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Brown Bag @ INSEAD - Going beyond pilot: Scaling up mHealth success stories

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Claire Penicaud

on 1 July 2010

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Transcript of Brown Bag @ INSEAD - Going beyond pilot: Scaling up mHealth success stories

Beyond Pilots:
Scaling Up Mobile Health Success Stories Claire PENICAUD Brown Bag 01/06/2010 Introduction 1. Key Sucess Factors for Scaling What are the main bottlenecks Mobile Health pilots face when they engage into a scaling-up process ?

What are the key success factors for scaling up Mobile Health pilots ?

How can we reach them ? Research Questions Mobile Health: a Huge Promise A definition Mobile Health is the use of mobile technologies for health. Scaling Mobile Health pilots: a Great Challenge Traditional health issues in the developing world + = The main driver: mobile penetration What mHealth can bring The Millenium Develoment Goals:
Goal 4: Reduce child mortality
Goal 5: Improve maternal health
Goal 6: Combat HIV/AIDS, malaria and other diseases Epidemics Malaria HIV/AIDS Tuberculosis Shortfall in medical personnel Remoteness Lack of affordable drugs 14 million people die each year from infectious diseases Poverty Lack of access to health services 36 million people with HIV/AIDS in the world; 25 million are in sub-Saharian Africa The cost of a year’s worth of the standard treatment, a combination of three antiretroviral drugs, was estimated at US$10,000-15,000 at the turn of the millenium. In 2005 2.5 billion people in developing world were living on $2 or less per day Among 57 countries, mostly in the developing world, there is a critical shortfall in healthcare workers, representing a total deficit of 2,4 million healthcare workers worldwide. http://www.itu.int/ITU-D/ict/statistics/ict/graphs/ICT_penetration_2007.jpg 4 billion mobile phones in the world Across the 50 poorest countries in the world, mobile ownership has grown by over 70% a year, every year, since the turn of the century. Malnutrition Speed Two-way flow of information Huge reach Huge data analysis capacity Real-time feedback Reduced HR needs Remote care, telehealth Fields of intervention Successful scaling up rate: less than 3% What mobile technologies bring... to address healthcare challenges. Conclusion Introduction 1. Key Sucess Factors for Scaling Scalability: Replicability:
Organizational structure 2. Lessons learned and recommendations 2. Lessons learned and recommendations Conclusion Business model Technology Ecosystem Local readiness Afghanistan's telemedicine's project Pesinet V1 / V2 INFSS / RapidSMS in Malawi XoutTB The ClickDiagnostics / BRAC Manoshi project Proteus HMIS / MEEDS Healthline The mobile industry: a BOP sector Fake drugs tracking

Remote Monitoring

Data collection

Diagnostics and treatment support

Communication and training for health workers

Epidemic outbreak detection

Education and awareness

Impacted population: fewer than 100,000 people Decision making level efficiency Management level efficiency Execution level efficiency Structure efficiency Gathering the skill set Capacity building •High level of ownership

•Dedication to the project
•The management team is based in the field.

•High degree of autonomy

•The management team works full time on the project.

•High level of ownership

•The management team members are paid enough.

•Contract technicians

•Contract health personnel

•Contract locals

•The execution team members are paid enough.

•Provision of initial training

•Provision of ongoing training


•High level of ownership

•The type of structure (status) is adapted to the needs of the project.

•Good communication between the levels of the structure

•Roles and responsibilities are clearly set between the levels of the structure.

•The project carries a vision that is shared at all levels of the structure.

Usability Flexibility Reliability •Design the technology at least with the users and beneficiaries in mind, at most with them in a process of co-conception.

•Take into account the level of education, the culture and the language of the users when you design the technology.

•The technology is intuitive and easy to use.

•The technology addresses the needs of the users.

•Use the simplest technology as possible.

•High level of modularity and scopability.

•The technology is adaptive and has built-in capacity for change.

•The software part of the technology can deal with a sudden and huge increase in the number of users.

•The hardware part of the technology can be readily available in huge quantity.

•Consistency of the technology architecture.

Structural Process •Local expertise of the technology.

•Changes in the technology can be made in a timely manner.

Structural Process •The breakdown and failure rate of the technology is low.

•The use of the technology and the access to the data produced are secured.

•Errors are easily fixable.

•A maintenance system has been set up.

