mHealth Implementation Opportunities, Issues, and Challenges Related to Family Planning and Reproductive Health mHealth Summit December 5, 2012 Washington, D.C.

Welcome and Introductions Everything depends upon execution; having just a vision is no solution. - Stephen Sondheim

Why Is mHealth Important? Mobile phone subscriptions (per 100 people) Growth (%) Low income countries Middle income countries High income countries Growth of mobile phone subscriptions (Source: World Bank and International Telecommunication Union 2012)

1st Generation Projects Established Usability (Source: GSMA 2012)

1 st Versus 2 nd Generation Programs Voice Text GPS Music Video Internet Apps

Categories of mHealth Programs 1. Client-centered – m4RH – CycleTel 2. Health system strengthening – CommCare platform – ILS Gateway

What is the Impact of mHealth? 1.Evidence on client-centered programs o Text message programs have high acceptability and may be effective for behavior change 2.Evidence on health system strengthening programs is sparse and still emerging o Improved treatment compliance by health workers o Supply change management o More efficient delivery of community health services (Sources: Deglise 2012, Cole-Lewis 2010, Gurman 2012, Horvath 2012, de Tolly 2012, Gold 2010, Florez-Arrango 2011, Zurovac 2012, Barrington 2010, Lemay 2012, L’Engle et al. 2012, Castano et al )

Peer Reviewed Evidence on mHealth for Family Planning Knowledge for Health (Malawi) o SMS, phone calls are 4 times cheaper and 134 times more efficient than traveling to talk with supervisors Mobile for Reproductive Health (Tanzania) o FP information can be delivered via mobile phone to different population segments o Has potential to impact contraceptive use Effect of daily SMS on OCP continuation (USA) o At six months, women in intervention group were significantly more likely to continue OCPs (Sources: Lemay 2012, L’Engle et al. 2012, Castano et al )

Evidence on mHealth for Other Topics SEXINFO (USA) o Text messaging is an acceptable way for youths to receive information and service referrals Mobile technologies improve adherence to ART in Africa (Kenya, WelTel Kenya) Wired Mothers (Zanzibar) o SMS reminders increased skilled delivery attendance Effect of mobile phone reminders on health workers’ adherence to malaria treatment guidelines (Kenya) o SMS reminders improved malaria case management (Sources: Levine et al. 2012, Pop-Eleches et al. 2012, Lester et al. 2012, Lund et al. 2012, Zurovac et al )

Evidence on mHealth for Other Topics Mobile rich media job aids for CHWs (Columbia) o Rich media clinical guidelines reduces CHW errors SMS for life (Tanzania) o SMS reporting reduced stock-outs of anti-malarials Impact of mhealth intervention for peer health workers on AIDS care in rural Uganda o Reporting on patient-specific clinical information showed no improvement in outcomes (Sources: Florez-Arrango et al. 2011, Barrinton et al. 2010, Chang et al. 2011) (continued)

Moving Forward: Priorities for mHealth Research Rigorous evidence and best practices are needed for: Impact of mhealth on clinical and behavioral outcomes Cost effectiveness and cost benefits of mhealth tools Influence of mhealth on the wider healthcare system, particularly at scale Conditions for and enablers of successful scale-up of mhealth (Source: GSMA 2012.)

Considerations for Implementing mHealth From published and gray literature and interviews with 18 mhealth experts (primarily FP) Guidance for five components of mhealth implementation 1.Planning and design 2.Technological considerations 3.Scale-up 4.Sustainability 5.Evaluation Family planning is “seed” focus but information is applicable across health and development areas

1. mHealth Planning and Design Determine if the proposed mhealth solution is appropriate for the context Is the health issue driving the solution (rather than the technology itself)? Is the technology solution appropriate for the setting? Is program design guided by evidence? Is program content based on international or national guidelines? Are local stakeholders supportive and involved? Are end-users involved in design and testing? Is there a monitoring and evaluation plan?

2. mHealth Technology Considerations Determine how the proposed project will work with existing technology, infrastructure and capacity Clear communication between program staff and the technology partner is critical. What tools need to be developed, and what existing open- source tools can be used? What is the local technology capacity to support the project? To what extent will existing regulations and policies enable the project? What is the extent of end-users’ familiarity with technology?

3. Scaling-Up mHealth Determine the project’s potential for scale-up Barriers to scale-up include limitations of funding, lack of evaluation, and absence of standardized indicators To what extent is the solution accessible to a wider audience and adaptable to other sociocultural contexts? What are the potential cost-efficiencies of going to scale? What is the technology capacity to support scale-up? How might the scaled program contribute to additional health and/or development issues and national mhealth goals?

4. Sustainability of mHealth Consider the accessibility of resources for the long- term operation of the project What is the potential value added for private sector support? Will the evidence generated by the project justify continued funding? Does the project use cost-effective technologies or open- source systems? What is the plan for building local capacity to maintain and develop state-of-the-art solutions?

5. Evaluation of mHealth Assess the potential contribution of evidence generated by this project How does the project incorporate M&E indicators to meet stakeholder requirements? Are project data leveraged for evaluation and reporting? Does the project measure health outcomes and/or influences on the health system? Does the project measure costs of implementation or include cost-benefit analyses? Does the project use standardized mhealth indicators?

Round Table Set-Up Two rounds of discussion Choose your topic Planning and design Technological considerations Scale-up Sustainability Evaluation Appoint a note taker for main points Spend 30 minutes in roundtable discussion Report out and discussion

Round Table Discussion Questions A.Experience and Challenges 1.What is your experience with this topic? 2.What barriers or obstacles have you faced in this area? B.Addressing Challenges 1.How have you seen these barriers successfully addressed? 2.What other ideas do you have about removing or overcoming these barriers? C.Help and Resources 1.Are there specific tools or resources that would be helpful? 2.What needs to happen next to implement these ideas?

Vote With Your Feet - 1 What’s Your Opinion? Phones: Do you give or not give mobile phones to health workers? Local versus global: Is a local technology partner essential?

Vote With Your Feet - 2 What’s Your Opinion? Should mHealth programs be designed for scale from the beginning? Money: Should mHealth users pay for the service? Technology: Use existing applications or have yours custom designed for the program?

Round Table #2 Choose your topic Planning and design Technological considerations Scale-up Sustainability Evaluation Appoint a note taker for main points Spend 30 minutes in roundtable discussion Report out and discussion

Next Steps/ Conclusions Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.

Acknowledgements Many thanks to: USAID The mHealth Working Group Knowledge for Health PROGRESS Contacts: Laura Raney: Kelly L’Engle: