Ken Banks recently wrote on kiwanja.net about the philosophy and niche of the core FrontlineSMS platform. He addressed five issues that are central to our field, and he called the post a social mobile line in the sand. While we work closely with the core FrontlineSMS team and share much of their philosophy, our motivation for forming our spin-off health oriented community was that we wanted to focus on a slightly different niche. Hopefully this post will help you understand how were are similar to and different from the core FrontlineSMS team, and every other mobile tool out there.

1. Who are your target audience?
The Frontline Philosophy: To begin with, we’re focused on serving organizations that work to improve human health. And like Kiwanja.net and the core FrontlineSMS team, we focus on the “long tail.” This graph sums up the long tail idea well:

Our team differs from Kiwanja.net’s approach to the long tail in one important way. Ken Banks usually talks about where organizations sit on this graph. Instead, we look at where specific use cases or projects sit on the graph. If you’re a grassroots NGO with 2-3 people on staff, no tech experience, and a shoestring budget, then all of your projects and capabilities should fall in the green part of this graph. You might also be an international NGO with a multi-million dollar budget and a big IT team, but chances are you have some use cases or projects that your IT experts can’t contribute much time to, or where you need to stretch every dollar a very, very long way, or where you work in an impossibly remote and low infrastructure area whose needs are entirely different than other parts of your service area. These are what we’d call long tail use cases. Such organizations might find a rewarding cost/benefit equation for implementing expensive, complicated medical record systems at referral hospitals, perhaps even district hospitals. But for long tail use cases at remote health centers they will need a tool with a frontlines philosophy (whether or not they end up using FrontlineSMS).

2. What is your position on scaling?
Like Kiwanja.net, we focus on horizontal scale, rather than vertical scale. For a generic example of horizontal scale, think of ten independently managed platforms serving 10,000 people each, as opposed to a single centrally managed platform serving 100,000 people. We choose the horizontal, modular approach because we do not want to centralize:

knowledge transfer, learning, and the empowerment that comes from a job well done.
use of gathered data
user ownership and enthusiasm
decision making authority
funding requirements (and potential for failure if they aren’t met)

We also like it when end users can make their own technology decisions (rather than having to defer to an official who will never actually use the tool directly), and we like it when ambitious groups can charge ahead without having to wait for their entire country/district/the domain of any vertically scaled system to catch up.

We do, however, find it absolutely essential to be able to centralize one thing: data. For a huge number of reasons, from pharmacy and supplies procurement, to fund-raising, to disease outbreak management, to research. Exchanging data, of course, can be achieved by representing data in agreed upon formats and transferring via a variety of channels – from Internet, to SMS, to USB sticks carried by bicycle.

3. How does it replicate and grow?
Kiwanja.net couldn’t have said it better: “growth is based on patience, and a “pull” rather than “push” approach, i.e. awareness-raising and then letting NGOs decide if they want to try out the tool or not. Those that do then go and request it from the website. Everything is driven by the end user.”
At the request of partner organizations, we do have a core team of experts that manage a small number of implementations. The majority of implementations, however, only rely on us for the free software and a lot of advice and support (mostly via email). As an organization, we have plenty of growing up left to do, and we’re still figuring out how to portray to the public that we don’t want to (and frankly can’t) manage or direct most implementations of FrontlineSMS and associated tools in health care settings.
We recently decided to start using the term reference implementations to describe the small number of programs that our core team of experts oversees directly. Moving forward, reference implementations will be selected because they pioneer a new piece of software, an important new use case or methodology, or in some way contribute substantially to the larger Frontline community. All other projects are community implementations, and we are pleased to support them with free software, direct email with our team, and upcoming public email lists and a wiki-based field guide. Hat tip to the OpenMRS community for the framing of reference and community implementations.

4. What is your position on open sourcing?
In addition to sharing source code, we strive to live up to principles that are common among community developed projects, such as openness and transparency, bias towards collaboration rather than reinventing the wheel, and sharing the fruits of our labors as freely and widely as possible. That said, we prioritize impact for our users, and we are realistic about the substantial resources required to collaborate – to license code and make sure it’s commented and documented thoroughly enough to support developer collaboration. We sympathize with the many young and low resourced open source projects that are so busy supporting users that they leave something to be desired for strict open source advocates. We’re still in the process of working out licensing of PatientView and setting up our wiki and public mailing lists. We hope you’ll give us the benefit of the doubt and (collegially) hold us accountable in this regard.

5. Does access to “the cloud” matter?
Yes, the cloud matters; it is the future, but not the present on the frontlines of global health. I mean this more as an observation than as an opinion – the cloud simply cannot be accessed with any regularity in the vast majority of places where we work. We want everything we do to accelerate movement towards sophisticated use of low cost, easily accessible cloud based apps, but starting with apps that work exclusively in the cloud or even rely on the Internet just isn’t the best way to do this. Paper based societies need to get their feet in the door with tools that work NOW, but have been designed to point the way to cloudville. How can an SMS platform built on disconnected laptops point the way to cloudville? Under the “scaling” section we hinted at the importance of data standards and platform interoperability. We’re making sure FrontlineSMS plays nice with various cloud based apps. We may even start working in the cloud ourselves someday, but not just yet.