Solution cost efficiency Solution cost opportunity Business model sustanability Design Implementation •You have low production costs.

•You reach a large number of beneficiaries.

•You consider price elasticity.

•You have a better cost efficiency than the available alternatives.

•In the long term, using your product / service allows the beneficiaries to save money.

•Your sources of funding are diversified.

•There is a link between your sources of funding and your activity.

•You have secured money for the scaling up phase.

•You are actually implementing your business model.

Partnering with the good people Partnering for the good reasons Partnering efficiently The State: the unavoidable partner Selecting other partners •Get at least approval from the State.

•Lean on existing healthcare structures and infrastructures.

•Select partners ready to get involved on a long-term basis.

•Select partners who share your vision.

•Select partners who will be available and able to spend time on the project.

•Look for complementary partners.

Objectives Incentives •Agree on the objectives of the project with your partners from the outset.

•Agree on the objectives of the partnership with your partners from the outset.

•Your partners have one of the following incentives to collaborate with you: market access, supply chain, or knowledge.

•Roles are responsibilities are clearly shared.

•Communicate and be transparent with your partners.

•Establish a common framework of action with clear steps and milestones.

Scaling up ambitions Inception: June 2007

Objective: to scale up nationwide

Stage of development:
Launched at the Bamyan hospital in June 2009
Launched in the regions of Pulukumri, Agatshan
Are continuing the roll-out to a 4th region

Stage of development compared to expectations: Unknown

Infant mortality in Mali : one child out of five does not reach the age of 5

43% of children are underweighted

Maternal mortality in Mali : maternal mortality is 120 higher than in developed countries. Scaling up ambitions Inception of Pesinet V2: 2007

Objectives in 2007: 5,000 subscribers in 2008, 10,000 in 2009 with new sites abroad

Stage of development: One site covered in Bamako with 200 subscribers

Stage of development compared to the expectations: Late
50% of children under five are chronically malnourished

13% die before the age of five

one third of these deaths are the direct result of malnutrition

ongoing food crisis Scaling up ambitions Inception: January 2009

Objective: to scale up nationwide (300 locations) starting with 15 locations in September 2009

Stage of development: January 2009: 3 locations covered; September 2009: 15 additional locations covered

Stage of development compared to the expectations: On time
In 2006 there were 9,2 million new TB cases and 1,7 million TB deaths.

The total cost of TB control programs in high burden countries is estimated to be about $2.3 billion in 2008. Scaling up ambitions Inception: 2007

Objectives in 2008: to be deployed in at least 4 countries in 2010

Stage of development: One pilot in Nicaragua launched in 2007 and one pilot launched in Pakistan in 2009

Stage of development compared to the expectations: Late Lesson 1: Efficient mHealth technological solutions exist. Tool 1: Overview of existing efficient mHealth technological solutions Some famous technological solutions widely adopted:
Epihandy, OpenXdata, FrontlineSMS, EpiSurveyor, RapidSMS

Some famous mHealth organizations providing technological solutions on several projects:
Voxiva, ClickDiagnostics, Datadyne, D-Tree, the UN

Lesson 2: Using existing solutions or working with specialized mHealth organizations minimizes the risk to face technological bottlenecks. Lesson 3: Do not outsource the creation of the technological solution. Lesson 1: Only governmental projects are likely to face a lot of bottlenecks regarding the organizational structure. Lesson 2: It is crucial that the project is carried by a structure totally dedicated to it and the best way to achieve it is to create a structure to carry the project. Lesson 1: mHealth can be financially sustainable. Tool 2: how to assess a mHealth business model sustainability Parameter 1: Diversification of the sources of funding
Level 0 = No diversification. Only one source of funding.
Level 1 = Limited diversification. Several sources of funding, one type of source of funding.
Level 2 = High diversification. Several sources of funding of several types.

Parameter 2: Link between the source of funding with the activity
Level 0 = No link.
Indirect link.
Direct link.

