5 Thoughts from Day 2

First, as I sit here in Day 2, let me say that the mHealth Summit could possibly be the best conference I’ve ever attended.  I am use the the academic setting, where you have people talk at you.  Here, every session, both large and small, is a panel conversation with diverse panelists and participant Q&A. 

The session from “Lessons learned across the globe” was an excellent session, if you watch one session, watch this one.  Here is are some thoughts put forth:

Thought 1:  mhealth in the developed world is about improving the efficiency of the system.   In the developing world mhealth is about improving access to health care.

Thought 2:  Technology isn’t the issue in mhealth.  The technology is there and it’s the simplest, cheapest $5  phone that people own.  Yes, this means that smart phones are not the solution in the developing world.  Even as android the prices drop below $100, this still not approachale for most people.

Thought 3:  That said, the solution should be technology agnositic, with a systems approach that can utlize incoorperate the basic and smart phones for different solutions in different settings.  “Let a thousand flowers bloom.” 

Thought 4: Community buy-in is key.  Multiple panelist have indicated the need for social science research in assessing the community needs , perceptions, values. 

Thought 5:  There are thousands of pilot project going on, but very few scalable and sustainable projects in mhealth.  When the money runs out for these pilots, may ideas will die.   This goes back to what I wrote about yesterday with mobile applications being in their infancy.  It also highlights the need for an open source and open communication so work from various efforts can be built upon or combined.

9 Applications of mhealth from Day 1

9. PDA for providers. The idea is to get medical information in the hands of providers – anyone from a family care physician in the bush who needs to look at a pharmacopia, medical guidelines or academic literature on the PDA, to a Maternal Health specialist aiding in a birth.

8. Patient finanical account. With a specific account number, a text can be sent to someone’s account so that they can receive health care.

7. Cell psurvey tool in recent household survey identifying pregnant women

6. Birth registration. In Kenya, villiage chiefs were given either a cell phone or minutes on their existing phone to call with village births, including still births.

5 “Core patient record.” Many of you will be familiar with how medical records are kept on cards that patients take with them in the developing world. The idea here is to provide a patient record that is downloadable in the field, and where information can be added to and uploaded.

4. Up-to-date CD4 Counts. Similarly to the idea behind the core patient record, there is a significant need to have an accurate CD4 count when providing care for people living with HIV.

3. Data gathering tool for decision makers. An example was seen in earthquake in Haiti, where cell phones were used to send and receive information in order to allocate resources to the proper places.

2. Money transfer. While not specifically medical, the lives of many Kenyans are being transformed by an innovative mobile phone money transfer service. M-Pesa is offered by Safaricom Kenya, has a monoply on the money transfer market. Along these lines, tranfering money to community health workers for bus fairs for patients with fistulas and cleft lips. CHW gets incentive of $3.5 once the patient comes in with the specific bus ticket receipt and the CHWs name. A simple solution that was hugely popular, helping many women long past childbearing years

1 . Text4baby. This is Health and Human Services’ mhealth poster child. It is a free mobile information service designed to promote maternal and child health that boast 98,000 users to date.

The Vision of mHealth

Note: The conference is being telecasted online, and questions can be sent in for the main sessions via twitter.


There were several key take always from the first session on the Impact and Future Vision of mHealth.   The first was that mobile applications in health are still in its infancy internationally, but also domestically.  To date, there have been various efforts domestically, such has the electronic medical records (EMR), that have had mixed results.  For example, even with the best EMRs, physicians are infamous for entering data poorly or not at all.  Additionally, system structures and databases are proprietary and often incompatible with competing EMRs.

This weakness appears to be well known, as one of the main strategies that I heard from more than one speaker is the idea of open architecture.  One of the speakers, Deborah Estrin, a professor at UCLA, had a recent article on mHealth open architecture.  What this means is that software has code that is available that can be added to, or upgraded.  

