Mobile Technology for Community Health (MoTeCH) in Ghana

1. Mobile Technology for Community Health (MoTeCH) in Ghana Bruce MacLeod Jim Phillips

2. MoTeCH Ghana: • Gates Foundation Learning Grant : “Can mobile technology improve health ? • Columbia University, University of Southern Maine, Grameen Foundation, & Ghana Health Service • Looking for transformative technologies that can scale to nationwide operations and inform global m-health strategies.

3. The Geographic Context: Sahelian West Africa The socio-economic Context: Ghana’s most impoverished region

4. In a challenging setting…. • …can mobile-phone-based health information technology incrementally improve health outcomes? • …and will m-Health enhanced services improve the quality and accessibility of care for needs that span “the continuum of care” Focus: • Information delivered to “pregnant parents” through “Mobile Midwives” • 2) Information relevant to the delivery of health services by “Community Health Officers” (CHOs) – part of the “Community-based Health Planning and Services” (CHPS) Initiative

5. Challenges in UER Region Challenges in Communities Challenges for CHPS Nurses

6. Problem #1: Constrained Information for Supporting Health Service Supply and Demand Catalyzing demand Enabling supply

7. Problem #2: Different information requirements across the “Continuum of Care” are poorly suited to paper systems…. Pre-pregnancy Pregnancy Delivery Newborn/Postnatal Care Childhood Family planning, prevention of STI, equal opportunity for girls Early detection of pregnancy, and a focus on ANC SBA, Improve linkages between home and facility, Clean childbirth practices, and essential newborn care Promotion of healthy behaviors (Baby – EBF, immunization, warming ,etc.; Mother –Family planning) Management and care of LBW, care of Sepsis for NBs, nutrition, malaria, immunizations

8. Despite pervasive poverty, the Mobile Technology Revolution has reached Africa: • The total African mobile subscriber base has passed 500 million which is probably greater than 50% of the population, • Subscription in Africa is the fastest growing of any region in the world (growing at 18%/yr) • Over 70% of the population has access to mobile telecommunication • At least 15 companies have already announced plans of introducing 3G voice and data services • SMS (Text messages) are being used in innovative ways such as • Pricing information for agricultural products, • Mobile banking • Human rights violations • Typically pay as you go with kiosks selling “minutes” • “Mobile Money” is emerging as a business model.

9. Cell Phone coverage

10. The MoTeCH Approach…. First, ease information capture for community-based healthcare workers by simplifying paper registers

11. MOTECH: alleviating these challenges using phones

12. MoTeCH Use Cases • 1) Supports Nurses with an information system: • Data entry using Java enabled phones, (16 distinct e-forms) • Alerts/reminders for service delivery to patients (weekly) • Query for “defaulters” (2 e-forms) • 2) Provides patients with health information, including: • Patient control of choice to enroll in the message program, selection of optimal time of day for messaging, language . • Support for personal phones, shared phones, community phones. • Regular health messages relevant to patient needs. • Alerts for Service Delivery . • Automated answers to health queries. • 3) Equips GHS & MoTeCH administrators with a medical record system with functionality for: • Maintaining and updating patient data. • Providing routine reporting information for District Health Information System. • Providing operational and supervisory reports.

13. Data Input on Mobile Devices Mobile forms, openXData using xForms specification

14. Nurses use Java Mobile Phone App 1 2 3

15. Server Side MoTeCHRequirements • Patient Data needs to be stored : • Service delivery, pregnancy, morbidity & immunization data; but expect more types of data later • Private, confidential, role based access • Appropriate to low-income country context • Patients sign up for health messages • Health information, ANC& PNC appointments, .. • Personalized, multiple languages, time preferences • Messages need to be sent to Patients • Healthy Pregnancy information, newborn care messages • Upcoming Appointment messages • IVR to patients (2 for more info, get message with ID) • SMS (unclear if this will be useful in Upper East, Ghana) • Nurses need to be notified of community members in need of service • SMS weekly summary of service delivery defaulters (ANC, PNC, Immunization) • SMS Immediate alert (6 hour updates) if women delivers • Support for Telecommunication protocols • SMS, Voice IVR, Java Forms & GPRS transmission • Reports for District Health Information System

16. Over 120 Clinical & Research sites around the world

17. OpenMRS/MoTeCH : Secure, Web Based Access to Registration, Message Program Enrollment, Editing

18. MoTeCH 1.0 Architecture

19. Health Policy in Ghana implements the conventional Global “Expanded Program of Immunization” (EPI) • Children:BCG (Bacillus Calmette-Guerin) - BirthOPV (Oral Polio Vaccine) - Birth, 6 weeks, 10 weeks, and 14 weeksPENTA (Pentavalent Vaccine, DPT-Hib-HeB) - 6 weeks, 10 weeks, and 14 weeksMeasles - 9 monthsYellow Fever - 9 months • Not to administer BCG or Yellow Fever immunization if child has HIV/AIDS • Women (12-44 years old):TT (Tetanus Toxoid) - 5 doses Early as possible (12 years old?) • Minimum 4 weeks after TT1 • Minimum 6 months after TT2 • Minumum 1 year after TT3 or during next pregnancy (When during pregnancy?) • Minumum 1 year after TT4 or during next pregnancy • Pregnant Women • Treated Nets in Malaria areas • IPT (intermediate preventative treatment for malaria) • PMTCT