Parameter 3: Amount of money you can expect to get from your source of funding
Level 0 = low willingness to pay.
Level 1 = willingness to pay but low ability to pay.
Level 2 = high ability to pay and high willingness to pay. Lesson 2: Only governmental projects are likely to face a lot of bottlenecks regarding the business model. Lesson 1: getting at least approval from the State is necessary but getting more is very difficult. Tool 1: the map of mHealth stakeholders. Next steps 1) Research: study of local readiness for the replication of scalable pilots

2) Action: making the case of each stakeholder Thank you! quality of the existing healthcare system

mobile landscape

legislative environement Scaling up ambitions Inception: mid 2007

Objective: to scale up nationwide and deploy the project in other countries
In April 2009 was planning expansion to East Africa by the end of the year

Stage of development: unable to move the project from research lab to field deployment

Stage of development compared to the expectations: Late
Scaling up ambitions Pilot results RapidSMS versus the INFSS Elimination of delays in transmission of data: from 3 months to 2 minutes: 64,800 times faster

Better data quality: error rate decreased from 14.2% to 2.8%

Lower child dropout rate thanks to the two-way flow of information system

Mobile services mBanking mCommerce mGovernance mEducation mFinance mHealth Context Pilot results mortality rate on the subcsribing base: 5 per 1,000 compared to an average of 150 per 1,000 in Bamako Scaling up ambitions Inception: July 2009

Objective: to cover all branches of BRAC in Bangladesh
1)Preparatory phase (2 months from January 2010)
2)Phase 1: trial deployment of Click-BRAC mHealth model in 5 ‘model branches’ in Dhaka (4 months)
3)Phase 2: roll out to all Dhaka branches (6 months)
4)Phase 3: roll out to all branches of BRAC nationwide (12 months)

Stage of development: Are in phase 1 of the scale up.

Stage of development compared to the expectations: on time

Scaling up ambitions Inception: late 2009

Objectives: to bring products to the European market with Novartis and to the US in 2012; to give products for free in developing countries later

Stage of development compared to expectations: on time Context Life expectancy: 42 years (men), 44 years (women)

children under the age of five : 16% ; under 5 mortality rate : 87 per 1.000

50% of out-patient consultations due to malaria Scaling up ambitions Inception: Spring 2008

Objective: to scale up nationwide
60 health facilities (half of all health facilities) should be covered by the end of 2009

Stage of development:
May 2008: 10 facilities covered
Summer 2009: 52 facilities covered (1/3 of all facilities)

Context Healthcare delivery in Pakistan:
“Lady Health Workers” (LHWs) : 100,000 government trained, first-line health workers ; in-home visits, triage and liaison ; children’s health, reproductive health, childbirth…
“Lady Health Visitors” (LHVs) : better trained, typically stay at clinics
Nurses, MDs

A 2002 study of 500 Pakistani CHWs found significant gaps in their knowledge, with 79% unable to identify simple pneumonia in a case-based test. Context the maternal mortality ratio: 320 per 100,000 live births

neonatal mortality rate: 37 per 1000 live births Your business model is sutainable if you get only one Level 0 out of the 3 parameters. The telecommunications industry The pharmaceutical industry The opportunity: generation of traffic and increasing the subscriber base Ex: project Masiluleke:
350 million please call me messages have been sent through South Africa
Calls to the AIDS helpline have increased by 300%
Over 1.2 million calls to the Helpline attributed to the please call me campaign

Ex: RapidSMS: For the national rollout, it is estimated that within a period of 12 months there will be 154,250 texts coming in to the server from HSAs and 124,250 messages being sent back to HSAs from the server.
mHealth for stock management
mHealth for addressing compliance

mHealth for intelligent medicine
Decreases the opportunity cost to work on the diseases of the poor Hypotheses For the projects we want to scale: Social impact demonstrated The for-ever pilot syndrom Tool 1: overview of potential funding mechanisms Financing specific actions:

sending SMS: partnership with a telco company to use of Please Call Me messages; partnership with an advertisement company
receiving SMS: reverse billing system; partnership with a telco company to use a toll-free number
giving calls: partnership with a telco company to give calls for free
receiving calls: partnership with a telco company to use a toll-free number
Financing mHealth projects in specific fields of action:

data collection: partnership with a governing body or an international institutions to monetize the aggregated data
prevention: the beneficiaries pay for subscribing to the prevention system; you can use a differential pricing model; you can partner with an insurance company that will decrease its subscription fees for the people subscribing to your service
addressing compliance issues: incentive-based systems: you incentivize patients to use your rewarding system and incentivize your partner to provide the incentive
Other traditional sources of funding:

Transfer of money from one profitable project to another project within the same organization
Philanthropic bodies, foundations, banks, etc

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