Workshop Agenda: 14 September 2011

A one-day gathering in New York City, bringing together key stakeholders from Community Case Management (CCM) and Mobile Health implementers to build alignment and research agenda around how mobiles can support the tools, processes and systems of CCM. The workshop will be hosted and facilitated by frog, a global innovation firm and UNICEF partner.

8:30-9am Breakfast and Introductions

9-9:30am Presentation: Framing the Question

9:30-10:30am Group Breakout/Provoking Unconventional Thinking

10:30-11:30am Group Breakout/Generating New Concepts

11:30-Noon Group Readouts

Noon-1pm Lunch

1-2pm Group Breakout/Sketching New User Scenarios

2-3pm Group Breakout/Prototyping and Live Testing Scenarios

3-4pm Group Readouts and Discussion

4-5pm Solution Voting and Prioritizing

5-5:30pm Final Thoughts: Themes, Solutions and Next Steps

Workshop ‘Must Reads’ and Background Resources

The links below download or link to information, studies, concept notes, presentations etc around the context of CCM and mobiles.

Community Case Management

Community Case Management of Diarrhoea, Malaria and Pneumonia of Sick Children for sub-Saharan Africa in 2010: Data Report of a Desk Based Survey of UNICEF Country Offices; UNICEF Headquarters, Eastern and Southern Africa Regional Office & Western and Central Africa Regional Office; July 8, 2011. This is important reading for those not intimately familiar with CCM implementation in sub-Saharan Africa. The study documents the status of national CCM policy and implementation of diarrhoea, malaria, pneumonia, and severe and acute malnutrition (SAM) and newborn care activities for children aged 2 months-5 years in sub-Saharan African countries in 2010. 

Community Case Management Essentials: Treating Common Childhood Illnesses in the Community. A Guide for Program Managers; CORE Group, Save the Children, BASICS and MCHIP, 2010. Inspired by the classic: Immunization Essentials, this guide methodically documents what is known about CCM and how to make it work. First, health program managers are introduced to the basics. Then, CCM Essentials walks its readers through the process of designing and managing a high-quality CCM program.  The ultimate result: lives of newborns, infants and children saved around the world.

Mobiles and CCM

Concept Note: Strengthening Community Case Management through mHealth; UNICEF, 2011. The potential of using mobiles to strengthen the quality of care, access to interventions and services as well as the quality of monitoring decisions, feedback and supervision for Community Health Workers in the context of Community Case Management.

Workshop Concept Note: Integrating Mobile in to CCM; UNICEF, 2011; initial concept note developed by UNICEF and frog

CCM and mHealth session description and notes; 2010

Landscape analysis of mHealth approaches which can increase performance and retention of community based agents; Malaria Consortium, 2010

Check out the mHealth work of some of the attendees

CommCare is open source software for CHWs that runs on Java-enabled and Android phones. It contains registration forms, checklists, danger sign monitoring, and educational prompts to help manage enrollment, support, and tracking of all of the CHW’s clients and activities.  Watch a video to see how it works.

Medic Mobile develops and extends existing open-source platforms, including FrontlineSMS, OpenMRS, and Medic Dashboard. These tools support community health worker coordination and management, patient tracking, emergency services, community mobilization for vaccination and satellite clinics, logistics and supply chain management, referrals, routine data collection, and mapping of health services. 

RapidSMS is a SMS-based (text message) framework that manages data collection, complex workflows, and group coordination using basic mobile phones — and can present information on the internet as soon as it is received. So far RapidSMS has been customized and deployed with diverse functionality: remote health diagnostics, nutrition surveillance, supply chain tracking, registering children in public health campaigns, and community discussion. RapidSMS was designed to be customized for the challenges of governments, multilateral, international- and non-government organizations, and development practitioners: working effectively in spite of geographical remoteness of constituents, limited infrastructure (roads, electricity), and slow data collection (due to paper-based records, slow courier systems, etc).

WORKSHOP GOALS: Integrating Mobile into CCM

UNICEF and frog are organizing a workshop on the 14^th of September 2011 that will bring together key stakeholders from Community Case Management (CCM) and mHealth implementers to build alignment and research agenda around how mobiles can support the tools, processes and systems of CCM. The workshop will be hosted and facilitated by frog, a global innovation firm and UNICEF partner.

The first order goal of the workshop is for the CCM and mobile health community to plan, prioritize and create a roadmap on how to best integrate mobile technologies into CCM. This supports the second order goal to better support frontline health workers to serve underserved communities more effectively and improve key child survival outcomes.

In this collaborative and action-oriented workshop we will:

• Generate a provisional model for how the different layers of health care providers and their user experience fits together
• Identify key opportunities for alignment in the planning and prioritization process to support this integrated user experience.
• Better understand how to integrate the needs for local and regional customizations.
  

Initial Ideas on How Mobiles can Strengthen CCM

The strategic integration of CHW’s mobiles into national CCM strategies and workflows (if done in an open, scalable and sustainable manner) could help decrease child mortality in underserved areas in a number of ways:

Increasing availability of essential curative medicines at community level

There can be no CCM without a constant supply of medicines to treat each of the childhood illnesses. Even with the necessary steps taken for successful management of medicines and supplies, delays in information transfer and necessary communication between CHWs, local health facilities and formal health logistics systems hamper restocking efforts, inventory management and record-keeping especially at the last mile of the supply chain.

Stock-outs of essential medicines undercut CHWs credibility within communities and feasibility studies have shown that if CHWs can see that reporting on usage and stock levels of key commodities using their mobiles translates in to the improved and timely availability of key commodities, they are very willing to participate in this reporting. CHW’s use of SMS in this area would allow for automatic codification of the communication between CHWs and the formal health system. This data could be aggregated in real-time, and integrated into more formal logistics system that usually does not descend past district facility level to inform supply strategies. 

Case management and referrals

Effective case management is the cornerstone of CCM, and a well-functioning referral system has many benefits for CCM, including treatment for severely ill children and reinforcing the links between CHWs and the formal health system.

If CHWs found that using their mobiles could help them easily improve their case management and make facilitated referrals easier (as a complementary addition to paper-based registers), then performance of CHWs on case management could be tracked as well as tracking and monitoring referrals through the system. An example of this can be seen in Zambia’s use of RemindMi - SMS reminders and tracking to bring mothers and infants back to clinics for key post-natal interventions.

Supervision and transparency

Supervision is the glue that holds different stakeholders together in CCM: parents, CHWs, health facility staff, and district managers. Supervision is a challenge for many programs, because the providers to be supervised are often dispersed in remote locations.

If CHWs find that using their mobiles is useful to their jobs – bringing them public recognition, a better ability to perform their duties, and providing small incentives, the data exhaust generated from their use of these systems would allow higher up levels of the health system to support, monitor and compare the work of CHWs and health facilities through real-time information.  Ideally the data exhaust generated by using the system for case management, referrals and medication management would help prioritize supervisory visits, find problem areas, and compare performance across districts. Recognizing that one of the main problems with supervision is lack of time and transport on the part of the supervisor, mobile technologies could remind and track the supervisors’ periodic “check ins” with CHWs on the illnesses that they are treating and challenges they are facing in CCM implementation.

Why Integrate Mobile in to CCM?

Pneumonia, diarrhea and malaria combined account for more than half of all childhood deaths, with malnutrition being the underlying cause in over 50 per cent of these deaths.

Children in underserved communities, especially in rural areas without easy access to formal health services, are the most at risk. Prompt and effective treatment for these killers through the use of evidence-based child survival interventions (antibiotics for pneumonia and dysentery, oral rehydration therapy and zinc for diarrhea, antimalarials for malaria, and RUTF for Severe Acute Malnutrition) is essential for reducing child mortality in underserved areas.  The use of trained Community Health Workers (CHWs) to provide these services is growing and is being recommended and supported by UN agencies and partners.