20. The patient care schedule is updated when new data arrives

21. Event/Workflow Engine : Health Tips & Upcoming Service Delivery Expected Service Delivery Dates are put on a Calendar : Send Messages to Patient for Upcoming Delivery Send Messages to Nurse when Overdue Support Query Messages from Nurse

22. Specification for care schedules and messaging do not require programming: XML Declarative Logic for Tetanus Eligibility • <bean id="pregnancyTetanusSchedule" class="org.motechproject.server.service.impl.ExpectedObsSchedule"> • <property name="name" value="TT" /> • <property name="conceptName" value="TETANUS TOXOID DOSE" /> • <property name="registrarBean" ref="registrarBean" /> • <property name="requirements"> • <list> • <bean class="org.motechproject.server.service.impl.AliveRequirement" /> • <bean class="org.motechproject.server.service.impl.AgeRequirement"> • <property name="minValue" value="12" /> • <property name="minPeriod" value="year" /> • </bean> • <bean class="org.motechproject.server.service.impl.GenderRequirement"> • <property name="gender" value="FEMALE" /> • </bean> • </list> • </property> This Service is interested any Tetanus Toxoid doses in the OpenMRS DB associated with presently living females, 12 years and older.

23. MoTeCH Technologies & Components(MoTeCH builds on past efforts) • OpenMRS : Medical Record System • OpenXData : Mobile client & form designer • Spring Framework Application • Hibernate, mysql, java libraries • Maven build • Many open source libraries • CI : Continuous Integration Server • IntelliIVR : IVR system • SMS Gateway Support

24. Technical Next StepsMoTeCH Ghana  MoTeCH Platform • Improved use of Standards • VoiceXML for IVR • SDMX-HD for data aggregation • Common concept dictionaries (PIH, MVP…) • xForms MRS • With support for Server side validation, complex mappings, & data can initiate program logic • IVR  MRS • Rules Engine (Drools) for scheduling messages • Large Scale Implementations • Build and Support Open Source Community

25. MoTeCH 2.0 Architecture

26. MoTeCH 2.0 Architecture

27. MoTeCH 2.0 Architecture

28. MoTeCH 2.0 Architecture

29. The Future: District Sub-district Community Expanding MoTeCH Functionality over the continuum of care…. Doorstep Pregnancy Post-partum + neonatal Post weaning Etc….. Etc….. Etc….. Etc….. Delivery Post-neonatal Late childhood

30. At each intersection there are unique information needs… Dimensions of the continuum of care… District Sub-district Community Doorstep Pregnancy Post-partum + neonatal Post weaning Etc….. Etc….. Etc….. Etc….. Delivery Post-neonatal Late childhood

31. Most problems that are point of service related are solved by MoTeCH…but At each intersection there are unique problems and needs… Dimensions of the continuum of care… District Sub-district Community Doorstep Pregnancy Post-partum + neonatal Post weaning Etc….. Etc….. Etc….. Etc….. Delivery Post-neonatal Late childhood

32. Dimensions of the continuum of care… District … but elements of the care continuum require development, such as family planning. Sub-district Community Doorstep Family-Planning Post-partum + neonatal Post weaning Etc….. Etc….. Etc….. Etc….. ANC & Delivery Post-neonatal Late childhood

33. …such as supply and logistics, reporting to the National Health Insurance System, and…. ..and some health systems support problems are not fully addressed by MoTeCH… Dimensions of the continuum of care… District Sub-district Community Doorstep Pregnancy Post-partum + neonatal Post weaning Etc….. Etc….. Etc….. Etc….. Delivery Post-neonatal Late childhood

34. Other problems are emergency support, referral and information feedback related. Dimensions of the continuum of care… District Sub-District Community Doorstep Pregnancy Post-partum + neonatal Post weaning Etc….. Etc….. Etc….. Etc….. Delivery Post-neonatal Late childhood

35. Other problems are emergency support, referral and information feedback related. “Mobile money” could pay a crucial role in supporting facility based delivery and emergency logistics Dimensions of the continuum of care… District Sub-District Community Doorstep Pregnancy Post-partum + neonatal Post weaning Etc….. Etc….. Etc….. Etc….. Delivery Post-neonatal Late childhood

36. Conclusions: MoTeCH … • Provides an information system for nurses

37. Conclusions: MoTeCH … • Provides an information system for nurses • Provides health information to pregnant women and young mothers.

38. Conclusions: MoTeCH … • Provides an information system for nurses • Provides health information to pregnant women and young mothers • Supports the system of care: Management, supervision, monitoring.

39. Conclusions: MoTeCH … • Provides an information system for nurses • Provides health information to pregnant women and young mothers • Supports the system of care: Management, supervision, monitoring. MoTeCH… • Builds on and adds to the open-source health information software community.

40. Conclusions: MoTeCH … • Provides an information system for nurses • Provides health information to pregnant women and young mothers • Supports the system of care: Management, supervision, monitoring. MoTeCH… • Builds on and adds to the open-source health information software community. • Supports the science of scaling up.

41. Thank you www.ghsmotech.org Feel free to contact Jim or Bruce for more information : jfp2113@columbia.edu or macleod@usm.maine.edu