By Oscar Abello
When something “just works”, there’s usually a mini-universe of people, technology and ideas behind it that the rest of us take for granted. Take bar codes for example; they’re ubiquitous, and serve multiple uses for every stage of a product’s manufacture and eventual sale. The tale behind them is an astounding story of vision, foresight, technological progress and, perhaps most importantly, the appropriate wrangling of partners that started with grocers and eventually cut across every industry.
Right now, something is brewing in global health that could transform the way it works just as bar codes transformed retail sales in the 20th century. It’s emerging from the global health experiences of a broad array of partners, drawn from NGOs as well as donor foundations, bilateral aid organizations, corporations and national governments.
Impact spoke with Trip Allport, who leads the work of Accenture Development Partnerships in the Africa region, about this vision for a cross-organizational, cross-sectoral, multi-audience platform that would provide key knowledge and information for health workers and consumers on the front-end, and data on the back-end to inform decisions and daily workflow for supervisors, supply-chain managers, ministries of health, implementers and donors.
Impact Magazine: What is your vision of this? What are we talking about here?
Trip Allport: We’re talking about building an integrated mobile health platform that performs a wide range of services and training for community health workers, which will drive greater impact on the ground. There are so many mobile phone-based solutions out there, some of them redundant but some of them very complementary, and beyond just sticking them together on a phone, can we have them really work hand-in-hand for greatest impact at the community health system level—among health workers and their supervisors, or even clients themselves? For instance how does data collection via mobile phones then influence stocks of medicine available in a given geographic area? And can that same data also influence what training community health workers can access quickly if suddenly there’s an outbreak of malaria or Ebola in a new area—how do we make sure health workers in that area then have ready access to a module customized for them on symptoms and response? That’s where we see this going. We want to collaborate across the public, private, and development sectors to build such a platform and deploy it. It’ll have to have a sustainable value proposition for all implementers that work with Ministries of Health in Africa, to ensure consistency in quality and cost-efficiency. And we want to work collaboratively to innovate solutions on that platform, bringing together expertise, learnings, applications, services and resources from multiple organizations to contribute to its ongoing development.
IM: How did Accenture become such a big believer in mobile phones as a way to support community health workers?
TA: 97 percent of community health workers have a mobile phone, according to studies we found. So they have a means of communication, a channel by which they could reach potential help and tools, but almost 70 percent of those are on very basic mobile phones.
These are front line health workers, right at the community level, going house-to-house, trying to support the improvement of health, and in my view could be a major factor because of the lack of doctors and other more formal health workers. If they’re properly supported, not only could they improve existing health, they could also get even more into prevention and keeping people from overburdening already under-resourced health systems.
Since so many have access to basic mobile phones, together with our partners at AMREF and the M-PESA Foundation we decided to figure out how to provide training and tools over that very basic technology, including SMS and interactive voice response. We ended up calling that our mobile pedagogy—we took the Ministry of Health curriculum, and along with AMREF and a series of partners, we were able to break down the content into bits and bites that could be delivered through a basic mobile phone. We needed to understand how much of this content could we move from the classroom or face-to-face training and put on the mobile phone, ultimately getting to a situation where we could take the ten day curriculum and bring it down to five days. That’s a significant savings from a cost point of view and also allows us to do double the training with the same amount of resources, including time. In the end, that delivery system became what’s now called our Health Empowerment and Learning Platform, or HELP.
IM: And there were good results cramming the curriculum into mobile phone based format?
TA: To me the secret sauce isn’t the technology. It’s the pedagogy—finding ways to channel content in a way that simulates the learning that would otherwise be face-to-face and doing it in a more efficient and cost-effective way. What we ended up seeing is we picked three different sites as dictated by the ministry of health—one rural, one urban, and one nomadic setting—to test our solution across very different population groups. We worked with a total of 300 community health workers and 18 of their supervisors across those three areas. The end result after doing about a three-month pilot at each of the three areas was we had something on the order of 80 percent completion rate. On a baseline study of the original training, we found that knowledge retained was somewhere on the order of 50-60 percent, and HELP ended up having a knowledge retention rate of somewhere around 75 percent or higher. We had very high satisfaction rates, and while it’s hard to really measure attrition in a three-month trial period, at least in terms of retaining knowledge we can see community health workers were more equipped to support health at the community level.
IM: Then how do you jump from just a learning platform to something much broader?
TA: There is a need for around 200,000 community health workers in Kenya alone. The fact that they’re volunteers also begs the question how do we find other forms of non-financial incentives and motivators. We saw through a baseline study there was up to 70 percent attrition so even those who were getting trained, getting that experience, at that rate of attrition you would never be able to keep up with training needs. We started to think about how could we motivate people, empower them in their jobs, or at least make the work more enjoyable and take away some of the stress and strain that volunteers must feel when they go into their community and face challenges they don’t necessarily have the tools to solve. That’s the challenge that we saw.
