Mhealth Specialedition 16may2016 Webv

mHEALTH
COMPENDIUM
SPECIAL EDITION 2016:
REACHING SCALE
May 2016
This publication was produced for review by
the United States Agency for International
Development. It was prepared by the
African Strategies for Health (ASH) project
implemented by Management Sciences
for Health (MSH).
Cover photo, Nigerian mother and child, by Gwenn Dubourthoumie.
mHEALTH COMPENDIUM
SPECIAL EDITION 2016:
REACHING SCALE
The authors views expressed in this publication do not

necessarily reflect the views of the United States Agency for
International Development or the United States Government.
The African Strategies for Health (ASH) project is a five-year project funded by
the United Stated Agency for International Development (USAID) and implemented by Management Sciences for Health (MSH). ASH works to improve the
health status of populations across Africa through identifying and advocating for
best practices, enhancing technical capacity, and engaging African regional institutions to address health issues in a sustainable manner. ASH provides information on trends and developments in the continent to USAID and other development partners to enhance decision-making regarding investments in health.
May 2016
This document was submitted by the African Strategies for Health project
to the United States Agency for International Development under
USAID Contract No. AID-OAA-C-II-0016.
Recommended Citation: Sherri Haas. May 2016. mHealth Compendium, Special Edition 2016: Reaching Scale. Arlington, VA: African Strategies for Health,
Management Sciences for Health.
Additional information can be obtained from:
African Strategies for Health
Management Sciences for Health
4301 N Fairfax Drive, Arlington, VA 22203
www.africanstrategies4health.org
[email protected]
Photo Credits: The photographs in this document are used for illustrative
purposes only; they do not imply any particular health status, attitudes,
behaviors, or actions on the part of any person who appears in the photographs.
Acknowledgements
his compendium was produced by the African Strategies

for Health (ASH) project in collaboration with the
US Agency for International Developments Africa Bureau
(USAID/AFR). Funded by USAID/AFR, the overall
objective of ASH is to contribute to improving the health
status of populations across Africa through identification of
and advocacy for best practices, enhancing technical capacity,
and engaging African regional institutions to address health
issues in a sustainable manner. ASH provides information
on trends and developments across the continent to USAID
and other development partners to enhance decision-making
regarding investments in health.
Sarah Konopka, JoAnn Paradis, Stephanie Rotolo, and Cindy
Shiner contributed to the production of this document.
Report design was by Erin Dowling Design. We extend our
thanks to USAID and, in particular, Ishrat Z. Husain from

USAIDs Africa Bureau, as well as Peggy DAdamo from the
Global Health Bureau, for their support and inputs.
Our gratitude goes to the organizations and individuals
who took the time to share their knowledge and experiences
by contributing the mHealth program profiles featured
in this report. They are pioneers in creative and useful
mHealth applications that are designed to improve health
systems and achieve health goals. We realize that there are
many more people worldwide who are actively involved in
mobile applications for health. While time and budgetary
constraints did not permit a more extensive review, we would
like to acknowledge them for their own contributions to the
field.
mH EA LT H CO MP ENDIUM SP ECIA L EDIT IO N 2016 n v
Acronyms
AEFI
API
ASH
BCC
BTRC
CBMNH
CDC
CHW
CHMI
CSR
DFID
DHIS2
DOH
DPAT
DSRU
EM
EPT
FAQ
FHIR
HC
HIP
HIS
HISP
HSA
HRIO
HRIS
iCCM
ICT
IEC
ICT4D
IDSR
IHSSP
IMCI
IT
adverse events following immunization

application programming interface
behavior change communication
Bangladesh Telecommunications Regulatory
Commission
community-based maternal and neonatal
health
U.S. Centers for Disease Control and
Prevention
community health worker
Center for Health Market Innovation
corporate social responsibility
UK Department for International
Development
District Health Information Software 2
Department of Health
district product availability team
Disease Surveillance and Response Unit
enhance management
efficient product transport
frequency asked questions
Fast Healthcare Interoperability Resources
health center
high-impact practice
health information system
Health Information Systems Program - SA
health surveillance assistant
health records information officer
human resources information system
integrated community case management
information and communication technologies
information, education, and communication
information and communication technologies
for development
integrated disease surveillance and response
Integrated Health Systems Strengthening
Project
integrated management of childhood illnesses
information technology
International Telecommunication Union

interactive voice response
Japan International Cooperation Agency
John Snow International, Inc.
Kenya Medical Research Institute
Mobile Alert Communication Management
Mobile Alliance Maternal Action
maternal and child health
Maternal and Child Tracking System
maternal, newborn, and child health
mobile network operator
Ministry of Health
Ministry of Health and Family Welfare
Mobile Technology for Community Health
National AIDS Council
non-governmental organization
National Health Mission
national product availability team
Office of the U.S. Global AIDS Coordinator
performance-based financing
premium rate service provider
A reproductive, maternal, newborn, child and
adolescent health
S4CCM
Supply Chains for Community Case
Management Project
SDG
Sustainable Development Goal
SMS
short message service
SOP
standard operating procedure
TOT
training of trainers
USAID
United States Agency for International
Development
USAID/AFR United States Agency for International
Developments Africa Bureau
USSD
unstructured supplementary service data
WASH
water, sanitation, and hygiene
WHO
World Health Organization
ITU
IVR
JICA
JSI
KEMRI
mACM
MAMA
MCH
MCTS
MNCH
MNO
MOH
MOHFW
MOTECH
MSH
NAC
NGO
NHM
NPAT
OGAC
PBF
PRSP
RMNCH+
mH EA LT H CO MP ENDIUM SP ECIA L EDIT IO N 2016 n vii
Photo by mHBB
Table of Contents
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
FEATURED CASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Airtel Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Aponjon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
cStock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iCCM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Kilkari, Mobile Academy, & Mobile Kunji . . . . . . . . . . . . . . . . . . . . . . . . . . . .
mHERO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mom Connect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
mSOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RapidSMS Rwanda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
U-Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
24
30
36
42
48
54
62
68
ANNEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A:1
NOTE:
This special volume of the mHealth compendium features ten scale-up cases, offering project
descriptions, publication references, and contact information for making further inquiries.
When using in a PDF format, resources and contacts can be accessed with a simple click on the
email or website address appearing in both text and references.
Afghanistan, photo by MPaisa
Executive Summary
Health is the use of mobile and wireless technologies to

support the achievement of health objectives. The rapid
growth in access to mobile phones and networks in Africa
has created opportunity for mHealth programs to positively
impact the health of Africans. mHealth programs have the
potential to contribute to innovative solutions to health
system challenges including: (1) disparities in access to
health services; (2) inadequacies of health infrastructure;
(3) limited human resources for health; (4) cost to the
individual of accessing health services; and (5) challenges in
health financing.
The United States Agency for International Developments
Africa Bureau project, African Strategies for Health (ASH)
has produced five volumes of the mHealth Compendium to
help USAID missions, governments, and health implementing organizations access information on a range of mHealth
example programs. mHealth Compendium Volumes 1-5
document over 150 case studies of mHealth programs and
applications being implemented mainly throughout Africa,
but also in other regions of the world. The compendium volumes offer project descriptions, publication references, and
contact information for making further inquiries.
mHealth Compendiums Volumes 15 include two-page case
studies of current or closed mHealth applications or programs with an introduction to the health area or problem;
a description of the mHealth intervention; a snapshot of
important results or evaluation findings; lessons learned; and

conclusion. In addition, each case study includes a summary
of the geographic coverage, implementation partners, donor
name(s) and contact(s), as well as contact information for
the implementing partner. As the mHealth landscape has
evolved and more programs and countries look to establish
scaled, sustainable programs utilizing digital technology,
the need for in-depth profiles of mHealth interventions or
programs which have successfully grown in scale has grown.
This Special Edition 2016: Reaching Scale was developed to
provide greater detail on the development and experience of
mHealth programs which have successfully grown in scale.
The ten profiles featured in this volume were submitted by
the programs. They were selected following a survey of current intervention status sent to previously featured programs,
with an intention to select a range of intervention types,
locations, and partner organizations. This list is not exhaustive of scaled mHealth programs.
Profiles of programs featured in the mHealth compendiums
can also be accessed on ASHs online mHealth Database. The
database facilitates a quick and targeted search for applications
based on health area, application type, and location. The compendiums, database, and additional digital health resources
can be downloaded at www.africanstrategies4health.org.
mH EA LT H CO MP ENDIUM SP ECIA L EDIT IO N 2016 n 1
INTRODUCTION
Photo by Aponjon
Photo by David Rochkind, USAID
What is mHealth?
Health is the use of mobile and wireless technologies to support the achievement of health objectives.
mHealth can be utilized for a wide variety of purposes,
including health promotion and disease prevention, health
care delivery, training and supervision, electronic payments,
and information systems. A 2009 global survey conducted
by the World Health Organization (WHO) in 114 member
states found that 83 percent of them were implementing
mHealth services that fell into 14 distinct categories: health
call centers, emergency toll-free telephone services, managing
emergencies and disasters, mobile telemedicine, appointment
4 n I N T RO D U C T I ON
reminders, community mobilization and health promotion,

treatment compliance, mobile patient records, information
access, patient monitoring, health surveys and data collection, surveillance, health awareness-raising, and decision-support systems. The five volumes of the mHealth Compendium
feature mHealth case studies representing each of these 14
categories. For the purposes of this compendium mHealth
includes mobile phones, personal digital assistants (PDAs),
tablets, mobile applications, and wireless medical devices.
The Rapidly Evolving mHealth Landscape
he mHealth landscape is consistently and increasingly

evolving, growing out of the early stages of isolated and
often short-lived pilots to a focus on scale, sustainability,
interoperability, and integration of mHealth and eHealth
interventions. According to GSMAs Mobile Economy 2016
report, there are over 7.6 billion mobile connections worldwide, representing 4.7 billion unique subscribers. With the
rapid growth of mobile technology access, many believe that
mHealth has the potential to transform the face of health
service delivery across the globe by offering new means of
when, where, how, and by whom health services are provided
and accessed.
Evidence for mHealth
One of the most promising aspects of mHealth is its potential for enhancing the smart integration of health services
and the continuity of care across provider, place, and time by
making information available at the right place and the right
time. Strengthening patient management and health systems
in this fashion can only be achieved if the various mHealth
and HIS platforms have sufficient common ground to reliably exchange messages in a way that minimizes errors and
misunderstandings. Known as interoperability, this ability
of diverse systems and organizations to communicate and
work together (interoperate) requires the establishment of
and adherence to standards. Much like speaking a common
language enables communication, using common standards
for how data is structured and exchanged enables mHealth
platforms and HIS to share data.
mHealth interventions are significantly more powerful when
health sector actors make their information systems interoperable. Through close cooperation, governments, donors, and
private health care providers can achieve interoperability by
applying the same standards. These actions will maximize
the power of mHealth as a tool for coordinating individual,
patient-level services and public health programs.1,2
Aponjon
Although still limited, the amount of evidence around the

effectiveness or efficacy of mHealth interventions is increasing. In recent years, there has been a significant upsurge
in mHealth-focused health outcomes researchincluding
several studies published in the Lancetand reviews that
aimed to synthesize the evidence. Additionally, the mHealthevidence.org website, which was developed as a resource
for cataloging, categorizing, and grading mHealth evidence,
currently contains more than 7,500 sources from peerreviewed and grey literature.
Standards for mHealth
Principles for Digital Development
he following set of principles are intended to serve as

living guidelines to help development practitioners
across sectors integrate established best practices in the use of
information and communication technologies. The Principles for Digital Development were written by and for international development donors, multilateral organizations, and
implementing partners to capture the most important lessons
learned in the implementation of information and communications technology for development (ICT4D) projects, and
are freely available for use by all.
These principles seek to serve as a set of guidelines that are
meant to inform, but not dictate, the design and implementation of technology-enabled development programs. They
have been endorsed by over 50 development donors, multilateral organizations, and implementing partners. From
Principle to Practice: Implementing the Principles for Digital
Development, released in February 2016, captures the experience, insights, questions, and recommendations of practitioners working in digital development. This report, as well
as more information on the Principles for Digital Development can be found at digitalprinciples.org.
1. Design with the User
Develop context-appropriate solutions informed by

user needs
Include all user groups in planning, development,

implementation, and assessment
Develop projects in an incremental and iterative manner
Design solutions that learn from and enhance existing

workflows and plan for organizational adaptation
Ensure solutions are sensitive to, and useful for, the

most marginalized populations: women, children,
those with disabilities, and those affected by conflict
and disaster
2. Understand the Existing Ecosystem
Participate in networks and communities of

like-minded practitioners
Align to existing technological, legal, and

regulatory policies
3. Design for Scale
Design for scale from the start, and assess and mitigate
dependencies that might limit ability to scale
Employ a systems approach to design, considering

implications of design beyond an immediate project
Be replicable and customizable in other countries

and contexts
Demonstrate impact before scaling a solution
Analyze all technology choices through the lens of

national and regional scale
Factor in partnerships from the beginning and start

early negotiations
4. Build for Sustainability
Plan for sustainability from the start, including planning for long-term financial health, e.g. assessing total
cost of ownership
Utilize and invest in local communities and developers

by default and help catalyze their growth
Engage with local governments to ensure integration

into national strategy and identify high-level government advocates
5. Be Data Driven
Design projects so that impact can be measured at

discrete milestones with a focus on outcomes rather
than outputs
Evaluate innovative solutions and areas where there are

gaps in data and evidence
Use real-time information to monitor and inform

management decisions at all levels
When possible, leverage data as a by-product of user

actions and transactions for assessments
6. Use Open Standards, Open Data, Open

Source, and Open Innovation
Adopt and expand existing open standards
Open data and functionalities and expose them in

documented application programming interfaces
(APIs) where use by a larger community is possible
Invest in software as a public good
Develop software to be open source by default with

the code made available in public repositories and
supported through developer communities
7. Reuse and Improve
Ensure equity and fairness in co-creation, and protect

the best interests of the end-users
9. Be Collaborative
Engage diverse expertise across disciplines and

industries at all stages
Use, modify, and extend existing tools, platforms,

and frameworks when possible
Work across sector silos to create coordinated and

more holistic approaches
Develop in modular ways, favoring approaches

that are interoperable over those that are monolithic
by design
Document work, results, processes, and best practices

and share them widely
Publish materials under a Creative Commons license

by default, with strong rationale if another licensing
approach is taken
8. Address Privacy and Security

Assess and mitigate risks to the security of users and
their data
Consider the context and the needs for privacy of

personally identifiable information when designing
solutions and mitigate accordingly
More information on the Principles for Digital Development can be found at http://ict4dprinciples.org
Photo by Kendra Helmer, USAID
Photo by David Dorey
Other Key mHealth Tools and Resources
number of tools, guidelines, and databases have been

developed to disseminate information and best practices
on mobile and digital health. The following list presents a
short summary of a range of resources available, but should
not be considered exhaustive.
mHealth Repositories
African Strategies for Health mHealth Database:

Compiles the more than 150 mHealth project and application profiles featured in the mHealth Compendium
series into a single database. Information can be filtered
by type of application, health area, and location. Profiles
include intervention descriptions, important results or
evaluation findings, lessons learned and contact information for both implementers and donors. (africanstrategies4health.org/mhealth-database.html)
Center for Health Market Innovation (CHMI):
Includes over 1,500 programs in a downloadable database of health innovations. Over 450 of the programs
list mobile phone or tablet use as a program component.
Results can be filtered by program type, health focus,
country, target population, legal status, reported results,
funders, and technology used. (healthmarketinnovations.org/programs)
GSMA mHealth Tracker: This database captures

and presents mHealth products and services around
the globe. It tracks solutions in planning and deployment phases. (www.gsma.com/mobilefordevelopment/
m4d-tracker/mhealth-deployment-tracker)
mHealth Evidence Database: This database includes
searchable peer-reviewed and grey literature on mHealth
activities in developed and developing countries and is
curated with sources proactively identified or included
based on request. Material is classified using a harmonized taxonomy, scored using objective criteria, easily
filtered, and searchable to facilitate the identification of
evidence-based, high-impact mHealth practices. (www.
mhealthevidence.org)
mHealth Knowledge: This web repository, managed
by K4Health, connects global health professionals to the
people, products, and ideas needed to work effectively
in mHealth. It connects users to mHealth resources
including: applications and platforms, communities of
practices, capacity building and learning opportunities,
tools and guides, and sources of relevant news. (www.
mhealthknowledge.org)
Guidelines, Toolkits, and Learning

Resources
mHealth: Mobile Technology to Strengthen Family

Planning Programs: Commissioned by the USAID
High Impact Practices (HIPs) in Family Planning series,
this brief highlights evidence in mHealth and family planning programs to date and synthesizes lessons
learned for implementation of mHealth programs.
(www.fphighimpactpractices.org/resources/mhealth-mobile-technology-strengthen-family-planning-programs)
The mHealth Planning Guide: Key Considerations for
Integrating Mobile Technology into Health Programs:
An interactive online guide intended for global health
practitioners, program managers, and staff working to
implement mHealth solutions in low-resource settings.
(www.k4health.org/toolkits/mHealth-planning-implementation-guide)
National eHealth Strategy Toolkit: Produced by the

WHO and International Telecommunication Union
to provide guidance to governments, ministries, and
other stakeholders in how to develop and implement a
national eHealth vision, action plan, and monitoring
framework. (www.who.int/ehealth/publications/en/)
SDG ICT Playbook: From Innovation to Impact:

A resource for development organizations providing
actionable information on leveraging ICT tools against
the goals of the SDGs. It includes a portfolio of recommended technologies as well as insights on governance,
partnerships, and strategies for affordable access. (solutionscenter.nethope.org/toolkit/view/sdg-ict-playbookfrom-innovation-to-impact)
Photo by Julia Ruben, D-tree International
Global Digital Health Network: Formerly the

mHealth Working Group created in 2009 as a networking forum for members to share information, engage
with the broader community, and provide leadership in
digital health for global public health. (www.mhealthworkinggroup.org)
Integrating Mobiles into Development Projects: This
handbook is intended as a practical and actionable guide
to help USAID staff and others consider the challenges
that can impede the realization of a more sustainable
and equitable future powered by mobile technology
and other digital solutions, and to think critically about
when and how to deploy mobile solutions. (www.usaid.
gov/sites/default/files/documents/1861/M4DHandbook_August_2014.pdf )
Making the Journey from Cash to Electronic
Payments: A Toolkit for USAID Implementing Partners
and Development Organizations: This toolkit was created for nongovernmental relief and development organizations to guide them in their journey of transitioning
from using cash payments to electronic payments in all
operational and program payment streams. (solutionscenter.nethope.org/programs/c2e-toolkit)
The MAPS Toolkit: mHealth Assessment and Planning for Scale: A self-assessment and planning guide to
help mHealth implementers successfully and sustainably
scale-up their innovations. The toolkit assists mHealth
project teams to critically assess their mHealth project as
they move from piloting to planning their next steps for
overcoming the challenges inherent in scaling up. (who.
int/reproductivehealth/topics/mhealth/maps-toolkit/en/)
mHealth Basics: Introduction to Mobile Technology
for Health: A free, three-hour, self-paced eLearning
course available on the USAID Global Health eLearning Center provides an introduction to mHealth and
an overview of best practices for mHealth solution
development. (www.globalhealthlearning.org/course/
mhealth-basics-introduction-mobile-technology-health)
mHealth Field Guide for Newborn Health: This
guide xplains how mHealth serves newborn health
through referral and tracking of mothers and infants, decision support for community health workers
(CHWs), CHW supervision, scheduling and tracking
postpartum and postnatal visits, and teaching and counseling for mothers and families. (www.coregroup.org/
resources/420-mhealth-field-guide-for-newborn-health)
Photo by Lisa Hoashi / Mercy Corps
FEATURED CASES
Delivering health microinsurance at

scale across Africa
AIRTEL INSURANCE
POWERED BY MICROENSURE
A maternity nurse with a mother and her two newborn twins. Marangu Hospital, Moshi, Tanzania. Photo by David Dorey.
12 n A I RT E L I N S U R AN C E AN D M I C ROE N SUR E
The Airtel/MicroEnsure partnership aimed to introduce millions

of emerging consumers to their first health insurance products
by offering simple cover, for free, aimed to establish trust through
transparent, reliable operations. It then offered products for
customers to increase options, creating a path to greater health
insurance coverage.
Health insurance penetration in Africa remains under 3%, serving fewer than 3 million people, even though more than
400 private and nonprofit health insurance schemes operate across the continent, according to the Landscape of
Microinsurance in Africa 2012. Moreover, these health insurance schemes on average are unsustainable, paying out
more in claims than they attract in premiums.
By contrast, all other forms of insurance operating on the continent have less than half as many products active, yet in
aggregate they serve 17 times the number of people.
The reasons for low penetration of health insurance are multifaceted, but a key issue has been the high expense of
traditional health insurance, which keeps it out of the hands of the mass market.While public health insurance projects
are underway in many markets, MicroEnsure decided to pursue a complimentary private solution with Airtel, a panAfrican telecommunications company, in order to deliver a sustainable health product to the emerging customer.
The Airtel/MicroEnsure partnership aimed to introduce millions of emerging consumers to their first health insurance
products by offering simple cover, for free. By introducing consumers to a basic health insurance product, MicroEnsure
aimed to establish trust through transparent, reliable operations. It then offered intuitive up-sell products to allow
customers to increase their coverage by paying for more cover for themselves and/or their families, which created a
path to greater health insurance coverage.
About Airtel/MicroEnsure
icroEnsure and Airtel launched their first simple health

insurance product in Ghana in January 2014, and eventually launched in seven African markets. The product was
relatively straightforward: Airtel would reward loyal customers (who registered for the product by dialing a shortcode)
with free insurance as long as they spent a minimum amount
of airtime (usually US$2). The more customers spent with
the telecom, the more free health insurance (and life and
accident insurance as well) they could earn. Customers were
educated as to how the product works via an unstructured
supplementary service data (USSD) menu showing policy
information and through monthly SMSs informing them
the amount of insurance they had earned for the following
month based on their airtime usage in the previous month.
The health insurance offered a simple benefit: qualifying
customers received one month of hospital cash insurance
a lump sum of up to US$300 paid to them via mobile money if they spent three nights or more in any hospital across
the nation, for any medical reason, with no exclusions. This
wide-open claims model was designed to eliminate the fine
print traditionally associated with insurance and to demonstrate a reliable product.
Furthermore, while it might seem nave to a typical, developed-market health insurance consumer that a lump sum of
$50, for example, would be attractive, MicroEnsure knew
from its 12 years of experience in the mass market that, when
there is no health insurance available at all, even a small
amount of health cover represented a massive improvement
over the status quo, and provided a stair-step into health
financing. In other words, $50 of hospital cash is viewed by
the mass market in Africa as an excellent cover, especially
when the cover is accessible for free.
Due to SIM-card swapping and a low level of brand loyalty

for many African telecoms, this product was designed to
increase loyalty as well as revenue for the telecom, hence it
paid the premiums to MicroEnsure and its partner insurance
companies in various markets. The customers airtime was
not deducted but rather the cover was provided for free and
paid by the telecom on the basis of the overall increase in
value to the core business (airtime spent) from the portfolio
of insured customers.
Sample Nigerian promotion by Airtel
This business model therefore offered a win-win-win for the

patient, distributor, and insurer alike. The patients received
free and reliable means of mitigating their risk; the distributor
received a product to grow revenue and loyalty; and the insurer
saw millions more customers become policyholders on a financially viable basisas premiums exceeded the cost of claims.
Program Design Process

MicroEnsure had previously delivered mobile insurance
through a freemium strategy, with Tigo in Ghana and
Tanzania (20102013). In its partnership with Airtel
MicroEnsure focused product design efforts on bringing a
simple, valuable health insurance product to the mass market
through the mobile channel.
MicroEnsure found from its experience that a traditional
health insurance model was unlikely to be sustainable. It
could not build a panel of hospitals and clinics and still meet
the telecoms requirements to serve all of its customers across
Africa within a year; nor could it operate a third-party payment scheme to health providers without experiencing the
fraud that dooms many health insurance schemes.
When MicroEnsure looked into provider insurance fraud, it
found that mutual distrust between providers and insurers
is likely an unsolvable problem for now in Africa, where developed information technology (IT) systems are few and far
betweendoctors resent being paid less by an insurer than
the service cost them to provide, and so they over-charge
knowing the insurer will pay less; then, the insurer sees the
overcharge and charges the provider with fraud. This vicious
circle dooms many health insurance products in Africa.
MicroEnsure resolved, therefore, to use a hospital cash
product, paying the patient directly instead of paying the
provider. However, many other hospital cash schemes had
experienced problems with fraud as well. MicroEnsure decided to work to limit fraud in three ways: 1) by providing the
product for free, thereby reducing the claimants incentive to
commit fraud; 2) by providing a small sum assured for most

of the telecoms customers (i.e. the lower spenders), reducing
their motive for a large payday; and 3) by providing a lump
sum benefit instead of a per-day benefit, thereby reducing
the incentive for customers with genuine claims to overstate
the size of their claim.
Once MicroEnsure had determined that hospital cash was
the correct approach from the supply side, it had to identify
whether there was demand for hospital cash insurance.
MicroEnsures research illustrated that nearly 30% of
health-related expenditure in these markets is for costs other
than the medical expenses themselves. These costs include
transport, food, lost income, and other foregone expenses,
such as childrens school fees. Furthermore, the research
showed that customers who had never been insured did
not expect a full indemnity product, as traditional health
insurance operates; rather, if they received a $50 payout from
MicroEnsure, they perceived it to be valuable, as it was greater than $0the amount of insurance they had ever received
before. With this knowledge, it appeared as though customers would value the product as designed.
Growth in Scale
MicroEnsure designs its products, systems, and distribution strategies for large-scale implementation. MicroEnsure
launched with Airtel Ghana in January 2014, and grew the
enrolled customer base to 1.2 million within its first year.
Once the product had demonstrated success, other countries
launched in quick succession:
Airtel Burkina Faso launched in August 2014, reaching
231,000 within its first year.
Airtel Nigeria launched in September 2014, reaching

1.02 million within its first year.
Airtel Madagascar launched in December 2014, reaching 57,000 within its first year.
Airtel Niger launched in December 2014, reaching

194,000 within its first year.Airtel Malawi launched in
May 2015, reaching 163,000 by March 2016.
Airtel Kenya launched in August 2015, reaching

173,000 by March 2016.
In aggregate, these products had enrolled 3.74 million

customers into hospital cash insurance in seven countries by
March 2016, a little over two years after the initial product
launch.
MicroEnsures board approved significant growth in its IT development and African regional team, as well as local teams to
deliver the product on the ground. Despite these investments,
by the end of the roll-out phase it was clear to MicroEnsure
that it did not plan enough expenditure on technologyespecially the process of integrating its systems with the local
telecom. Experience showed that it should have planned for
more cost in recruiting, training, and development.
Photo by Airtel
Photo by Airtel
Evaluation and Results

The major objectives for the project concerned: scale of
health microinsurance, financial sustainability, and creation
of new market penetration by offering customers their
first-ever health insurance policies.
As of March 2016, MicroEnsure had enrolled 3.74 million
customers into hospital cash insurance in seven countries, a
little over two years after launch. Airtels continued expansion and the fact that no insurance companies dropped the
product indicate overall financial success of the product.
MicroEnsure expects to break even on its investment in the
mobile insurance model in 2017. Customer surveys across its

operating markets have indicated that for 86% of its customers,
Airtel Insurance was their first insurance policy of any kind.
Unfortunately, there are no assessments of health outcomes,
as MicroEnsure does not track patients beyond the submission of a claim, nor does it track any additional information
about their health, including the cause of hospitalization.
However, with a large-scale footprint, MicroEnsure expects
to be able to have a much more significant impact on health
outcomes, as it has built the customer base.
Lessons Learned in Program Implementation and Scaling

Low health insurance penetration is often assumed to be a
function of low demand for insurance in general. MicroEnsure has found that low penetration of traditional insurance
is more likely a function of: high cost, low trust, poor access,
and product complexity. If these barriers can be overcome,
enrollment numbers indicate that mass-market consumers
are very eager to be protected from health risk.
MicroEnsure research shows that a simple health insurance
benefit is perceived as better than having no health insurance
at all; it is not necessaryor financially viablefor the uninsured customer to enroll in full health coverage from the start.
Furthermore, mobile channels offer important assets to enhance an mHealth service, but the telecom will only unleash
those assets if they will directly benefit in their own core
business growth; if this is not clear to them they will not lend
their brand and footprint to the initiative.
MicroEnsure experienced several challenges during the rapid
growth of the program. For example, due to Airtels emphasis on rapid expansion across markets, MicroEnsure did
not invest in client education and impact to the degree that
it might have with a slower roll-out. This underinvestment
led to lower uptake in some markets than initially expected,
and to fewer claims than expected as well. Additionally, the

overhead and administrative cost as well as the day-to-day
operational headaches of expanding in market after market
often served as a distraction from the key program focusto
drive value for the customer. MicroEnsure learned that in

future multinational roll-outs, it should move more deliberately in order to ensure each project is performing according
to best practice prior to the next product being rolled out.
Future Plans
MicroEnsures main plans for Airtel Insurance are currently
centered on transitioning from a free product to a product
that customers pay for in order to make the product sustainable for the long term. The free product was successful in
generating additional revenue and reducing customer churn
for Airtel, but the company will not pay for free insurance in
perpetuity. MicroEnsure has launched a prototype of a paid
product in Ghana, which more than 100,000 people have
purchased to date. It expects to roll out the lessons learned
from the prototype to other Airtel markets throughout 2016.
MicroEnsure expects not expect that all Airtel Insurance
products will remain live, as telecoms priorities change;
however, it expects 3-4 of the products to remain live, including in its largest markets of Ghana and Nigeria. By yearend 2017 it expects to have more than 2 million paying customers on Airtel Insurance overall. If it successfully converts
a sufficient number of customers from free to paid products,
MicroEnsure plans to seek to drive additional value through
higher-value products with greater health benefits. MicroEnsure is currently prototyping telemedicine and health
education products in Kenya and is designing other mHealth
solutions, which it expects to make available at scale near the
end of 2016 and early 2017. n
Snapshot: Airtel Insurance powered by MicroEnsure
Geographic
Coverage
Burkina Faso, Ghana, Kenya, Malawi, Madagascar,

Niger, Nigeria
Implementation
Dates
2014 to present
Implementation
Partners
Microensure (product design, mobile

implementation, insurance arrangement, field
engagement, back office support)
Airtel Africa (marketing and distribution)
Various insurers (risk underwriting)
Donor(s)
N/A
Contact
Information
Peter Gross, Marketing Director, MicroEnsure,

[email protected]
References & Additional Resources

1. McCord, Michael J, et al. The Landscape of Microinsurance in Africa 2012. Munich/Eschborn, Munich Re Foundation and GIZ. March 2013.
2. Mulupi, D. How to sell insurance to low-income earners in Africa. 2015. http://www.howwemadeitinafrica.com/how-to-sell-insurance-tolow-income-earners-in-africa/51547/.
3. Chrispinus, J. MicroEnsure: Providing microinsurance to the mass market. 2015. http://www.biasharaleo.co.ke/index.php/en/2014-10-19-1825-47/techie/item/116-microensure-providing-microinsurance-to-the-mass-market.
4. Jarvis, E. Microensure. 2015. http://www.africaoutlookmag.com/outlook-features/microensure.
APONJON
In Bangladesh, the power of health in

every mothers hand
Photo by Aponjon
18 n A PO N J O N
Aponjon (meaning dear one(s) in Bangla) aims to help to

substantially reduce maternal and newborn deaths by improving
health-seeking behaviors and preventive care among pregnant
women, new mothers, and their families.
The Mobile Alliance Maternal Action (MAMA) program launched nationally in December 2012. A Bangladeshi social
enterprise, Dnet, implements Aponjon in partnership with the Ministry of Health and Family Welfare (MOHFW) and
with support from the US Agency for International Development.
Although under-five child mortality has decreased considerably in Bangladesh, neonatal mortality has decreased at a
slower rate, with neonatal deaths a larger share of infant mortality. Greater progress was needed at that stage. Given
that newborn survival and health are intrinsically linked with the health of women before conception, during pregnancy,
and around the time of birth, and recognizing limitations in human resources for health, Aponjon developed as a
mobile-based behavior change communication (BCC) program to increase health-seeking behavior at the household
level and use of health facilities to prevent neonatal deaths.
The service is designed for women between 6 and 42 weeks of pregnancy and mothers with a child under one year of
age. It features critical health information and reminders based on gestational stage and age of baby in the form of text
and voice messages.The messages also address gatekeepers such as the womens partners, mothers, and mothersin-law. In addition, Aponjon also launched a mobile application Shogorbha for pregnant women and redesigned its
website as a host of web services.
About Aponjon
lobally, Aponjon is a unique mHealth initiative because it functions through all of the countrys telecom
operatorssix. About 81% of Aponjon users are from rural
areas; 60% of women users have their own mobile phones.
Technology stakeholders in the program include the telecom
operators and value added services platform aggregator.
Aponjon has two major components: content (voice/
text) and call center (counselling). The primary audience
(expecting and new mothers) are delivered two messages,
either by SMS or interactive voice response (IVR), a week
while the secondary audience (partners, in-laws, parents,
etc.) receive one, with each message costing about US.03
cents. The voice messages are a mix of direct messages and
mini-skit messages, with local actors playing the roles of
a doctor, pregnant woman, mother, and mother-in-law.
Gatekeepers information reinforces messages provided to
the mother and encourages family involvement in healthy
decision-making around pregnancy, birth, and infant care.
Figure 1.
Aponjon has two major components:
content (voice/text) and call center (counseling).
Business Logic
Aggregator
Platform
ISP Cloud
Telecom
Operator
Content
(voice/text)
ICX
IPTSP
Call center
(counseling)
All Aponjon content complies with the governments BCC

guidelines. Content is identified, designed, and adapted
based on ethnographic research; semi-structured content
surveys; a review of national guidelines and international
literature on maternal, newborn, and child health (MNCH);
and an expert review by a panel of Bangladeshi physicians,
researchers, and communications professionals. Followed by
feedback from BabyCenter, the messages are approved by the
Information, Education, and Communication (IEC) Committee of the MOHFW. The service is available in Bangla
and two local dialects. Aponjon also offers a counseling line
to subscribers, serving as a direct channel to communicate

with a doctor about health problems. Aponjon partners
with the field forces of BRAC, Infolady (Dnets program),
MaMoni, Social Marketing Company, Smiling Sun, and
several local nongovernmental organizations and agencies for
customer acquisition. Customers can also register themselves,
and provide information to ensure that the messages are in
sync with the gestational stage or babys age. Users are also
able to select a preferred time of day for message delivery so
that the message is received when it is most convenient.

Dnet carried out extensive formative research from September 2011 through May 2012 before launching the service
nationally. The research included 1,403 subscribers from five
divisions, including 349 pregnant women (25%), 575 mothers of children under age one (41%), and 479 other household
decision-makers (e.g. husbands, mothers-in-law) (34%). Areas
of interest included: gender and mobile phone ownership;
effective strategies for enrollment and promoting user awareness; acceptable cost models; user satisfaction of the content
and tech platform; influence of content on MNCH-related
health-seeking behaviors; and the involvement of family members in the service. Data collection included a pretest focus
group, registration forms, deregistration data, payment status
data, structured interviews, field observations, and phone
surveys. The Johns Hopkins School of Public Health mHealth
Initiative jointly produced a report with Dnet that examines
and analyzes Dnets formative research.
Aponjon conducts widespread bi-annual phone surveys.
Apart from tracking health-seeking knowledge and practice
indicators, the surveys query users if the service benefitted
them and what could have been done better in terms of
content and design of service delivery.
Aponjon received support from the Access to Information Program II (A2I-II) hosted by the Prime Ministers Office, which
facilitated coordination among various government agencies
for the program. Aponjon actively participates in the district
health information system initiative of the Directorate General
of Health Services-Management Information Services office
and has already streamlined its system data landscape.
Another important public sector contribution comes from
the Bangladesh Telecommunications Regulatory Commission (BTRC), which helped secure approvals for differential
charging and approved the short code and Aponjon counselling line. Aponjons partners in the private sector have also
included Johnson & Johnson, Agora, Lal Teer, and Beximco
which contributed through corporate social responsibility
(CSR) funds and sponsorships and helped in brand propagation. Telecom operators also complied with the mode of
differential charging and made it possible for Aponjon to
reach people across the socioeconomic spectrum.
On the technical side, SSD-Tech provides the technical
platform for service delivery with MT charging, meaning
clients are charged when messages are received. Synesis IT
serves as the call center service provider that developed a
customer relationship management system and a separate
system for the counseling line.
Growth in Scale
After the national launch, Aponjon acquired 100,000
subscribers by July 2013. The subscriber base hit 750,000 in
August 2014, 1 million in September 2014 and 1.5 million
in December 2015. In addition to standard SMS and IVR,
the service has made content available through a mobile
application, Shogorbha, for pregnant women. Aponjon
aims to reach 2 million subscribers by September 2016 and
launch newer products.
During its pilot phase, Aponjon served 1,403 subscribers
in a few urban and rural areas across five divisions of Ban-
20 n A PO N J O N
gladesh. A core research team had evaluated various aspects

of the service before national roll-out. Community health
workers from BRAC and USAIDs MaMoni project assisted
in enrolling most of the initial subscribers. Popular campaign strategies were executed in select urban locations and
their contribution in the overall growth of subscription was
reviewed. Using local leaders and spokespeople to increase
awareness of Aponjon while also forging greater trust in the
brand, building partnerships with more community-based
organizations, including more detailed messages on nutrition, arranging for refresher trainings for call center agents
and initiating a ticketing system for better management of

service issues by vendors are some major pilot phase outcomes that paved the way to a large-scale implementation.
panies interested in using the messaging for advertising make

up slightly less than 1% of Aponjons funding.
Aponjon has faced some vital challenges in the process of
scaling up its operations. Lack of funding for above-the-line
campaigns crippled the programs ability to sustain its brand
communication efforts. In spite of co-branding efforts with
products of high rural market penetration, the program never
overcame the need for launching above-the-line campaigns as
the rate of self-registration was persistently low. Also, mostly
due to the former, Aponjon had to heavily rely on customer
acquisition led by community-based agencies that had to be
paid more than some leading nongovernmental organizations.
Dnet uses innovative financing models, leveraging CSR

funding at local and global levels, and providing the service
for the poorest subscribers free of charge while charging
the better-off users the full price. Dnet also uses advertising
and sponsorship donations. Aponjon is financed primarily
though support from development agencies (88%), namely USAID. The next largest portion of Aponjons funding
comes from local CSR (7%), followed by the Sponsor-a-Ma
campaign (4%). Together, user fees and fees charged to com-

Aponjon conducts periodic surveys to understand the impact
of the intervention and to gather feedback for further modification of the service. Annual sample surveys have been conducted
since 2013 to understand how the service impacted users both
in knowledge and practice, if at all. Reasons behind non-compliance with content instructions and the process of and barriers
to behavioral changes are explored. Two sample surveys have
been done so far, reaching 799 expecting and new mothers.
These surveys revealed that about half (54%) of Aponjon users
are first-time mothers, while 66% of them reported having been
actively using some form of family planning. About 14% of users
reported to have spaced previous births by at least 3 years. When
users were asked about their level of satisfaction with Aponjon
services, 91% indicated they were satisfied and 35% gave the
services the highest possible rating.
interviewed. User feedback and preferences on message length,

content type, message frequency, and usability were translated
into actionable recommendations. Some of the major actions
based on findings included the introduction of content in two
major local dialects, incorporation of content specific to the
rural version, and advanced messages on pregnancy care and
home remedies.
Aponjon performs regular bi-annual phone surveys to track
the status of 11 health milestone indicators, including antenatal and postnatal care visits, exclusive breastfeeding, and
BCG (TB) vaccination, and to gauge customer satisfaction
and loyalty through net promoter scores. The outcomes of
these health indicators are then compared to national level
values (see Figure 2 below).
A third-party mixed methods evaluation of the program was
conducted by the USAID-funded TRAction project. Results
indicated that respondents who had used Aponjon for a
Aponjon also conducted a content survey in 2013 to better

understand user acceptability and comprehensibility of messages received. A total of 335 women and 88 gatekeepers were
Figure 2.
Evaluation results for health-seeking behavioral indicators
(Sources: *National Data Source: BDHS 2014, WHO 2013, and Unicef 2012); **Aponjon subscriber phone survey VII, July 2015)
4 or more ANC visits
31%
Family-based delivery
67%
62
37
Home-based delivery by SBA

Use of safe delivery kit at
home-based delivery
Post natal care visit rate
Early initiation of breastfeeding
42
65%
88%
32
57
93%
Exclusive breastfeeding to 6 mo.
100%
68
55
85
98%
Vaccinated BCG
91%
Vaccinated Pentavalent
Blood group detection
Improved water source
100%
93%
70
83%
0
NATIONAL*
20
40
APONJON SUBSCRIBER**
60
80
87%
100
Images provided by Aponjon
minimum of six months, received at least three messages

per month and carefully listened to most of the messages
showed both increased knowledge and practice of maternal
and newborn health care. Study recommendations included
that the program should emphasis continued use of services
for a longer duration, and to explore reasons for not receiv-
ing or carefully listening to all messages. (Chowdhury, 2015)

Other findings indicated that some non-eligible clients were
registered by agents, and also that users demanded another
service on early childhood development. Based on this research, Aponjon formed an in-house quality control unit and
content for early childhood development is being developed.

One of the main challenges Aponjon faced was to gather all
mobile network operators under one umbrella. Given that
Grameen Phone was the only operator during the pilot, areas
such as Chittagongwhich had low Grameen Phone coveragehad much fewer subscribers. After a lengthy process of
negotiation and technological integration with each operator,
four operators were added before the national launch.
Receiving the right and disaggregated service delivery metrics
from the technology platform vendor SSD-Tech posed another challenge for the program. Aponjon needed to be able
to track message acceptability by content area and monitor
fluctuations of deregistration by exposure to content.
Over the last two years, revenue from local CSR funds has
decreased alarmingly as local companies are increasingly
channeling their CSR funds through in-house charity foundations. This tendency has limited the programs ability to
extend the service to ultra-poor families for free.
Aponjon devised a workaround, where possible, to each of
the abovementioned obstacles. Soon after the pilot, the team
built on the partnership with the BTRC and brought all
six of the countrys telecom operators (including the stateowned Teletalk) aboard. Dnet redesigned service metrics and
ensured routine tracking of service delivery based on disaggregated measures. Lastly, the decline in CSR funding from
local companies has been tackled with increased sponsorship
and fundraising efforts globally. Prior to its dissolution in
22 n A PO N J O N
December 2015, MAMA helped Aponjon broker instrumental partnerships with international donors and corporations
such as Johnson & Johnson. Johnson & Johnson offered
sponsorships covering the entire service package for over
5,000 mothers in fiscal year 2015-16.
Although the initial program delivery commitment was for
500,000 expecting women and pregnant mothers, Aponjon
went on to cater to over 1.6 million subscribers to date. This is
not only due to support from USAID but also because of partnerships across the public and private sectors that Aponjon has
forged over the years. Furthermore, some major outgrowths
from the initial structure of project deliverables are as follows:
Aponjons official website has been redesigned with the

introduction of a diverse host of web services, including
articles on food and medicine in pregnancy to breastfeeding practices, a growth tracker, event calendar,
estimated due date calculator, ovulation calendar, and a
social timeline called Mothers Forum.
Aponjon launched the first mobile app in the Bangla

language with a range of comprehensive information for
expecting mothers. Features include week-by-week gestational information, an expected due date calculator, event
calendar, nutrition routine, weight chart, and kick-tracker.
The Aponjon counseling line features 16 doctors/general

physicians who are available with first-line medical counseling for registered subscribers.
Future Plans
Aponjon, based on a tested sustainability model approved
by USAID, will transform into a for-profit business called
Lifechord. All organizational formalities and legal paperwork
have been completed. Initial capital for Lifechord includes
program income from non-USAID funds, CSR funds, and
Dnets own investment. Lifechord will be able to explore
radical cost-cutting and income-generation options beginning with the launch of Dnets own technology platform in
March 2016. This marks an important transition in the program; running the service from its own technology platform
means greater control over service delivery metrics, stronger
negotiation with mobile network operators as a content
provider, as well as opportunities for generating revenue from
diverse service innovations. This systemic changeover will
translate into efficiency gains, broader developmental leeway,
and fewer challenges to exploring new market segments and
replicating in different contexts.
However, as an initially donor-funded program, one major
roadblock to working out the current transition and sustainability plans is the limited opportunity to attract angel and
impact investors, as investments arising from such initiatives
cannot be declared as assets for LifeChord going forward.
Therefore, Aponjon has been busy crafting its service portfolio with new developments paving a way to diverse revenue-generating activities.
Activities recently launched or in development include:
Aponjon Shoishob: Weekly mobile content in the form

of IVR/SMS. It will target parents of children aged 15
years and address issues pertaining to early childhood
development.
Aponjon Koishor App: Mobile application targeting
adolescents aged 1019 years and their parents. Features a
counseling line and live web chat. Launched April 7, 2016.
Aponjon New Mother App: A mobile application which
will target mothers of children aged under one year. n
Snapshot: Aponjon
Geographic
Coverage
Bangladesh
Implementation
Dates
December 2012 to present
Implementation
Partners
Dnet: a social enterprise that designs innovative

products and service solutions for women, children,
and youth in rural and urban settings to create
social impact, and for institutions to enhance
capacity and productivity. It runs Aponjon in
partnership with USAID and the Government of
Bangladesh.
Donor(s)
USAID
Contact
Information
Tahsin Ifnoor Sayeed, M&E Specialist, Dnet,

[email protected]

Understanding mHealth impact among Aponjon (MAMA Bangladesh) subscribers through a phone survey in Bangladesh.
http://dl.acm.org/citation.cfm?id=2517920
M&E of MAMAs mHealth program to improve quality of maternal health care.
https://apha.confex.com/apha/141am/webprogramadapt/Paper294315.html
Improving health awareness through mobile-based health messages in Bangladesh.
http://www.journalmtm.com/2012/improving-health-awareness-through-mobile-based-health-messages-in-bangladesh/
MAMA APONJON Formative Research Report.
http://www.mobilemamaalliance.org/sites/default/files/MAMA%20Bangladesh%20Formative%20Research%20Report.pdf
References:
1. GSMA Data
https://www.gsmaintelligence.com/markets/240/dashboard/
2. Bangladesh Demographic and Health Surveys 2014
http://www.niport.gov.bd/wp-content/uploads/publication/1432536472-BDHS%202014%20KIR.pdf
3. Health Workforce Crisis in Bangladesh
https://everyone.savethechildren.net/articles/health-workforce-crisis-bangladesh
4. MAMA Bangladesh: Lessons Learned on the Way to 500,000 Subscribers. http://mobilemamaalliance.org/sites/default/files/
BangladeshCaseStudy2014.pdf
5. Chowdhury, Mahbub Elahi. Key Findings Presentation: Evaluating accessibility, acceptability and effectiveness of Aponjon mobile health messaging for
improved maternal and newborn health behaviors and practices in Bangladesh. September 2015. http://www.tractionproject.org/resources/keyfindings-mama-study-traction-supprted-study-conducted-international-center-diarrheal
cSTOCK
Using mobile technology to improve

community health supply chains in Malawi
Photo by cStock
24 n C S TO C K
The combination of mobile technology, user-friendly dashboards,

and quality-improvement teams have improved the reliability of
supplies of life-saving commodities in community-based health
programs.
In 2015, nearly 6 million children under the age of five died from treatable causes such as pneumonia, diarrhea, and
malaria.1 Integrated Community Case Management (iCCM) is one strategy for reducing childhood mortality by having
community health workers (CHWs) trained to treat children under five close to home. However, investments in training
CHWs to treat these children are often undermined by weak supply chains which are unable to consistently deliver
medicines to CHWs.
The Supply Chains for Community Case Management Projects (S4CCM) goal was to find proven, simple, and
affordable solutions for the supply chain challenges faced by CHWs in Malawi, Rwanda, and Ethiopia. iCCM was
first introduced in Malawi in 2008.Two years later, John Snow International, Inc. (JSI)s SC4CCM project conducted
a baseline assessment that revealed poor medicine availability, with only 23% of CHWs having in stock the four key
lifesaving medicines needed to treat all three targeted childhood illnesses on the day of the survey. A lack of visibility
into stock levels at the community level and weak coordination and management practices used to respond to the
needs of the CHWs were identified as the primary causes of the weak supply chain. However, the survey results also
identified an opportunity, with 94% of CHWs owning simple mobile phones and 85% having network coverage at least
some of the time.2
About cStock
n collaboration with Malawis Ministry of Health (MOH),

JSI designed the Enhanced Management (EM) approach.
EM was developed to promote superior team performance
practices and the use of data to inform decisions and improve supply chain performance to increase the availability
of medicines for community health programs. The following
three key components ensure the programs success:
1.
cStock: The overall goal of cStock is to improve

reporting and visibility of community health logistics
data. It is a RapidSMS-based reporting and resupply
system that facilitates timely data transmission and
communication between the CHWs and the facility
that supplies them with medicines. Using a streamlined,
demand-based reporting and resupply process, stock
data reported by the CHW triggers the re-order
process, whereby cStock automatically calculates
resupply quantities and transmits a request via SMS to
supervisors at health facilities. The facilities then send
feedback to the CHW when the order is ready or if they

are out of stock. Urgent matters, such as stock-outs or
low stock levels, are communicated through SMS alerts.
2.
A user-friendly dashboard: The web-based dashboard

provides visibility of real-time CHW logistics data
for district- and central-level managers. The system
transforms two reported data elements into more than
10 supply chain indicators that are displayed on the
dashboard as easy-to-use, relevant graphs and reports
that facilitate rapid decision-making. These data can be
used for coordination, planning, and identification of
stock issues.
3.
District product availability teams (DPATs): They

complement cStock, building strong leadership and
creating teams of CHWs that work together to support
the goals of the intervention. They are comprised of
district management, health center (HC) staff, and
CHWs. DPATs have a common goal of improving
availability of essential medicines, and are designed

to regularly use data provided by cStock to monitor
community supply chain performance and address
supply chain challenges. HC staff meet CHWs every
month when they come to HCs for resupply; districts
meet with CHW supervisors every quarter.
All cStock users received a two-day training at the launch of

the pilot. In addition, quarterly monitoring and implementation support were provided throughout the pilot period
and feedback received was used to refine cStock and other
accompanying tools and training.

Formative research, including quantitative and qualitative
assessments, was conducted from May to June 2010 in 10
districts across Malawis three geographical regions. Based on
the results of the assessment, the project explored and consulted stakeholders on many different intervention options,
focusing on transportation, motivation, and technology, and
considered issues of affordability, scalability, and sustainability as criteria for selection. Two intervention packages were
then designed and piloted over 18 months (see evaluation
and results).
The design and development of cStock is based on a user-centered and iterative approach that combines the knowledge of supply chain experts with user experiences. The core
principles of the design are to keep it simple; design with the
end-user in mind; focus on feasibility, practicability, relevance, and usability; build ownership from all stakeholders
throughout the process; and plan for scale and sustainability
from the outset. The system was also designed to align and
integrate into the current system by including workflows
that streamlined existing procedures and practices, reducing
workloads rather than increasing them.
Figure 1.
Sample cStock dashboard
In designing the system and workflows, consideration was

given to ensure that key stakeholders have access to the data
they need, and in a format that is easily accessed and interpreted. User inputs during the initial design phase were
limited mainly to defining the workflows in terms of the
recipients, content, timing, and format of the messages. The
initial design of the dashboard was rudimentary, with limited
time invested, and included only the basic supply chain
metrics identified by the supply chain experts. The decision
to begin with a simple dashboard was based on users lack
of experience with receiving, visualizing, and acting upon
real-time supply chain data. After the users gained experience
in using online reports, and a better understanding of how
they could use logistics data to measure and monitor supply
chain performance, the project engaged the users for input
on the dashboard design.
Monitoring data were also used to design some targeted intervention-support activities, including sending group SMS
messages to users on common data entry errors and conducting extra training sessions for HC staff on how to run
effective meetings. Throughout the pilot, monitoring data
were also shared with stakeholders, including MOH central
staff and implementing partners, to get their input and ideas
on addressing challenges.
Growth in Scale
The scale-up approach was defined by four primary strategies
over two years (20132014). Strategies included gaining
MOH endorsement, maintaining close engagement and
coordination with partners, creating a dedicated cStock taskforce, and developing a national product availability team.
In this way, the necessary political will, buy-in, continuous
engagement, and ownership was in place to maximize the
potential for sustainability over time.
1.
26 n C S TO C K
MOH endorsement: The MOH initially endorsed

scale-up of cStock (but not DPATs) before the project
had completed a full evaluation. The endorsement
was triggered by enthusiasm for the unprecedented
levels of access to community logistics data, positive
Photos by cStock
feedback from users, and high adoption of the system.

After conclusion of the pilot, the evaluation data
clearly showed that although supply chain performance
improved with the implementation of cStock,
performance was significantly better with the EM
package that combined both cStock and the DPATs.
Based on these findings, the MOH endorsed the full
EM package.
2.
Continued engagement and coordination with

partners: A vital part of planning for scale entailed the
projects ongoing engagement and coordination with
local partners, led by the MOH. This served to broaden
ownership for the intervention and avoid duplication.
As a result, multiple partners financed and supported
the scale-up of cStock and DPATs to districts outside
the original pilot districts. cStock, with DPATs, is now
implemented and used in all of Malawis districts.
During the scale-up phase, partners financed and jointly
conducted the trainings with MOH, while the project

provided technical support and quality control.
3.
Creation of a taskforce: An MOH-led taskforce that

includes key stakeholders was set up to monitor the
progress of the scale-up, assist in resource mobilization,
and contribute to the development of a five-year
transition plan. The plan outlined a structured and
deliberate process on how to sustain cStock and DPATs
for the next five years and build capacity within the
MOH to take full ownership of the system so that EM
becomes a core business practice of the health system.
4.
Development of the National Product Availability

Team: The MOH also established a National Product
Availability Team (NPAT) to manage the EM approach.
This team meets to review data on performance and
provide leadership and support as needed to ensure all
districts can realize the full benefits of the EM approach.

The project tested two different intervention packages: EM
(cStock plus DPATs) and Efficient Product Transport (EPT)
(cStock plus bicycle maintenance) over 18 months (2011
2013). Each package was tested in three districts, and four
districts from the baseline assessment were used as a comparison group. The monitoring and evaluation strategy included three large mixed-method evaluations, one at baseline
(2010), a second after the testing phase (midline2013),
and a third after the scale-up phase (endline2014).
The midline evaluation compared the effectiveness of the two
intervention groups (EM and EPT) in reducing stock-outs
and strengthening key supply chain processes. The evaluation

compared results from baseline to midline and compared
each intervention group with the non-intervention comparison group. cStock proved to be feasible and acceptable in all
six districts; however, combining cStock with DPATs (three
districts) resulted in significantly better supply chain performance and supply reliability.3-5
Data visibility improved from baseline in all districts

where cStock was implemented, but improved more significantly in EM districts: Results showed average CHW
reporting rates of 94% in EM districts and 79% in EPT
100%
93%
80
%
79% 79% 80
71%
60
63
67%
83%
%
%
%
%
%
%
%
%
% 98% 99
97% 98 98 99 99 99 99 99
96% 96% 97
%
%
91 91
90%
90%
88% 88%
86%
85%
84%
75% 75% 76%
73%
69%
63
40
20
Jan Feb Mar Apr May Jun

2012
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
2013
Figure 2.
Mean reporting rates to
cStock by HSAs, on all
commodities in EM (n=393)
and EPT (n=253) districts,
January 2012June 2013
AVERAGE EPT (EFFICIENT PRODUCT TRANSPORT)= 79%

AVERAGE EM (cSTOCK PLUS DPATs)= 94%
districts over the testing period (January 2012June

2013). At baseline, only 43% of CHWs interviewed
reported that they submit some kind of logistics report
(see Figure 2 above).
Supply reliability was found to be significantly higher in

EM districts compared to EPT districts. Supply reliability was defined as the mean percent CHW stock-out
rates by product over 18 months (January 2012June
2013). Stock-outs for all products ranged between 57%
in the EM group and between 1021% in the EPT
group. These differences were statistically significant at
the p=0.000 level for all products (Figure 2).
The endline evaluation assessed scale, sustainability, and

institutionalization. The evaluation consisted of qualitative
case studies and quantitative analysis of cStock data in two
original districts and two new districts. The results proved
that cStock is easily scaled and provides a simple process for
reporting on and resupplying community-level products in
a systematic way. In addition, the benefits (coordination,
communication, and collaboration) and challenges(transport,
resources, and time) of the DPATs were quickly realized in
the new districts and highlighted the importance of intense
implementation support at the initial stages.6

The overarching lesson from this research is that mobile
health strategies in isolation cannot create a reliable and
robust public health supply chain. However, if these strategies are implemented as part of broader supply chain
system strengthening activities that address the larger system
constraints, mHealth solutions can be game changing. Other
implementation challenges during development, deployment, and scale-up ranged from issues related to setting up
the technology to the question of government readiness to
assume ownership of the system after the initial implementing project ends.
Setting up a mobile information technology system: The two
mobile network operators (MNOs) initially charged commercial rates for SMS messages. Recognizing the difficulties
that the MOH would have in sustaining these costs without
continued donor support, the project engaged in intensive
advocacy efforts with both MNOs, urging them to provide
28 n C S TO C K
reduced rates as part of their corporate social responsibility

to the health sector. The efforts proved successful, with one
MNO providing a three-year waiver for SMS costs and the
other reducing SMS costs by 40% and only charging for
incoming messages.
Achieving broader ownership beyond a few champions:
Turnover of district champions, staff who were the primary
trainers and leaders for the EM approach at the district level,
resulted in some loss of momentum for the uptake of cStock
and for conducting DPAT meetings. It is important to plan
for new staff training to ensure continuity and quality of
intervention implementation. Training should also build a
sense of ownership and develop champions. For instance,
finding opportunities for district staff to attend larger
meetings where they can proudly present their successes at a
national level or across districts can motivate champions. To
mitigate staff turnover effects, trainings during the scale-
up phase included more district-level staff and all program

coordinators whose programs extend to the community level
were included as DPAT members.
Developing MOH readiness for system maintenance and
data storage / server hosting: Building capacity within the
MOH to manage the cStock system has taken time and resources. The capacity to host the data in the private sector is
still emerging. Therefore, the decision was made to outsource
data storage and software maintenance to US-based companies. While outsourcing is the appropriate choice at present,
in-country capacity for hosting and maintenance should be
revisited as the program scales.
Future Plans
While most innovation projects strive to move from pilot
to practice, achieving goals of scale-up and sustainability are
often a challenge. Over the project period EM achieved full
scale and began the journey toward being integrated as an
organizational practice. Following the close of the SC4CCM
project in 2015, JSI placed a secondee in the MOH for 12
months to transfer skills in managing cStock and the DPATs.
The secondee worked closely with MOH staff to fully establish the NPAT and institutionalize national support for the
innovation. cStock is now being funded through the Global
Fund grant, and MOH staff have taken full responsibility

for all system administration for cStock and support for the
DPATs. JSI no longer has staff dedicated to cStock and only
provides ad hoc support to the MOH as needed. cStock continues to operate at full scale and is integrated into existing
structures and processes for the CHWs. n
Snapshot: cStock
Geographic
Coverage
Malawi
Implementation
Dates
2011 to present
Implementation
Partners
Malawi Ministry of Health (MOH)(implementing)

JSI (design, pilot, and scale-up)
Dimagi (software developers)
Save the Children (scale-up)
World Health Organization (scale-up)
Donor(s)
Bill & Melinda Gates Foundation (pilot)

mHealth Alliance International Working Group
Grant (sustainability)
USAID/Presidents Malaria Initiative
Global Fund
Contact
Information
Sarah Andersson, Senior Technical Advisor, John

Snow, Inc. (JSI), [email protected]

Reports:
Strengthening Supply Chains at the Community Level: findings from the SC4CCM project in Malawi, Rwanda, and Ethiopia http://sc4ccm.jsi.com/files/2015/01/SC4CCM-Findings-Report_FINAL.pdf
From Pilot to Practice: lessons on scale, institutionalization and sustainability from the (in-progress) journey of the SC4MM project
http://sc4ccm.jsi.com/files/2014/11/Pilot-to-Practice-Brief.pdf
Malawi Intervention Strategy for Improving the Community Health Supply Chain: Implementation and M&E Plan
http://sc4ccm.jsi.com/files/2012/10/Malawi-Implementation-Plan.pdf
References:
1. WHO. Child mortality rates plunge by more than half since 1990 but global MDG target missed by wide margin. 2015. http://www.who.int/
mediacentre/news/releases/2015/child-mortality-report/en/
2. SC4CCM. 2010. Malawi Community Health Supply Chain Baseline Assessment Report. Arlington,Va. SC4CCM. http://sc4ccm.jsi.com/
files/2013/10/Malawi-Baseline-Report_FINAL.pdf
3. Chandani Y, Andersson S, Heaton A, Noel M, Shieshia M, Mwirotsi A, et al. Making products available among community health workers:
Evidence for improving community health supply chains from Ethiopia, Malawi, and Rwanda. J Glob Health [Internet]. 2014 Dec;4(2).
Available from: http://www.jogh.org/documents/issue201402/Chandani_FINAL.pdf
4. Shieshia M, Noel M, Andersson S, Felling B, Alva S, Agarwal S, et al. Strengthening community health supply chain performance through an
integrated approach: Using mHealth technology and multilevel teams in Malawi. J Glob Health [Internet]. 2014 Nov 4(2). Available from:
http://www.jogh.org/documents/issue201402/Shieshia_FINAL.pdf
5. SC4CCM. Malawi Community Health Supply Chain Midline Evaluation Report [Internet]. Arlington,VA: JSI Research & Training Institute, Inc.;
2013 [cited 2014 May 21]. Available from: http://sc4ccm.jsi.com/files/2013/11/Malawi-Midline-Report_FINAL.pdf
6. SC4CCM. Malawi SC4CCM Project Endline Evaluation Report [Internet]. Arlington,VA: JSI Research & Training Institute, Inc.; 2014. Available
from: http://sc4ccm.jsi.com/files/2014/11/Malawi-Endline-Report.pdf
iCCM
Improving the quality of child health care

in Malawi at the primary level through
decision-support tools
Hotensia Dzuwa, HSA, Mlangali Health Centre, Dedza

30 n I N T E G R AT E D C OM M U N I T Y C A S E M ANAGEMENT
Integrated Community Case Management is used in hard-toreach areas to complement facility-based services. In this project,
health surveillance assistants use a mobile application to assist in
providing health services to children under five years.
Malawi is among the nine low-income countries that reduced their under-five mortality rate by 60% or more between
1990 and 2011. Despite this progress, many children continue to die from conditions that are easily preventable and
treatable.
-A large proportion of children in Malawi are still at increased risk of mortality due to common childhood infections.
The leading causes of under-five mortality in Malawi are malaria (13%), AIDS (13%), pneumonia (11%), diarrhea
(7%), and neonatal conditions (31%). The Ministry of Health (MOH) and its partners have been scaling up a package
of high-impact interventions to reduce under-five child mortality since 2007 under the Accelerated Child Survival and
Development strategy. These efforts have included integrated Community Case Management (iCCM) in hard-to-reach
areas to complement fixed or scheduled facility-based services. D-tree International is the partner providing mHealth
solutions to support the implementation of iCCM to improve the quality of care provided to children under five.
About iCCM
n this project, health surveillance assistants (HSAs), a cadre

of community health workers, use a mobile application to
assist them in providing health services to under-five children (2-59 months) in line with the MOH-approved iCCM
protocol. The iCCM mobile application is a Mangologic
application which runs on an Android platform.
The components of the mobile application strengthen the
ability of HSAs to deliver effective and efficient care. These
components are synergistic in providing a comprehensive array
of tools and a supportive supervisory framework for the HSA.
The first component of the iCCM application captures all
the elements of the village register used by the HSA. The
application supports HSAs to make the appropriate decisions
on treatment. HSAs are also enabled to accurately report on
their work in a timely manner. The iCCM mobile application therefore enforces adherence to clinical protocols and
iCCM holistically.
The second component links the iCCM application to the

logistics management system to improve the availability of
needed drugs to the rural clinics where HSAs see patients.
This work has been coordinated with the MOH cStock program to improve its use in tracking drug inventories. D-tree
developed a simple user interface within the application for
the health workers to use to report stock levels, which is then
submitted to cStock via structured SMS.
The third component of this project is the supervisory tool
for those who are managing and supervising HSAs. The tool
is based on the new paper-based routine supervision checklist
developed by the MOH and Save the Children. It focuses on
key performance indicators for the HSAs. The tool facilitates
both collection and interpretation of data and also has a
dashboard so users can see the status of the work being done
by HSAs; it will also provide information for project-related
decision-making.

The algorithm for the application was developed using the
MOHs approved iCCM protocol. After the development
and design of the application, D-tree trained six HSAs from
Ntchisi District to use the application in their respective
village clinics. The six HSAs were engaged to solicit feedback
about the functionality, relevance, and user friendliness of
the application to refine it. The refinement process took two
months. The district health management team and Integrated
Management of Childhood Illnesses (IMCI) Unit were then
informed and permission was granted to roll out the application to all HSAs conducting iCCM in the district. D-tree
trained MOH officials to train the HSAs. MOH officials were
used as trainers with the objective of ensuring sustainability,
support, and easy management of mobile application use.
To keep the MOH and other relevant stakeholders informed
about the progress of the implementation, presentations on
the application functionality and roll-out were made during
IMCI technical working group meetings, which are hosted
by the MOH and attended by partners such as the Malaria Control Program, Central Monitoring and Evaluation
Department in the Ministry of Education, Save the Children,
UNICEF, Support for Service Delivery Integration, and the

World Health Organization.
D-tree employs a number of avenues to solicit feedback to
improve the application. D-tree has set up a chat group on
Whatsapp which serves as a community of practice among
the HSAs in their respective health facilities to share information on the usage and difficulties they may be facing. HSA
supervisors also have a chat group on Whatsapp where they
share ideas and give feedback on the use of the application.
There is a dedicated helpline, which is available to all HSAs to
call during working hours. D-tree interacts with IMCI experts
who have the mandate from MOH to make changes to the
protocols and to give feedback which is incorporated into
the application. As part of project implementation, there are
scheduled review meetings at the district and health facility
levels where HSA supervisors and HSAs review progress and
give feedback on use of the application. When feedback has
been incorporated into the application, a new version is created and deployed remotely to the users. Users are informed
through their respective chat forums and/or through SMS
about the changes.
Growth in Scale
After initial development and refinement, the iCCM
mHealth application was rolled out in Ntchisi District with
about 20 HSAs in 2013. By December 2014, 138 HSAs and
15 HSA supervisors in Ntchisi District had been trained. The
application was expanded to HSAs in Dedza and Ntcheu

districts in 2014 and in Mzimba North District in 2015.
By February 2016, 128 HSAs and 33 HSA supervisors in
Dedza, 116 HSAs in Mzimba North, and 133 HSAs and 38
Figure 1.
Total number of children seen
80,000
Dowa
Machinga
Ntchisi
60,000
Ntcheu
40,000
Mzimba
North
20,000
Dedza
Q3
2013
Q4
Q1
2014
Q2
Q3
Q4
Q1
2015
Q2
Q3
Q4
Q1
2016
Flackson Chibwato, HSA, Chinguluwe Health Centre, Ntchisi
supervisors in Ntcheu had been trained to use the iCCM and

supervisory applications. The HSAs have dedicated two to
three days a week to running the village clinics. However, they
see children who come to the village clinic even outside the
dedicated days. On average, 75% of the HSAs are consistently
using the mHealth application when assessing and treating
children at the village clinics.
HSAs are responsible for a number of health services, including family planning; community case management;
community-based maternal and neonatal health (CBMNH);
nutrition; and water, sanitation, and hygiene (WASH).
D-tree plans to integrate as many services as possible into one
application to support the work of the HSAs. The current

iCCM application was integrated with CBMNH protocols to
have an integrated CCM/CBMNH application. This application was rolled out to 350 HSAs in Dowa District and 166
HSAs in Machinga District in 2015. In total, the program
has trained and equipped 1,031 HSAs and 84 HSA supervisors since 2013. The total number of clients seen as of March
2016 is 307,762 (see Figure 1).
During 2016, D-tree will also add a family planning component to the application and add coverage to at least one
more district.

