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In our series of interviews from the Bellagio conference on mobile health, here is David Sasaki's last interview with Patricia Mechael who is coordinating the mobile strategy for the Millennium Village Project. She talks about mobile adoption, user-centric design, women and mobiles, how Millennium Villages is using mobiles to improve health outcomes, and what she sees as the next big projects in mobile health.

David Oso:  You have worked in a number of countries -- Egypt, Sudan, the UK, Bangladesh, Cambodia, Mozambique, Russia, Rwanda, the list keeps going on and on. How are cell phones used differently in these different countries where you've worked?

Patricia Mechael:  I think a lot of it is dependent on the penetration, the reach, and the quality of cell phone coverage. For example, when I first started doing my Ph.D. research, I  I did a feasibility study in Bangladesh. This was in 2002, and at that point, the penetration was very low. They had the village phone program and a lot of the village phone women were selling airtime. Phones were predominately being accessed by businesses, and by people who wanted to save money on travel. There was very little uptake within the health sector. There was very little uptake within the general population.

So, it was very interesting to see how in Bangladesh things were actually quite low in the beginning. Things have changed dramatically overtime. I think any network is only as good as the number of other people who are connected to that network.

I ended up doing my actual Ph.D. research in Egypt; because there was actually enough uptake within the health sector, as well as the general population to consider the natural progression of uses of cell phones to support health care. Medical professionals were one of the first groups to prioritize having cell phones. Part of that was probably because they could afford it. They found ways of applying it to their professional work, as well as to their social lives.

Then, in the general public, the people who picked up on the phones to begin with were business people who travelled for work; or families that had children that were traveling, that needed to make sure that they could stay in contact with their children. But, in Egypt they had a longer history of these 'centrales'; these telecommunication centers, where you could call from a fixed line phone to other places. Whereas in Bangladesh they just didn't have the preceding infrastructure.

David Oso:  So, how did those differences relate to developing applications for mobiles in health?  We were here at this week's conference talking about what would be great applications of using mobile phones in healthcare. But do they need to be designed at the national or even regional level? Or can you build a kind of universal application which is then adapted at local levels?

Patricia Mechael:  I think you have to do both. I think you have to look at what the local realities are within the health systems, and the health sector. I think some of the best developments are when you have your endusers involved in the design process. We have a computer science doctoral student working on the development of CommCare in the Millennium village in Uganda. So he's just spent the last few works following community health workers around the village, watching what they do in the household; watching what they do in the facilities, and how long it takes that individual to get from one place to another. 

Having focus groups with them about what their priorities are in terms of work, in terms of communications, desires, and those sorts of things. We take that information into consideration.

I think you have a much better chance of developing an application that will be meaningful for the end user. Then taking that information, and then working it through a business model to look at "OK, how do you operationalize that?" How do you go from five community health workers piloting a system, and developing a system, to 50 community health workers using the system in real time, collecting data, getting the support that they need?

Plugging that into a system that spits out real-time monitoring reports that they can then use to figure out types of ways to modify their activities, what types of ways to improve either access to health services or health service delivery. I think a lot of times the users are often absent in the technology design process. Then you can take it and look at how do then scale that up?

David Oso:  But, you would say that the first step is: following the people who are going to be using this. And seeing how you can make something that helps their work flow?

Patricia Mechael:  Yes, and also, from the beginning what was nice about the study in Egypt, I just looked at "how are people using mobile phones in general without any external support." Often times you can find patterns of use that you can just standardize or strengthen. Or develop the access to the information that they would need; the automated systems for some of the things they were already doing.

There are different ways of approaching it strategically, so that you're not starting from scratch. There are a lot of really good projects out there. They are small, and they are pilots. But it's a good starting point to look at what already exists before coming out and starting something new.

David Oso:  What about the difference between how men and women use mobile phones? Does that relate in health applications? Are they specific in health applications for example?

Patricia Mechael:  It's interesting. When I did my research it was really difficult to find female cell phone users, in general. I think in the mobile health sphere, we are actually going to be pushing the envelope on some of these things. A lot of community health workers, a number of the facility based health professionals that are working in Sub-Saharan Africa, and throughout the world are women. Putting the technology in their hands may have a very different result or outcome than putting it in the hands of a male community health worker, or a business person, etc.

