls to colleagues. with the development of Switchboard, physicians in Ghana and liberia gained a nationwide support network, while telecoms gained valuable customers. As physicians in Ghana and liberia registered for the Switchboard networks, Switchboard was able to create the first-ever doctor directories in 2010 and 2011. Every physician received a print directory, allowing them to expand their support network nationwide, consult with new col-leagues, and refer patients more effectively.

OBJECTIvES & GOAlSUsing even the simplest mobile phones, Switchboard aims to make nationwide networks of health workers enabling them to seek medical advice and make referrals free of charge. Switchboard works to achieve this by: (1) creating free call-ing networks between health workers enabling them to call or text each other for free; (2) building nationwide phone registries; and (3) implementing a bulk SmS messaging plat-form. This platform will enable bi-directional communication between health workers and moH officials to relay disease

outbreak information, drug supply levels and receive lab results in real-time.

SCAlE UP ACHIEvEDFree calling networks have been established between all 181 doctors in liberia and all 2,200 physicians in Ghana – gener-ating four million calls since 2008.

FURTHER SCAlE UP PlANNEDSwitchboard is expanding into Tanzania with the aim of creat-ing a network between all 34,000 health workers in Tanzania.

out of these 34,000, only 6,505 medical and clinical officers manage all rural health centers in Tanzania – acting as the main points of care for a population of 45 million. These isolated health workers are currently unable to seek advice from almost 2,500 urban doctors or receive government support. To allow health workers to freely seek advice nationwide, Switchboard is initially creating a free calling network for the 9,000 doctors, medical and clinical officers in Tanzania through local telecom partner, Vodacom.

For every isolated health worker in Tanzania to receive best practices or disease outbreak alerts instantly on their mobile phone, Switchboard will work with the ministry of Health to utilize their bulk SmS platform, enabling them to send critical information to large groups of health workers, and allowing practitioners in the field to also reply to vital questions or report medical supply levels.

Switchboard� LOCATION: GhANA, LIBErIA, TANZANIA (rOLLING OUT) � STATUS: GhANA, LIBErIA: National scale achieved (reach-ing 100% of doctors). TANZANIA: Ongoing, with the target of national scale (reaching all health workers).

CASE STUDy


PARTNERS ROlES

Switchboard Lead implementer and partnership broker

MTN (Liberia), Vodafone (Ghana), Vodacom (Tanzania) Technology providers: providing free calling networks

Ghana Medical Association (GMA), Ghana Medical & Dental CouncilLiberia Medical & Dental Association, Liberia Medical & Dental Council

Local implementers

Ghana MOH, Ghana Health Service; Liberia MOH; Tanzania MOH

Supporting and implementing scale up

Google.org Providing strategic funding for scale up in Tanzania

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Switchboard designed their program for scale from the beginning and incorporated strong incentives for each partner to participate, with a particularly strong commercial incentive for the mobile network operator. Switchboard designs and employs creative business models to engage private sector partners. For example, Switch-board’s free calling networks save doctors money on calls to colleagues to seek advice or refer patients, so they provide a significant incentive to switch carriers. Vodafone has only 18% market share in Ghana, yet they have all 2,200 physicians as subscribers. while practitioners make free calls to seek advice, they also make paid calls to friends and family – already generating $1.5 million in revenue for Vodafone and mTn. Switchboard believes these creative business models are the key to nationwide mHealth scale and expansion to new markets.

Switchboard sought partnership agreements with ministries of Health and the mnos to ensure the type of monitoring and evaluation they needed internally to collect the data necessary to build their business cases.

Success factors

LiberiaDoctors 181 People 4 million

GhanaDoctors 2,200People 24 million

TanzaniaHealth Workers 9,000People 45 million

- 9,000 health workers in Tanzania- All 2,200 doctors in Ghana- All 181 doctors in Liberia

The Ghana Doctor Directory in use at Korle Bu Teaching Hospital, Accra, Ghana. Credit: Dania Maxwell

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04 recommendations Introduction

recommendations

04IntroductionStrategic partnerships combine the distinct core competencies, knowledge, exper-tise, resources, market access and networks of each partner in order to achieve scale and impact of an initiative that, if pursued as individuals, may not be possible. It pro-vides a unique opportunity to share risks, rewards, responsibilities and investments to achieve common goals. This section delivers recommendations on how to best proceed through different phases of partnership development for mHealth projects with a constant focus on achieving scale up.

1

2

3

4

Building the Partnership

implementing the Partnership

sustaining the Partnership

ensuring Partnership driven scale Up

What are key success factors for build-ing and sustaining partnerships that can achieve scale of a mobile health initia-tive? How can partnership-driven scale up be ensured? These questions are an-swered through interviews with various major partnership brokers, stakeholders and decision-makers, with the content organized into sets of recommendations according to partnership development phases. The recommendations were then evaluated by an Expert Review Panel in order to ensure the perspec-tives of diverse fields were represented. The recommendations were crafted according to the following partnership development phases →

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EXPERT INTERVIEWEES

EXPERT REVIEW PANEL

Sean Blaschke Health Systems Strengthening Coordinator, UNICEF Uganda

Awa Marie Coll-Seck Minister of Health, Senegal | Former Executive Director, Roll Back Malaria

Amir Dossal Founder & Chairman, Global Partnership Forum

Sarah Emerson Country Manager, mHealth Tanzania Public-Private Partnership, CDC Foundation

Kirsten Gagnaire Global Director, Mobile Alliance for Maternal Action (MAMA)

Patricia Mechael Executive Director, mHealth Alliance

Judy Njogu Product Manager for eHealth & eLearning, Safaricom

Yunkap Kwankam CEO, Global eHealth Consultants | Executive Director, International Society for Telemedicine & eHealth

Chris Locke Managing Director, GSMA Mobile for Development

Carole Presern Executive Director, The Partnership for Maternal, Newborn & Child Health (PMNCH)

Sandhya Rao Senior Advisor, Private Sector Partnerships, Office of Health, Infectious Diseases and Nutrition, USAID

Véronique Thouvenot Head of International Women and eHealth Working Group, Millennia 2015

These recommendations were drawn from partnership experts with experience from a variety of sectors (non-profit, government, donor, and private sectors), and present a diverse set of perspectives and insights for a comprehensive view on what are the key elements for successful strategic partnerships to drive the scale up of mHealth.

sustaining the Partnership

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04 recommendations Recommendations Overview

Perform a thorough landscape analysis of

local contexts

Employ an inclusive

multi-stakeholder approach

Partner with government & private sectors

Ensure

strategic alignment & commitment

Create acompelling

partnership proposal

Understand differing

organizational cultures &

how to work together

Establish a formal partner-ship agreement & governance

structures

Employ a collaborative

approach on pro-ject design for scale

Agree on goals and targets; set realistic and flexible expectations

Be aware of risks

& rewards of partnering

Establish a strong

communication strategy

Build trust & minimize

human resource obstacles

Implement a broad

monitoring & evaluation

strategy

Maintain flexibility

& adaptability

Start small, think big, &

design a smart model for scale

Ensure government ownership & involvement

Establish a cross-agency committee to steer scale up

Avoid high human

resource & technology costs

Recommendations Overview

Build

Implement

Sustain

Scale

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4.1 Building the Partnershiprecommendations

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BUilding the PartnershiP

Perform a thorough landscape analysis of

local contexts

Employ an inclusive

multi-stakeholder approach

Partner with government & private sectors

Ensure

strategic alignment & commitment

Create acompelling

partnership proposal

Understand differing

organizational cultures &

how to work together

Establish a formal partner-ship agreement & governance

structures

Employ a collaborative

approach on pro-ject design for scale

Agree on goals and targets; set realistic and flexible expectations

Be aware of risks

& rewards of partnering

Establish a strong

communication strategy

Build trust & minimize

human resource obstacles

Implement a broad

monitoring & evaluation

strategy

Maintain flexibility

& adaptability

Start small, think big, &

design a smart model for scale

Ensure government ownership & involvement

Establish a cross-agency committee to steer scale up

Avoid high human

resource & technology costs

Building the partnership covers an in-depth exploration of the target issue, contexts, stakeholders, potential partners and possibility for alignment, and finally creating a win-win proposal to secure partners to form the desired core part-nership. This initial phase of partnership development can last from a few months to more than a year, depending on the scope and context. The following recommendations cover strategies for successfully building a partnership.

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Perform a thorough landscaPe analysis

of local contexts

emPloy an inclusive multi-stakeholder aPProach

Partner with government & Private sectors

ensure strategic alignment & commitment

create comPelling PartnershiP ProPosal

recommendations:

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4.1 recommendations Building the Partnership

the first step is to perform a landscape analysis to develop a thor-ough understanding of the problem to be tackled, the existing solu-tions, the potential major stakeholders, and the national information and health infrastructures and systems in the area of implementation.

dr. awa marie coll-seck, current minister of health of senegal and former executive director of the major public-private partnership roll back malaria, advises having a clear and strong identification of the problem the proposed partnership wishes to tackle. she recommends analyzing the problem and the different ways in which to resolve the problem, as well as identifying what are the different sectors needed to participate in solving the problem.

once this is done, sean blaschke, health systems strengthening co-ordinator of uniceF uganda, recommends mapping what solutions already exist and what is being implemented, as well as what is working and what isn’t. Without such information, an initiative could easily run into trouble. one example is unknowingly investing a great amount of time and energy in proposing and getting funding for a duplication of an existing project, which would likely not get accepted or approved by the ministry of health (moh).

another important element is ensuring there is an enabling environ-ment for electronic and mobile health (e/mhealth) in the country of implementation. “You really need to know what the existing laws and policies are. i’ve seen a number of projects fail where a donor gave money to an ngo who then hired a technology company to create a solution which, once presented to the ministry, was rejected because certain things – like patient privacy – weren’t taken into consideration,” says blaschke. For this reason, blaschke says it is de-cidedly important to use the landscape analysis to determine what current government structures, policies and legislation are in place that can impact the project and to develop an understanding of the local ecosystem. if the partnership is lacking local knowledge of how the government works, and of the policies, legislation and frame-works in place, it is crucial to involve individuals with this knowledge

as navigating the government can be quite complex and difficult. seek out local communities of practice, such as the mhealth com-munity of practice in tanzania, co-led by the tanzanian ministry of health and social Welfare and rotating co-chairs.17 sarah emerson, country director of the mhealth tanzania public-private partner-ship, shared how this community of practice provides a forum for sharing experiences, challenges and advice, as well as identifying potential collaborations within the tanzanian ecosystem for mobile health. blaschke says that uganda, like many other countries, provides additional challenges because the government has not yet officially endorsed its ehealth strategy. there is also an ehealth moratorium in place since december 2011, meaning the ministry is currently not considering new projects until the ehealth strategy has been completed. ideally, with these strategies governments should be able to outline what their priorities are, where they are currently investing and where there is need for investment. While more than 80 countries have ehealth strategies in place, unfortu-nately very few countries in africa have such a framework in place.18

the landscape analysis should also identify major potential stake-holders that can play a role in the partnership.

after performing the landscape analysis, blaschke identifies the next step as understanding how different information systems fit together in the country or area of implementation. this is something that many organizations don’t do in the early phases, even those looking to broadly strengthen health management information sys-tems (hmis). What is not taken into account, according to blaschke, is that “an ehealth enterprise-level architecture typically includes many domains, including logistic management information systems, patient records, and health insurance systems, all of which must work together.” as such, there usually are other information systems that overlap with the tools and systems being developed. blaschke notes that uniceF is working with the ugandan moh to identify what these areas of overlap are and to ensure that existing tools and those being developed can actually work together in a coherent and cohesive way.

Perform a thorough landscape analysis in the local context(s) of implementation.

• Clearly identify the problem, existing solutions, major stakeholders & local infrastructure and systems.• Ensure there is an enabling environment for e/mHealth & understand how information systems work together.

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17 The Tanzania mHealth Community of Practice is currently co-chaired by the Tanzania MOHSW and D-Tree International, and has over 90 members from 30 organizations across government, industry and NGO sectors. The community can be accessed here: https://groups.google.com/forum/?fromgroups-!forum/tanzania-mhealth#!forum/tanzania-mhealth

18 A directory of national eHealth policies can be found in the WHO’s Global Observatory for eHealth: http://www.who.int/goe/policies/countries/en/index.html

https://groups.google.com/forum/?fromgroups-!forum/tanzania-mhealth#!forum/tanzania-mhealth

https://groups.google.com/forum/?fromgroups-!forum/tanzania-mhealth#!forum/tanzania-mhealth

http://www.who.int/goe/policies/countries/en/index.html

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amir dossal, Founder and chairman of the global partnerships Forum, advises employing a multi-stakeholder partnership approach by engaging a variety of actors to address social problems in a cohesive way. partners from different sectors and fields can offer different sets of assets and strengths to benefit the project. consider not only their core competencies, but also their history, networks and reputation in the area of implemen-tation. partners’ assets should be identified in early discus-sions to determine areas of expertise and knowledge, existing relationships, access to markets, etc. dossal highlights specific competencies from different sectors that can support the part-nership, including: management skills of the private sector, nor-mative leadership of the public sector, and successful delivery mechanisms of ngos and civil society who understand how to deliver programs on the ground. emerson further recommends focusing on the complementary abilities of each partner that can leverage the project and carefully determining where each partner can and should play a role. according to minister coll-seck, it is important to identify which partners are the best fit – based on what is needed for the project, where each partner adds value and how they fit with the other partners.

be inclusive and consider all stakeholders when building the partnership; always keeping scale up in mind. local stakehold-ers, particularly community and traditional leaders, community health workers (chWs) and local populations, should also be engaged as partners in the development and roll out of mhealth

solutions. blaschke suggests that partnering with local com-munity service organizations can be key to ensuring uptake of the initiative by the target beneficiaries. uniceF’s ureport and mtrac’s anonymous hotline were able to leverage existing grass roots organizations to mobilize their communities around community monitoring. uniceF identified various organizations including the church of uganda, islamic supreme council and the uganda scouts association who already have huge net-works that they could tap into to make people aware of these community-monitoring programs. “as an organization, a few years back uniceF started looking at signing strategic partner-ship agreements with more local organizations,” says blaschke, and this has certainly been beneficial for them.

Kirsten gagnaire, global director of the mobile alliance for maternal action (mama), recommends identifying what assets are specifically needed to scale the initiative: access to a new market or demographic? subsidized mobile services such as bulk sms rates? in-depth local knowledge of a particular health issue and target population? tailored content and delivery mechanisms for a specific demographic? gagnaire advises organizations to use this information to carefully determine which partners are needed based on what is needed to support scale up. choose partners with the strongest competencies based on the needs of the project and strive for the optimal combination of added value to support its success and be conducive to scale up.

The idea for and formation of MAMA started at USAID headquarters in Washington D.C. USAID was interested in creating a model that was built for scale, by catalyzing country-based public-private coalitions to support the development and scale-up of sustainable mHealth services for maternal and child health, beginning in Bangladesh. USAID was keen to leverage and build local capacity, and decided to partner with a Bangladeshi social enterprise that would serve as the coalition coordinator. This enter-prise would “own” the service, created with initial catalytic

funding from USAID, and it would create and maintain the relationships with mobile operators, outreach part-ners, corporate sponsors, government entities and others. Building on the model developed in Bangladesh, USAID worked with Johnson & Johnson, who had created a similar model in the U.S. with Text4Baby, to join forces and form the Mobile Alliance for Maternal Action, to scale this model to other countries, in partnership with the mHealth Alliance, the United Nations Foundation and BabyCenter. continued on the next page

CASE EXAMPLE: FORMATION OF GLOBAL PUBLIC-PRIVATE PARTNERSHIP MAMA

employ an inclusive multi-stakeholder partnership approach when selecting the partners.• Carefully select each partner based on core competencies, strengths, areas of expertise, resources & networks.• Focus on complementarity & strive for the optimal combination of added value to scale the project.

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developing partnerships with local government officials and institutions can be a key success factor to ensuring the scala-bility and long-term sustainability of the initiative. Judy njogu, product manager for ehealth and elearning at Kenya’s leading mobile network operator (mno) safaricom, explains: “You cannot achieve scale unless you are working with the government,” while describing safaricom’s relationships with local Kenyan govern-ment leaders, including the director of public health. minister coll-seck specifically advises partnering with government bodies at the beginning of the project, and involving them in the entire planning and development processes to generate government ownership of the project, which can strongly impact the likelihood of sustaining and scaling the project. once ownership is secured, this government body, such as the moh, can then promote the project within the government itself at ministerial meetings and across the ministeries. therefore, the initiative would get present-ed within the government by a government official, driving the uptake and possibility for scale from within. the government’s perception of being part of the partnership, rather than having their country as a location for piloting the intiative, can be a key factor in securing buy-in for the project.

partnering and working with the government is critical for many other reasons. if the mhealth initiative involves the delivery of con-tent through mobile phones, this content may have to be reviewed, approved, and in some cases, endorsed by the ministry of health, according to sandhya rao, senior advisor for private sector part-nerships in the office of health, infectious diseases and nutrition at the united states agency for international development (usaid). blaschke emphasizes the importance of partnering with the gov-ernment to ensure the initiative is aligned with their national strat-egies and vision, or plans for such national policies or strategies in contexts where they don’t yet formally exist. this is particularly

true in contexts where national policies and laws related to ehealth, such as privacy and security of electronic health records, don’t yet exist. in the context of uganda, the lack of a national policy, strategy and vision with regards to e/mhealth has been one of the main barriers to getting private sector investment in the health field. “For some risk averse companies, it is just too dangerous and people are too wary of investing at this stage,” says blaschke. links to the government are critical in this case because if a partnership is formed that the government is not involved in, and new legis-lation or policies are put in place that conflict with what has been developed or is being deployed, the partnership is then suddenly at a huge disadvantage. “You’d have to stop the project and change everything,” warns blaschke. in order to build awareness of and be able to advocate to the government for supportive policies and laws related to ehealth to create an enabling environment for the scale up of mhealth, it is also important that the government be engaged in the partnership’s activities.

successfully getting government partners on board and ensuring uptake of the initiative is not always easy and may require differ-ent approaches. blaschke recommends helping the government see the initiative from a systems point of view. For uniceF ugan-da to secure buy-in and uptake from the government for mtrac, they developed and positioned mtrac not as a project, but rather as a tool to strengthen and extend the local district health and information software (dhis2) and health management informa-tion system (hmis) by building an sms transaction layer and an sms communications engine that could then be used for supply tracking campaigns and for extending electronic medical records to the community level. this meant building an sms tool for a wide range of government purposes that fit into the larger moh strategy for how the government was going to deploy ehealth in the country. “this actually fit in with where the ministry of health

Partner with the government.• Partner with government institutions in the local area of implementation to generate buy-in and drive local

ownership, scale and sustainability of the project.

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MAMA was initially formed as a three-year initiative with the founding partners, USAID and Johnson & Johnson, each committing US$5 million to the initiative in three country programs: Bangladesh, South Africa and India. Now MAMA is evolving beyond a three-year initiative to a longer-term entity.

MAMA is also looking to embody a repository of tools, infor-mation, lessons learned and best practices, in addition to the existing mobile messaging library, that can be accessed and used by any program in the field looking to scale these kinds of MNCH programs.


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Partner with the private sector.• Partnering with private sector players can provide important know-how and technology to scale

the initiative.

4

PAtrICIA MEChAEl, ExECUtIvE DIrECtor of thE MhEAlth AllIAnCE, ShArES how thIS PUBlIC- PrIvAtE PArtnErShIP CAME togEthEr.

The mHealth Alliance joined a new partnership with the Nigerian Federal Ministry of Health and Intel to leverage mobile computing and telecommunications technologies to support Nigeria’s Saving One Million Lives Initiative.

The partnership is now developing an interagency adviso-ry group that cuts across Ministry of ICT, Federal Ministry of Health, National Primary Health Care Development Agency, and various different public agencies. It is now also engaging the private sector such as MNOs and multinational corporations through the business council to see how they can leverage the expertise of a diverse range of stakeholders.

How was the partnership formed?All partners were present in Nigeria for the launch of Saving One Million Lives and there was a special session on the use of ICTs in this initiative where several commitments were made. Intel made a commitment to the Federal MOH to lev-erage their technology to train 10,000 health workers, while the mHealth Alliance proposed studying the enabling envi-ronment issues and helping facilitate the development of an ICT framework. The Federal MOH guided the partnership, requesting that each partner come up with a joint proposal that would link all these pieces together under the umbrella of Save One Million Lives. Patricia Mechael highlights that an important success factor is “thinking pragmatically and tactically about where different technologies are going to accelerate the achievement of the targets set under the initiative as well as enable the partners to systematically track progress against the goals being set.”