Where this conversation gets really interesting is where do we go from here. The biggest questions in mHealth [using mobile phone technology in healthcare] really are around how do we get things to scale, how do we sustain them. Ultimately this is about the community health worker and their supervisors, how do we ensure that that tool that we provide is there consistently over time, and as the health worker matures how do we make sure they can rely on this tool that they’ve become accustomed to. How do we ensure that the content and anything else we provide over it is of the highest quality, up to appropriate standards, approved by the ministry of health and so on. There’s a symptom of “pilotitis” in global health where too many solutions come out, driven by a program, and they fizzle out once the funding dries up and you end up with different solutions doing different things that are very siloed—one doing HIV, another doing malaria or what have you—very siloed solutions with different methodologies, different partners.
IM: So how close are we to getting all those modules to play together? Where is the process right now?
TA: What we’re now looking at, in series of discussions with private sector partners, donors, multilaterals, and many NGOs, is having a wide ranging dialogue to capture input and feedback from the diverse range of stakeholders in this sector. We are trying to get a real sense of what the needs and requirements would be to not only drive real impact on the ground, but work collaboratively together to make it happen. The M-PESA Foundation and Accenture Foundation deserve recognition for supporting this programme and partnership, and allowing the implementing partners to explore different approaches and ideas with these stakeholders to figure out what is really needed, and design and build to that.
IM: How do you get all these varied players on board?
TA: We quite frankly asked the question of how can we stop these problems of duplication, of pilotitis, multiple mobile solutions going out into the world that don’t necessarily reach scale. It was also a discussion about how to get everyone to play together—to leverage a common platform. If we could, it would be a much smoother and efficient way to get to scale. We want to see this common platform used by all the biggest implementers in the world. So how do you get a Save the Children, an AMREF, a World Vision to work together? That was one of the goals of this London workshop. What we were able to do was to lay out the challenge that we’re all facing, and to get us to all agree that the way we’re working today is not going to work. It doesn’t work. We need to try something radically different.
We had all the donors get up to lay out all these challenges from their perspective that innovative typically means new, but new is not always better. New can end up meaning we just keep trying over and over again and realistically, we’re all trying to solve roughly the same challenge in community healthcare in Africa, so presumably there’s a different and better way using a common platform to which we all contribute?. So we had a great session where the major donors outlined a new vision and paradigm to encourage greater collaboration, which was encouraging for all the implementers to hear and set the stage for continued dialogue thereafter. Donors in the room really encouraged the idea that many of the biggest implementers come together with the Ministry of Health in various countries in Africa to work together on a common platform to get to real scale, and they may in the future be able to support such an expansion if the theory proves out.. So having a common understanding of the challenge, a common understanding of where the industry is going from a donor and funding point of view, I think laid the groundwork for us to say okay, now let’s collaborate, let’s build off this solution.
IM: Do you foresee any non-technological obstacles to bringing all these solutions into a single platform? Political opposition?
TA: There is a concern on the part of ministries of health to sign up to any one solution—there’s always questions of what if they get stuck with it, should the ministry of health be backing one solution, which often leaves them stalled. So to mitigate that, what if Save the Children and CARE and AMREF went together to them and said look, we’re already your largest implementing partners, we’re committed to working together to provide high-quality, consistent delivery of health worker training on a common platform of your national curriculum all across the country. I am optimistic that we will then be able to have full ministry of health support, donor support, to allow that scale in a way that we have very rarely seen in the mHealth space. I’m not suggesting this will be easy, but it is worth us trying and learning together and seeing if we can finally crack the code on the scale problem. Will there be challenges in working together – absolutely. But with the right set of like-minded partners, I’m sure we can prove out a model and do something really special together for community health in Africa.
IM: So what then? What’s at stake here for community health workers and for the communities they serve?
TA: Measuring the health outcome is of course very difficult—lives saved, improvements of health are hard to measure, as everyone knows. But if we can see the performance of the learning and we can see they’ve taken the courses and their supervisors remind them and monitor their progress, and they’re communicating among themselves to ask questions and use that new lifeline for help, that means a lot in our theory of change for better health. There’s an internal messaging system in HELP, similar to WhatsApp, and we’ve seen some the messages they send to each other and to supervisors asking each other for help – its incredible the power of knowledge and communication at that level and what it is doing to save lives. If the supervisor can see what’s going on in the community and can see the data, they can share that with the ministry and everyone can respond more efficiently. Learning and productivity tools lead to greater knowledge, preparedness and empowerment for health workers, and for us the signs of change and strengthening at the community level are very encouraging.
For donors and implementers too, there’s a lot at stake. Working together also means we can learn from each other. Different countries, different contexts, different experiences—if we can bring all that together and have open innovation where we’re not each developing a solution and nobody owns a specific instance of it but rather any features, new content, new customizations get fed back into the same system, in time I think we’re going to see a solution backed by a coalition that is unlike anything the world has seen to date – and so we will try, and we hope other partners and implementers will join us.
Photo credit: Margaret Kareithi