One of the greatest gaps in potential mortality reduction in most high burden countries is the unmet need for treatment of diarrhea and pneumonia, and of malaria in endemic countries.  Current treatment levels for these main childhood killers are low especially in rural and underserved communities[1].

Community Case Management (CCM) is a strategy to deliver these lifesaving curative interventions for these common childhood illnesses, in particular where there is little access to facility based services[2].  CCM does not stand alone. The best efforts upgrade the skills of CHWs so they can deliver curative interventions, refer children with danger signs; such efforts also ensure strong links with the formal health system.

In resource-poor settings, often characterized by geographical remoteness of constituents, limited infrastructure (roads, electricity, functioning logistics systems), and slow information flows (due to paper-based records, slow courier systems, etc.) CHWs need a steady supply of essential child survival interventions, logistics support, supervision, training and incentives if they are to carry out their work effectively.

Community Health Workers and Mobiles in underserved communities

Many M-Health initiatives have recognized and capitalized on the fact that more and more CHWs own mobile phones – even in areas with uneven mobile service coverage.  81 per cent of worldwide mobile connections still use very simple phones (ability to make calls and send text messages only)^[3].  While few phones have the rich application and data abilities of the latest smart phones, all existing phones are capable of voice and text messaging. When planning for sustainability or scale from the outset, it makes sense to consider the use of CHWs personal phones as even at a low cost (e.g. US$50 for a smart phone), providing this hardware and necessary technical support around it at scale will become incredibly costly. 

Information and Communication Challenges in CCM

Under the CCM results framework, the goal of decreasing under-five mortality by using curative intervention for childhood infection at the community level is supported through the success in four intermediate results:

•  Increased access to and availability of interventions and services including strengthening links between CHW and health facilities, successful diagnosis and case management, facilitating referrals to health facilities for severe cases, and strengthening essential curative services logistics and procurement mechanisms at a local level.
• Increased quality of services including training reinforcements, job aids, supervision and monitoring quality through feedback and dialogue.
• Increased demand requiring awareness of CCM services and timely recognition of illness and care-seeking as well as effective home management of sick children.
• An enabled social and policy environment, requiring demonstrable feasibility, effect and cost of CCM and increased community capacity to support CCM.[4]

One of the main bottlenecks that runs through all of the four intermediate results and presents major challenges for countries implementing successful CCM initiatives is successful and timely information transfer and dialogue.  M-Health initiatives have shown localized and often very vertical successes around using mobiles to improve timely information transfer which has resulted in better availability of key commodities, demand seeking behavior and improved quality of services, particularly where geographical remoteness of beneficiaries, limited infrastructure, and slow data collection are prevalent.  However, too often, these initiatives have not been well integrated into formal health systems or national id systems, and are not designed for scale and sustainability at the outset – either in cost, flexibility or openness [5].

[1] Inter-Agency Joint Statement – Integrated Community Case Management (iCCM): an equity-focused strategy to improve access to essential treatment services for children

[2] Community Case Management Essentials: Treating Common Childhood Illnesses in the Community (A guide for Program Managers) www.coregroup.org/storage/documents/CCM/CCMbook-internet2.pdf 

^[3] GSMA Q2 2009 market data summary http://www.gsmworld.com/newsroom/market-data/market_data_summary.htm

[4] CCM Results Framework: Inter-Agency Joint Statement – Integrated Community Case Management (iCCM): an equity-focused strategy to improve access to essential treatment services for children 

[5] Barriers and Gaps Affecting M-Health in Low and Middle Income Countries: Policy White Paper, P. Mechael et al.http://www.mobileactive.org/research/barriers-and-gaps-affecting-mhealth-low-and-middle-income-countries-policy-white-paper-0