Another take away is that, while there are more cell users in Africa now than North America, the statistic was shared that over 50% of people over 45 years old have never sent or received a SMS text message.  Given this, mobile solutions may be only applicable to a narrow portion of the global population.    Additionally, with 50-60% of the world being illiterate, visual and graphic alternatives to text-based communication need to be developed.  

The last take away is that there is currently more health data than we know what to do with.  I believe the term “massive amounts of data” was used multiple times.  Mobile phones are only adding to the data capture.  Given this, efficient databases and user interfaces that best allow users to access data are needed.  Addtionally, with “massive amounts of data” there is a significant problems in analysis.

Live Blogging from the mHealth Summit

I am in Washington D.C. and will be blogging live from the mHealth Summit.  For those of you who do not know, the “m” in mHealth stands for mobile.  So the conference is looking at how mobile applications can impact and improve health care.  Surprisingly but gladly, there is a significant international component to the conference.   While the conference is focused on health care, I am here in hopes of “cross pollination” with an eye towards applying what is said and learned toward the philanthropic sector.  Stay tuned.

The Metrics Behind No Child Left Behind

Stay tuned.  An article on the NCLB metrics is on its way

Photos from the field: Burundi Survey

Burundian Child Taking the Survey

Burundian Classroom

Here are photos from our recent neglected tropical disease survey on primary school children in Burundi.

Qualitative Research Methods Utilized in Burundi Survey

By Mara J. Roberts

As we mentioned back in June, we recently were contracted to measure the impact of a Neglected Tropical Disease program in Burundi.  The client had measured the medical benefits of the de-worming program, but wanted to know the social benefits that resulted from the de-worming.  Were more children going to school? Were communities being empowered?  The difficult part of accomplishing this task was that the three year program had already concluded.

Because of the retrospective nature of the assessment, we decided to employ a mixed mode approach that blended both quantitative and qualitative methods. We utilized quantitative methods to measure things like body mass index, literacy and cognitive development. From our literature review, this was likely the first assessment of literacy and cognitive development on primary school children (ages 10-19) undertaken there.  We also used a cluster sample in two stages to 1) randomly select which schools would participate in the survey, and 2) to randomly select which students at these schools would take the survey. The sample was stratified by both geography and gender.

The qualitative methods included an arts based approach through student drawings.  Students were asked to create two drawings: 1) what the life was like before the medications and 2) what life was like after the medications.    Then, through the iterative process known in qualitative research circles as Action Research, we determined how the NTD program impacted students’ access to education.  This Action Research process is comprised of three steps: look, think, and act. These iterative stages formed an “adaptive” or “dynamic” process where the results and conclusions from one stage was the basis for how the questions and design for the next stage was determined. 

Action Research Process for the Burundi Survey

Given the results from the drawings, we looked at how the school enrollment and standardized test scores at the primary schools in the survey had changed over the course of the de-worming program by obtaining this information from the school headmasters.  The last step in this iterative process was to survey a sample of teachers to assess their opinions on the connection between the improved health of the students as a result of the NTD program and the change in enrollment and test scores. 

While the preferred method for evaluating the social impact of the NTD program in Burundi would have been a randomized control trial, the use of a mixed mode survey, given the retrospective nature of the project, proved to be a valuable tool in the assessment process.

SMS Used to Monitor Burundi Election Violence

By Mara J. Roberts

The series of elections in Burundi ended in July with president Nkurunziza, being reelected to a second term.  New Dominion Philanthropy Metrics implemented a pilot surveillance system to examine the ability of SMS texting to be utilized in monitoring the election-related violence.   Nine different districts were randomly selected throughout the country to gauge the number of violent acts reported due to the elections.  Our hypothesis was that SMS texting would be an ideal surveillance tool because it is readily available even in remote areas of Burundi.  If successful, this system could be replicated in other African nations. 