D-tree International carried out an evaluation to determine
the clinical effectiveness of the electronic CCM. A mixed
approach was used to collect both quantitative and qualitative
data. The results showed higher scores in assessment, identification of danger signs referrals (diagnosis), treatment, and
counseling. These are the key elements in the management of
illnesses in children under-five.
Adherence to assessment using the eCCM app was 100%
compared to 91% for those using paper. With the phone
application, all questions are asked and recorded before going
on to the next phase to encourage the HSA to go through the
complete assessment. Paper users correctly identified 60%
of the danger signs compared to 100% of the phone users.
Treatment of cases with no danger signs was higher in the paper users (79%) compared to the phone users (74%). While
the phone provides the recommended treatment, the actual
treatment given depends on the availability of the drugs and

supplies recommended. Sixty percent of cases were referred
appropriately in the intervention (phone) group while 48% of
the cases were referred correctly in the control (paper) group.
Counseling and treatment advice were seen to be higher
among the phone users (93%) than the paper users (87%).
From the HSA and caregiver interviews, considerable positive feeling and feedback were recorded. HSAs felt more
confident in using the iCCM application. They also felt that
there was a reduction in the frequency of visits by the same
children as compared to before, which they attributed to the
comprehensiveness of the assessment and care given to the
child when using the phone. HSAs expressed knowledge gain
in using the application from the prompts and advice as well
as counseling messages they get from the phone. HSAs also
expressed improved follow-up rates for cases. However, they
were concerned with the double entry of data as they use both
the phone and paper registers.
Quotes from the district health team and HSAs include:
It is better to use the phone than the paper, because the phone has
everything you need to do CCM. District IMCI coordinator
The phone enables me to conduct a comprehensive assessment

of the child. The phone makes a diagnosis for me, so it makes
my work easier, unlike before where I had to make sense of the
symptoms to make a diagnosis. Daniel Mandevu, Bembeke
Health Centre, Dedza
It takes effort to train and generate stakeholder interest in using data arising from the implementation of
a mHealth application; simply building program dashboards is not enough. We have now worked to ensure
that the results from each districts activities are reviewed
and presented at the quarterly program meetings. For
instance, based on the usage levels from Dowa District
in 2016, D-tree was able to establish that the HSAs
faced acute drug shortages and therefore were unable to
operate the village clinics at full scale. This was brought
to the attention of the IMCI unit, which sent a team to
try to resolve the situation.
The involvement of communities in managing the
phones is critical to their sustainability. There have
been occasions when an HSAs phone was stolen and
later returned by another community member, as they
saw this as a tool that belonged to the community and
not just an individual. This is because after the application training, the HSAs sensitize the communities that
they will now be using the phone to assess and treat the
children. The community then sees the phone as a tool
for running the village clinic.
The implementation of the mHealth system is not
a panacea to fix all the problems of the health
system. It is and should be part of an integrated system
to improve health care and outcomes. Specific to the
iCCM system, when there are drug stock-outs, the

HSAs tend to close the village clinics, so a mobile tool
will only have limited effectiveness. Therefore, continued supervisory support is needed for both eCCM and
non-mobile sites to help the HSAs feel confident to still
see sick children even if they lack medication, as they
should be able to successfully diagnose them and identify those who need home care and those who need to be
urgently referred.
When scaling up, it is important to have clear and

sustainable follow-up and support processes in place.
It is more helpful to avoid creating parallel structures and
instead use existing structures to provide the support.
In order to enhance coordination efforts between programs at the MOH and to support the use of data for
decision-making, D-tree placed a team member at
the IMCI unit to serve as mHealth coordinator.
Although the mHealth application does not yet directly
connect into the District Health Information Software2
(DHIS2), the monthly reporting feature has shown
to be useful as the districts using the mobile application
have shown improved reporting rates into DHIS2. In
the Central West Zone, for example, the mobile districts
showed 100% reporting rates for the last 5 months with
89% reporting on time as compared to a 77% reporting
rate and 53% on time in the non-mobile districts.
Future Plans
D-tree plans to develop a supervisory application for the
integrated CCM/CBMNH application, which will allow the
HSA supervisors to monitor the performance of their HSAs
from a mobile device. As the program has grown, we have
seen the need to engage HSA supervisors as well as assistant
environmental health officers as a way of extending the ability
of the program to identify HSAs who are struggling and to resolve common issues. In addition, the supervisory application
will improve interaction between the HSAs and their supervisors through remotely checking the HSAs performance.
Currently, physical supervisions to check HSAs performance
are irregular due to financial constraints in the MOH.
With the continuous support to improve quality of care, the

next step for D-tree is to integrate family planning into the
existing CCM/CBMNH application. This is another key
component of the work of the HSAs and was identified as
a priority following discussions with the MOH. With the
addition of family planning, the application will now serve
to support most of the functions the HSAs perform. The
integration of applications is in line with the MOH strategic
plan where standalone services are being integrated to ensure
a holistic approach to health care given to clients whose health
needs span across multiple services.
Two HSAs doing a role play at a CCM mHealth app training in Ntcheu
D-tree, in collaboration with other partners, is working with

the MOH to put systems in place that will enable interoperability of both systems to allow data from the mobile application to be sent to DHIS2. Currently, the health information
system (HIS) policy has been approved and standard operating procedures (SOPS) are being developed. The SOPs will
determine the process of interoperability.
While there is strong support from the MOH for continued use of the application and scale-up, the current funding
streams end in 2016 and 2017, presenting a challenge for the
future. This is an issue the MOH faces in other programs as
well, as donors are directing funding through development
partners rather than through the MOH, limiting the governments ability to fund their priorities. n
Snapshot: iCCM
Geographic
Coverage
Malawi
Districts: Dedza, Mzimba North, Ntcheu, Ntchisi,
Dowa, and Machinga
Implementation
Dates
July 2012March 2017
Implementation
Partners
D-tree International (project design and

implementation support)
ThingsPrime (solutions architect)
Ministry of Health (implementer)
Save the Children (project partner)
Support for Service Delivery Integration (project
partner)
Donor(s)
Barr Foundation
Save the Children (Malawi)
Support for Service Delivery Integration
Contact
Information
Steve Ollis, Chief Operating Officer, D-tree

International, [email protected]

1. Agarwal Smisha, LeFevre Amnesty E, Lee Jaime, LEngle Kelly, Mehl Garrett, Sinha Chaitali et al. Guidelines for reporting of health
interventions using mobile phones: mobile health (mHealth) evidence reporting and assessment (mERA) checklist. BMJ. 2016.
2. UNICEF. Committing to Child Survival : A Promised Renewed. Progress Report 2012
3. Bryce J, Requejo JH. 2010. Countdown to 2015 Decade report (20002010):Taking stock of maternal, newborn, and child survival. New York,
Countdown to 2015 for Maternal, Newborn and Child Health.
mHEALTH FOR MOTHERS
KILKARI, MOBILE ACADEMY,

& MOBILE KUNJI
Photo by BBC Media Action

36 n K I L K A R I , M OB I L E AC AD E M Y, AN D M OBILE KUNJI
Scaling up free mobile health education to 1 million community

health workers and 10 million women in partnership with the
Government of India
Indias maternal and infant mortality rates remain above the Sustainable Development Goal targets. The Government
of India is making considerable investments in this area and various innovative approaches and initiatives are evolving
to bolster these efforts. Leveraging mobile phone technology (mHealth) to change peoples health-seeking behavior is
key among them.
In 2012, BBC Media Action, as a part of the Bill & Melinda Gates Foundation-funded Ananya program, designed,
developed, and rolled out three mHealth services to increase the uptake of life-saving preventative maternal and child
health behaviors by pregnant women, mothers of children up to two years old, and rural families in Bihar State. Ananya
is a collaboration between the Gates Foundation and the Government of Bihar to dramatically reduce maternal and
infant mortality in the state.
Kilkari (a babys gurgle) is an outbound service that

delivers weekly, time-appropriate audio messages
about pregnancy, childbirth, and childcare directly to
families mobile phones from the second trimester of
pregnancy until the child is one year old.
Mobile Academy is an IVR training course designed
to refresh CHWs knowledge of simple steps
families can take to improve the health of mothers
and babies, and to improve their ability to clearly
communicate them.
Mobile Kunji is a free audio-visual job aid that

brings together an interactive voice response (IVR)
mobile service with a printed deck of cards with
important health messages. It is designed to improve
engagement between community health workers
(CHWs) and families, thus leading to healthier
behavior by new and expecting mothers.
Given the success of these services, on 15 January 2016 the Government of India launched Kilkari and Mobile
Academy nationally to train one million health workers and help nearly 10 million new & expecting mothers make
healthier choices.
About Kilkari, Mobile Academy, and Mobile Kunji
ilkari, Mobile Academy, and Mobile Kunji all use IVR

technology that is already being used by the commercial mobile industry to make audio content available to any
mobile phone across India. No new handsets, software, or
technical skills are required for target groups to use the projects services, allowing accessibility at scale from the outset.
A robust, open source mobile health platform called Mobile
Technology for Community Health (MOTECH) powers all
three services.
At the national level, both Mobile Academy and Kilkari have

been integrated with the governments Maternal and Child
Tracking System (MCTS). Currently 1.3 million pregnant
women and mothers across six states who have registered
mobile numbers on MCTS are automatically subscribed so
that they begin receiving weekly calls. Similarly, only CHWs,
who are registered in MCTS can dial into Mobile Academy
and access the four-hour training course. They dial a 12-digit
for access; bookmarking technology allows them to return to
the exact location in the course whenever they like.

When the three services were first being designed for rollout
in Bihar, the goal was to create mHealth services that are
scalable across the state and eventually across the country.
Bihar alone has a population of 108 million people, including 27 million women of childbearing age, and over 80% of
the population is rural with limited access to traditional media (TV and radio). However, 83% of women have access to
mobile phones, but most of these are low-end basic phones.
The aim was to use low-end technology for high-end gains,
sustainably scale the solutions for millions of people, and
create services that did not require smartphones, software, or
technical skills to use.
began to conceptualize and design the services. This involved

technological design and development, checking health
content, and conducting several rounds of user-testing and
content pretesting.
The solution was found through Kilkari, Mobile Academy,

and Mobile Kunji. All services are handset agnostic and employ easy-to-use familiar IVR technology. Mobile Academy
empowers CHWs to access affordable standardized training
content on their own terms; Kilkari delivers time-sensitive
audio messages directly to the mobile phones of families; and
Mobile Kunji gets around the challenge of delivering audio
and visual content without distributing expensive hardware.
BBC Media Action collaborated with the Ministry of Health

and Family Welfare (MOHFW), the National Health System
Resource Centre, and National Health Missions (NHMs) in
the states and experts in the field of reproductive, maternal,
newborn, child, and adolescent health (RMNCH+A) to
compile the technical health content for all three services.
Before services were launched, the technical health content
went through a rigorous vetting and approval process at
MOHFW. This ensured that health content was aligned
with national guidelines. In addition, a plan for periodically
updating content was developed to ensure that it remains
accurate and relevant to the audiences.
BBC Media Action began by researching its audiences:

CHWs, pregnant women, and mothers of young children
and their families. It conducted a landscaping study to
understand their mobile ownership and usage patterns and
A user-centric design approach was employed during development involving feedback and inputs from CHWs. Mobile
Kunji, Mobile Academy, and Kilkari (user interface and content) went through four rounds of rigorous user-testing and
pretesting with CHWs and families to assess comprehension,
usability, and perceived value. The services were modified
based on the results of each round of user-testing and then
tested again until satisfactory results were achieved.
Growth in Scale
The rollout and scale-up of the three services in individual
states has involved working with the MOHFW at the national level, the NHMs at the national and state level, and
an alliance of donors (Gates Foundation, USAID, Barr
Foundation, and UK Department for International Development (UKAid)).
In May 2012, BBC Media Action launched Mobile Academy
and Mobile Kunji in Bihar as part of the Ananya program.
In August 2013, BBC Media Action then launched Kilkari
in Bihar under the same program. In 2014, Mobile Academy
and Mobile Kunji were launched in Odisha with funding
from UKAid and the state government, and in 2015, with
funding from the Gates Foundation and the state government, the two services (Mobile Kunji and Mobile Academy)
were launched in Uttar Pradesh.
In 2014, the MOHFW expressed interest in rolling out
Mobile Academy and Kilkari nationally. At that time, BBC
Media Action and the Gates Foundation began working with
MOHFW to take the services to scale. The national launch
of Mobile Academy and Kilkari by the MOHFW took place
in January 2016. The services will be rolled-out in three

phases to train 1 million community health workers and help
nearly 10 million new and expecting mothers make healthier
choices and lead longer, healthier lives. In phase one of the
national scale-up, Kilkari was rolled out in six Empowered
Action Group states (Jhakrhand, Madhya Pradesh, Odisha,
Rajasthan, Uttarakhand, Uttar Pradesh) and Mobile Academy was rolled out in Jhakrhand, Madhya Pradesh, Rajasthan, and Uttarakhand. In phase two, the two services will
be scaled to an additional three states (planned for 2017);
in phase three, the services will be scaled across the country
(planned for 2018 onwards). In 2015, the Barr Foundation
and USAID joined the national scale-up effort. BBC Media
Action has worked in partnership with the Grameen Foundation since 2011 to scale MOTECH to power the services.
MOTECH continues to be the engine for the national
deployment. BBC Media Action, in partnership with state
governments, is also scaling Mobile Kunji in Bihar, Odisha,
and Uttar Pradesh, and rollout is planned in Jharkhand later
in 2016.
Photo by Priyanka Dutt

Mobile Kunji (left) and Mobile Academy (right)

Kilkari is being rolled out in six states currently to reach
approximately one million families, with a goal to rapidly
scale to reach 10 million families a year. Mobile Academy
is now being rolled out to 432,000 health workers in Bihar,
Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttarakhand, and Uttar Pradesh. The MOHFW plans to scale
Mobile Academy to reach nearly a million health workers
over the next three years. Mobile Kunji is being rolled out on
a state-by-state basis to more than 282,000 CHWs in Bihar,
Odisha, and Uttar Pradesh, with plans to scale to Jharkhand
soon.
The results of a usage and engagement study, commissioned
by BBC Media Action and carried out by the Indian Market
Research Bureau in Bihar in 2014, indicate that exposureto
Mobile Kunji is positively associated with: significant increases in the knowledge, confidence, and credibility of CHWs;
positive significant difference in the quality of CHWs interactions with new and expecting mothers; positive significant
difference in levels of knowledge of life-saving preventative
health behaviors among new and expecting mothers; and
positive significant difference in adoption of life-saving
preventative health behaviors by new and expecting mothers.
A limited evaluation of Mobile Academy was also carried out
as part of the usage and engagement study. It showed that
Mobile Academy had a positive impact on the knowledge
and confidence of CHWs, improved their standing in the
community, and resulted in recognition from their peers.
Mobile usage data provides real-time information about
Kilkari usage patterns by beneficiaries as well as CHWs
progress through Mobile Academy and which Mobile Kunji
content has been played to families (in what volume and

with what frequency). Tracking these indicators over time
provides key insights that enable on-ground project staff and
government officials to make timely decisions about implementation and planning.
Indicators to monitor the usage of Mobile Academy include
the uptake of the service by CHWsthis includes the number of unique users, the minutes consumed, progression and
competition by CHWs in the four-hour course. This data
can be aggregated for each block (smallest administrative
unit in a state), district, and state. Project staff and government officials at these levels can monitor this data and use it
to support and encourage CHWs in low-performing blocks
to complete the course and help them if they have run into
difficulties.
The indicators to assess the uptake of Kilkari include the
number of users called by the service, the number of successful calls, minutes of content heard. The data generated can
be aggregated, analyzed, and used by project and government
staff to understand why the duration of messages listened to
in one block, district, or state is lower than another.
Indicators for Mobile Kunji include the number of CHWs
using the service, how many minutes heard, and specific
health information accessed. This data can be used by project
and government staff to understand why CHWs are not discussing a particular behavior. Based on this information, field
staff can provide additional support in the form of training
or mentoring.
Demonstrate sustained adoption at scale, as well as

health impact. One of the biggest challenges that state
and national governments face is in scaling mHealth solutions beyond pilot stage. It is necessary to plan for growth
early to figure out the significant financial, technical,
operational, and legal challenges involved in scaling.
Take the path of least resistance. Modify the approach to reduce government procurement challenges.
In India, as in many other countries, the government
must first go through a procurement process to adopt a
technology, product, or service. This can be a time consuming process. To help avert delays, BBC Media Action
set up a toll free centralized long code platform, where
shortcodes and integration with multiple operators
billing systems were not required, and government only
needed to contract one operator via a standard competitive process.
To generate wider interest, demonstrate demand for
services not just from users, but from state governments. The national governments interest in BBC
Media Actions services grew after it scaled beyond Bihar.
The launch in Odisha with support from UKAid and the
state government in February 2014, and further program
growth in other states drew attention at the national level.
Be prepared to cope with the challenges of scaling
and supporting open source software. Open source
software is used to power Kilkari, Mobile Academy, and
Mobile Kunji because by investing in an open source
mobile health platform, the financial hurdles that the
government faces in adopting the system are limited.
Essentially, it reduced the total cost of government

ownership. However, when deciding to use open source
software, it is critical for the development community to
acknowledge the risk in using open source technology.
Firstly, open source software may be created by organizations that might not have the capacity required to support
the software to industry standard service level agreements
after launch at scale. In addition, although open source
technology can be adoptable by anyone, in many cases the
people who know best how to fix or further develop an
application are those who built it.
Localize content, test that it works, and keep technical information relevant and up-to-date. Understand who the target audience is and ensure that content
is relevant, understandable, and engaging. Its vital that
the technical health content is reviewed periodically and
updated as required. Its best to set up a process that
ensures that key stakeholders review and update content
periodically.
Content licensing protects quality. BBC Media
Action is licensing its mobile health content, developed
with funding from the Gates Foundation, DFID, and
the Barr Foundation, to the government of India at
no cost. However, the content is not open sourceit
cannot be downloadable by anyone under a Creative
Commons license. BBC Media Action licenses its health
contentusually royalty freeon a case-by-case basis
to ensure that it remains factually accurate, complies
with government policies and guidelines, is used in the
context it was designed for, and is being used with the
consent of the people featured.
Future Plans
National launch of Mobile Academy and Kilkari by the national government took place in January 2016. The services
will be rolled-out in three phases, adding states in phase one
and two during 2016 and 2017 dependent on feedback from
users and successful adoption of the services in the phase
one states. In 2018, there are plans to begin scaling the two
services to the rest of the country, reaching a total of 1 million CHWs and 10 million pregnant women and mothers of
children under one year of age. BBC Media Action, in partnership with state governments, is also scaling Mobile Kunji
in Bihar, Odisha, and Uttar Pradesh, and rollout is planned
in Jharkhand later in 2016.
The Gates Foundations investment has covered the cost of
scaling the software for the two services (including
MOTECH) so it can handle calls to and from 35 states,

and to support software for a period of three years (through
December 2018). Support from USAID and the Gates
Foundation contributes to the national scale-up effort over
the next two and a half years. Further investment is required
for developing different language versions of the two services,
to carry out monitoring and evaluation of the project, and
to document the five-year learning journey from research
and development to national scale-up. BBC Media Action is
currently working to design impact-evaluation studies and a
cost-benefit analysis of all three services to assess the value of
delivering free health education to millions of beneficiaries
and health workers. n
Snapshot: Kilkari, Mobile Academy, Mobile Kunji

Geographic
Coverage
India
Mobile Kunji: Bihar, Odisha, Uttar Pradesh
Mobile Academy: Bihar, Odisha, Uttar Pradesh,
Rajasthan, Madhya Pradesh, Jharkhand, and
Uttarakhand
Kilkari: Odisha, Uttar Pradesh, Rajasthan, Madhya
Pradesh, Jharkhad, and Uttarakhand
Implementation
Dates
May 2012 to present: Mobile Kunji and Mobile

Academy
May 2013 to present: Kilkari
Implementation
Partners
BBC Media Action (implementing organization)

Pathfinder Intl. (Dec 2010-Mar 2016)
(implementation partner)
Grameen Foundation; OnMobile; Onion
Development Technologies; IMIMobile; GSMA
(technology partners)
Government of India Ministry of Health & Family
Welfare, State National Health Missions (partners)
Donor(s)
Bill & Melinda Gates Foundation; USAID; Barr

Foundation; UKAid
Contact
Information
Sara Chamberlain, Director, Digital, BBC Media

Action, India
[email protected]