CASE EXAMPLE: NEw PUBLIC-PRIVATE PARTNERSHIP LEVERAGING MOBILE TECHNOLOGIES TO SAVE ONE MILLION LIVES IN NIGERIA

engaging the private sector as partners can harness their tech-nical core competencies, technology, know-how and resources. these benefits are immediately obvious for mhealth programs looking for technology providers or mobile network

operators as partners. however, consider also the ability to expand the scope of the program based on integrating partners with diverse products and services, such as partnering with an insurance provider and mobile money service to deliver mi-

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wanted to go with their emerging [ehealth] strategy,” says blaschke. From the initial phases, uniceF started working on integrating mtrac with dhis2 so it wouldn’t be a parallel project, but rather a way for health workers who didn’t have access to computers to enter their data into dhis2 via their mobile phones using the mtrac tool.

in order to secure government buy-in, it is really useful for organ-izations to look at government plans and policies, for example a five-year health strategy. blaschke recommends looking at these first, and seeing if the initiative can be aligned with these

government priorities. using the same language, and prioritizing the same areas they and the donors have prioritized, will result in higher chances of success.

emerson also highlights the importance of government owner-ship or buy-in, coupled with the need to have realistic expec-tations of the amount of time that may be involved in securing government support. it may be possible to avoid protracted timelines associated with garnering government sponsorship; however, it is highly beneficial for the partnership in the long-run to invest time in securing this buy-in as early as possible.


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19 See the Case Study on the Disease Surveillance and Mapping Project on page 10.20 With the exception that validation of registration for insurance must be done in person.21 Hoefman, B. “Opportunities and challenges for use of mobile phones for learning.” Edu-

cational Technology Debate. Available: https://edutechdebate.org/affordable-technology/opportunities-and-challenges-for-use-of-mobile-phones-for-learning/ (Cited on 13 February January 2013)

Linda Jamii, Swahili for “protect your family”, is a mobile health micro-insurance program implemented by Safaricom in part-nership with Changamka Micro-Health and insurance provider Britam, as the underwriter. It provides in-patient and out-patient cover, maternity cover, dental and vision, income replacement, funeral expense payout, and more to self-employed Kenyans. The premium is US$150 per family per year. Every component of the program, from registration to submitting claims, is done through a mobile phone.20

Changamka has already been working with Safaricom’s m-Pesa service for their maternal health micro-savings program. For Linda Jamii, Changamka’s contribution was to bring in a cloud-based

application that manages the whole process from registration to the provider side.

Kenya’s Ministry of Public Health and Sanitation (MOPHS) is not a formal partner of the initiative but they are very interested in inte-grating Linda Jamii into other programs. MOPHS is also providing all public hospitals as part of the provider panel for Linda Jamii. The Minister of Health wants to integrate Linda Jamii as part of the KimMNCHip program which will be rolled out in all 8,000 health facilities (see the KimMNCHip Case Study on page 12). Over 3,600 families have already subscribed prior to the full launch. Safaricom is planning a full roll-out out at the end of March 2013 with a target of getting one million families subscribed within 2013.

Bas Hoefman shares his thoughts on his organization,Text to Change, partnering with MNOs.

“Orange is providing us with technical support in countries where they have operations; however, the partnership does not demand exclusivity- we are open to work with other existing operators within the region. I then must argue that Corporate

Social Responsibility (CSR) is always a short-term association. To have a sustainable working relationship with the mobile oper-ators we must ensure a win-win situation since the primary goal / core business of the operator is to provide network services and make profits. This is how it should be. I [would] rather have pre-mium services and pay for it than a CSR project that doesn’t have priority for the service provider because it is not profitable.”21

CASE EXAMPLE: LINdA jAMII

CASE EXAMPLE: TEXT TO CHANGE ON PARTNERING wITH MNOS

cro-health insurance (see case example of safaricom’s linda Jamii program below). emerson advises moving away from the traditional notion of public-private partnerships that solely involves private sector partners donating their services or products for free. instead, she encourages those seeking to partner with the private sector to leverage companies’ inherent capabilities as profit-seeking entities to find sustainable, win-win business models for the partnership, instead of only appealing to their corporate social responsibility (csr) side. bas hoefman, Founder and managing director of text to change, shares this view, stating that csr projects are typically short-term associations and that in order to have a sustainable work-ing relationship with mobile network operators, a win-win proposal must be developed (see case example on text to change below).

regarding technology partners specifically, Katy digovich, director of operations and Founder of positive innovation for the next gen-eration (ping), makes the case that the willingness of technology providers to be very involved from the beginning in logistics, as well as the building and maintenance of the partnership ecosystem

around the project, can be critical to moving projects beyond the pilot phase. With regards to the disease surveillance and mapping project19, ping had to evolve from a technology partner to a hands-on implementing partner actively engaged in on-the-ground activities and working closely with the moh to ensure the success of the project (success being defined as the moh deciding to scale the project beyond pilot phase).

dossal highlights that there are also operational benefits of part-nering with the private sector, including incorporating their smart reporting mechanisms and operating discipline into the partner-ship’s activities, in addition to providing technical and technolog-ical capacities. partnerships can also immediately benefit from their management and financial skills, efficiency systems and outreach capacities.

partners should be aware that the pace of operations in companies is very different from the non-profit and public sectors and the timeframes for achieving results are considerably shorter.


https://edutechdebate.org/affordable-technology/opportunities-and-challenges-for-use-of-mobile-phones-for-learning/


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consider the answers to the following questions: Will the partnership benefit all partners’ broader strategic plans? is the perceived value of the partnership consistent across all partners? is there commitment and enthusiasm for the part-nership from all sides and at various levels within each partner organization?

looking for strategic alignment and commitment among the partners is important to determining whether the partnership will survive and succeed. according to emerson, this comes from doing an open assessment of each organization’s core principles and identifying whether there is an overlapping

vision and matching values. strategic alignment must be evident not only to the top-level executives, but also to those working on partnership implementation. belief in the shared objectives and values of all the partners, as well as having a strong win-win or mutually beneficial value proposition for all sides, will ensure a long-term commitment to making the relationship work.

how can this be achieved? by having frank discussions during the initial conversations with each partner to identify wheth-er there is a shared interest and value, and thereby strategic alignment and commitment to the partnership. according to

have a credible and neutral partnership broker.• Partnership brokers should identify the needs & objectives of each partner, & find areas of mutual benefit.• Brokers should communicate these using language that each partner will understand.

5both dossal and njogu advise using the right partnership broker to ensure smooth partnership development. the partnership bro-ker should have a neutral background and no agenda behind the partnership proposal, as well as have strong credibility to demon-strate that the partnership aims to tackle a collective issue. the broker can also ensure that a collective solution is put together to form the partnership initiative. For private-sector partnerships, njogu recommends using a partnership broker who is not part of the consortium and is able to have frank conversations with each partner to ensure the partnership is moving in the right direction.

to effectively bring the partners together, the broker is rec-ommended to take on certain tasks. the first set of tasks is to identify the needs, assets and objectives of each partner. the broker’s goal is to express these in terms that each desired partner will understand. Finding areas of mutual benefit is another critical success factor for partnership building, according to patricia mechael, executive direc-tor of the mhealth alliance. the broker should be able to demonstrate a collective issue that has mutual benefits for all parties involved.

ensure strategic alignment and commitment across all partners.

• Have each partner clearly define & articulate their goals & objectives, and how they perceive scale & success.

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“Finding areas of mutual benefit is another critical success factor for partnership building, according to Patricia Mechael. The broker should be able to demonstrate a collective issue that has mutual benefits for all parties involved.”


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njogu, it is important in this phase that partners are transparent and honest about their real goals and objectives, as well as expected success, so that the other partners can determine whether achiev-ing these will benefit their missions. it is also critical that partners paint their picture of success at the very beginning. “if all partners come to the table with a clear picture of what success would look like to them, then it becomes much easier to manage expectations and the project,” said njogu. assumptions in these areas will likely result in conflict later on.

strategic alignment coincides with identifying what each

partner’s definition of scale is and whether it can reconcile with the others. Kai-lik Foh, mhealth program manager at the gsma, clearly articulated the potential differences in definitions of scale according to players from different sectors in a recent devex article.22 to a global health organization, scale can mean reaching a bigger target population and achieving greater impact such as improved health outcomes. to a mobile network operator scale may mean covering a larger geographic area; growth in customer base, market share or usage of services; and/or reinforced brand recognition. determine which type of scale is the goal of the partnership.

22 Useem, A. (11 December 2012). “Mobile health initiatives look to service providers for scale.” DevexImpact. Available: https://www.devex.com/en/news/mobile-health-intitia-tives-look-to-service-providers-for-scale/79932 (Cited on 10 January 2013)

create a compelling partnership proposal incorporating scale.

• Identify value propositions for each partner, and define the strategy & framework for engaging each partner.• The proposal should contain a credible initiative that is evidence-based & packaged for scale.

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partnership proposals should be tailored for the desired partners and demonstrate an understanding of each partner’s needs and priorities, and present a solution that matches up with each partner’s goals.

corporate, non-profit, and public sector organizations have differing drivers, methods of operation, priorities, timelines, and languages they communicate in. understanding these factors and building them into the partnership proposal is important. if a company is being sought as a partner, consider their core business drivers and priorities in demographic and geographical coverage. if looking to partner with a non-profit, understand their mission and program-matic goals, and if it is a government institution, look at their nation-al and public health priorities. mechael highlights the importance of considering a strategy or framework for engaging each partner so that they are contributing their core strengths to the partnership.

PRIVATE-SECTOR PARTNERSHIPSa successful proposal for a private-sector partnership first involves speaking the language of the desired partner. For example, accord-ing to Foh of the gsma, mnos find that global health organizations tend to overestimate the business value of being associated with social-good projects. therefore, consider the priorities of the private sector, and translate the objectives and potential results of the initia-tive in terms that they understand, such as costs, revenues and scale.

companies need to have a clear understanding of why partnering on this project is a smart business decision for them by focusing on the business case. a common claim of the private sector is that when approached by non-profit organizations, they often are pre-sented with initiatives or solutions that don’t have a strong business case or win-win value proposition for them, making it difficult for them to convince their leadership and garner commitment within their company. this is a consequence of non-profits not knowing potential private-sector partners well enough and what their busi-ness priorities are before pitching a partnership opportunity. Keep in mind that both parties can be to blame for this. building a pri-vate-sector partnership requires investment in time and effort from both sides: the proposing party should develop an understanding of the potential partner’s priorities and frame the proposal in these terms. this, however, requires the private sector partner to be trans-parent, to articulate their goals and priorities from the outset, and to avoid camouflaging their real business drivers with social-good mo-tivations merely to demonstrate to the non-profit they are the right fit rather than a competitor. dossal advises organizations seeking to partner with the private sector to understand and present clearly how to use corporate assets to create value for the company.

another important factor is packaging the initiative for scale that the private sector partner can help achieve – for example,




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23 International Partnership for Innovative Healthcare Delivery virtual panel on building sustainable public-private partnerships.

designing the program to involve or have as an objective a large uptake of the desired partner’s core services. this means understanding their business model and developing a proposal around it, rather than requesting partnerships based on philan-thropy or donations of hardware or services.