So, that’s our line in the sand. If anyone else has a mobile tool – or is working on a mobile tool – I’d encourage them to clear up any possible confusion and write a post outlining their thinking in these five areas.

Pop!Tech has published the presentations from this year’s Social Innovation Fellows, and I thought I’d share the 5-minute talk on FrontlineSMS:Medic and the Hope Phones campaign. The fellowship program challenged us to rethink our presentations, impact models, financial sustainability, and media strategy — making sure we left with a ‘way forward’ and a community of support.

PopTech 2009 Social Innovation Fellow Josh Nesbit from PopTech on Vimeo.

Be sure to check out the other fellows’ amazing work here.

Rickshaw Traffic in Dhaka, Bangladesh

This update was originally posted on DeshMedic.

Good afternoon, world!  My name is Nadim Mahmud and I am serving as the Research Director here at FrontlineSMS:Medic.  Our program has been expanding rapidly throughout Africa over the past several months, and this summer marked our official foray into South Asia.  Back in February, we were contacted by an organization called the Smiling Sun Franchise Program (SSFP) inquiring about communication solutions for community service providers (CSPs).  SSFP is a USAID-funded project based out of Dhaka, Bangladesh that seeks to improve the standard of care in over 300 clinics throughout the country.  Working with nearly three dozen NGOs, the goal of the project is to help clinics become self-sustainable and successfully wean them off of foreign aid money.  Utilizing CSPs to bridge care between patient and physician, the clinics under the SSFP umbrella chiefly provide family planning and maternal/child health services.

CSPs are SSFP’s equivalent of the community health workers (CHWs) that we write about so frequently.  Their list of responsibilities is extensive, but fortunately their dedication to their work is equally matched.  They provide counseling services to newly married couples and expecting mothers, sell condoms and other family planning methods, play crucial roles in health education, and refer patients for antenatal/postnatal care and serious illnesses.  Each CSP manages between 200 and 300 households and many live at a considerable distance from their parent clinic.  Within the SSFP network, a huge challenge for rural clinics has been managing CSPs and monitoring the types of services that are being provided in their catchment area.  In the status quo, some 6,000 CSPs are reporting service statistics to clinics on a monthly basis.  Aggregating this data takes at least another 15 days and is prone to errors at several stages (there are seven layers of forms that need to be filled out at successive administrative tiers).  NGOs and SSFP headquarters receive data that is at the very least 45 days old.  As a result, they cannot respond effectively to changing dynamics in healthcare trends, inventory stock-outs, high patient dropout rates, etc.

A quick example of why this is problematic:  suppose SSFP conducts a nationwide clean-water educational campaign that is administered through their community educators and service promoters.  They would hope to see greater a disbursement of water purification tablets from their CSPs immediately after this campaign, but without reliable or timely reporting data they have no idea what the outcomes are.  This makes it difficult to decide whether or not the specific program was an effective use of resources, whether or not similar programs should be scrapped or modified, and sustainability margins consequently suffer.

CSP Focus Group – I’m the tall one in the back

To address problems like these, we planned to supply CSPs with java-enabled phones and utilize the FrontlineSMS Forms Client to allow them to fill out and send in daily reports on services provided.  Using this platform, the 42-field paper form currently being filled out by hand can be compressed down to a single text-message.  After a few days of brainstorming and getting up to speed on SSFP, I headed out to a few field sites to talk with clinic managers and CSPs and introduce the idea to them personally.  Once accustomed to the idea of a real-time communication network, the CSPs began to buzz with ideas exploring how it might be used.  One that was particularly popular involved a time-saving referral system:

Currently, CSPs that refer patients to clinics fill out a paper receipt that the patient is supposed to bring to the clinic.  Too often the patients do not show up.  Because of this high dropout rate, CSPs have been walking to the home of each referral patient a week after they refer them to check if they kept their appointment or not, a process that takes hours.  This is time that could otherwise be spent conducting health education sessions, promoting zinc tablet usage, water purification methods, or family planning services.  With FrontlineSMS, CSPs will provide patients with a paper receipt as before, but will also fill out a duplicate referral form on their cell phone and send this to the clinic.  When patients show up with their receipt, the clinic will match this up with the form received in FrontlineSMS.  If a record goes unmatched for a week, the clinic will send an SMS to the CSP with the name of the patient that needs to be checked on or nudged to visit the clinic.  This will allow CSPs to conduct targeted follow-ups rather than lose time seeing patients who have already received care.