Yvonne MacPherson and Sara Chamberlain. Health on the Move: Can Mobile Phones Save Lives? February 2013.
www.bbc.co.uk/mediaaction/publications-and-resources/policy/briefings/asia/india/policy_mhealth
Sara Chamberlain. A Mobile Guide Toward Better Health. Innovations. MIT Press. 2014.
mitpressjournals.org/userimages/ContentEditor/1415302178306/INNOVATIONS_DIGITAL-INCLUSION.pdf
Video: Design thinking behind Mobile Kunji and Mobile Academy: youtu.be/IUIDhU_Zjcc
Video: Impact of Mobile Kunji and Mobile Academy: youtu.be/KtI-XgCuhTg
Priyanka Dutt. Six Lessons I learnt while Trying to Reach 10 Million Women in India with Life-saving Health Information. April 2016.
blogs.worldbank.org/publicsphere/blog-post-month-six-lessons-i-learnt-while-trying-reach-10-million-women-india-life-saving-health
Bihar project website: www.rethink1000days.org
References
1. Impact of Audio-Visual Job Aid on Influencing Family Health Outcomes in Bihar: Findings from the Usage and Engagement study on Mobile
Kunji. www.rethink1000days.org/wp-content/uploads/2016/02/Detailed-presentation_-study-on-effectiveness-of-Mobile-Kunji.pdf
2. Priyanka Dutt. Technology saving millions of lives. Huffington Post. January 2016. www.huffingtonpost.co.uk/priyanka-dutt/technologysaving-millions-of-lives_b_9058016.html
mHERO
Connecting ministries of health with frontline

health workers via SMS
Photo by Emily Nicholson for IntraHealth International

42 n M H E RO
MHero is a two-way, mobile phone-based communication

platform that uses basic text messaging, or SMS, to connect
ministries of health and health workers. mHero operates
on simple talk-and-text mobile devicesno smartphone or
tablet required.
MHero is not a new technology. Its a way to connect data from existing health information systems (HIS) to allow
targeted, real-time communication. mHero brings together components of a countrys HIS using open international
interoperability standards for health information exchange. Health officials can use mHero to:
communicate critical messages to health workers

during a crisis;
target messages to health workers based on cadre,
location, or skill set;
collect critical information that supports resilient
health systems, including stock levels, routine formal
and informal indicators, one-time assessments, and

validation of health worker and facility data; and
support surveillance systems for real-time reporting on active cases and potential outbreaks and to
reinforce health workers skillspart of a countrys
solution for Integrated Disease Surveillance and
Response (IDSR).
Harnessing the principles for digital developmentguidelines that can help development practitioners integrate
established best practices into technology-enabled programsIntraHealth International and UNICEF created mHero in
August 2014 to support health sector communication during the Ebola outbreak in Liberia.1 mHero is currently being
scaled up in Liberia, piloted in Guinea and Sierra Leone, and deployed in Mali and Senegal as part of the Global Health
Security Agenda to support IDSR use cases.
About mHero
Hero combines iHRIS, an open source human resources information system (HRIS) developed by IntraHealth, and RapidPro, UNICEFs SMS platform that allows
users to create SMS messages in a workflow through a
website. mHero supports one-time messages to health workers or two-way communication between health workers and
the ministry of health. Health workers can initiate messages
themselves by sending a standardized SMS to the mHero
phone number.
The technology behind mHero includes interoperability with
other systems, such as DHIS2, through OpenHIE, an architecture that supports mHero as HIS expands and evolves.
Using these open source systems, ministries of health are able
to efficiently leverage health information technologies, many
of which they have already invested in scaling to improve
their own HIS.
What makes mHero work at national scale is rigorous

adoption of open international standards for health information data exchange. These include the Care Services
Discovery (CSD), Mobile Alert Communication Management (mACM), and HL7 Fast Healthcare Interoperability
Resources (FHIR) standards for sharing health worker and
health facility data and to provide standards-based communication protocols for health workers. The open source and
open standards approach means that the mHero platform is
not tied to any specific piece of software and allows ministries of health to readily integrate mHero into their HIS.
A variety of tools support the mHero platform.2 These
include video tutorials on operating the platform; operations
and management tools to support implementation; and a
wiki to guide developers and program implementers setting
up their own instances of the platform.3,4

The mHero platform is designed by facilitating interoperability of existing HIS. Linking iHRIS and RapidPro via
an interlinked health worker registry, information on health
workers (including cadre, facility, location), as well as their
mobile numbers, are pulled from iHRIS and attached to the
workflow developed in RapidPro. mHero was also created to
be interoperable with District Health Information Software2 (DHIS2) and interlinked facility registries to ensure
standardized facility data are part of the mHero platform.
Security, access control, and data synchronization services are
provided through the OpenHIM software.
mHeros initial development was supported by UNICEF,
the US Agency for International Development (USAID)
through the K4Health Project, and Johnson & Johnson.
The design process engaged a number of partners, including
Jembi Health Systems, Thoughtworks, USAID, and others.
An intentional multistakeholder approach was undertaken in
the development and implementation of mHero to include
as much collaboration as possible to ensure the platform
aligned with other digital efforts to reach health workers,
especially during the Ebola response. These stakeholders
have expanded to include the World Health Organization,
MEASURE Evaluation, Jhpiego, Management Sciences for
Health, mPowering Frontline Health Workers, eHealth Af-
rica, Johns Hopkins Center for Communication Programs,

International Medical Corps, Dimagi, the Clinton Health
Access Initiative and many others.
The most important stakeholder, however, is the ministry
of health in the country in which mHero is implemented.
mHero is fully integrated into and operated directly by the
ministry. The ministry decides which use cases to prioritize
and which health workers to target with messages, and develops and sends the workflows. IntraHealth works with the
ministries and partners in the respective countries to align
mHero with national policies and strategies so the platform
can be utilized to support the existing (or future) HIS and to
respond to priority health needs.
IntraHealth and UNICEF are building the capacity of
mHero implementers at ministries of health in Liberia,
Sierra Leone, and Guinea. This includes collaboration to
strategically integrate mHero into existing data collection
and reporting structures, training in RapidPro to create
workflows and in operation of the platform through iHRIS,
establishing interoperability between RapidPro and iHRIS,
and developing standard operating procedures and other
critical management processes to integrate mHero into the
existing HIS framework.5
Growth in Scale
The first mHero use cases were developed to help Liberias Ministry of Health and Social Welfare determine the
location of health workers during the Ebola response and
which facilities were open. After a successful pilot in four
facilities in four counties, the mHero team at the ministry
began raising awareness of the platform among county-level
stakeholders.
Interest in the system grew as officials realized the platforms
accessibility and flexibility, allowing for new use cases to
be developed. These included collecting information about
mental health services, conducting an assessment of anthropometric nutrition tools, alerting new staff to their payroll
IDs, and collecting information from health workers on their
level of family planning training, commodities supply, and
service provision.6 To date, 22 distinct use cases have reached
over 5,000 health workers throughout the country. The ministry is now engaging external partners in the development
and sending of use cases, demonstrating its role in leading
health worker communications in Liberia.
44 n M H E RO
The success of mHero in Liberia can be attributed to the

ministry mHero teams ownership of the platform and
commitment to ensuring mHero is aligned with Liberias
HIS and that the platform is successful in responding to the
ministrys information and communication needs.As mHero
scaled in Liberia, ministries in Guinea and Sierra Leone
began planning implementations. Officials from the three
countries met through iHRIS and mHero trainings to share
experiences developing and deploying the platform, including integration into ministry and HIS structures and best
practices for strategic development of meaningful use cases.
As of March 2016, the ministry in Sierra Leone had planned
its use cases and was close to piloting the platform. Efforts
to build a sustainable base for mHero in Guinea are gaining
momentum as the ministry develops its HIS strategic plan.
USAID has supported scale-up of mHero in the three countries through the Ebola Grand Challenge Innovation Grant
through the Global Health Bureau.
Photos by Emily Nicholson for IntraHealth International
In Mali, IntraHealth is working with the Ministry of Health

to develop and deploy mHero in both SMS and interactive
voice response (IVR) formats to support the surveillance
system, including enhancements in real-time reporting and
reinforcement of health workers skill sets during the surveillance process. In Senegal, the Ministry of Health is deploying
a version of mHero across its health regions.

In November 2015, one year after the initial pilot, a baseline
assessment was conducted in Liberia to measure frontline
health workers awareness of, use of, and attitudes toward
mHero. Ten-question phone surveys were administered to
266 randomly selected recipients who fit the definition of
a frontline health worker. A randomly selected subsample
of 20 health workers responded to an extended survey. This
survey featured additional queries that elicited more detailed
information about respondents phone use, including mobile
technologies such game playing, accessing social media,
and taking online courses. The extended survey also probed
participants phone use patterns, such as preferred times for
receiving and responding to text messages.
associated with Liberias Ministry of Health and Social Welfare. The largest factor contributing to awareness of mHero
was exposure, as 81% of those who knew of the platform
had received an SMS sent via mHero. Health workers identified various factors motivating them to respond to these
messages, with the most frequent reason being that they had
been told about mHero prior to receiving the text. Responses
to the extended survey indicate that health workers almost
universally bring their phones to work each day, and more
use their phones for connecting to social media than they do
for playing games or taking courses. Health workers report
receiving a wide variety of health-related texts each month of
varying origin.
Overall, survey findings at baseline proved very preliminary

due to a lack of awareness of mHero among respondents.
Out of the 266 respondents, only 7.9% of the health workers
had heard of mHero, and even fewer knew that mHero was
An endline assessment using the same questions will be conducted in Liberia in July 2016 toward the end of the USAID
Ebola Grand Challenge Project.
Photo by Emily Nicholson for IntraHealth International

A number of key insights and lessons learned have emerged
since mHeros initial pilot in late 2014. These include:
Ministry of health leadership and ownership: mHeros success depends on the ministry stakeholders who
utilize and implement the platform. It can take time
to build a sense of ownership, to identify the strategic
home for mHero within the ministry, and to integrate
mHero into the HIS architecture.
Awareness-raising with health workers: To encourage their active engagement, health workers need to
know that mHero messages are legitimately from the
ministry and that their responses are important for
decision-making. Flyers, brochures, and other communication tools can help spread the word.
Infrastructure: mHeros functionality depends on a

number of infrastructure components, including adequate software and hardware to operate the platform and
mobile network service throughout the country. Inadequate infrastructure has delayed mHero implementation,
in some cases more so than expected, but IntraHealth is
46 n M H E RO
working with other implementing partners to improve

infrastructure in Liberia, Guinea, and Sierra Leone.
The needed infrastructural investments are not extreme
and can support other subsystems of an HIS and basic
operations of the ministry. This includes basic Internet
connection, procuring laptops for ministry staff, and
provision of servers and backup servers for data and ensuring security of mHero and iHRIS data. Working with
other partners and donors to ensure a strategic approach
to infrastructure improvement is important, especially
during an emergency response when coordination of
investments is challenging.
Implementation capacity: Though mHero harnesses

existing technology, the processes for implementing
mHero are new. Ensuring ongoing capacity-building
for mHero team members to not only facilitate the
interoperability of the systems but also establish procedures that fit within their local context is important, as
is building capacity to manage and use data. Through
ongoing training and mentorship, both from a distance
and through short-term technical assistance, IntraHealth
continues to work with mHero teams in the respective

ministries to foster skills-building in systems operations
and data use. Staff turnover and non-mHero work
demands have posed challenges, thus an organizational
development approach must be taken in capacity-building efforts.
Engaging other external partners: Many other donors

and implementing partners have been operating in
Liberia, Guinea, and Sierra Leone to support the Ebola
response and rebuilding efforts, creating an additional
but important layer of collaboration and commitment
for mHero implementation to be successful.
Streamlined integration for communication with a

health facilitys point of contact
Integration with other communication platforms as

alternatives to RapidPro (e.g., CommCare) for countries
that are comfortable with their existing platform
Expanded analytics capabilities n
Future Plans
The future of mHero focuses on thoughtful steps toward the
full integration of the platform into ministry of health HIS
plans and procedures, ensuring strategic use of the platform
to support the needs of health workers and ministries, and
raising awareness to encourage message response. Future
trainings on both iHRIS and mHero have been planned, as
well as workshops on the strategic use of data to inform programmatic and policy decisions. Discussions about interoperability are underway to ensure mHero can directly support
other HIS subsystems. Pilot messages will be initiated in
Sierra Leone, Guinea, and Liberia in the coming months,
demonstrating full regional scale of the platform. In addition, the Liberia ministry is interested in decentralizing use
of mHero so that county human resource officers can use it
to communicate with health workers in facilities.
Other future plans to expand the capability of the mHero
platform include the following:
Providing mHero functionality at the level of the Interlinked Health Worker Registry, rather than iHRIS, for
countries or programs that do not use iHRIS
Tighter integration with DHIS2 for routine data collection as well as alerts and reminders to support the
routine data-collection process
Snapshot: mHero
Geographic
Coverage
Guinea, Liberia, Mali, Senegal, Sierra Leone, Tanzania
Implementation
Dates
November 2014 to present
Implementation
Partners
IntraHealth (co-founder of platform);

UNICEF (co-founder of platform)
mHero is implemented by Ministries of Health
Donor(s)
USAI
Johnson & Johnson
UNICEF Global Innovation Centre
UNICEF Liberia
Contact
Information
Amanda Puckett BenDor, Technical Advisor,

IntraHealth, [email protected]

1. The Principles. Principles for Digital Development, accessed March 15, 2016. http://digitalprinciples.org/
2. Toolbox & Resources. mHero.org, last modified April 19, 2016, http://www.mhero.org/toolbox-resources
3. Leitner, Carl. mHero Videos by Carl. YouTube.com, last modified September 1, 2015, https://www.youtube.com/playlist?list=PLVSgzqqaj15C4JEF-_GD5n8553ZgO_Nc
4. MHero Installation and Configuration. ihris.org, last modified March 1, 2016. https://wiki.ihris.org/wiki/MHero_Installation_and_
Configuration
5. RapidPro Table of Contents. RapidPro.io, accessed March 21, 2016. http://docs.rapidpro.io/
6. Puckett BenDor, Amanda; Nicholson, Emily. Spotlight: mHero Connects Frontline Health Workers with Mental Health Services in Liberia.
IntraHealth.org. December, 2015. http://www.intrahealth.org/page/mheromentalhealth
MOM CONNECT
Promoting maternal and child health in South

Africa through mobile health messaging and
feedback on services received
Photo by MomConnect
48 n M O M C O N N E C T
The MomConnect technical solution has a number of linked

elements that enable pregnant women to receive information
about their own health and also that of their infants. Women can
both ask for more information and supply feedback to improve
the quality of health care.
In 2014, the South African Minister of Health, Dr. Aaron Motsoaledi, launched an initiative (MomConnect) to use
mHealth technology as part of a suite of interventions, such as increased access to contraception and improved
coverage of breastfeeding, to address the relatively high maternal mortality ratio (MMR) and child mortality rate in
South Africa.The Medical Research Council estimated the MMR in the country at 155 deaths per 100,000 live births
in 2013. South Africas Sustainable Development Goal (SDG) for MMR is 70 deaths or less per 100,000 live births by
2030. Similarly, the child mortality rate of 39 deaths per 1,000 births in 2014 has an SDG target of 25 or less deaths
per 1,000 by 2030.
MHealth projects in a number of countries have successfully used mobile phone technologies to enhance interventions
which have been shown to improve maternal and child health (MCH) outcomes. In South Africa, virtually every
pregnant woman has either her own mobile phone or access to one. Because of this virtual universal access,
MomConnect was introduced.
MomConnect aims to improve both the demand for MCH services, through providing pregnant women with
information via messages, and the supply side through impacting on quality via user feedback.
About MomConnect
he MomConnect technical solution has a number of

linked elements that enable pregnant women to receive
information about their own health and also that of their infants. They also enable interaction with a helpdesk. Women
can ask for more information and give feedback to provide
impetus for the supply side of the health system to improve
the quality of care.
Women who think they are pregnant subscribe to MomConnect using a free of charge unstructured supplementary
service data (USSD) number on their phones (*134*550#).
This number works on all mobile networks in South Africa.
They initially receive messages encouraging them to register
their pregnancy at an antenatal clinic.
Women attending the antenatal clinics are registered into
a central database. Based on the estimated gestational age
of the fetus, stage-based messages are sent to the pregnant
woman. Similar messages linked to the age of the infant are
sent after delivery. Variables linked to the identification of
the women and the facilities allow MomConnect to link
with other national information systems under development. The women can choose one of the 11 official languages for messages.
There are 150 messages in the full suite. These include hard
health messages that address hypertension, HIV, and immunization for the baby. There are also softer messages about
the growth of the baby and importance of bonding. These
messages continue until the infant is one year old.
Several components allow women to give feedback to the
helpdesk located in the national Department of Health
(DOH). These include: frequently asked questions (FAQs);
a five-question service quality rating survey the day after
women register their pregnancy; and a compliments and
complaints system which the women can use at any time.
MomConnect sends information via a national health information exchange to a central database in the DOH, where it
can be linked with other information in the DOH.

Between 2008 and 2013, a number of small-scale pilot
mHealth projects were started in South Africa, many of
these dealing with maternal health. After reviewing these
projects, the DOH set up a task team to design a national
mHealth program to register all pregnant women and send
them messages.
The team was made up of DOH staff as well as people with
expertise in various aspects of mHealth, including those with
links to mobile network operators; expertise in the back-end
of data systems, databases, and information interoperability;
prior experience of sending mHealth messages; and links to
the international mHealth community. The DOH gave leadership and ownership to MomConnect, which enjoyed considerable political support as a ministerial flagship project.
The feedback mechanism has a number of discrete components.
While the team developed the technical aspects of MomConnect, the political mandate was to make it a nationally
scaled-up project to be implemented throughout South
Africa. In addition, the political mandate was to incorporate
a feedback mechanism so that the voices of pregnant women
could be heard loudly and clearly.
Because the task team was chaired by a senior manager of the
DOH, national managers are consulted in all aspects of the
project to ensure that it aligns fully with the overall direction
of the DOH. For example, a message set was initially developed by the task team. Several managers in the DOH then
reviewed all of the messages to ensure that they were fully
aligned with DOH policies and guidelines.
FAQ service: Pregnant women, who are registered for

the service, are able to ask question via SMS. The MomConnect helpdesk, with a professional nurse in charge,
responds by giving standard approved answers or directs
the women to a clinic for further assistance.
Service Rating: The day after registering her pregnancy
on MomConnect, the pregnant woman is sent an SMS
which prompts her to complete a free survey. This survey
covers friendliness of staff, patient privacy, facility cleanliness, and waiting times. A single follow-up message is
also sent if women do not complete the survey.
Compliments and Complaints: Women are able
to send a complaint or compliment via a free SMS.
These are logged at the helpdesk. Each of the 52 health
districts in South Africa has a focal person in charge of
MCH. After sorting the complaints into the relevant
health district, based on the clinic where the complaint
arose, these are sent to focal persons. They are expected
to act on these and give feedback to the helpdesk within
10 days. If no action is taken the complaint is escalated
to the provincial health management.
Growth in Scale
There are about 4,000 public sector facilities in South Africa,
so implementing the MomConnect technical solution on
a national scale required partnerships and a considerable
Figure 1.
Scale-up model for MomConnect
National Department of Health
Central Coordination
Tra
i
g
in
rt
ine
Re
a
Tr
po
nin
of
Provincial & District Health

MCH coordinators
rs
PEPFAR
Partners
M&E
Implementation Partners
dT
A
Ac
ct n
tri atio
s
i
D rd i n
C oo
an
M&E
C P ro
oo vi
rd n c i
ina al
tio n
tiv
i ti
es
Tr
FACILITIES
Hospitals, Clinics, CHWs
i
ain
ng
amount of coordination. The scale-up approach is shown

in Figure 1.
The DOH provides overall leadership and coordination of
MomConnect. A project manager was appointed, reporting to
the senior manager in the DOH responsible for MCH. The
project manager, based in the DOH, coordinates all MomConnect activities and acts as the central point of responsibility.
MomConnect was rolled out in a high-profile campaign
across South Africa in 2014. This followed a visit by the
Minister of Health to each of South Africas nine provinces
where he gave a presentation on MCH in South Africa and
the potential impact of MomConnect.
To register, pregnant women go to one of the countrys 4,000
health facilities and receive assistance from health care workers who have been trained in the registration process. Follow-
ing the announcement campaign by the Minister, each of the

district support partners funded by the Presidents Emergency Plan for AIDS Relief were trained to support the facilities
in the districts in which they work. This enabled wide-scale
training (23 hours) on how MomConnect works and how
to register pregnant women.
Between August 2014 and February 2015, over 30,000
health care workers were trained to register women on MomConnect. Nearly all (95%) of public sector facilities have
registered women on MomConnect. However, the numbers
of registrations are still not optimal. Operational research has
identified that lack of connectivity and timeouts as two major constraints. Also, in some places the registration processes
could be streamlined. New methods have been designed to
overcome these difficulties and retraining of health workers
that take these factors into account has begun.

As of March 2016, over 34,000 health workers have been
trained to register pregnant women in the system. They work
in 95% of all government health facilities in the country.
During the first year and a half of MomConnect they registered 663,513 women. This represents nearly half of all the
pregnant women attending antenatal care.
More than six times as many compliments (4,924) were
received compared to complaints (788) since the launch of
MomConnect in August 2014. The compliments give positive
feedback on MomConnect generally, as well as on particular
facilities or staff. The complaints fall into three main categories: health systems issues (e.g. lack of drugs and vaccines);
health services issues (e.g. long waiting times), or those related
to individual health workers (e.g. rude treatment).
In July 2015, a telephone survey was conducted with 10,000
registered users of MomConnect. There was a response rate
of approximately 20% (1,980 respondents).
Of the respondents to this survey, over:
98% (1,962) felt that MomConnect messages had

helped them.
80% (1,611) had shared the messages with friends or

their partners.
80% (1,606) reported that the messages helped them to

remember their clinic visits.
75% (1,531) reported that the messages had helped

them feel more prepared for childbirth and delivery.
70% (1,414) actually wanted more messages than the

100-plus they already receive during their pregnancy and
the first year of the childs life.
An overall impact assessment interviewing women before and

after getting messages has been developed. It has received ethics
approval from the University of Stellenbosch and the US Centers for Disease Control and Prevention (CDC) and is awaiting
final approval from the Office of the U.S. Global AIDS Coordinator (OGAC). This will be conducted in May and June 2016.
Service ratings were submitted by 30% of all women registered on MomConnect since March 2015 when a reminder
to complete the survey was introduced. The MomConnect
clients satisfaction with the friendliness and helpfulness of
the staff varied between 85 and 88%, and was the highest of
all the categories rated for the period January to December
2015. Client satisfaction with facility cleanliness and respect

of privacy received a satisfaction rate between 74 and 85%
for cleanliness and 82 and 85% for privacy. The clients were
least satisfied with waiting time length which ranged between
71 and 76% satisfaction.