PuBLIC-PRIVATE PARTNERSHIPSpresenting the government with a strong proposal resulting in a public-private partnership can really drive the scale of an initiative through regional or national scale up. merrick schaefer, senior innovation specialist at the World bank, shared an ex-ample of how a government pushed forward the scale up of an mhealth initiative at the 2012 mhealth summit. he described a project implemented in nigeria to register seven million children and provide them with birth certificates using an sms-based platform, which scaled by itself thanks to the drive and push of the government and the head of the ministry of health.

What is the best way to get the government on board? emer-

son recommends approaching the government by framing the initiative vis-à-vis the public health issue, with evidence of how the mhealth solution can help address the challenges. emerson advises partnerships to identify and tackle existing national health priorities, and focus less on the technology itself and more on the public health impact of the intervention. emphasize how the partnership can help support the country’s national health goals.

defining the total cost of ownership of the initiative for the government and detailing the investment and support needed are important elements of proposals for government partners. it is critical for the government to fully understand the total cost of ownership in order for it to decide whether to commit its resources to the initiative. the goal is to have the initiative transform from a temporary contract to a permanent line item in the budget of the relevant government institution or depart-ment, thereby leading to a long-term investment in sustaining the initiative and ensuring local ownership and scale.23

“Sarah Emerson advises partnerships to identify and tackle existing na-tional health priorities, and focus less on the technology itself and more on the public health impact of the intervention. Emphasize how the part-nership can help support the country’s national health goals.”

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4.2 recommendations Implementing the Partnership

imPlementing the PartnershiPOnce a partnership is formed it moves into the implemen-tation phase, which covers identifying how to effectively work together, putting in place formal structures to ensure this, collaborating on designing the initiative for scale, set-ting goals and expectations, and understanding the risks and rewards of partnering. The following recommendations advise on successful strategies for this phase.

understand differing organizational

cultures & how to work together

establish a formal PartnershiP agreement

& governance structures

emPloy a collaborative aPProach on Project

design for scale

agree on goals and targets; set realistic

and flexible exPectations

be aware of risks & rewards of Partnering

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4.2 Implementing the Partnershiprecommendations

Understand each partners’ organizational culture and guiding principles, and identify how to effectively work together.

• Take into account each partner’s organizational culture, bureaucracies, guiding principles, etc.• Make compromises together to collaborate and partner effectively.

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if the partnership is seeking players from different sectors, it is important to consider and understand the different organiza-tional cultures of each partner, which can mean differences in drivers, priorities, approaches to decision-making, philosophies, modes of operation, and histories. this comes into play quite often in mhealth projects where technology and global health have to work together. gagnaire highlights this specifically when discussing how the technology field is fast moving, and is now butting up against structures of global health and international development which move much more slowly. this presents inherent culture clash, which is why dossal recommends making an effort to understand the organizational or corporate culture of each partner early on. this involves understanding how part-ners operate, their bureaucracy, and identifying ways to meet in the middle to ensure all partners can work effectively together.

blaschke also suggests taking into account partners’ guiding principles. For example, uniceF has two emerging principles for designing ict solutions: (1) move away from investing money in developing tools that are owned by external companies to ensure government ownership; and (2) ensure memorandums of understanding (mous) and contracts don’t lock them into exclusive device or telecom use. a case example: when uniceF uganda sought a partnership with uganda telecom (utl) for

development of the national birth registration system, they stipulated that this service would eventually be offered on all networks.

private sector companies also have their own guiding principles that are important for partnerships to take into account. an example of an mno’s guiding principles was shared by njogu: “We want to ensure that the technology so far invested in is be-ing used to improve the lives of Kenyans.” therefore, safaricom identified four key areas in which they could make the most impact and are now developing products according to these priority intervention areas. one of these is access to quality healthcare, through which safaricom aims to tackle Kenya’s low doctor-to-patient ratio. “not only are there few healthcare professionals, but they are for the most part all centrally located in nairobi. so you find the rest of Kenya doesn’t have access to doctors,” says njogu. developing a partnership with safaricom and the formation of partnership activities would require taking this into account.

When it comes to working with government partners, coll-seck advises that partners must be prepared to accept that it takes time to push through initiatives given inherent bureaucracy issues of working with governments.

“If the partnership is seeking players from different sectors, it is important to consider and understand the different organizational cultures of each partner, which can mean differences in drivers, priorities, approaches to decision-making, philosophies, modes of operation, and histories.”

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employ a collaborative and comprehensive approach when designing the initiative for scale.

• Work together to design and build the initiative for scale using all available assets of each partner.• Avoid duplicating existing solutions.

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there are several important strategies that should be employed when designing the partnership’s initiative.

First, it is important to work with all partners to design the mobile health initiative for scale by agreeing on and using a collaborative approach, advises emerson. For example, several partners within the mhealth tanzania partnership, as well the broader campaign team, contributed to the development of the partnership’s mnch mobile messaging service supporting the government of tanza-nia’s Wazazi nipendeni campaign. gagnaire also emphasized the importance of working closely with all partners by demonstrating that mama’s partners were instrumental in designing, implementing

and rolling out its country programs. For example, mama south africa’s new partnership with Vodacom is thanks to their local partner, praekelt Foundation’s, existing relationship with Vodacom Foundation. praekelt Foundation informed Vodacom of mama’s activities and Vodacom agreed to put the mama mobisite on their operator deck, which means it is available for free to all of their 25 million subscribers. they are now working out the details around a communications and marketing plan for increasing public aware-ness of mama south africa. Second, use a comprehensive, integrative approach when collec-tively designing the partnership initiative. emerson highlighted

establish a formal partnership agreement and strong governance structures

• Have all partners agree to a formal partnership agreement.• Set governance structures defining roles and responsibilities of each partner early on, covering

the full spectrum of partnership implementation.• Develop clear platforms for conflict resolution and decision-making.

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to concretize the partnership, it is important to have a formal partnership agreement in place defining what the partners have agreed to. this agreement can be useful for defining the struc-tures of the partnership and building credibility among the part-ners. gagnaire and mechael strongly recommend ensuring that a good governance structure is put in place to define the roles, responsibilities, and contributions of each partner. it can also be used to identify plans of communication, decision-making and conflict resolution processes, as well as support the sustainability of the partnership.

establishing and defining each partner’s roles and responsibilities from the beginning of partnership implementation will ensure that the program will start smoothly and all objectives will be covered by the end of the period of implementation. if the de-fined roles and responsibilities do not cover the full spectrum of

partnership implementation, there may be hiccups along the way preventing the program from proceeding as expected. this may also hinder the achievement of certain objectives and potential-ly reduce the impact and scale of the program. rao highlights that the roles determined for each partner should relate to their relative strengths and comparative advantages on specific areas of the partnership.

mechael also identifies having a systematic approach to deci-sion-making and resolving issues as critical. through clearly out-lined mous or governance structures and systems, infrastructure can be created that minimizes some of the potential fallout that can be found in partnerships. she recommends identifying poten-tial risks within the partnership, such as conflicts of interest, and dealing with them in a systematic and transparent way. this is part of the due diligence and process of partnering, notes mechael.


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this element as one of the key success factors of the Wazazi nipendeni ‘healthy pregnancy’ campaign, which extended its original focus beyond malaria prevention during pregnancy to include broader maternal, newborn and child health informa-tion, such as prevention of mother to child transmission of hiV (pmtct), nutrition, family planning, and more. therefore, it is also important to maintain an open mindset to improvements and adaptations of the initiative suggested by each partner, and genuinely assess whether it can result in more effective and productive scale and impact.

another example of this strategy arises when mnos may suggest integrating the mhealth initiative with other mobile services, such as mobile money, rather than implementing it in isolation. during a gsma mobile for development webinar, george held, the Vice president of commerce for mobile net-work operator etisalat, said the integration of money and health services is central to the operator’s strategy for scale up. this is echoed by mobile network operator safaricom, explains njogu, who describes a new initiative they are launching called linda Jamii (see the case example on linda Jamii on page 42).

Third, ensure the initiative is not duplicating the efforts of other projects. if a similar initiative exists, look for strategic ways to engage them. this was a key point from blaschke who high-lighted the importance of not replicating what others are doing, but rather building on existing efforts. blaschke put this advice in action when he advised the uniceF tanzania office not to replicate what Wazazi nipendeni was implementing, which was well-funded and had great technical partners on board, but rather to identify strategic opportunities to strengthen the part-nership. blaschke’s recommendation is to use the partnership’s resources more effectively and smartly by working with existing initiatives to try to make them better rather than introducing a new project. his belief is that “a decent tool that everybody uses is much better than a perfect tool that nobody uses.”

Fourth, design the initiative for scale from the start, advises blaschke, because “there is a graveyard of successful pilots. it is quite easy to run a successful pilot, but much more difficult to scale it up.” employ a systems-focused approach, rather than an independent project approach, as a horizontal approach can promote integration within local systems and avoid the creation of vertical systems and vertical information silos that present barriers to sustainability and scale. When designing for scale, it is important to consider all possible costs from the start for taking the pilot to a higher scale. For example, consider the nec-essary restructuring and increase of human resources required,

the multiplied hardware and software costs, and so on. “You would be surprised with how many pilots were designed that with simple mathematics would show that they couldn’t scale,” blaschke adds. also consider the replicability of the initiative in different contexts and further refine the design based on this assessment. another example of designing for scale is if the in-itiative involves local populations as target beneficiaries, ensure they will be able to access the solution. according to njogu, safaricom developed afya tips (“afya” is the swahili word for health) as a ussd solution, instead of an application, to make it accessible to their customer market as not as many people have a smartphone in Kenya. this type of solution is still robust enough to offer the user a menu to select different kinds of messages they wish to receive, for example healthy pregnancy tips or diabetes prevention and management tips, thereby still enabling the user to tailor the service to their needs.