Moving forward, we have selected two rural clinics to test out this system- one in Gopalpur and another in Rajoir.  In total, 90 CSPs at these clinics work to provide care to more than 180,000 people.  Beginning in early October, each clinic will be running a Huawei laptop with the latest install of FrontlineSMS (including a Bengali translation that we managed to complete).  Nokia has graciously agreed to provide 130 Nokia 2330s for these pilots, along with several free subscriptions for their Ovi web-based platform.  Because neither pilot site has internet access, exported CSP data will be sent to NGOs and SSFP headquarters using Ovi (summarized below).

Reporting Schema from CSP to SSFP Headquarters

I will be posting updates on these pilots as well as other projects in Bangladesh in the near future, but two more things before I sign off: 1) I would like to thank the Clinton Global Initiative for supporting my work this summer in Bangladesh, and 2) thanks again to Nokia for providing the hardware needed to move these pilots forward.  Needless to say, we are all very excited to have this level of sponsorship for such a noble cause, and hope that our relationship with Nokia will continue to benefit clinics, community health workers, and patients across the globe.

\+/ Nadim

A dam near St. Gabriel’s Mission Hospital in Namitete, Malawi

This update was cross-posted from isaacholeman.org

A few weeks ago I packed my bags and moved to Malawi; I’ll be living here at least a year. In case you were wondering where I am, why I left my beloved Cascadia, or what I’m doing, I’m now the Field Director for FrontlineSMS:Medic. I’m currently the only member of our team who will be working full-time for the coming year based out of East Africa. My work in Malawi is supported by a Compton Mentor Fellowship, a program which exists:

to promote the creativity and support the commitment of graduating seniors from participating schools as they move beyond academic preparation to focus on continuing “real world” application and contribution.

This fellowship has a few basic ingredients:

1. Select a cause you care about, and explain how serving this cause will enrich your life and the lives of others.
The Compton Foundation gets bright young people to work full-time on service projects right after they finish undergrad, that critical juncture where we are making career choices that will affect how happy and productive we are well into the future. A big part of my application was explaining why mHealth is right for me – why I find it so invigorating that a year in the field is sure to get me hooked on service work for the rest of my life. Medicine has made sense for a long time, however, until recently I thought dabbling in technology was just a hobby.
Then I decided I wanted to work in East Africa before starting medical school… what skills did I have to offer? I was honestly considering everything from teaching English to mopping floors when I realized that medicine needs geeks too! In a countless number of ways, having access to the information you need, when you need it, is essential to helping people be healthy. Somehow that was the difficult realization for me. Once I began looking at medical information problems in East Africa, cell phones seemed an obvious game changer and it was only a matter of time before I would discover FrontlineSMS and OpenMRS.

2. Find a mentor who you admire, who serves the same cause as you, and who would like to help you grow.
I’m very fortunate to be working with Ken Banks, founder and champion of the FrontlineSMS platform. Ken writes extensively about technology (especially mobile phones) and development from an anthropological perspective. My ethnographic work in Havana convinced me that participant observation reveals a certain subtlety that is essential to service outside of one’s homeland. If an estimate is an educated guess, I might say that ethnography is educated empathy. More important still, Ken is a great guy and an excellent communicator; he’s already been very helpful with my project.

3. Develop a plan of action to make full use of your intellectual resources and more than $35K from the Compton foundation over the course of one year.
My first plan of action was called MobilizeMRS. A far cry from what FrontlineSMS:Medic is doing today, but the basics were there – I wanted to integrate OpenMRS (the medical records system) with FrontlineSMS (for managing large groups of text messages). The plan had just enough spunk to become a finalist in the USAID sponsored Mobile Development Challenge. That small nod of encouragement helped put me in closer touch and eventually a working relationship with Josh Nesbit, and later Lucky Gunesekara and Nadim Mahmud, and the re-launch as FrontlineSMS:Medic is history (which you can read about at MobileHealthNews.com).

Fast-forward a few months – I now live in room #2 of a guest house at St. Gabriel’s Hospital in Namitete, Malawi. This rural mission hospital serves about 250,000 patients spread 100 miles in every direction. A year ago Josh Nesbit helped local staff train about 75 volunteer health workers to use FrontlineSMS to coordinate and provide better home-based care. I’ll be helping the same staff double the number of community health workers using phones in the field, train the community volunteers to provide more structured descriptions of their activities, and use PatientView to sort the data being sent to the hospital. At the same time, I will be helping the hospital transition from paper forms to a computer-based system for some of their medical records keeping. I’m also responsible for developing our Field Guide or Do It Yourself guide explaining our implementation model, and helping (via skype and email) clinics all over the place put this field guide to good use.

The eventual goal is to integrate the mobile phone program with some components of the electronic medical records system, probably beginning with the treatment program for persons with HIV/AIDS. After working in the clinic for a couple weeks, I couldn’t be more excited about the people I’m working with, and the project’s potential here.