The most important lesson is that to ensure scalability and sustainability there has to be political support and leadership. Because MomConnect is championed by the Minister of Health,
it is automatically given endorsement by many stakeholders,
who would otherwise not give their active support, including
managers in the national and provincial DOHs. Having a
senior manager in the DOH responsible for leading the implementation also gives MomConnect the necessary authority to
attract support from a range of stakeholders.
Another key lesson is the importance of partnerships
and harnessing capacity and skills from all stakeholders.
MHealth is a burgeoning field and no one party has all the
knowledge and experience to implement complex projects
at scale. Much of the success of MomConnect has been the
ability to integrate and harness the skills and contributions
from a number of players. This has been done by having an
inclusive task team, as the key advisory body for the project,
meet regularly to discuss implementation and augmentation
of MomConnect. The team has brought continuity to implementation and ensured that the program has been oriented
around its initial plans. Also, MomConnect has had a transparent process from the outset and welcomed contributions
from all stakeholders.
As MomConnect is the first mHealth project of national
scale in South Africa it has had to break new ground all
along the implementation chain. This requires a management

structure that is flexible and able to make quick decisions to
respond to the various needs of different stakeholders, including donors, mobile network operators, and other interest
groups, such as the private sector, which want to be included
in MomConnect activities.
MomConnect is constantly monitored, and opportunities for
improvement are continually assessed. These include monitoring of costs, and the project is continuing to assess more
economical ways of providing certain services. New alternatives, such as instant messaging, are being explored to reduce
the costs related to messaging. Local innovations are adopted
for national scale-up. For example, one province introduced
a sticker which is placed on the outside of the womans antenatal folder. This bright sticker indicates that the woman is
registered on MomConnect and serves a dual purpose: other
women are stimulated to get a sticker, and health workers
immediately have another chance to motivate the women
without stickers to register on MomConnect.
One of the challenges to MomConnect is paradoxically due
to its success. A number of stakeholders want to use this
success for their own areas of interest. For example, a number
of researchers want to add particular messages in which they
are interested.
Future Plans
This work serves as an important foundation that can be built
upon to reach new audiences. Processes are in place to extend
MomConnect to provide additional support to HIV-positive
mothers and partners and to lengthen the period of messaging until children reach age five. MomConnect is also being
extended to the private sector, as there is anecdotal evidence
that many women first book with private general practitioners
but then deliver in public health facilities. These efforts will
strengthen the continuum of care between reproductive, maternal, newborn, child, and youth health, while facilitating the
development of high-quality, accountable health services.
In addition, new technology approaches, such as using instant
messaging services, are being explored. This is expected to give
opportunities to both reduce costs and improve the service by

expanding the content available for women.
MomConnect has a component (NurseConnect) aimed at
supporting and empowering frontline nurses with mHealth
messaging and information so that they are better equipped
to give high--quality MCH service. NurseConnect has been
piloted and will be rolled out nationally by August 2016.
One long-term challenge is the cost of information transfer,
in particular SMS costs. The mobile network operators are
being asked to zero-rate these costs as a public good and at
the same time alternatives to cheaper forms of data transfer
are being explored. n
Geographic
Coverage
South Africa
Implementation
Dates
August 2014 to present
Implementation
Partners
National & Provincial Departments of Health

Praekelt Foundation;
Health Information Systems Program/SA
MEASURE Evaluation
mHealthEnabled
Universities of Stellenbosch and Western Cape
Donor(s)
USAID
Johnson & Johnson
Elma Philanthropies
Discovery foundation
Contact
Information
Dr.Yogan Pillay Deputy Director-General HIV/AIDS,

TB & MCHW, [email protected]
Photo by MomConnect
Snapshot: MomConnect

SA DoH, Health Enabled, MomConnect: One Year of Operation: A Case Study August 2014 - August 2015 http://www.healthenabled.org/
resources/momconnect_case_study.pdf
Vumi is an open source mobile messaging platform project, developed and maintained by Praekelt Foundation and individual contributors. The project is released under the BSD license. http://vumi.org/developers/
References:
1. Ngabo F, Nguimfack J, Nwaigwe F, Mugeni C, Muhoza D, Wilson DR, et al. Designing and Implementing an Innovative SMS-based alert system
(RapidSMS-MCH) to monitor pregnancy and reduce maternal and child deaths in Rwanda. Pan Afr Med J. 2012; 13:31.
2. Agarwal S, LeFevre A, Lee J, LEngle K, Mehl G, Sinha C, Labrique A for the WHO mHealth Technical Evidence Review Group. Guidelines for
reporting of health interventions using mobile phones: mobile health (mHealth) evidence reporting and assessment (mERA) checklist: BMJ 2016;352:i1174
http://dx.doi.org/10.1136/bmj.i1174
3. Mendoza, G, Okoko L, Morgan M, Konopka S. May 2013. mHealth Compendium,Volume Two. Arlington,VA: African Strategies for Health project,
Management Sciences for Health. http://www.jhsph.edu/departments/international-health/_documents/USAIDmHealthCompendiumVol2FINAL.
pdf (accessed 4 December, 2015)
4. United Nations Foundation. MomConnect: Launching a National Digital Health Program in South Africa. February 2016, Geneva. Accessed 28 March
2016. http://www.health.gov.za/index.php/mom-connect-docs
5. Peter J, Barron P, Pillay Y. Using mobile technology to improve maternal, child, and youth health and treatment of HIV patients. S Afr Med J
2016;106(1):3-4. DOI:10.7196/SAMJ.2016.v106i1.10209
6. National Department of Health (2011). Towards Quality Care for Patients National Core Standards for Health Establishments in South Africa.
Department of Health. Pretoria, 2011. http://www.rhap.org.za/wp-content/uploads/2014/05/National-Core-Standards-2011-1.pdf (accessed 6
December, 2015)
7. National Committee for Confidential Enquiry into Maternal Deaths. Saving Mothers 2011-2013: Sixth report on the Confidential Enquiries into
Maternal Deathsin South Africa. Short [Internet]. 2014. Available from: http://www.kznhealth.gov.za/mcwh/Maternal/Saving-Mothers-2011-2013short-report.pdf
8. Victora CG, Requejo JH, Barros AJD, Berman P, Bhutta Z, Boerma T, et al. Countdown to 2015: a decade of tracking progress for maternal,
newborn, and child survival. The Lancet [Internet]. 2015 Oct; Available from: http://dx.doi.org/10.1016/s0140-6736(15)00519-x
9. Dorrington RE, Bradshaw D, Laubscher R, Nannan N. Rapid mortality surveillance report 2014 [Internet]. Cape Town; 2015 Dec. Available from:
http://www.worldcat.org/isbn/978-1-928340
10. South African National Department of Health. Strategic Plan 2014/15 to 2018/19. Department of Health; 2014;153. Available from: http://
www.health-e.org.za/wp-content/uploads/2014/08/SA-DoH-Strategic-Plan-2014-to-2019.pdf
11. Mechael PN.The Case for mHealth in Developing Countries. Innovations [Internet]. :10318.Available from: http://www.uio.no/studier/emner/
matnat/ifi/INF5761/v12/undervisningsmateriale/Mechael - 2009 - The case for mHealth in developing countries(1).pdf
12. Free C, Phillips G, Watson L, Galli L, Felix L, Edwards P, et al. The Effectiveness of Mobile-Health Technologies to Improve Health Care Service
Delivery Processes: A Systematic Review and Meta-Analysis. PLoS Med [Internet]. Public Library of Science; 2013 Jan;10(1):e1001363+. Available
from: http://dx.doi.org/10.1371/journal.pmed.1001363
13. Noordam AC, Kuepper BM, Stekelenburg J, Milen A. Improvement of maternal health services through the use of mobile phones. Trop
Med Int Heal [Internet]. Blackwell Publishing Ltd; 2011 May;16(5):6226. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.13653156.2011.02747.x/epdf
14. Praekelt G. The Role of mHealth in South Africa. Stanford Soc Innov Rev [Internet]. 2013 Feb; Available from: http://ssir.org/articles/entry/
the_role_of_mhealth_in_south_africa
mSOS
Enhancing event-based disease surveillance

and response efforts in Kenya through SMS
reporting and web portal dashboards
Photo by Takeshi Kuno

54 n M S O S
Mobile SMS-based disease outbreak alert system (mSOS)

enhanced timely notificationand the technology can be used to
enhance disease survellance in resource-limited settings.
Disease outbreaks pose serious public health risks worldwide as seen in the recent SARS, Ebola, and Zika epidemics.
Resource-limited settings lack strong disease surveillance mechanisms to quickly detect, diagnose, and contain
outbreaks.1 This hinders a nations ability to fully comply with the World Health Organization (WHO)s International
Health Regulations (IHR 2005) and the Integrated Disease Surveillance and Response (IDSR) strategies.2-4
In Kenya, as in other African countries, paper-based reports or ad hoc information from the health facilities reach the
authorities at the national and sub-national levels late, which in turn limits abilities to respond in a timely manner
to control the outbreaks.4 To overcome these challenges, the Ministry of Health (MOH) and the Japan International
Cooperation Agency, Japan Agency for Medical Research and Development, Science and Technology Research
Partnership for Sustainable Development (JICA-AMED SATREPS) project piloted the mSOS (mobile SMS-based disease
outbreak alert system) in 20122014.5-7
A randomized controlled trial was implemented, which showed that mSOS enhanced timely notification and that the
technology can be used to enhance disease surveillance in resource-limited settings.8,9 Based on recommendations from
the stakeholders, a technical working group was formed at MOH, and the system is currently undertaking a series of
modifications before a nation-wide rollout.10-13
About mSOS
obile SMS-based disease outbreak alert system (mSOS)

is a formatted text-message system that allows real-time
communication between health facility workers and disease
surveillance coordinators at the sub-county, county, and
national levels in line with the IDSR guidelines.5-7
At the time of the pilot, the IDSR guidelines recommended
health facility workers completing and submitting paperbased forms to the sub-county-level disease surveillance
coordinators, and sub-county-level disease surveillance
coordinators electronically transmitting information to
higher-level managers at the county and national-levels.
Sub-county disease surveillance coordinators are the firstlevel responders to the reporting facilities. mSOS tried to
eliminate redundancies of data entry at multiple levels, and
to make information-sharing instant at all levels.4 The system
consists of two components: text messaging function, and
web portal (see Figure 1, next page).
1.
mSOS (text messaging): The text messaging function

allows health facility workers to input formatted text
messaging with patient-level information of suspected
disease outbreaks. A text message is immediately sent
to relevant health authorities at the national and subnational levels with information on the place, time, and
details of a patient with suspected disease that needs to
be reported within 24 hours.
2.
mSOS web portal (dashboard): mSOS web portal

displays a dashboard with patient-level information, bar
graphs with cumulative incidents, and hot spot maps
indicating the health facilities that reported the cases.
The relevant authorities at the national and sub-national
levels can also enter the time and details of actions taken
on the notifications sent.
Figure 1.
Structure of the mSOS Integrated Disease Surveillance and Response Mobile System
Emergency
Operations Centre (EOC)
WHO
Rapid Response Team
DHIS Web
Portal
mSOS Integrated Disease

Surveillance and Response
Alert
Messages
Ministry of Health
(national)
Central
Server
County Health
Management Team
Sub-County Health
Management Team
Health
Facility
Verification and
approval at sub-county
DHIS IDSR Weekly
Report
Weekly MOH505
Priority Disease Reports
(including zero reporting)
DHIS Event Capture

Immediately Notifiable
Diseases
Public Health Events
Immediate and Weekly Reporting
Twelve diseases and conditions were picked for the pilot

from the immediately notifiable diseases list in IDSR. The
list included adverse events following immunization (AEFI),
anthrax, cholera, dengue fever, Guinea worm, measles, neonatal tetanus, plague, Rift Valley fever, viral hemorrhagic fever, yellow fever, and any public health event of concern (e.g,
infectious, zoonotic, foodborne, chemical, radio nuclear, or

caused by an unknown condition). The pilot was implemented in two counties: Busia and Kajiado. Busia County borders
Uganda by the Victoria Lake basin with 7 sub-counties, and
Kajiado County borders Tanzania with 5 sub-counties.8-14

The design process took 1 year: 6 months in conceptualization, 3 months in programming, and 3 months in beta
testing. The implementation period was 6 months.
1.
Conceptualization: mSOS was conceptualized in

mid- to late-2012. The JICA expert conducted informal
interviews with MOH employees and workers in health
facilities to objectively understand the practice and
implementation of IDSR guidelines and bottlenecks of
disease surveillance activities on the ground.
2.
Technical working group: A technical working group

was formed at the MOH Disease Surveillance and
Response Unit (DSRU), and mSOS was developed
in early 2013. The technical working group consisted
of the head of DSRU, managers in charge of national
disease surveillance and data management, the JICA
expert, and experts from the WHO and Kenya Medical
Research Institute (KEMRI). Minutes were written and
56 n M S O S
circulated to all members.

3.
Contracting: Strathmore University Faculty of

information technology (IT) was identified as the
institution to perform programming for mSOS because
of past experience working with the MOH. One of the
servers at the MOH was identified to host mSOS. Due
to strict regulations by the Kenyan telecommunication
authorities, a contract for a toll-free number was signed
with a premium rate service provider (PRSP) and not
directly with a telecommunication company.
4.
Programming: Several students at Strathmore

University Faculty of IT undertook mSOS
programming as part of their internship. Students and
their supervisor regularly attended the technical working
group meetings to understand user requirements, and
presented progress in the technical working group
meetings.
5.
Stabilizing the system: After repeated prototyping of

the system, mSOS was pretested in a few health facilities
in Nairobi in early 2013, and several bugs and issues
with power outages were identified. A tracking system
was programmed in order to monitor downtime, and
redundant backup was created.
6.
Pilot implementation: mSOS pilot was implemented

for 6 months, October 2013April 2014. A 1-day
training or refresher course for IDSR guidelines and a
1-day training on mSOS was conducted in September
and October 2013 for 67 health facility in-charges in
Busia and Kajiado counties. All 12 sub-county disease
surveillance coordinators were also trained on how to
troubleshoot and use the mSOS web portal.
3.
mSOS Ebola (KEMRI Laboratory module): Results

on the laboratory confirmation of the patient serum
samples were updated using the mSOS Ebola web
portal, and text messages were automatically delivered to
senior management at DSRU and a few policy decisionmakers at the MOH.
After mSOS Ebola was implemented, the mSOS
stakeholders meeting was held to disseminate the
preliminary results of the pilot.
4.
mSOS pilot dissemination: At the stakeholders

meeting, mSOS was very well received. Health workers
appreciated the ease of use of the system and rapid
feedback from their managers through mSOS.11-12
Health managers especially appreciated the real-time
information sharing. The system was unanimously
recommended for integration into the national health
information and management system, specifically to the
open-source District Health Information Software 2
(DHIS2) platform.18
Growth in Scale
After the implementation of the pilot, and before the results
were analyzed, DSRU recommended mSOS to be modified
as mSOS Ebola.15-17
1.
2.
mSOS Ebola (text messaging): When a patient

suspected of having Ebola was identified by the Ebola
Rapid Response Team, patient-level information was
sent through formatted text-messaging using mSOS
Ebola. The messages with the detailed information on
the time, place, and nature of the suspected patient
case were delivered to senior management at DSRU
and a few policy decision-makers at the MOH. An
alert message was also sent to the designated KEMRI
laboratory workers.
mSOS Ebola (web portal): Patient-level information
on the suspected cases, response action conducted,
and laboratory confirmation were displayed on the
password-protected web portal dashboard.
Sample mSOS alert messaging (left) and web portal dashboard (right)
5.
Buy-in from the MOH: Due to the overwhelming

recommendations at the stakeholders meeting on the
ability of mSOS to quickly adapt to the needs on the
ground (as seen by mSOS Ebola), the scale-up of mSOS
was included in the Cabinet Secretarys Performance
Contract 2015/16, a contract between the MOH
Cabinet Secretary and the President of Kenya.19
6.
Technical working group for scale-up efforts: A

technical working group coordinated by DSRU includes
multiple units within the MOH, such as the Health
Information System; Information, Communication,
Technology; eHealth; Zoonotic Disease; and Disaster
Response units. It also includes multiple international
partners, such as the WHO [SIKIWIS], Centers for
Disease Control and Prevention (CDC) [mHealth
Kenya, I-TECH], JICA [JICA-AMED SATREPS
project], and United States Agency for International
Development (USAID) [AfyaInfo project].13
7.
Establishment of mSOS/IDSR Weekly Mobile

Reporting System: A new enhanced version of the
mSOS pilot, mSOS/IDSR Weekly Mobile Reporting
System was developed through the technical working
group in late 2015. This new system combines
event-based and indicator-based disease surveillance
information. Once a suspected disease outbreak or
public health event is detected at the health facility
level, information is sent through the system to a central
server at the MOH. The central server then sends alert
messages to multiple officers responsible for outbreak
and disaster response. The list of diseases and conditions
is expanded to not only suspected disease outbreaks of
immediate concern, such as cholera and measles, but
also public health events (event-based) and routine
disease information (indicator-based), including diseases
such as malaria.20

As part of the cluster randomized controlled trial to test
the effectiveness of the system, the research study included
quantitative and qualitative assessments of the current IDSR
guidelines implementation, and the impact of mSOS implementation.21
A baseline assessment was conducted in June 2013, including retrospective data for the six-months before the intervention (December 2012May 2013), reviewing all information
from outpatient, inpatient, and maternal and child health
registers for the 12 diseases and conditions selected for the
study. In addition, in-depth interviews with health facility
in-charges and sub-county disease surveillance coordinators
were completed. A post-intervention survey, including documents review, and in-depth interviews with health facility
in-charges and sub-county disease surveillance coordinators
were completed in May 2014. In addition, a focus group
discussion was conducted at the national level.
A total of 153 health facilities were assessed for eligibility,
and 142 completed the baseline survey in the selected 12
sub-counties in Busia and Kajiado counties. Health facilities
included public, private, faith-based, and non-governmental organization-owned facilities at all levels of care. A total
of 135 health facilities attended the IDSR training and the
randomization was conducted during the IDSR training by
58 n M S O S
stratifying health facilities by sub-counties and randomly

selecting intervention facilities from each stratum by a 1:1
ratio. Sixty-eight facilities were in the control group and 67
were in the intervention group. A total of 65 health facilities
in the control group and 66 health facilities in the intervention group were assessed during the follow-up survey.
The quantitative analysis included examining the reporting
rates comparing paper-based and mSOS reports. A retrospective review at the baseline survey showed that 36 cases
(17 cases in the control group and 19 cases in the intervention group) required immediate notification. Only one
paper-based report in the control group was completed.
During the post-intervention survey, we found that 130 cases
in the intervention group and 39 cases in the control group
required immediate notification. One paper-based report in
the control group was completed, and 25 cases were reported through mSOS in the intervention group. The results
showed that the health facilities that used mSOS achieved
more timely notifications than those that did not (+16.7%).
The results of the evaluation were published in Emerging
Infectious Diseases in April 2016.8
Analyses are currently ongoing for qualitative data collected
during field interviews and focus group discussions.

Lessons learned from mSOS pilot implementation were that
timing, leadership, and feedback are important components
of the implementation success.
1.
Timing: mSOS was conceptualized, piloted, and

disseminated during a time when the MOH was
exploring ways to move from paper-based reporting to
electronic reporting. It was also a time when various
outbreaks occurred within Kenya and around the
world, most notably Ebola in West Africa. At the same
time, mobile phone penetration skyrocketed within
the country, even in hard-to-reach areas. Compliance
with IHR 2005 was also a task that the MOH needed
to address. Overall, there was an increased awareness
and willingness of the ministry to look at a mobile
phone solution that could enhance disease surveillance
and compliance with IHR 2005. The scale-up was also
suggested at a time when the MOH is addressing a
number of related efforts including: trying to integrate
all information systems within DHIS2, preparing an
electronic nationwide master facility list, conducting
a review of event-based surveillance, proposing
mobile phone-based indicator surveillance, holding
various taskforce meetings for national outbreaks, and
construction of an Emergency Operation Centre at the
MOH. mSOS was able to leverage these timings to not
only pilot the system, but also to tie into current disease
surveillance efforts within Kenyas MOH.
2.
Leadership: Strong leadership by the DSRU, which

promoted buy-in from the national government,
county governments, and international partners,
lead to mSOS being recommended for scale-up and
integration into the national health information and
management system. DSRU included mSOS in its
work plans, and staff members from the unit helped
support the system. DSRU also worked with the Health
Information Systems (HIS), ICT, and eHealth units and
their partners to assure that the maintenance could be
conducted within the ministry through DHIS2. This in
turn would help mSOS be a sustainable system.
3.
Feedback: Inclusion of the opinions from all aspects,

such as the end-user, programmers, and health managers
were an important component of the development and
implementation of mSOS pilot. Repeated pretesting
and informal feedback from users helped mitigate
system abruption and solve bugs in a timely manner.
In addition, engagements with various stakeholders
through the technical working group helped mSOS
be programmed and evolve as a flexible tool to offer
local solutions to local problems. The large stakeholder
meeting and users feedback helped move mSOS into
the next stage.
Future Plans
The MOH envisions that real-time reporting and response
through the mSOS/IDSR Weekly Mobile Reporting System
will reduce lag time for notification and response to outbreaks and disasters, and minimize morbidity and mortality in Kenya. The system will continue to improve as the
MOH rolls it out to all levels, including all 47 counties,
all sub-counties, and the 7,500 health facilities across the
nation.
1.
Stakeholders meeting: A stakeholders meeting was

held in December 2015 and pretesting was completed
with the relevant MOH units and international
partners.
2.
Training: In early 2016, national-level officers in the

MOH attended a training of trainers (TOT) workshop.
Since February 2016, a series of TOT workshops
including county and sub-county disease surveillance
coordinators (DSCs) and health records information
officers (HRIOs) have been ongoing by the MOH
with funding support from international partners. The
training materials, including manuals and slides, were
drafted and printed. As of April 2016, approximately
350 national, county, and sub-county DSCs and
HRIOs were trained in half of the regions in Kenya.13
A launch ceremony is scheduled in 2016 after TOT is
completed at the national, county, and sub-county levels.
3.
Expansion of modes: The system would be modified to

smartphone- and feature phone-based applications so that
health workers could use their personal phones to report.
4.
Emergency Operation Centre: The system will be

linked to the national Emergency Operation Centre for
24/7 analysis of information and prompt response action
60 n M S O S
to notifications that need further investigation. The

system will serve as an early warning mechanism, whereby
analysis on trends could inform potential outbreaks and
mitigate morbidity and mortality in the nation.
5.
Expansion of users: In the future, the system will be

expanded to the community level and to the public
where suspected cases can be reported and filtered
automatically by the system.
6.
Paperless reporting: Once the system is rolled out to

the whole nation, it may also replace the current paperbased reporting guidelines in the future. n
Snapshot: mSOS
Geographic
Coverage
Kenya
Pilot: 67 health facilities
Scale-up: 7,500 health facilities
Implementation
Dates
2013 to present
Implementation
Partners
Ministry of Health (multiple units), Kenya