Fifth, mechael encourages partnerships to set specific targets in specific issue areas and then work backwards to determine which technologies would make sense, and determine how they would need to interact with each other. this ensures the con-tinuum of care is factored into the design and implementation in a way that strengthens the overall health system and doesn’t contribute to existing fragmentation (currently the case in most countries) or duplication. blaschke also notes the importance of not placing too much importance on the technology part, but rather consider aspects such as the interaction with users, en-suring that the data is being utilized effectively and disruption has been minimized. ensure the bigger picture of where the ini-tiative fits in is being looked at. is there any proposed enterprise level architecture in place that should be taken into account? if working with patient records, is the partnership aware of what the government is doing and of other national records they may have in place? blaschke observed that many projects were not able to go to scale because they didn’t anticipate the need to in-tegrate and use data coming from different sources or the need to feed data into other tools.

Sixth and finally, consider external factors, such as local health-care infrastructures, that could affect the initiative. blaschke explains this point in the context of uganda: “the healthcare system in uganda is not perfect: there are a ton of gaps. We tried to operate with those gaps in place, and found that in some scenarios we couldn’t effectively scale up these tools be-cause management wasn’t very strong or the chWs tended to drop out of the system because they weren’t being incentivized properly. these are things that were outside the scope of the project but were key factors that could have been tackled.”

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“It is important to maintain an open mindset to improvements and adap-tations of the initiative suggested by each partner, and genuinely assess whether it can result in more effective and productive scale and impact.”

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The roll-out of Uganda’s new birth registration system – Mobile-VRS – was linked to a social cash transfer program for orphans and vulnerable children. During the initial mass birth registration campaign, the implementers, such as community health workers, would also be identifying vulnerable households. As of early 2013, 1.2 million births were registered through this system, with 20,000-30,000 children identified as vulnerable and meant to be receiving cash transfers. The group charged with develop-ing the cash transfers program partnered with MTN, another MNO in Uganda, for the mobile money component. Vulnerable

households were then given “sim credit cards” that could be used on new devices MTN was rolling out that were essentially solar-powered phone booths operated by mobile money agents. In the past, with social cash transfer programs, vulnerable peo-ple would have to travel to a bank many kilometers away to get their money. Or, even worse, individuals would be going around with briefcases of money to provide the cash transfers. Sim cards enabled vulnerable households to use these free public phone booths rolled out by MTN to get access to mobile money without having a mobile phone.

CASE EXAMPLE: HOw UNICEF UGANdA’S BIRTH REGISTRATION PROjECT INCORPORATEd MOBILE MONEy SERVICES

mTrac came together when the Ugandan MOH, UNICEF and WHO jointly identified a very successful pilot that had already been running for eight months at the time, implemented by FIND Diagnostics and supported by Columbia University’s Earth Institute. They were essentially running a very early version of mTrac. Their initiative had identified an already existing data source that the MOH was using and built their intervention around it. This data source was a weekly surveillance form with-in the HMIS that already captured many of the indicators that they were looking to track, such as notifiable diseases, maternal and neonatal death, case management and treatment of malar-ia and malaria drugs. Their method was to take a small part of a process that was already existing and functioning but faced various challenges such as communication and distance - and solve these challenges using mobile technology. With funding

from DFID, the MOH, UNICEF and WHO built strong governance structures for mTrac, spanning the entire MOH. From the outset, the partnership didn’t approach mTrac as a project but more as a tool that would fit into the larger MOH strategy for how they were going to deploy eHealth. They immediately started working with integrating mTrac with DHIS2 so it wouldn’t be a parallel project but rather a way for people who didn’t have computers to enter the data into DHIS2, by submitting the data directly from the Health Workers mobile phones using mTrac into DHIS2. After initial interviews with end-users, it became clear that the use of mobile phones to submit this data was not something new as many Health Workers were already using SMS or calling districts to send the data in. “mTrac was a way to move the flow of information from the grey market into the mainstream,” highlights Blaschke.

CASE EXAMPLE: HOw MTRAC BUILT ON EXISTING EFFORTS ANd INTEGRATEd wITHIN THE EXISTING HMIS

“They had identified an already existing data source that the MOH was using and built their intervention around it. Their method was to take a small part of this process that was already functioning but faced various challenges such as com-munication and distance - and solve these challenges using mobile technology.”


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agree on goals and targets; set realistic and flexible expectations.

• Jointly define goals, how they will be achieved, and set realistic expectations.

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partners should work together on defining short, medium and long-term goals and targets for the initiative to ensure all partners are on the same page and agreeing to the same objectives. mechael notes the importance of being very clear on defining the initiative’s targets and how they will be achieved. identifying clear targets helps clarify to partners what they each want to achieve, what outcomes they are looking for, and what they are trying to gain. the process of goal setting should be an ongoing process, and not a one-time action, in order to ensure that goals will be

adapted to necessary changes in contexts and implementation.

Jointly defining and agreeing on goals and targets can support continued alignment across the partners and the setting of expec-tations of projected outcomes and achievements of the partner-ship and its initiative. emerson, dossal and mechael specifically recommend setting realistic yet flexible expectations as it ensures there is no misunderstanding across sector boundaries of what can and should be achieved through the partnership.

Be aware of the risks and rewards involved in partnering.• Be aware of and willing to share risks, rewards, investments, and responsibilities.

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each partner should be aware of what the potential risks, rewards, necessary investments and individual responsibilities are before proceeding with implementation. if this understanding is in place, it is much easier to proceed with the partnership’s objectives.

sometimes the short-term costs of involving a particular

partner, such as the increased bureaucracy and stringent requirements of a government or funding partner, may seem like too high a barrier for the project. it is important, however, to consider the long-term benefits of having that partner on board, particularly for scale up, in terms of securing government buy-in or longer-term funding for the project, among other things.

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4.3 recommendations Sustaining the Partnership

sUstaining the PartnershiPSustainability of the partnership and its activities will be an important factor in ensuring it can achieve its goals and targets, as well as help prove the continued relevancy of its initiative. It can also increase the possibility of gathering enough data on impact and outcomes to present a strong case for and secure the transition of the initiative to local stakeholders, ensuring sustainability of the initiative itself. The following recommendations can help ensure sustainability of the partnership and its initiative.

establish a strong communication strategy

build trust & minimize human resource obstacles

imPlement a broad monitoring & evaluation strategy

maintain flexibility & adaPtability

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4.3 Sustaining the Partnershiprecommendations

establish a strong communication strategy.• Use the same language as the partner and frame what needs to be communicated in terms

that the partner will understand.• Develop more than one point of contact between each partner’s team.

1a strong internal and external communication strategy among the partners is crucial to making partnerships work, whether they are private-sector or public-private partnerships. building strong relationships is particularly important when partners from different sectors come together with different philoso-phies, architectures of organization, modalities and operations, and have to cooperate on a common task.

different sectors speak different languages not only in the terms that they use but also in the way they value and prioritize things differently. according to mechael, the health sector at times does not do a good job of articulating what they need from the technology sector, while the technology sector may be willing to engage but they have a hard time understanding where they can be of best use, and vice versa.

to break down this barrier, each partner should make an effort to communicate in terms other partners will understand, when-ever possible. if communicating with a government partner, think about their objectives, such as national health priorities, and frame the discourse in these terms. if working with a pri-vate sector company, consider their business priorities and use terms that translate the business importance for them, such as reduced cost or increased revenues. a strong communication strategy can reduce any misunderstanding or mistrust that is commonly found when non-profit, government or civil society players work with private sector companies.24

a good communication strategy further requires having more than one point of contact and interconnectedness among each partner’s high-level executives and the team dedicated to working on the partnership. avoid depending on a single point of contact; by having more than one point of contact, the chances that the partnership loses commit-ment during staff turnovers and changes in leadership will be reduced. this is particularly important when working on public-private partnerships. typically, partnerships with government institutions rely on relationships with specific government officials, which can be quite unpredictable giv-en the nature of politics. building relationships and multiple linkages throughout various levels and departments of gov-ernment can reduce these uncertainties and lead to stronger buy-in and sustainability. dossal recommends maintaining an open communication channel between all partners through all steps of the project and creating an efficient system of dynamic and constant in-formation-sharing so each stakeholder is aware of the progress made. by sharing information, it pushes other partners to see things from different points of view and think from different perspectives. it also enables the partnership as a whole to check progress against objectives and identify areas of failure. sharing lessons learned from these areas of failure is key to avoiding those same mistakes repeating themselves through-out the project.

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“A strong communication strategy can reduce any misunderstanding or mistrust that is commonly found when non-profit, government or civil society players work with private sector companies.”

24 At the 2012 mHealth Summit, Kai-Lik Foh highlighted a survey conducted of GSMA members and global health organizations (requested by the WHO), which identified a significant amount of mistrust and misunderstanding between these two groups.

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minimize human resource obstacles.• Build trust between the partners through transparency.• Avoid reduced commitment due to changes in management by identifying a strong investment

case for each partner.

2a major challenge in sustaining partnerships is maintaining good relationships and adequate staffing throughout the project. part-nerships bring together different cultural backgrounds, work ethics, terminology and methods of operation, which can create barriers to trust and cohesive teamwork. identify the right people to lead and implement the partnership, ideally individuals who are willing to look for areas of cultural synergy and invest time in building per-sonal relationships to help promote understanding and trust among the partners. if a partner is unwilling to do this, depending on their level of involvement in the partnership, it is likely that conflicts and misunderstandings will arise which can break down commitment to the partnership over time.

building trust between the partners is also critical for minimizing human resource obstacles of the partnership. if partners or their representatives have hidden agendas for participating in the part-nership, this will present a great obstacle to strong partnerships, warns minister coll-seck. she suggests that every partner should demonstrate that they are not there to drive their own agenda, but rather a common agenda on a collective issue. her recommendation is to build trust by maintaining transparency of motivations, goals and targets.

as mhealth is still a developing field, it requires having the right people in place to continuously advocate for the partnership and its activities to ensure sustained commitment. this means individuals who are innovative in tackling challenges and coming up with solutions, and who are willing to take risks and invest time and effort to drive the program and partnership forward. as partnerships for mobile health are still a new area and don’t have an evidence-base of best practices to follow, or the processes, policies or leadership firmly in place to support their formation,

this means the right people are needed at the core of the part-nership to ensure open and flexible mindsets to help adapt the partnership processes and implementation as needed.

blaschke notes that identifying strong investment cases for each partner is critical for neutralizing the oft-found challenges for sustainability that come with changes in management. blaschke shares an example of this where uniceF uganda created a part-nership with uganda telecom (utl) based on csr for their birth registration project. because of this, when the senior management champion who was managing this partnership left, they were challenged with keeping the same levels of support dedicated to the project. uniceF is now looking to renegotiate and engage utl on a paid basis. therefore, if there is a strong business case and value proposition, then when management changes and new people come in, it is far easier to secure continued commitment to the partnership and its activities. this is indeed true for partners from all sectors. blaschke highlights that a stronger, more sustain-able partnership with companies can be developed if the private sector partner can quantify some form of financial value that they can derive from the partnership and its activities, just as non-profit or public sector partners quantify the social and health impact they can achieve. if the partnership can prove that their activities present an investment case for all partners, then sustainability is easier to secure. one critical way of producing the investment case is to address the opportunity costs of the partnership initiative. blaschke notes that “everything has an opportunity cost, so we need to know: is buying 5,000 iphones as effective as paying the salary of 10,000 health workers for two years or buying drugs or bed nets for the population? everything has a tradeoff and this should be addressed. What will we get from each intervention? how many lives will we save from each one?”