Two primary school teachers of different tribes were select in each district.  Many of these schools function as community centers where information is exchanged and where networking occurs.   Each person was sent questions through SMS asking about any election-related violence they saw, experienced or heard about indirectly either  preceding or during the presidential election.

Two people who originally elected to be a part of  the conflict surveillance later decided not to participate due to concerns for their personal safety.  Of the remaining sixteen, 44% said that they personally experienced or saw violence due to the election.  Additionally, 50% heard of, on average, two election related acts of violence occurring within their districts.  Between the two questions, election related violence was reported in eight of the nine districts that were included in the surveillance. 

A post-election survey was sent to participants of the surveillance asking them their thoughts on the election.  Most interestingly, 88% indicated that they did not believe the outcomes of the various elections.  But yet 94% reported that they were satisfied with the presidential election. 

 Overall, the results of the pilot surveillance indicated a low level of violence related to the election, which was validated through various media reports coming out of the country.  The use of SMS texting in the surveillance worked well, though not perfectly.  Since most rural areas are without electricity, cell phones were not kept on all the time.  Because of this, there was a lag of several days from when the messages were sent and when they were delivered.  Additionally, we noted that cell phones are utilized in a very selective way due to the cost incurred.  This is especially true in the context of Burundi where 93% of the population lives on under $2 per day.  Knowing this, we incentivized individuals 7.5 USD to participate and cover any costs that were incurred.  Providing such incentives may not be desirable or even possible in all contexts.

Burundi in Crisis: Election Violence and Democracy in Question

By Mara J. Roberts

The small country of Burundi had its presidential election today – only the second election since the county’s civil war ended in 2004.  Burundi is a little-known country surrounded by highly visible neighbors—Rwanda to the north, the Congo to the west, and Tanzania to the southeast.  Yet the success or failure of Burundi’s elections could have far-reaching consequences for the region.  If the post-election period is peaceful, Burundi could set the tone for other East African countries slated to hold elections in the next eight months.  Conversely, if the post-election period sees violence, Burundi may saddle its neighbors with yet another wave of refugees.  During Burundi’s 13-year civil war, 200,000 refugees sought sanctuary in Tanzania and other neighboring states.  Over 50,000 of those only returned to Burundi this year.  A peaceful election at this juncture is critical to the development and stability of the small nation.  Sadly, early post-election reports from Burundi are not optimistic.  The only candidate on the Burundian ballot was the incumbent, Nkurunziza, and voter turn-out was low, thanks to a boycott by the opposition and persistent fears of violence, which materialized in grenade attacks across the country.  Though it is too soon to reach any conclusions, all indicators suggest that the government in Burundi is in crisis.  For Burundi to achieve true democracy, it must not only assure the peaceful transition of power, but it must also encourage a well-rounded ballot with diverse candidates and a high voter turn-out among its citizens.  Today’s election suggests that these reforms may be years away.

The Importance of Evaluation

Abhijit Banerjee, co-founder of the MIT Poverty Action Lab, expresses the need for and value of proper evaluation in a recent article:

“Politicians prefer not to be told that they need to wait three years before they can launch their flagship programme; journalists prefer stories about grand successes to qualified endorsements; donors want to eliminate poverty today, and being told that we don’t know how to, puts a pall on the proceedings. But in the end these are our resources that are being wasted, our hopes that are being betrayed. And all these people are meant to be our agents. We have to convince them that we want evidence rather than emotions, measured success rather than failed miracles, trial rather than error.”

Here, Banerjee refers to the example of the promotion of micro-finance projects in development circles and the recent research concluding that their benefits were not as great as anticipated.  His point is that a method needs to be evaluated before it is whole heartedly endorsed.  Similarly, in the field of HIV/AIDS, billions of dollars are being spent on prevention education with no evaluation of its benefits. Unlike the micro-finance example, measurement tools need to be created in order to evaluate how participant’s knowledge and attitudes change as a result of the education. Read about our continued work in creating these measurement tools using Item Response Theory.