SATREPS Project
Japan International Cooperation Agency (JICA)
Japan Agency for Medical Research and
Development (AMED)
Strathmore University Faculty of Information
Technology
Donor(s)
World Health Organization

Centers for Disease Control
USAID
JICA
AMED
Contact
Information
Dr. Daniel Langat, Disease Surveillance and

Response Unit, Ministry of Health, Kenya,
[email protected]

1. Gates, B., The next epidemiclessons from Ebola. N Engl J Med, 2015. 372(15): p. 1381-4.
2. World Health Organization, International Health Regulations (2005), 2008.
3. Kasolo, F., et al., IDSR as a platform for implementing IHR in African countries. Biosecur Bioterror, 2013. 11(3): p. 163-9.
4. Ministry of Public Health and Sanitation. Integrated Disease Surveillance and Response in Kenya:Technical Guidelines 2012, 2012.
5. Ministry of Health Disease Surveillance and Response Unit. Mobile SMS Based Disease Outbreak Alert System. 2015 [cited 2015 December
15]; Available from: http://ddsr.or.ke/mSOS/about.
6. Mendoza, G., et al., mSOS: Using mHealth to strengthen real-time disease surveillance and response in Kenya, in mHealth Compendium
2014, African Strategies for Health (ASH), Management Sciences for Health (MSH); USAID: Arlington,VA.
7. Osamu, S., Feature Story: Using Mobile Phones to Prevent an Epidemic of Infectious Diseases, 2016, Japan Journal.
8. Toda, M., et al., Effectiveness of a Mobile Short-Message-Service-Based Disease Outbreak Alert System in Kenya. Emerg Infect Dis, 2016.
22(4): p. 711-5.
9. Njeru, I., et al., mSOS (mobile SMS-based disease outbreak alert system) Preliminary Report, 2015, Disease Surveillance and Response Unit
(DSRU) at the Ministry of Health: Nairobi, Kenya.
10. Njeru, I., et al., Meeting Highlights: mSOS Stakeholders Meeting: Dissemination of findings, 2015, JICA-AMED SATREPS project.
11. Japan International Cooperation Agency. mSOS Stakeholders Meeting (05 June 2015). 2015 [cited 2015 June 5]; Available from: http://www.
jica.go.jp/project/english/kenya/006/news/general/150605.html
12. Japan International Cooperation Agency. mSOS: A Versatile Tool for Disease Outbreak Alert. 2015 June 5, 2015 [cited 2015 June 5]; Available from:
http://www.jica.go.jp/kenya/english/office/topics/150605.html
13. Japan International Cooperation Agency. Activities towards nationwide scale-up of mSOS. 2016 [cited 2016 April 4]; Available from: http://www.
jica.go.jp/project/english/kenya/006/news/general/160404.html
14. Toda, M., et al., mSOS User Manual, 2013, Disease Surveillance and Response (DDSR), Ministry of Health (MOH); Japan International
Cooperation Agency (JICA): Nairobi, Kenya.
15. Japan International Cooperation Agency. One year after the declaration of an Ebola state of emergency. 2015 [cited 2015 July 31]; Available
from: http://www.jica.go.jp/english/news/focus_on/ebolaphotos.html
16. Japan International Cooperation Agency. mSOS Ebola handover ceremony was held at the Ministry of Health in December 9, 2014. 2014
[cited 2014 December 9]; Available from: http://www.jica.go.jp/project/english/kenya/006/news/general/141209.html
17. Japan Science and Techology Agency. Using Mobile Phones to Contain Infectious Diseases. 2015 April 27, 2015 [cited 2015 March]; Available
from: http://www.jst.go.jp/report/2014/150313-2_e.html
18. Ministry of Medical Services. Ministries of Health Launch District Health information System. 21 Feb 2012 5 July 2012 [cited 2012 5
July]; Available from: http://www.medical.go.ke/index.php?option=com_content&view=article&id=136:ministry-of-health-launch-dhissoftware&catid=34:news-and-events&Itemid=62
19. Japan International Cooperation Agency. Meeting with Mr. James Macharia, Cabinet Secretary, Ministry of Health. 2015 [cited 2015
December]; Available from: http://www.jica.go.jp/project/english/kenya/006/news/general/150708.html
20. Wanjiru, R., et al., mSOS/IDSR Weekly Mobile Reporting:Training Manual, 2016, Ministry of Health Kenya; World Health Organization (WHO);
Centers for Disease Control and Prevention (CDC); Japan International Cooperation Agency (JICA); United States Agency for International
Development (USAID): Nairobi, Kenya.
21. ISRCTN Registry. ISRCTN79529838: Evaluating the response to suspected disease outbreaks using a short message service (SMS) model.
Available from: http://www.isrctn.com/ISRCTN79529838, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN79529838
RapidSMS Rwanda
Tracking the first 1000 days of life, preventing

unnecessary mother and newborn deaths
Photo by Todd Shapera

62 n R A PI D S MS RWA N DA
The overarching goal in instituting RapidSMS was to make each

pregnancy everyones business. RapidSMS aims to ensure that
no woman dies due to pregnancy or delivery and to have all 30
districts record zero preventable maternal deaths.
Between 2000 and 2015, Rwanda achieved some of the worlds highest average annual reductions in both the
maternal mortality ratio and under-five mortality rate. Rwanda Demographic and Health Survey data show that the
maternal mortality ratio fell from one of the worlds highest in 2005 at 750 deaths per 100,000 live births down to
210 in 2014, and the under-five mortality rate declined by two-thirds during the same period. 1,2
Rwandas 45,000 volunteer community health workers (CHWs) have been major contributors to this success. Each
of the countrys 15,000 villages has three CHWs who provide a broad range of preventive, promotional, and curative
services. Starting in 2009, the Rwanda Ministry of Health (MOH), together with UNICEF, Management Sciences for
Health (MSH), and other partners, initiated an mHealth system with CHWs called RapidSMS, which has become a key
intervention in promoting maternal and neonatal health.
The overarching goal in instituting RapidSMS was to make each pregnancy everyones business. RapidSMS aims to
ensure that no woman dies due to pregnancy or delivery and to have all 30 districts record zero preventable maternal
deaths.This system has since been extended to enable CHWs to monitor and report on a wider array of health events
involving pregnant women and children for the critical window of 1,000 days from the first signs of pregnancy
through the age of two years when risk of death is highest.
About RapidSMS
apidSMS is a mobile phone-based technology being used

throughout Rwanda to improve community maternal
and child health. This tool helps CHWs track womens antenatal care visits, identify women at risk, refer them to health
facilities, and improve communication with the facilities in
the event of an emergency. The system also requires CHWs
to regularly reach out to families at the household level and
send simple text messages to the MOH reporting significant
events occurring during a womans pregnancy, delivery, and
the first year after the infants birth. Once received at the
central level, these messages are stored in a web-enabled
database and used to inform the ministrys strategic planning, technical supervision, monitoring and evaluation, and
resource coordination. For certain messages sent by CHWs,
the system raises an alert and provides immediate feedback
with guidance to the CHWs about specific actions to take.
It can also be used for widespread distribution of messages
related to specific behavior change communications campaigns or health threats that CHWs should be aware of in
their community.
The RapidSMS system enables CHWs to rapidly communicate with other levels of the health system, promotes routine
contacts between CHWs and at-risk populations in their
communities, and enables supervisors at the health center
level and above to monitor CHWs performance. It has a
very simple message format and works with basic mobile
phones. Plasticized instruction cards serve as quick reference
guides that make it very easy for CHWs to send messages for
each type of alert. Since their simple mobile phones lack the
capacity to store all of the guidelines for health service delivery and use of the RapidSMS system, these A4 cards list the
codes for each event and give examples of how to compose
the different type of SMSs CHWs may need to send. Each
message contains the National ID number of the mother
Figure 1.
RapidSMS Rwanda sample
registration code format
Republic of Rwanda
Ministry of Health
Register Yourself
You only need to do this once!

Remember to re-register if you move!
REG 324576834571245 324

Start with REG
National ID
RW
Clinic ID
Report Pregnancy
Biyogo
Language
(RW, FR, EN)
Report Maternal Risks / Deaths
so that they can be linked together and allow for tracking the
history of individual pregnant women.
The slightest evidence of warning signs, as itemized in the
list of codes, should prompt the CHWs to not only refer the
woman for care but also accompany the mother to a facility,
reducing a potentially life-threatening delay in receipt of care.
RISK 624576811417124
Start with RISK
HO
80.2kg
Date of Last
Risk Location Mother's
Menses Period Codes Code
Weight
Mother's
National ID
During Check Ups, report

risks and mother's weight
FE CI
Risk
Codes
Mother's
National ID
HO
Location
Code
71.2kg
Mother's
Weight
Report Birth
Start with BIR
CI
BO
CL
3.3kg 5.5cm
Child Risk Child Location Child

Num Code Sex
Code Weight
MUAC
Report Child Health / Death

CHI 624576811417124 01 28.02.2010 V1 FE 3.3kg 5.4cm
Start with CHI

With technical and financial support from UNICEF, RapidSMS was first piloted by the MOH in Musanze District
in 2009. The application follows national and international
guidelines for care and was intended to address three delays
which can cause maternal death, namely in seeking care,
reaching care, and in effective intervention. The logic of
the program is to have 100% registration, following up on
identified risk cases, ensuring assisted deliveries, and using
emergency alerts when appropriate.
After demonstrating positive results in the pilot district
(highlighted below), the MOH began a national roll-out
of the system in June 2010. The USAID-funded Integrated
Health Systems Strengthening Project (IHSSP), managed
by MSH, helped the ministry to develop a roll-out plan and
Mother's
National ID
Start with REG
National ID
Based on this success, the MOH, through its eHealth

technical working group and the Community Health Desk,
strongly urged other partners to participate in a national
roll-out of RapidSMS. USAID provided funding for 10,000
phones, the Bill & Melinda Gates Foundation provided
another 5,000 (through the Phones for Health project),
and the MOH purchased the remainder. MSH, which had
recently introduced a new computerized community health
Re
is
PRE 624576811417124 21.0

Start with PRE
Mother's
National ID
Dat
Mens
Report Maternal Risks / De

RISK 624576811417124
Start with RISK
Mother's
National ID
Child Child's Date Vaccine Risk Child

Code Codes Weight MUAC
Num
Of Birth
BIR 624576811417124 01
Start with BIR
Mother's
National ID
Child
Num
Report Child Health / D
CHI 624576811417124 01 2
Start with CHI
Mother's
National ID
budget, design a training curriculum, and train over 1,000

community health supervisors who then trained over 45,000
CHWs, many with no experience in the use of mobile
phones. Through IHSSP, USAID also procured and distributed phones to 10,000 of the CHWs in 30 districts and
provided the first series of plasticized instruction cards for
the CHWs to prepare and send messages through the system.
When the system was initially set up, it had a fairly basic interface that enabled staff at the health center level and above
to monitor the logs of messages received, but only provided
limited decision support. Significant effort went into designing compelling graphic interfaces that calculated indicators
and helped these staff more easily navigate their way through
the system.
Growth in Scale
The system was introduced in 2009 by the MOHs Community Health Desk with UNICEF support in Musanze, one of
Rwandas 30 districts. By May 2010, one year after initiating
the RapidSMS system, prenatal care visits in Musanze District had increased by 25%, home deliveries had dropped by
54%, health facility deliveries rose by 26%, and under-five
mortality had declined by 48%.
Clin
Report Birth
BIR 624576811417124 01
Mother's
National ID
You
Rem
REG 324576834571245 32
Report Pregnancy
Register only AFTER it

is confirmed!
PRE 624576811417124 21.02.2010 FE

Start with PRE
Village
Name
Register Yourself
information system (SISCom) nationwide, helped the MOH

develop a roll-out plan, budget, curriculum, and schedule
of training of trainer sessions to be implemented across the
country. The initiative also benefited from support from
the highest levels of government, with Her Excellency Mrs.
Jeannette Kagame, First Lady of the Republic of Rwanda,
participating in the ceremony to hand out the first 10,000
phones. Other partners working at the district level, including HealthBuilders, focused on reinforcing the use of the
system through supervision and the creation of dashboards
that enabled health center staff to monitor the coverage of
the different services provided by their CHWs.
In November 2012, the first RapidSMS retreat took place
where the group expanded RapidSMS from one module that
tracked the pregnancy cycle (version 1) to version 2 which
Child C
Num
consists of six modules: the pregnancy cycle, post-delivery

period, newborn care, deadly childhood diseases (pneumonia,
diarrhea, and malaria), nutrition, and children living with
disabilities (cleft palate/cleft lip). The latter was later dropped
to avoid overloading CHWs with multiple program activities.
The system currently receives approximately 12,000 messages
a day (average since January 2016) from CHWs. The MOH
is interested in using the system for other data-collection
needs, including immediate reporting of maternal deaths
from hospitals.
SMS messages are sent to a toll-free numberusing a short

codeso there is no cost to the CHWs to use the system.
The MOH pays the SMS charges. Initially, this project was
linked with Phones for Health, which included a public-private partnership with MTN and Voxiva, so the SIM cards
and server hosting were provided for free, and SMS messages
were charged at a discounted rate. When that initiative was
discontinued in 2014, the server was relocated to Rwandas
state-of-the-art National Data Center.

Rwanda has achieved impressive progress in reducing maternal and child mortality between 2010 and 2015. While a
key intervention implemented by the MOH, RapidSMS was
one of a number of initiatives in the health system over this
period of time, making it challenging to attribute specific
improvements in maternal and child health to the mHealth
program alone.
An impact evaluation of a separate program, Rwandas
CHW performance-based financing (PBF) program, implemented from 2012-2014 tested several different approaches
to incentivizing high-impact services at the community level.
The study looked at both the demand and supply sides of
service delivery. The study found relatively little impact from
the CHW performance incentives for a variety of reasons:
performance was calculated at the CHW cooperative level
(there is one cooperative per health center catchment area),
and all CHWs received the same amount within a cooperative, regardless of their individual efforts. Realizing that
RapidSMS provided a source of data on the activities of each

CHW, the Community Health Desk saw an opportunity to
address this by using the RapidSMS data to calculate specific
indicators of individual performance and split the cooperatives PBF funds to reward CHWs in the top performance
quintiles with a greater share of the funds.
This new approach, utilizing individual-level RapidSMS
data, is still in the process of nationwide implementation.
Now health centers are aware of the number of pregnant
women in their community, CHWs can easily communicate
with health centers during emergencies, and patients needing
urgent care can receive ambulance transportation to health
facilities. The system helps to ensure that CHWs in the community maintain regular face-to-face contact at the household level with all pregnant women and infants. This keeps
the CHWs accountable to the people they serve, as the data
are triangulated with information on expected pregnancies
and births that are collected at the health facilities.
Sample regional dashboard
Figure 2.
RapidSMS Rwanda Contiuum of Care Model

The initial implementation plan for the RapidSMS program
did not account for the challenges of charging phones in
a village setting without convenient access to electricity,
nor the malfunctioning of nearly one-quarter of the phone
chargers during the first year of national roll-out. Some
solar chargers were purchased but have not been available in
sufficient quantities. In most cases, the CHW cooperatives
replaced chargers by using their own funds.
A discounted SMS rate had been negotiated for the program,
however, after several years; the negotiated cost per message was actually higher than the market price, which had
decreased over time. Organizations need to ensure that the
contract with their mobile network provider enables them to
index their discount on the actual rates.
Other key challenges encountered included the following:
Misunderstanding by CHWs of case definitions for

RapidSMS indicators
Difficulties in using mobile phones due to English language barriers and lack of knowledge of how to use the
text message capabilities of their phones
Limited use of RapidSMS data by local leaders and medical personnel (doctors and nurses)
Lack of full coverage of all pregnant women reported by

CHWs using RapidSMS, especially in urban areas
Lack of printed registers for recording RapidSMS messages for better follow-up
Insufficient funding for supervisors to follow up with

CHWs on RapidSMS activities
Future Plans
RapidSMS Rwanda is currently operating at national scale.
The system is used by over 45,000 CHWs and their supervisors in 475 health centers, and provides information for decision-making at the national level as well. Part of the platform
is being upgraded to RapidPro, an open source platform
released in 2014 which features easier-to-configure data visualization. As part of Rwandas Health Enterprise Architecture
initiative, the MOH worked with many partners (including Jembi Health Systems, Regenstrief, and InSTEDD) to
integrate RapidSMS data into a national shared health record
repository and to generate alerts to CHWs immediately after
registering a pregnant women with known pregnancy-related
risk factors. While this has not been rolled out nationally,
it was a proof of concept that sets the stage for a range of
interoperability scenarios that can improve referral and continuity of care at the community level.
Additional ongoing and future plans for the program, and
the partner organization, include:
Continue work to improve interoperability between

RapidSMS and other data management systems used
within the country. In particular, interoperability with
the PBF system in District Health Information Software 2 (DHIS2) is planned to allow for payment of
performance incentives. Connection with the electronic
medical records systems shared health record would
allow for CHWs to be alerted to pre-existing conditions
in pregnant women that need to be handled carefully

(e.g. HIV+) (MSH)
Connect the program with a mobile money system to

pay CHW performance incentives directly through their
phones based on metrics calculated using data reported
through RapidSMS (MSH)
Continue to support the use of the RapidSMS data by

health center and district-level staff through training and
supervision to monitor the performance of their CHWs
and triangulate with the health center data on antenatal
care, deliveries, and treatment for malaria, pneumonia, and diarrhea (UNICEF). This will address many
challenges such as clarifying case and indicator definitions, learning how to use phones more effectively, and
reinforcing the importance of routine use of the system.
Strengthen the RapidSMS coordination mechanism

through monthly and quarterly national-level meetings,
including annual reviews of the system and tools and
technical validation meetings (UNICEF)
Consolidate SMS, USSD, and other high-volume communications contracts within the MOH and Rwanda
Biomedical Center to negotiate better terms for RapidSMS communications charges with the local mobile
phone companies (MOH)
Snapshot: RapidSMS Rwanda

Geographic
Coverage
Rwanda
Implementation
Dates
20092011 (pilot)
2012 to present (scale-up)
Implementation
Partners
Ministry of Health (coordination, funding, and

project management)
UNICEF (funding, technical assistance)
MSH (technical assistance for systems,
interoperability
Donor(s)
USAID
UNICEF
Contact
Information
Randy Wilson, Team Lead: Research, M&E and KM,

Rwanda Health Systems Strengthening Project,
[email protected]
Additional Resources/ Information

References:
1. Rwanda Demographic and Health Survey 2005. Calverton, MD, National Institute of Statistics of Rwanda and ORC Macro, 2006.
2. Rwanda Demographic and Health Survey 2014-5. Calverton, MD, National Institute of Statistics of Rwanda, Republic of Rwanda Ministry of
Health and ICF International, 2015.
U-Report
Ending adolescent AIDS through mobile-based

counselling and polling
Photo by UNICEF / Zambia / Maseka / 2016

68 n U - R E PO RT
U-Report has been used as a focused mHealth application,

specifically providing real-time mobile counselling and conducting
coordinated polls on AIDS among adolescents and young people.
Despite incredible progress over the last decade in placing people on HIV treatment and preventing mother-to-child
HIV transmission, adolescents aged 1019 have been largely left behind in the global AIDS response. Adolescents are
the only age group for which AIDS-related deaths have not decreasedin fact they have tripled since 2000.1 AIDS is
the leading cause of death for adolescents in Africa, and the second globally.2 Every hour 26 new HIV infections occur
among older adolescents (aged 1519), 40% of which happen outside sub-Saharan Africa.3 Moreover, risk is high
among this age group due to their very limited knowledge about HIV. In sub-Saharan Africa, 70% of boys and girls
(1519) have low comprehensive knowledge on how to protect themselves and access services.4
To address this critical gap in HIV/AIDS response, and with youth being the greatest users of mobile devices
globally, UNICEF decided to invest in innovative solutions that can achieve quick wins in service-delivery, while
creating real, long-lasting change for adolescents. One such innovation is U-Report, a general mobile-enabled youth
engagement platform. U-Report has been used as a focused mHealth application, specifically providing real-time
mobile counselling and conducting coordinated polls on AIDS among adolescents and young people. Objectives
of the program are to: improve access to sexual reproductive health (SRH) knowledge; increase utilization of HIV
prevention services; and better understand perceptions on HIV-related issues in order to contribute to reducing new
HIV infections among adolescents and youth.
About U-Report
obile Powered by RapidProUNICEFs opensource software platform for international developmentU-Report is a user-centered tool that empowers
young people to speak out on various issues that they care
about in their community, encourage citizen-led response,
and magnify voices locally, nationally, and globally to create
positive change. The platform is interoperable with various
technology platforms, allowing U-Reporters to communicate
with other young people and communities via SMS, Twitter, App, Facebook Messenger, and Telegram depending on
country context. First launched in Uganda in 2011, there
are currently over 2 million U-Reporters, operating in 23
countries: Brazil, Burkina Faso, Burundi, Cameroon, Central
African Republic, Chile, Democratic Republic of Congo,
Guinea, Indonesia, Ireland, Liberia, Mali, Mexico, Mozambique, Nigeria, Pakistan, Senegal, Sierra Leone, Swaziland,
Uganda, Ukraine, Zambia, and Zimbabwe.
Young people are targeted to join U-Report through local

nongovernmental organizations (NGOs), youth groups,
and faith-based organizations. Traditional media campaigns
are also used to advertise the service and encourage young
people to sign up. By sending the text message, join, to a
toll-free number and answering a few registration questions
(e.g. age, gender, region within a country in which they
reside), any young person with a mobile phone can become a
volunteer U-reporter in their country. Weekly poll campaigns are conducted on a wide range of issues, including
poverty, bullying, Ebola, and gender equality.
While U-Report is designed as a multithematic social messaging tool, some countries, like Zambia, have chosen to
optimize on the tools large user base and real-time analytics.
The program is utilized in a targeted approach to achieve
HIV outcomes among adolescents and young people, partic-
ularly to: increase knowledge on HIV and SRH; generate demand for and increase uptake of HIV testing and counselling
(HTC) and related health services, and better understand
barriers to HIV-prevention services.
UNICEF, in partnership with Zambias National AIDS
Council (NAC), launched U-Report Zambia during the
2012 World AIDS Day. It currently has a national reach

of over 98,000 subscribers, 65% of whom are adolescents
(1019 years) and young adults (2024 years). U-Report, as
an SMS-based intervention, provides confidential, free-ofcharge, and real-time counselling services on HIV and SRH
to adolescents and youths.