“Identify the right people to lead and implement the partnership, ideally individuals who are willing to look for areas of cultural synergy and invest time in building personal relationships to help promote understanding and trust among the partners.”


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implement a broad monitoring and evaluation strategy to measure results.

• Measure success and results against partnership objectives.• Ensure partnership activities are achieving jointly agreed objectives and goals.

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mechael advises implementing a strong and thorough monitor-ing and evaluation (m&e) strategy to ensure the partnership’s activities and results are matching the objectives and goals laid out in the partnership agreement. collecting data and measuring the results consistently across all partner activities ensures that efforts remain aligned and partners hold each other accountable.

soumya alva, senior m&e advisor with the usaid funded maternal and child health integrated program (mchip), is the m&e lead for the mama partnership and drafted mama’s global m&e Framework. she highlights that every project needs an m&e strategy, however a partnership requires a broader m&e strategy that is not restrictive to certain indicators. the indi-cators chosen for the m&e strategy will depend on what each partner’s perspective is and what they want to measure. alva recommends developing m&e strategies to do performance monitoring and measure from each partner’s perspective how well the program is doing. this means understanding each part-ner, what they want out of the partnership and/or initiative, and what is relevant for them.

alva advises involving all partners in the development of the m&e plan by maintaining good relationships with the partners to get honest answers on questions such as: What are their data needs? What information do they want to measure? by asking these questions, specific indicators can be identified and how they will fit into the implementation of the program, as well as how important they are for each partner to monitor. For example, mnos want to know how many people are subscrib-ing, advertisers want to know how much advertising revenue is being generated, and development organizations want to know what health impact there is, including what the health outcomes and outreach are. setting targets for each indicator can be time-intensive but is very important for measuring the success of the partnership.

What are the best practices in data collection methods? because mhealth involves delivering through a technology medium, alva suggests that data collection methods can be built into the system to automatically measure and generate

data on certain indicators on a regular basis, such as how many people are being reached by the program, how many people are getting dropped, etc. When focusing on the hu-man impact, for example knowledge and behavior change of women as in mama, acquiring that information can be more challenging. alva recommends coming up with creative ways on gathering information of this kind on a regular basis to understand the progress of the program. one example is to link the m&e plan to health centers involved in the program to check the clinical records on a regular basis to identify how people are accessing services. in other cases, phone surveys may have to be performed to get information on self-re-ported behaviors and whether knowledge has increased. if the project is dealing with a highly illiterate population and they are not used to sharing information over the phone, any method involving sms-based surveys will prove more difficult. if the project involves a mobile website, a pop-up quiz can be implemented to gather information.

determining the timetable of data collection depends on how much effort is required to gather specific information and how often the program wants to review changes in performance. For regular performance monitoring, such as identifying the number of new subscribers, these could be measured on a weekly or monthly basis through routine data collection methods built into the technology. For evaluations focusing on measuring outcomes, such as how were services being accessed or did behavior change, this requires a more generous timeframe, such as three to six months, as it can be expensive and time-con-suming. in-depth evaluations focused on the causality require a sufficient gap in evaluations because they are thorough and rigorous, expensive and require enough time between data points to measure changes in impact over time.

gagnaire cautions that it is important to not get caught up in get-ting perfect information. instead develop a stepped plan that can identify what can be known now or in 6 months, and what should be known in 3 years. What can be reported on every quarter? gagnaire’s recommendations are to avoid saying nothing and use interim information.

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• Update partnership based on partners’ evolving assets; update initiative based on results of monitoring & evaluation.

• Be flexible; adapt to changing environments, adjust for failures & update strategies to achieve success & scale.

Maintain flexibility and adaptability of the partnership and its initiative.4

throughout the implementation of the partnership, continue to evaluate the initiative to identify areas of success and failure and build this information back into the project to adjust for this. the scope and strategies of the partnership and its activities that were identified at the outset may need updating as the local e/mhealth ecosystem and national strategies develop. if partnering with the government, identify ways to support this evolution of national strategies and ensure the partnership’s initiative contin-ues to fit in these frameworks.

as the partnership progresses, it can also be beneficial to identify new areas through which each partner can add value and leverage the initiative based on the evolving needs of the partnership, and each partners’ evolving resources and capabilities, such as network expansion, new products, services and technical know-how, and new staff. update the roles and responsibilities based on changes within partners’ organizations and operations. this may require the updating of existing agreements and mous, including governance and operational structures.

The MAMA M&E framework is implemented at the global level and at the country level. The country level programs draw relevant points from the global M&E plan rather than start from scratch to develop their M&E strategies. A unique aspect of the MAMA M&E plan is the identification of multiple types of stake-holders, or “information users”, who will need different types of information depending on their roles in the partnership. For example, MNOs need statistics on subscribers, average revenue per user and call volumes; while implementing agencies need information on service quality, missed calls, and number of subscribers; and USAID needs information on progress and health impact, etc. A list of the different types of stakeholders/investors within MAMA was developed with sets of indicators created for each type. Through this method, MAMA is hoping to streamline the M&E process and effectively collect the infor-mation needed by the global consortium of partners.

Further to that, each country has a slightly different approach as they employ different methods, have engaged different partners and technologies, and focus on different health areas and target populations with different characteristics. The aim was, therefore, to come up with guidance from the global level that would guide these country implementing partners and their partnerships. It was flexible enough so that it could fit into each country program and help them develop their own coun-try M&E plans, taking their contexts into account. At the global level, MAMA needed to maintain consistency and this resulted in the creation of a short-list of critical indicators that is impor-tant for measuring how different countries are performing and comparing these performances at a global level.

The MAMA M&E framework is a working document that is be-ing constantly updated and can be found on their website.25

CASE EXAMPLE: MAMA’S GLOBAL ANd COUNTRy LEVEL M&E PLANS

25 Access to the MAMA Global M&E Framework can be requested here: http://mchip.wufoo.com/forms/mama-global-me-plan/

“Collecting data and measuring the results consistently across all partner activities ensures that efforts remain aligned and partners hold each other accountable.”


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For their national SMS campaigns, UNICEF Uganda initially contracted two third-party aggregators to provide toll-free short codes on all of the mobile networks in Uganda, which included getting a yearly license from the Uganda Com-munications Commission (UCC) and activation of the short codes on all the major networks and bulk SMS rates, now at 28 Uganda shillings per message (equivalent to US$0.01). Essentially, UNICEF Uganda has been operating its uReport program for the last four years using these short codes that are still being managed by third-party aggregators. For national communication campaigns, such as uReport with almost 200,000 users, between 500,000 to 1,000,000 SMSs are processed each week when a poll is sent out and responses are received; therefore, costs can start to accumulate quickly. “The telecoms previously were not as interested in talking with us because they didn’t believe the scale that UNICEF was promising. At the time we said we could guarantee 50,000 users and 250,000 SMSs per month. Now we can say concretely that we are already sending two million messages per month to 250,000 users, which is not a hypothetical anymore,” outlines Blaschke.

“We’re at the stage now where we’re going to be re-ap-proaching the national regulatory bodies to see if we can renegotiate rates for critical government services.” UNICEF is now considering the best way to do this, which may in-volve going through the UCC, the national regulatory body, and advocating that they put in place a special category for government and humanitarian services that require SMS or USSD. Currently, because of anti-spam regulations and laws, the telecoms have been categorizing the project’s SMSs in commercial categories. “Effectively, a system used to report Ebola outbreaks is in the same category as those sending out love tips. The spam regulation says you can only send one message per week, on Monday to Friday between 9 a.m. and 5 p.m. Ebola doesn’t happen from 9 a.m. to 5 p.m. on Monday through Friday. What we require is a whole different set of regulations applied to us.” These discussions are still underway and will likely have to be at the ministeri-al level – meaning the Minister of Health, Minister of ICT and Executive Director of the UCC may have to meet with the telecoms requesting certain short codes at certain rates for all government services that meet certain criteria.

CASE EXAMPLE: UNICEF UGANdA’S EVOLVING STRATEGIES ON IMPLEMENTING NATIONAL SMS CAMPAIGNS

CASE EXAMPLE: MAMA: REdEFINING ROLES ANd RESPONSIBILITIES

Kirsten gagnaire shares how MAMA is in the process of re-defining roles and responsibilities based on the evolvement of partnership activities.

“mama was initially launched without solid agreements with all partners detailing the governance structures of the part-nership, what role each partner would play and how exactly each partner would be contributing to the partnership. it was also launched as a large-scale partnership with a lot of press and attention without any staff at the global level. this resulted in a lot of ambiguity across the partners on who was responsible for what and how decisions got made.

We have now gone through a strategic planning process that just wrapped up at the end of 2012 where mama is no longer a three-year initiative but rather a longer-term entity. this now leads to another set of organizational, operational and governance issues that must be addressed in terms of how mama operates. this also required the creation of new mous with the partners to move for-ward. What each partner had initially proposed to do has changed drastically as the clarity on what mama needed to be in the world has formed. now what each partner needs to bring to the table is quite different compared to what the assumptions were one and a half years ago.”

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“The scope and strategies of the partnership and its activities that were identified at the outset may need updating as the local e/mHealth ecosystem and national strategies develop.”