In an actual progression in Egypt, the women who did have mobile phones were often times highly skilled professionals who were travelling for work. So the husband prioritized the mobile phone for their wives, to make sure they could keep in contact with them. So that women in some ways could serve their dual roles, they could continue to serve their role in the household, as the mother, the wife, as well as their professional role.

There are some really neat studies on some of the dynamics of that. In India and other parts of the world, that kind of look at our mobile phones creating a burden for women or are they relieving things; creating more freedom for them. I think that they're doing a combination of the two.

In the Millennium Village in Kenya in the northeast part of the country, we're working with pastoral nomads. We've put mobile phones, through the partnership with Ericcson, in the schools. The school actually has gone from, in the last year, from two girls, and this was before the cell phones. They've gone through two girls to 50 girls staying in the school in the dormitory, etc. One of the sort of hypothesis is that now with the cell phone and families ability to stay in contact with their daughters, that we may actually be able to retain more girls in the school; or convince families to allow their girls to come for education, stay in the school setting, and not be, sort of, pushed and pulled by the pastoral, nomadic life that then disrupts their educational opportunities.

David Oso:  Do you think that resentment could grow because of that, toward cell phones -- keeping young girls and women in school rather than out in the fields working where they could help bring in more money that way?

Patricia Mechael:  Well, it's not like they're working and making more money, it's that they are following the pastoral, nomadic community and the fear of...like I did this focus group with key leaders in that community. The fear is that if something happened they won't be able to contact them. It takes three or four day for families to be able to communicate with each other because they send a messenger boy who then has to run and do all sorts of things.  In this particular community, their assets are their livestock. Often times it is herdsmen and boys that are more likely to follow the livestock around than the girls. So they're not actually contributing to the economic well being of the family, but it is that fear of, my daughter going off.

But in some ways they are an asset because depending on the people group there is this level of, our daughters are wealth because when they do get married we get cows for them, that sort of thing, but the education piece and the value of education is really changing in this nomadic community. We're hoping and we're looking and we're watching the trend to see if the communication improves the likelihood of continuing on in education.

David Oso:  So bringing up the Millennium Villages Project, could you give a very brief description of what it is for those people who don't know? You're also the mHealth Advisor to the project. So what is your role in that and what advice do you give?

Patricia Mechael:  Millennium Villages Project was established about two years ago to provide real life evidence of proven intervention, targeting the achievements of the Millennium Development Goals. The Millennium Development Goals were created in 2000, so that targets would be set in 2015 for things like reducing maternal mortality by certain amounts; by a certain time across the world.

So, the way that we're looking at mobile health is: how do we strategically target the application of mobile phones; whether it's basic voice and text functions to improve access to emergency services; whether it's a mobile phone application to improve diagnostic capabilities and identification of disease; or data collection for decisionmaking.



I am making sure that the interventions that we implement  in partnership with Ericsson and the operators that we're working with in each of the 10 countries  are really aimed at contributing to the achievement of Millennium Development Goals.

  My area is specifically in health. But we're also looking at how do we apply mobile technologies and other technologies  in an ecosystem approach  to achieving the MDGs for poverty eradication, for women's empowerment, for education, which is really exciting.  

It's really a test bed. For me, as somebody who has been studying this for a really long time, it's like a dream to be able to really spend time working through the kinks of how all these things can work that will likely have an impact, hopefully later on down the line.

David Oso:  Are there any success stories already, or any lessons learned? Or, is it still very much in the initial, pilot project phase

Patricia Mecheal:  It's still pretty much in the initial pilot phase, although we do have some anecdotal evidence. We set up a toll free number in Rwanda for emergency medical transportation. There is evidence that people are getting to care faster. There is this impression that case fatalities are going down. That more women are getting into health facilities to be delivered by a skilled, labor and delivery professional; whether it's a nurse-midwife, or an obstetrician/gynecologist.

So, that's kind of exciting.  I was there a few months ago; and was talking to some of the facility-based staff and the ambulance workers. They are from the local community. They could see changes just from having this toll free number.

David Oso:  The idea being that if women can call the hospital or get into a hospital easier, then child mortality rates go down?

Patricia Mechael:  Child mortality rates go down, as well as maternal mortality rates go down  that's just one of the known interventions. A woman delivering in a health facility is a known public health intervention that contributes to the reduction of maternal mortality.