U-Report Zambia is built on the foundation of its Uganda
counterpart, where the platform was first implemented. It
was further developed through a participatory, consultative
process including a design workshop that involved young
people and program experts from NAC, the ministries of
health, education, youth and sports, and local NGOs, representatives from mobile companies, and information technology and software developers. Throughout design and implementation, the opinions of adolescents and young people
from both urban and rural areas were continuously sought,
either in person or via U-Report to shape and improve the
platforms programming and content, so that messages are
locally adapted to the language and tone of its young users.
The mHealth application of U-Report Zambia has two components: Knowledge Bank and Poll/Campaign. Knowledge
Bank is a dynamic repository of up-to-date information on
HIV and SRH, which over time has expanded to other related issues, such as gender-based violence. SMS-counsellors
use this resource to provide correct and consistent information to U-Reporters. The weekly Poll/Campaign module
obtains and gauges the opinions of adolescents and young
adults on HIV issues, and promotes national events to create
awareness, promote positive behavior change and increase
utilization of services (e.g. national HIV testing day). Survey
results are disaggregated, analyzed, and displayed on its website in real-time, and integrated in key decision-maker meet-
ings. The results inform policy dialogue and programmatic

decisions, and establish a baseline on knowledge, access, and
utilization of high-impact HIV prevention services.
UNICEF provides technical leadership and manages the
systems operations (e.g. Poll/Campaign module, and reporting and analytics), and NAC acts as U-Reports primary
champion and country-wide coordinator of various partners,
ensuring that the program aligns with national HIV guidelines and plans. UNICEF negotiated discounted bulk SMS
rates with all three mobile phone operators in Zambia
namely Airtel, MTN, and Zamtel, offering SMS service to
U-Reporters at no cost.
To implement the mHealth counselling component of U-Report, UNICEF entered into a partnership with CHAMP, a
local NGO, which already managed the national 990 voice
counselling service. CHAMP provides counsellors, manages
the Knowledge Bank module, and conducts the day-to-day
operations of the 878 SMS-based U-Report counselling
service. Integrating and ensuring interoperability of the
phone and SMS services, while challenging, is crucial to the
programs goals as it both streamlines operations, and gives
young people options to better access HIV counselling and
information. The two-way SMS communication between
young people allows for anonymity, while a voice conversation allows for more in-depth conversation when necessary.
Growth in Scale
In less than five years, U-Reports membership has rapidly
grown to over 2 million users worldwide, going live in 23
countries, with 11 in the pipeline. In addition to its country roll-outs, U-Report has a global roll-out (U-Report
Global), which enables adolescents and young people from
all over the world to voice issues that affect them through
Facebook Messenger, Twitter, Telegram, and App, regardless
if they have a national U-Report. U-Reports digital reach
has expanded to over 40 countries in both developing and
developed countries.
U-Report collaborates and builds relationships with multiple
stakeholders, who want to work on a common program-
70 n U - R E PO RT
matic issue/s in their country to ensure local ownership and

long-term investment, while achieving the three U-Report
global strategic goals: scale, engage, and change. U-Report is based on the theory that the strength of its voice is
in its numbers. Using transferable technology developed
in the South, UNICEF is able to launch in a new country
within 8-12 weeks, working towards the objective to create
an international community of young people. To ensure
sustainability, UNICEF also works with telecommunication
providers to make U-Report a free platform within interoperable technologies.
Photo by Mark Naftalin
U-Reports advantage is that not only is it a multiplatform

technology, but it is also a multithematic platform that goes
beyond mHealth per se. U-Report can focus on a specific outcome area (e.g. HIV/AIDS) or population group (e.g. adolescent girls and boys) like in the case of Zambia, but it can also
concurrently tackle a broad range of issues that is most press-
ing to young people. While HIV and health are important

issues, they are often the least of concerns among the youth, so
its important to have a flexible platform. U-Reports holistic
approach constantly engages adolescents to discuss issues that
affect them today, while giving them access to health information and HIV services they need the most.

Of the over 98,000 Zambian U-Reporters who have voluntarily signed up, about 62% have asked questionsthrough
both poll-based solicited and unsolicited messageswith
the counsellors.5 Most respondents are aged 1024 years
(65% of users), male (60%), and located around the urban
areas (55%). The average monthly traffic for 2016 ranges
between 8,000 and 10,000 SMS messages, 90% of which,
if addressed to counsellors, are responded to within a twohour window. By capitalizing on the growing use of mobile
phones and through reliable and correct information from
the counsellors, U-Report Zambia contributed to increasing
access to and improving comprehensive HIV knowledge
among adolescents and young people. While its crucial to
promote and reinforce information through multiple channels, U-Report added value by disseminating information in
real-time to a targeted and particularly vulnerable population
at a relatively low cost.
Through a 10-day U-Report campaign on HTC, a package of

SMS messages designed to trigger a two-way interactive SMS
counselling session, was delivered to all registered Zambian
U-Reporters in Lusaka and Chongwe districts. SMS counsellors addressed questions and referred U-Reporters to the
nearest HTC site in their location. The evaluation analyzed
HTC uptake among U-Reporters at baseline, and measured
the increase in uptake two weeks after the campaign.6 Out of
the 1,139 U-Reporters (1024 years) who claimed that they
have not tested for HIV in the past 12 months, 18% reported
going for HTC during the SMS campaign, most (62%) of
them adolescents (1519 years). In a short period of time, the
U-Report SMS campaign was able to generate 1 additional
HIV test for every 5 young people who had not tested for
HIV in the previous 12 months. While the results are promising, the methodology relies on self-reported data on HTC
uptake, and it would be important to conduct future studies
that allow such claims to be verified by health facilities.
Photo by UNICEF / Zambia / Maseka / 2016
Zambian U-Reporter Beatrice Phiri (right) speaks to a youth about

HIV and AIDS information received on U-Report.
U-Report conducted a polling initiative focused on better

understanding barriers to HIV prevention in Zambia among
adolescents and on generating user feedback and solutions
for more youth-friendly health services. The main barrier to
HTC, according to analysis of a sample of 15,228 U-Reporters aged 1024 years, was fear of a positive test.7 Lack
of awareness of the importance of HTC was highest among
younger adolescents. Older adolescents and youth proposed
to increase tailored HTC campaigns, while younger adoles-
cents prioritized the use of incentives and campaigns targeting parents. While all age groups suggested to make condoms
more widely available, older adolescents and youth preferred
confidential condom distribution centers managed by other
young people. These findings were presented by adolescents
themselves at the Third National HIV&AIDS Prevention
Conventiona national-level forum on HIV, which allowed
young people to meaningfully participate in policy and program design on HIV and health in their country.

Voluntary medical male circumcision (VMMC) decreases
the chance of men acquiring HIV by 60%.8 Accordingly,
U-Report Zambia launched an SMS campaign on VMMC
as part of an impact evaluation, conducted by IDinsight and
funded by the International Initiative for Impact Evaluation.9
The randomized controlled trial, with a sample of 2,312
male U-Report subscribers (aged 1530) in urban Lusaka
and peri-urban Chongwe districts, examined the effects of
SMS-based interventions on circumcision uptake. In a span
of five months, participants received 21 SMSs, providing
VMMC information, encouraging them to go for circumcision, and engaging them in SMS counselling via U-Report.
The evaluation found that the SMS campaign did not have
evidence of impact on uptake of circumcision within six
months. However, the U-Report campaign showed significant information-seeking behavior on VMMC and spurred
high levels of engagement with SMS counsellors. While SMS
interventions and counsellor access alone may not lead to
increased circumcision uptake, policy-makers and program
implementers should consider integrating low-cost SMS
72 n U - R E PO RT
promotion as part of a broader range of behavior change

interventions.
U-Report is committed to providing free access for the user
anywhere in the world, making negotiations with mobile
network operators (MNOs) crucial. Negotiations on packages with MNOs vary from country to country. One lesson
learned is to work closely with the operators at the onset, and
bring them in as part of the U-Report program. In U-Report
Zambia, the counselling component has an annual fixed
cost of over US$200,000 covered by the Global Fund to
Fight AIDS, Tuberculosis, and Malaria over the next three
years. This price provides a dual SMS and voice service 24/7,
with counsellors working out of a call center. However, this
expense can be further reduced with more cost-effective solutions, such as using a telecommuting model (i.e. counsellors
work remotely) and automated counselling systems. The lower the cost, the more scalable and sustainable an innovative
solution is in the long-term.
Future Plans
During World AIDS Day 2015, more than nine countries
engaged over 1.3 million U-Reporters to participate in a
multicountry dialogue on HIV/AIDS related issues. The
coordinated poll gauged young peoples perceptions on
common themes, such as testing, treatment, knowledge on
prevention and transmission, and stigma around HIV/AIDS.
While its results should not be taken as statistically accurate,
as a crowdsourcing tool U-Report can complement ongoing
processes and interventions. In 2016, U-Report will conduct
a series of questionnaires on HIV throughout the year to
amplify the voices of adolescents and young people worldwide, with quantitative and qualitative responses feeding
into UNICEFs biennial Stocktaking Report on Children
and AIDS. This initiative will give adolescents an opportunity to recommend solutions, influence decision-makers
and government leaders during the 21st International AIDS
Conference (AIDS 2016) in Durban, South Africa, and actively participate in shaping the future of HIV programming
in UNICEF.
In the pipeline, UNICEFs priority is to expand mHealth
applications of U-Report linked to HIV services and programmatic results. Several countries are working on linking
U-Report to help improve antiretroviral treatment adherence, promote condom use, increase HIV testing, and supplement country assessments on adolescents and HIV data.
Nigeria and Zimbabwe have started adopting the Zambian
model of providing real-time counselling via U-Report.
Zambia is looking into optimizing its SMS counselling
through artificial intelligence. Currently in the testing phase,
the automated version uses machine learning algorithms that
pick out key words from messages, sort them into categories,
and send standard responses, with the goal to provide faster

and more accurate counselling services.
Beyond mHealth, U-Report is looking to further diversify
channels over which young people can communicate. Smartphone apps for iOS and Android are being released this year,
with the ability to send and receive rich media. This feature will
enable U-Reporters to share their experiences and stories in their
own voices, and connect with others. U-Report is also launching a web-based registration, which could be applied during a
humanitarian crisis and/or a health emergency response. n
Snapshot: U-Report
Geographic
Coverage
U-Report is live in 23 countries: Brazil, Burkina Faso,

Burundi, Cameroon, Central African Republic, Chile,
Democratic Republic of Congo, Guinea, Indonesia,
Ireland, Liberia, Mali, Mexico, Mozambique, Nigeria,
Pakistan, Senegal, Sierra Leone, Swaziland, Uganda,
Ukraine, Zambia, and Zimbabwe.
U-Report Global (ureport.in/) has a digital reach in
an additional 28 countries.
Implementation
Dates
2011 to present
Zambia
Partners
UNICEF
National AIDS Council (leadership and coordination)
Christian Health Association of Zambia (management
oversight of counseling service activity funds)
CHAMP (management of the national 990 voice
counseling service and operations of the 878 SMS
counseling service, promotion activities)
Zambia
Implementation
Donors
Global Fund
Mobile phone operators (i.e., Airtel, MTN, Zamtel)
provide SMS services at discounted rates
Contact
Information
James Powell, U-Report Global Coordinator

UNICEF, [email protected]

References:
1. UNAIDS 2014 HIV and AIDS estimates, July 2015.
2. WHO, Health for the Worlds Adolescents: A second chance in the second decade, World Health Organization, Geneva, 2014.
3. UNAIDS 2014 HIV and AIDS estimates, July 2015.
4. UNICEF global HIV and AIDS databases (September 2015) based on MICS, DHS, AIS and other nationally representative household surveys,
2010-2014.
5. As of end of April 2016, there are 98,277 members and 61,108 unique conversations in U-Report Zambia.
6. Zambia U-Report: Innovative demand creation for HIV testing and counselling using mobile phones. Abstract was written by authors from
UNICEF Zambia, CHAMP, National AIDS Council (NAC), and UNICEF Eastern and Southern Africa Regional Office.
7. Using real-time SMS to understand barriers to HIV prevention services among adolescents in Zambia: Lessons learned and implications
for adolescent health programming. Abstract was written by authors from UNICEF Zambia, University of Zambia, National AIDS Council
(NAC), CHAMP, and UNICEF Eastern and Southern Africa Regional Office.
8. Bailey, RC, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet, 2007, 369:643656.
9. IDinsight, Measuring the Impact of SMS Campaigns on Uptake of VMMC in Urban Zambia, Lusaka, Zambia, June 2015.
Ed Owles, Worldview
ANNEX
Case Studies from Previous Volumes

VOLUME 1.
BEHAVIOR CHANGE COMMUNICATION
Chakruok Interactive Radio Program
CycleTel
iCycleBeads Smartphone Apps
La Ligne Verte Family Planning Hotline
Mobile 4 Reproductive Health (m4RH)
SMS and IVR to Improve Family Planning Services
Text Me! Flash Me! Call me!
Workplace-based SMS Awareness Campaign
DATA COLLECTION
Automating Data Collection for HIV Services
Child Status Index (CSI) Mobile App
EpiSurveyor/Magpi
Integrated Health Systems Strengthening Project IHSSP: RapidSMS
JSI Early Warning System
FINANCE
Changamka Maternal Health Smartcard
Mobile Finance to Reimburse Sexual and Reproductive Vouchers
LOGISTICS
cStock
Delivery Team Topping Up System
Integrated Logistic System ILSGateway
International Quality Short Message Services (IQSMS)
Mobile Product Authentication MPA
mTrac: Monitoring Essential Medicine Supply
Tupange SMS Community Tracking System
SERVICE DELIVERY
CommCare for Home-Based Care
Community IMCI (cIMCI)
eFamily Planning (e-FP)
eNutrition
Maternal Health (Antenatal and Postnatal Care)
mHealth for Safe Deliveries in Zanzibar
Mobiles for Quality Improvement (m4QI) SHOPS Project
MOTECH Suite
Project Mwana SMS for Early Infant Diagnosis of HIV
SIMpill Medication Adherences Solution
Supportive Supervision (SS) for TB in Nigeria
The Malawi K4Health Mobile Learning Pilot
A:2 n M AY 2 0 1 6
www.africanstrategies4health.org/resources
VOLUME 2.
CommCare for Antenatal Care Services in Nigeria
JustTested: SMS-Based Support and Information for HIV Testing and
Counseling Clients
MAMA Bangladesh
MAMA South Africa
Tobacco Kills: Say No & Save Lives
Wazazi Nipendeni (Parents, Love Me): mHealth Initiative to Support
Maternal Care in Tanzania
DATA COLLECTION
Community-based Health Promotion for Safe Motherhood using
mHealth
DataWinners Platform
iHRIS and Mobile Reference Dictionary
iPhones for Malaria Indicator Survey
The Last 10 Kilometers: What it Takes to Improve Health
Outcomes in Rural Ethiopia
Mobile Phone Microscopy for the diagnosis of Parasitic Worm Infections
OpenHDS
FINANCE
Heartfile Health Financing - an mHealth enabled innovation in health social protection
Jamii Smart | KimMNCHipreferrals, mSavings and eVouchers
Tanzania National eVoucher Scheme
transportMYpatient: Facilitating access to treatment for obstetric fistulae
LOGISTICS
Enat Messenger for Maternal Health in Ethiopia
Mobile Phone Survey Software for End-Use
mPedigree
mTRAC Stop Malaria Program (SMP)
SERVICE DELIVERY
AliveCor Heart Monitor - Mobile ECG
FioNet: Mobile Diagnostics Integrated with Cloud Information Services
GxAlert
MarieTXT: A Mobile Powered Management Information System
mCARE: Enhancing Neonatal Survival in Rural South Asia
txtAlert for Patient Reminders
mH EA LT H CO MP ENDIUM SP ECIA L EDIT IO N 20 16 n A:3
VOLUME 3.
Heart Health Mobile
Mobile Integrated Resources for Aurat-Women (MIRA) Channel
NightWatch: Mobile
Wired Mothers
DATA COLLECTION
Child Profiling Survey
Global Trachoma Mapping Project
Malaria Control Program (MACEPA)
Real-Time Biosurveillance Program
ZiDi
FINANCE
Interactive Alerts
mHealth for Safe Delivered: Ezy Pesa mobile banking services
Pona na Tigo Bima
LOGISTICS
Fone Astra
Project Optimize: Albania
SMS for Life
SERVICE DELIVERY
ACT of Birth, Uganda
Baby Monitor
eNUT
Mobile Media Rich Interactive Guidelines
MobiUS Ultrasound
mSakhi
Pre-eclampsia Integrated Estimate of Risk (PIERS) on the Move
Sky Social Franchise Network
SMART
A:4 n M AY 2 0 1 6
VOLUME 4.
BEHAVIOR CHANGE COMMUNICATION (BCC)
Ananya
Empowering and Mobilizing People Living with HIV/AIDS
mCenas!
Mobile Information for Maternal Health
No-Yawa
DATA COLLECTION
Community Led Total Sanitation Mobile Surveillance
GIS Mapping of Health Facilities
Ma Sante
Mobile HIV & Malaria Diagnosis and Reporting System
mSOS
mSpray
mWater
Participatory Monitoring and Evaluation (PartMe)
Reduction of Maternal Mortality Through ICT
FINANCE
The Mobile Health Research Lab: Mobile Wallet
LOGISTICS
The Liberian Agriculture Upgrading, Nutrition, and Child Health
(LAUNCH) Project
SERVICE DELIVERY
Better Health for Afghan Mothers and Children
Chipatala cha pa Foni (Health Center by Phone)
eCompliance
Emergency Triage Assessment and Treatment (ETAT)
Engage TB
Grand Challenge Exploration Phase 1 Project
inSCALE
IVR mLearning Platform in Senegal
Malaria Community Surveillance for Elimination
Mobile-based Early Detection and Prevention of Oral Cancer (mEPOC)
Mobile Phones for Improved Access to Safe Water (M4W)
Mobilise!
Peek Vision
The Referral Exchange System (SIJARIEMAS)
The Safe Delivery App
mH EA LT H CO MP ENDIUM SP ECIA L EDIT IO N 20 16 n A:5
VOLUME 5.
BEHAVIOR CHANGE COMMUNICATION (BCC)
Hesperian HealthWiki
EbolaTxt
Project Khuluma
U-Report: Fighting Diseases Across Borders
Alive & Thrive
Projecting Health
iDEA: Interactive Distance Education Application
MomConnect
mHEALTH
COMPENDIUM
VOLUME 5
DATA COLLECTION
MP3Youth
PMI Africa Indoor Residual Spraying (AIRS)
Hang-Up and Track
CRS Senegal mHealth Pilot
SEDA Automated Health Data Exchange System
OpenSRP: Open Smart Register Platform
SMS for Life: Sightsavers
mHBB
FINANCE
Accredited Drug Dispensing Outlet
mHealth for Safer Deliveries
Heartfile Health Financing
M4Change + mCCT
Airtel Insurance with MicroEnsure
LOGISTICS
Informed Push Model
mHealth for iCCM
IQSMS International Quality SMS
eLMIS Bangladesh
DrugStoc
cStock Supply Chains for Community Case Management
SERVICE DELIVERY
OppiaMobile
mCare Enhancing Neonatal Survival in Rural South Asia
mTIKKA
HELP: Health Enablement and Learning Platform
ETAT
mHealth for Community-Based Family Planning Services
ePartogram
mHero
Mobile App for Management of HIV in Pregnancy
Maternal and Child Health Integrated Program, Kenya
ASHA-LINKS
CommCare Mobile Job Aid for Sahiyas
MobyApp
CycleTel Family Advice & CycleTel Humsafar
A:6 n M AY 2 0 1 6
May 2015
This publication was produced for
review by the United States Agency
for International Development. It was
prepared by the African Strategies for
Health (ASH) project.

4301 N Fairfax Drive, Suite 400, Arlington,VA 22203
Telephone: +1-703-524-6575
[email protected]
www.africanstrategies4health.org

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mHEALTH

Cover photo, Nigerian mother and child, by Gwenn Dubourthoumie.

The authors views expressed in this publication do not

his compendium was produced by the African Strategies

thanks to USAID and, in particular, Ishrat Z. Husain from

mH EA LT H CO MP ENDIUM SP ECIA L EDIT IO N 2016 n v

adverse events following immunization

International Telecommunication Union

mH EA LT H CO MP ENDIUM SP ECIA L EDIT IO N 2016 n vii

Afghanistan, photo by MPaisa

Health is the use of mobile and wireless technologies to

important results or evaluation findings; lessons learned; and

mH EA LT H CO MP ENDIUM SP ECIA L EDIT IO N 2016 n 1

Photo by David Rochkind, USAID

reminders, community mobilization and health promotion,

The Rapidly Evolving mHealth Landscape

he mHealth landscape is consistently and increasingly

Evidence for mHealth

Although still limited, the amount of evidence around the

Standards for mHealth

mH EA LT H CO MP ENDIUM SP ECIA L EDIT IO N 2016 n 5

Principles for Digital Development

he following set of principles are intended to serve as

1. Design with the User

Develop context-appropriate solutions informed by

Include all user groups in planning, development,

Develop projects in an incremental and iterative manner

Design solutions that learn from and enhance existing

Ensure solutions are sensitive to, and useful for, the

2. Understand the Existing Ecosystem

Participate in networks and communities of

Align to existing technological, legal, and

3. Design for Scale

Employ a systems approach to design, considering

Be replicable and customizable in other countries

Demonstrate impact before scaling a solution

Analyze all technology choices through the lens of

Factor in partnerships from the beginning and start

4. Build for Sustainability

Utilize and invest in local communities and developers

Engage with local governments to ensure integration

Design projects so that impact can be measured at

Evaluate innovative solutions and areas where there are

Use real-time information to monitor and inform

When possible, leverage data as a by-product of user

6. Use Open Standards, Open Data, Open

Adopt and expand existing open standards

Open data and functionalities and expose them in

Invest in software as a public good

Develop software to be open source by default with

7. Reuse and Improve

Ensure equity and fairness in co-creation, and protect

Engage diverse expertise across disciplines and

Use, modify, and extend existing tools, platforms,

Work across sector silos to create coordinated and

Develop in modular ways, favoring approaches

Document work, results, processes, and best practices

Publish materials under a Creative Commons license

8. Address Privacy and Security

Consider the context and the needs for privacy of