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ensUring PartnershiP- driven scale UPIf all phases of partnership development have been success-ful so far, and the measured results of the initiative are prov-ing that goals are being met and real impact is happening or is possible, it is then time to consider scaling up the initiative through the partnership, which may include expanding the partnership itself. By having a plan for scale up and follow-ing the recommendations in this section, the partnership can help ensure it is able to scale when the time is right.

start small, think big, & design a smart

model for scale

ensure government ownershiP & involvement

establish a cross-agency committee to steer scale uP

avoid high human resource & technology costs

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start small, build a smart model designed for scale, then scale it.1

to ensure scale up, dossal recommends to start small, build a smart model and then scale it. don’t go for large-scale impact immediately. think big, but start small and implement the initiative with the aim of replicating it. come down to the village or community level and identify lessons learned for future ex-

tensions and scale up of the initiative. gagnaire shares a similar recommendation, and emphasizes having a plan for how to scale as important. look at what resources are needed to scale: What is the level of staffing needed? What m&e strategy is needed? What is needed in the short-term and long-term?

Merrick Schaefer describes how Programme Mwana was successfully designed for scale26:

“From the very beginning, we designed the system with scale in mind. We chose to see if we could create significant health impacts using only sms and clinic workers’ personal phones. purchasing phones and creating the it capacity to support them, may not seem that expensive, but when multiplied by the number of clinics in the entire country, it becomes quite costly. and while sms is an expensive information medium, as we scaled, we were able to negoti-ate much lower rates than what could be purchased on the street. We spent the time negotiating with all of the major telecom companies in Zambia, knowing that we couldn’t scale to the whole country unless it worked on all networks. We also used the open source software rapidsms, eliminat-ing licensing fees and allowing us to replicate the program in other countries like malawi. We could use every dollar saved in procurement to add another facility during scale up.

We also designed the system in the most rural communities we were seeking to serve. our team of researchers and pro-grammers moved for a month to the town of mansa, twelve hours from the capital of lusaka, to create the programme in an iterative way, involving the local community members who would be using it. this human-centered design process, assisted by Frog design, was critical to scale, as it assured the software would make sense in the local context and be easy

for new health facilities to adopt. through this participatory process, we learned that the system could be used in facilities that had no mobile coverage if we designed it to allow staff to use it at nearby markets where there was coverage.

most importantly, technology was the foundation, not the focus, of the program. the team went to great lengths to understand and strengthen the existing health interventions, not replace them with something new. and we did this in close partnership with the government and partner ngos.

despite this, we initially had issues raising funding for scale. We had a low-cost, well-designed, and well-evaluated program with a mandate from the ministry of health to scale, and yet it was not easy to sell donors on the scale up. donors want to be perceived as innovators, and the ngos they fund often compete for funding by differentiating their approaches. We were asking them to fund collaboration and mainstreaming rather than developing their own separate mhealth systems. only after Johnson & Johnson stepped in with some seed funding did the program start to scale. the initial funding issues delayed the scale-up by close to a year, and affected the momentum and continuity of the project.

now with the scale up in full swing, programme mwana shows how designing mhealth solutions with scale in the mind from the beginning can help them escape the intense gravity of pilotitis.”

CASE EXAMPLE: HOw PROGRAMME MwANA dESIGNEd FOR SCALE

26 Reproduced from the Skoll World Forum online debate on “How do we cure mHealth Pilotitis”, available here: http://skollworldforum.org/debate-post/programme-mwana-design-ing-mhealth-programmes-with-scale-in-mind/

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involvement and ownership of the initiative by the government is critical for sustainability and scale.2

minister coll-seck and blaschke advise that government ownership of the program is critical for its sustainability and scale, and that the government should be involved in all the processes. scale can be identified through different indicators: number of people involved, geographic coverage, or percentage of target population. no matter the type of scale desired, cautions blaschke, this cannot be achieved if ownership and sustainability issues haven’t been addressed. it may be possible to scale up an intervention by increasing the numbers of people reached or the geographic coverage, but if it is being driven solely by donor funding there is a risk that the initiative will not con-tinue, despite its success, if the government has not been involved or ownership hasn’t been addressed. this is because there is typically a set timeframe for donor funding, and once project funding ends it would need to be handed over to the government to sustain it. if the government hasn’t made a provision in their budget to finance it themselves and the factors required for national adoption are not in place, the initiative likely won’t be sustained or achieve national scale. therefore, blaschke recommends not relying only on raw numbers or geographic coverage as gauges of scale up, but rather on the government’s capacity and willingness to sustain it as important indicators of sustainability and scale.

to achieve these indicators, minister coll-seck advises partnering with the governments themselves at the beginning of the project and involving them in the development process. she explains the government perspective when being approached for a partner-ship: “as a minister, i would like to see partners that think that what they are doing will be useful for the country.” this is in contrast to using the country to simply pilot the initiative. the im-portance of engaging governments for sustainability, particularly in regulatory environments where policies and laws guiding the implementation of mhealth initiatives are not in place, is further emphasized on page 40 in the recommendation on partnering with the government.

developing and implementing mhealth initiatives in close collab-oration with governments will increase the chances of producing country-led initiatives that meet the needs of their long-term health strategies and are integrated into country health systems. this would drive the sustainability and commitment of the govern-ment to scale mhealth as it is no longer viewed as an independent pilot project, but rather an integrated strategy to support the achievement of national health priorities.

the establishment of a cross-agency committee with the involvement of high-level government officials can steer the scale up of an initiative.

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a critical success factor for achieving scale of an initiative is to ensure the involvement of high-level government officials and securing their buy-in through the establishment of cross-cutting groups or committees across ministries and relevant agencies to coordinate and steer scale up. this is evident in the recent partner-ship charged with putting together a mobile telecommunications component of nigeria’s save one million lives campaign. mechael shares that an interagency advisory group is being convened, which cuts across the ministry of ict, Federal ministry of health, national primary health care development agency, and various public agencies. the advisory group is also engaging the private

sector, such as mnos and multinational corporations, through the business council to ensure all stakeholders have a voice.

mtrac presents another prime example of this. it was appointed an inclusive steering committee by the permanent secretary that comprised the moh, the national medical stores (in charge of distribution of all drugs to government facilities and includes state houses monitoring unit for accountability issues, trans-parency and corruption), along with a number of other external stakeholders. the technical working group that the permanent secretary put in place had representatives from each of the pro-

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avoid building in high human resource, software and hardware costs into the initiative to ensure it can scale.4

careful assessment of hardware, software and human resource requirements and costs can be a good determinant of whether an initiative can be sustainable and achieve scale up. several mobile health projects have provisioned for buying users mo-bile phones as a way to incentivize mobile reporting. blaschke warns that this presents high hardware costs when considering scale, and might set a dangerous precedent if government is not able to support this across the country: “With 100,000 to 200,000 chWs in uganda, the government cannot current-ly provide and manage that many mobile phones for these people. however, when you provide a subset of chWs with phones for a specific project, the rest will begin demanding the same.” equipping chWs with mobile phones can also create distortions in the market and challenges for the moh in carry-ing out its core functions. For example, blaschke notes several instances where chWs were refusing to submit government data because ngos had given them mobile phones to submit their own program data.

For mtrac to scale quickly, uniceF relied on using the per-sonal mobile phones of health Facility workers but ensured they have a free way to communicate, and this worked quite well, according to blaschke: “We use the phones they already own; they will take care of them and ensure these phones are charged.” part of mtrac’s activities required equipping the 112 district level health facilities with computers and internet to access the mtrac dashboard, among other things. managing 112 computers at the district level has already been very difficult with computers breaking down and technical support needed. therefore, equipping health Facility workers and chWs with mobile phones was not feasible if they wanted to quickly scale mtrac across uganda. avoiding equipping health Facility work-ers and chWs, but instead working through their personal mo-bile phones was, therefore, a strategy used to both scale very quickly as well as put in place a system that the government was comfortable taking on and didn’t impose a huge hardware burden that other systems may have required.

gram divisions. therefore, the users of the national malaria control program, surveillance division, pharmacy unit and moh resource center were all represented in the technical working group. these were the primary reasons that mtrac was able to circumnavigate the initial ehealth moratorium in uganda and provided them with space to scale. a lot of other projects run by health development partners using mobile phones would typically go to an individual technical work-ing group within the ministry, or an individual department

and get approval there, according to blaschke. For example, “in the past, the national malaria control program might approve sms tools for collecting malaria data while those in charge of overseeing disease surveillance were not aware of this,” notes blaschke. lack of awareness and agreement across the relevant agencies is an obstacle when it comes to scaling up the program. this can be tackled through the establishment of a cross-agency committee tasked with steering scale of the initiative.

“A critical success factor for achieving scale is to ensure the involvement of high-level government officials and securing their buy-in through the establishment of cross-cutting groups or committees across ministries and relevant agencies to coordinate and steer scale up.”

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05 challenges

challenges

05Several challenges in partnership development and the scale up of mHealth were shared by the experts. This section high-lights the most important challenges identified, with the aim of preparing the reader and raising awareness of the barriers that may arise in partnership-driven scale of mHealth.

Weak national e/mhealth strategies and structures, or lack thereof.

countries often do not present enabling environments for mhealth initiatives due to the lack of electronic or mobile health (e/mhealth) strategies and structures in place to support scale.

an overarching national vision and strategy for the implementation of ehealth and mhealth initiatives and systems within the country is essential to building the success and sustainability of programs. these strategies present clear roadmaps for projects to scale and compatibility with the national information systems. the Who and itu have developed a national ehealth strategy toolkit for this pur-pose, with the precise aim of supporting governments in developing these roadmaps in order to provide strategic direction on e/mhealth to which all projects should be aligned. the toolkit is a practical guide that provides governments, their ministries and stakeholders with a solid foundation and method for the development and im-plementation of a national ehealth vision, action plan and monitor-ing framework.27 Where these national e/mhealth strategies exist, projects that do not align with the strategy risk increased health system fragmentation, reduced local buy-in, lack of interoperabil-ity, shortened lifespan, and reduced impact.28 investment should

be made by the partnership to understand the existing national e/mhealth frameworks, strategies and visions to ensure efforts do not contradict or fall outside these parameters, or risk failure.

Finally, the creation of national infrastructures for ehealth will not only ensure sustainability, but also help accelerate the efforts to scale up, through building both institutional and individual capacity for mhealth. the international society for telemedicine and ehealth developed a basic conceptual framework for ehealth infrastructure that can be implemented in any country, particularly those with a strong central authority in the health sector.29 this framework pre-sents various structures, including an ehealth corps, steering com-mittee, and center/network of excellence, supported by a national ehealth council to provide relevant policy advice to the national government. benefitting from this is an ehealth professional society created to promote knowledge- and information-sharing among ehealth professionals. the creation of these structures could benefit and accelerate the process of scale up among mhealth projects.another challenge is that regulatory frameworks to support mhealth are also not yet in place in many countries, resulting in

27 WHO-ITU National eHealth Strategy Toolkit. (June 2012).28 Payne, J. (March 2013). “The State of Standards and Interoperability for mHealth among Low- and Middle-Income Countries.” mHealth Alliance.29 Kwankam, SY. (1 May 2012). Successful partnerships for international collaboration in e-health: the need for organized national infrastructures. Bull World Health Organ. 2012;90:395–397.