David Oso:  What about last week's meeting on mobile health? What have been your impressions? Today's the last day. So, what are you going away with? What are you hoping that everyone goes away with?

Patricia Mechael:  We haven't had a one-day meeting on mobile health; let alone a four-day meeting on mobile health. So I'm incredibly jazzed about just even being in the room with as many of the key players in this phase as well as people who maybe haven't been active but are really interested in becoming active from the corporate side, from the NGO side, from the foundation side. I'm looking at what can we all do together to really advance the field. The fact that we're all talking about the creation of a mobile health alliance of some sort to provide a platform for collaboration, for standardization, for advocacy, those types of things. I wasn't even thinking that that was something that would come out of this meeting; so to advance that far along in the discussion and the thinking, is really exciting.

Then there have been a number of projects that have come out of the discussions that I think we're going to implement. I think we are going to.

David Oso:  What is something that you're excited about?

Patricia Mechael:  The one group that I was involved in looking at limiting the effects of disease outbreaks and limiting outbreaks in general. A lot of the tools for mobile surveillance, as well as for alert systems exist. But they haven't been applied on a strategic scale to have an impact on global health. So one of the things that I'm excited about is working to figure out, can we come out with a global system platform that enables people to collect data and view data on a mobile phone; on a computer, that is aggregated across multiple countries, that is localized. So if I'm working in a province, I can just see my provincial data. If I'm working at the national level, administrative health, I can look and see what's going on in the country overall.  If I'm at WHO or the SAO looking at humans versus animal disease outbreaks, I can look at data that's aggregated across a bunch of different countries.



What's interesting and exciting is that the framework exists. The paper-based system exists for doing these things. People are reporting into the WHO on these 14 diseases. So how do we create an  mhealth system that supports this? We're not so naive in the sense that just because you have a tool does not mean that you're actually having an impact. One of the great things about some of the discussions that we've been having is looking at: How do we build the necessary capacity in some of the supporting areas to make sure that this is successful.

So looking at lab systems, what type of capacity building support do we have to build to make sure that the lab tests and the lab technicians are detecting the diseases that they need to be reporting on? What types of support do we need to make sure from a management perspective that supply chain management for either diagnostic supplies, equipment are there, as well as the drug supplies that need to go out? So if you have a massive outbreak within the animal health population or the animal population you need to initiate a mass vaccine response to that that those systems are also in place.

To me, it's exciting to look at how we have a comprehensive approach to these things because technology alone is not going to do it. It's going to be technology in combination with a bunch of other things that need to really make it work.



The other projects which I wasn't directly involved in discussing are building systems and tools for positive living. One of the major areas that Mobile Health can have an impact on is in the prevention of disease as well as helping people to maintain a positive well being. So looking at nutrition, exercise; support groups for people living with HIV and AIDS so that they have a positive outlook on life.

 Those are some of the interesting areas, just basic voice and text systems could really have an impact. 

Then some of the other things that people talked about were a teledoc or an m-doc kind of diagnostic tool and system for medical doctors to have; like a decision, support tool. How do you improve clinical practice and decision making and outcomes and quality of care that's provided?

David Oso:  It sounds like that's the big key word this week, is scaling up and then integrating. So the Mobile Health Alliance is obviously going to go towards that and there's even been talk of a big conference in February. What can we expect?

Patricia Mechael:  I think we can expect much better, coordinated projects, much more visible projects. I think we'll start to see it featured in journals and publications. I think people are really committed to establishing it as a collaborative base and field. I think we'll actually have some form of an organization that is the alliance with representation from corporations, from MGO's, from research institutions, academic institutions, both in developing countries as well as from developed countries.

 It's an exciting space.  Nobody will deny that the spread of mobile technology does not have the potential to transform people's lives; people's lives for health, people's lives for banking, people's lives for business development. It's already happening. Mobile Health is happening, whether or not we're a part of it, whether or not it has external support, people are engaging in Mobile Health activity; whether they are thinking about it in those terms or not. I think we're in a great position to really help solidify that. Really help have it become more strategic and targeted so that people are really feeling the benefits in their daily lives.

You can listen to the entire interview with Patricia Mechael here.