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major delays in implementation. according to blaschke, one major bottleneck making it incredibly difficult for uniceF or, particularly, smaller ngos to set up projects similar to mtrac, is the incredibly time intensive process of negotiations with telecoms. in many countries, negotiations must be done di-

rectly with the telecoms as there are no third-party aggrega-tors that will do the negotiations on the partnership’s behalf. blaschke supported similar direct negotiations in malawi and rwanda, which took between six months and one year to resolve.

building partnerships in the absence of a national e/mhealth strategy or vision is incredibly difficult. to highlight the importance of this issue, blaschke performed a brief map-ping of uganda’s mobile health pilots two years ago before a national e/mhealth strategy was being developed, through which he identified several instances of duplication, including at least five projects creating unique patient identifiers and collecting patient records, with little or no coordination from the government side. this prompted uniceF to advocate for a greater coordination role by the ugandan ministry of health (moh). the moh articulated that ehealth shouldn’t

simply be relegated to the realm of information technology, as it was cross-cutting and impacted all of their programs. in december 2011, the director general instituted an immediate ehealth moratorium on all existing and proposed ehealth projects to give the ministry some time to come up with an ehealth vision and strategy. this moratorium has not yet been lifted, however the ministry is moving quickly to devel-op their ehealth strategy. two projects have been approved for national scale up: dhis2 and mtrac, which uses a locally branded version of the open-source rapidsms framework widely used across the developing world.

CASE EXAMPLE: THE EHEALTH MORATORIUM IN UGANdA

lack of standards supporting interoperability and technology integration.

the majority of governments have not yet decided which technologies should address which health issues in a sys-tematic and strategic way. mechael notes that oftentimes multiple systems are doing different things with different data standards and are not integrated with each other so they can not seamlessly move or track information from one system to another, even within the same health facility. the current lack of health informatics standards and frameworks allowing technological integration and interoperability among mhealth solutions is a particular challenge to the meaningful use of icts for health at scale cited by implementing organizations.30 the lack of national e/mhealth strategies typically means lack of standards and country-specific frameworks to guide sustainable mhealth interventions. Without these standards

and frameworks in place, the movement and integration of health data will be limited, thereby preventing the continuity of care across providers, time and institutions, according to a new report on the state of standards and interoperability in low- and middle-income countries by the mhealth alliance31. this report advocates that donors, technology providers, and most importantly governments, play a key role in transition-ing towards promoting interoperability and supporting the development of standards covering privacy, security of data, etc. governments can be the biggest contributors to this by setting up regulatory mechanisms to support the shift of market dynamics towards incentivizing interoperability and reducing the benefits associated with using proprietary or non-interoperable systems.

30 Mechael, P. et al. (2010). “Barriers and Gaps Affecting mHealth in Low and Middle Income Countries.” Policy White Paper. New York, Columbia University.31 Payne, J. (March 2013). “The State of Standards and Interoperability for mHealth among Low- and Middle-Income Countries.” mHealth Alliance.

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different sets of challenges arise when scaling across countries versus within a country

technology as a disruptive force

Working with different sectors can present conflicts in organizational cultures and operational structures.

partnerships face completely different sets of challenges when looking to scale across countries versus within a country. these different sets of challenges have not yet been adequately addressed within the international mhealth community.

an example of this is the case of ureport. according to blaschke, their initial strategy was to set up a version of ureport in every country. however, uniceF quickly realized that maintaining this type of scale up from a technical standpoint was too heavy a burden as they would

have to hire software teams in every country. another challenge with scaling technologies to different countries is that systems typically become their own versions over time as they adapt to local contexts. supporting this type of diversification in the technology is increasingly difficult. uniceF is now exploring centrally hosting ureport as a web-based service. another example is the replication of programme mwa-na, which was launched in Zambia and malawi a few years ago, and already the two software sets are no longer the same. how can a tool be successfully scaled in one country and then replicated in another?

mobile health initiatives can face barriers to uptake, particularly within governments, due to the perception of mobile technology as a disruptive force, presenting new forms of use and processes with-in healthcare. blaschke suggests minimizing technology disruption by building mhealth solutions around existing interventions or data sources already in use by the government in order to improve their processes. as described in the case example on page 50, mtrac was built based on an existing data source – a weekly surveillance form within the hmis being used by the ministry of health – and

applied mobile technology to solve challenges to processes related to distance and communication. the only factor that changed was how information was being moved. after initial interviews, uniceF discovered that even this didn’t change much as people were already using their mobile phones to send in data via sms or phone calls. mtrac therefore presented a way to move the flow of information from the grey market into the mainstream by formaliz-ing the use of mobile phones with regards to sending information to the hmis.

njogu highlights that working with different sectors can mean differences in modes of operations, timelines, expectations, and targets, and thereby present conflicts if not addressed early on.

With regards to Kimmnchip, “each partner was pulling from different directions,” says njogu. safaricom comes from a very commercial per-spective and requires a shorter timeline when implementing projects and achieving results. non-profits place more importance on studying

and designing the intervention, thereby requiring a longer timeline. according to njogu, this was strange to encounter as an mno. “We had to find a middle ground where each partner stated what they wanted or needed, and what timelines we were looking at.” safaricom realized they had to slow down while the non-profit partners realized they had to move more quickly on safaricom’s behalf.

another challenge that arose was the differences in requirements for

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Funders remain focused on technology and innovation, rather than sustainability, coordination, scale up and necessary partnership processes.

proceeding with the project. For mnos, if there is a business case they will move forward. if there is demonstrable social impact, safaricom can use its own resources to invest in a program. ac-cording to njogu, “if there is social impact, eventually the business case will follow. this was the case with m-pesa.” it was originally developed as a “stickiness” product (to increase customer loyalty) because it was beneficial for safaricom users, but now it is one of their largest revenue streams. this is the same circumstance for their mhealth work: the revenue is not very high in the beginning as it is not the most lucrative service, however the social impact is significant. in working with non-profits, they can only move for-

ward if there is adequate funding or certain bureaucratic require-ments in place, which imposes different timelines and modes of operation on the project.

dossal cautions that another significant challenge in partner-ships across sectors is that each party tends to come with the preconceived notion that they have the right solution to the problem. lack of an open mindset and a collaborative approach to designing the solution breeds mistrust and wariness among the partners. dossal recommends that attitudinal change should take place to ensure a collective solution is identified.

the experience in programme mwana has been that the focus of funders and sponsors remains on technology and application development. organizations and partnerships more importantly need co-investing in processes to build inter-organizational relationships across government, private, ngo and civil society

sectors. donors should move away from only funding innova-tive new projects, i.e. pilots, towards funding the scale up of programs, identifying sustainable models of financing and the coordination of activities. For more on this point, see the pro-gramme mwana case example on page 59.

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conclUsion

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partnerships present a strong mechanism for supporting and even driving the scale up of mhealth in developing country contexts through the combination of complementary core competencies, expertise, resources and networks of partners directed towards this common goal. partnership development in the field of mhealth typically brings together diverse actors, including global health and development actors, private sector technology providers and government agencies, and is still a nascent process lacking an established evidence-base of best practices to follow. partnerships in mhealth present complex processes of coordination and collab-oration among actors with potentially conflicting organizational cultures, modes of operations and missions. to develop an effective partnership that is able to achieve scale, several key elements are recommended in the different phases of partnership development to ensure the implementation of a partnership mhealth initiative that can reach scale.

this report presents case studies of partnership initiatives currently scaling up or in the process of achieving scale to exemplify various factors that are key for scale up, followed by sets of recommenda-tions for each phase of partnership development. essential ele-ments within the first phase, which covers building the partnership, include an in-depth and thorough landscape analysis, an inclusive multi-stakeholder partnership approach, credibility of the partner-ship broker, strategic alignment and commitment among the poten-tial partners and a compelling partnership proposal incorporating scale. the second phase covers partnership implementation. the

recommended strategies for this phase include taking into consid-eration differing organizational cultures and compromising to work together, implementing strong governance structures, collaborating on project design for scale, setting realistic targets and expecta-tions, and possessing an awareness of risks and rewards involved in partnering. sustaining the partnership is the third phase outlined in the report, with the following recommended strategies: employ a strong communication strategy, build trust and minimize human resource obstacles, implement a broad monitoring and evaluation strategy, maintain the flexibility and adaptability of the partnership and initiative. the final phase of partnership development covered in this report looks at partnership-driven scale of mhealth and identifies four recommendations, including building a smart model designed for scale, ensuring government ownership and involve-ment, establishing a cross-agency committee to steer national scale up, and avoiding high human resource and technology costs which can present barriers to scale and sustainability.

though the field of mhealth is rapidly expanding, the structures needed to guide interoperability and ensure security around data are still not in place in many countries due to the lack of national e/mhealth strategies, regulations and standards. For this reason, many challenges still exist presenting barriers to ensuring scale up. however, this should not deter partnering organizations. strong collaboration among different sectors through partnerships can support and accelerate the building of an enabling environment for the scale up of mhealth.

this report presents case studies of partnership initiatives currently scaling up to exemplify various factors that con-tribute to achieving scale, followed by sets of recommenda-tions for each phase of partnership development.”

“

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With operational offices located in the centerpiece West Africa, Mali, Advanced De-velopment for Africa (ADA) is an African-based non-profit organization with its major focus on fostering maternal and child health in Africa. ADA seeks to accomplish its mission through proven methods of capacity building, technology transfer, forums, and cross cutting-sector partnerships that move forward the following goals:

• Improving maternal and child health and reducing the disease burden on the population, especially the Millennium Development Goals (MDGs 4, 5 and 6);

• To promote educational excellence by giving youth the opportunity to receive training through Information & Communication Technology and virtual learning;

• To boost gender equality and empower women by giving them the right tools and equal opportunities for education;

• To combat HIV/AIDS, malaria and other diseases.

ABOUT ADAADA’s main objectives are to act as a driving engine to accelerate the scale of sustainable development in Africa through complementing traditional development pro-grams with innovative technologies, particularly ICTs, to contribute to achieving the MDGs.

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SCALING UP MOBILE HEALTH:

AdvANCEd dEvELOPMENT fOr AfrICA (AdA)2 Rue des Granges,1204 Geneva, SwitzerlandPhone: +41 79 644 22 85www.adaorganization.org

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