THE JOURNEY

TO SCALE
Moving together past digital health pilots

Copyright 2014, PATH. All rights reserved.

The material in this document may be freely used for educational or noncommercial purposes,
provided that the material is accompanied by an acknowledgment line.
Suggested citation: Wilson K, Gertz B, Arenth B, Salisbury N.
The journey to scale: Moving together past digital health pilots. Seattle: PATH; 2014.
Inquiries: [email protected]
Cover photo: Drew Arenth.

THE JOURNEY
TO SCALE
Moving together past digital health pilots
Kate Wilson
Beth Gertz
Breese Arenth
Nicole Salisbury
December 2014

CONTENTS

THE JOURNEY TO SCALE: Moving past digital health pilots . . . . . . . . . . . . . . . . 3

KEY TERMINOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ACRONYMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
AUTHORS NOTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
EXECUTIVE SUMMARY: The journey to scale . . . . . . . . . . . . . . . . . . . . . . . . 8
THE JOURNEY TO SCALE SO FAR: Why is a new approach required? . . . . . . . . . . . 10
DECIDING ON THE DESTINATION: Defining successful scale for digital health . . . . . 13
PLOTTING THE COURSE: Levers for achieving institutionalization . . . . . . . . . . . . 17
REACHING INSTITUTIONALIZATION:
What are some strategies to accelerate our journey? . . . . . . . . . . . . . . . . . . . . . . 24
CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Appendix 1: Standardizing Shipping Containers Analogue . . . . . . . . . . . . . . . . . . 35
Appendix 2: Barcodes Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Appendix 3: Vaccine Vial Monitor Case Study . . . . . . . . . . . . . . . . . . . . . . . . .38
Appendix 4: Mobile Alliance for Maternal Action Analogue . . . . . . . . . . . . . . . . . . 41
Appendix 5: District Health Information Software (DHIS 2) Case Study . . . . . . . . . . .42
Appendix 6: BBC Media Action Case Study . . . . . . . . . . . . . . . . . . . . . . . . . .44

KEY TERMINOLOGY

BBC MEDIA ACTION

BBC Media Action is the BBCs international development charity which uses media
and communication to reduce poverty, improve health, and support people in
understanding their rights. In Bihar, India, it partnered with the Bill & Melinda
Gates Foundation and the government to improve reproductive, maternal, newborn,
and child health (RMNCH) through use of mobile services for frontline health
workers (FHWs) and families.

DIGITAL HEALTH
INTERVENTION

The use of information and communication technology (ICT) as a tool to improve

health systems and services. This definition deliberately includes concepts of both
mobile health (mHealth) and electronic health (eHealth).

DISTRICT HEALTH
INFORMATION SOFTWARE
(DHIS 2)

The District Health Information Software (DHIS) is widely-adopted software used

to strengthen public health systems by improving the collection and use of health
indicators.

DIGITAL HEALTH
COMMUNITY

Includes all global health community actors including countries, donors,

international nongovernmental organizations (INGOs), private- and public-sector
developers, and multilaterals.

INSTITUTIONALIZATION

Embedding in policies, practices, workflows, and daily life.

INTEROPERABILITY

Defined by the Healthcare Information and Management Systems Society as:

Interoperability describes the extent to which systems and devices can exchange
data, and interpret that shared data. For two systems to be interoperable, they must
be able to exchange data and subsequently present that data such that it can be
understood by a user.

LEVERS OF SCALE

Key enabling factors whose absence may hinder an intervention reaching scale, and
whose presence may accelerate it.

MOBILE ALLIANCE FOR

MATERNAL ACTION
(MAMA)

The MAMA partnership delivers vital health messages to new and expectant
mothers in developing countries via their mobile phones. MAMA started with a
three-year, $10 million investment to create and strengthen programs in
Bangladesh, South Africa, and India. MAMAs efforts align with the UN
Secretary-Generals Every Woman Every Child campaign and efforts to achieve
Millennium Development Goals (MDGs) 4 and 5.

PRINCIPLES FOR DIGITAL

DEVELOPMENT

Principles for design that capture the most important lessons learned by the
development community in the implementation of information and communication
technology for development (ICT4D) projects. These principles were inspired by the
Greentree Principles of 2010, the United Nations Childrens Fund (UNICEF)
Innovation Principles of 2009, and the UK Design Principles, among others.

STANDARDS

Norms or requirements that must be met.

VACCINE VIAL MONITOR

(VVM)

A label placed on vaccine vials that measures cumulative heat exposure.

ACRONYMS

BMZ

German Federal Ministry for Economic

Cooperation and Development

DHIS

District Health Information Software

eHealth

Electronic health

EPI

Expanded Programme on Immunization

FHW

Frontline health worker

GIZ

Deutsche Gesellschaft fr Internationale

Zusammenarbeit

GSMA

Groupe Speciale Mobile Association

HISP

Health Information Systems Program

HMIS

Health management information system

ICT

Information and communication

technology

ICT4D

Information and communication

technology for development

IT

information technology

ITU

International Telecommunication Union

IVR

Interactive voice response

MAMA

Mobile Alliance for Maternal Action

MDG

Millennium Development Goal

mHealth

Mobile health

MoHFW

Ministry of Health and Family Welfare

MOTECH

Mobile Technology for Community

Health

NGO

Nongovernmental organization

NORAD

Norwegian Agency for Development

Cooperation

OPV

Oral polio vaccine

PEPFAR

US Presidents Emergency Plan for

AIDS Relief

RMNCH

Reproductive, maternal, newborn,

and child health

SD

Supply division

SMS

Short message service

TCO

Total cost of ownership

UNICEF

United Nations Childrens Fund

UPC

Universal product code

USAID

US Agency for International

Development

VVM

Vaccine vial monitor

WHO

World Health Organization

AUTHORS NOTE

This paper was commissioned by the

Bill & Melinda Gates Foundation to motivate
the digital health community to consider
new approaches to scaling digital health
interventions.
The Bill & Melinda Gates Foundation asked PATH to consider
why scale remains a continuing challenge for digital health
interventions in the developing world and to examine if there
were key factors in which further investment is needed to reach
scale. Because scale is a much-studied concept in business and
global health generally, we built upon this rich foundation to
understand which existing frameworks for scaling products
might apply to digital health, linking and applying these concepts
in a new way and verifying them against current digital health
case studies.
Our hypotheses and findings, based on review of more than 121
books and articles and 40 expert interviews, are intended to
spark an ongoing dialogue in 2015 and to develop some specific
reference examples. This paper is not intended to be a peerreviewed or academically-rigorous publication that provides final
answers to the challenges faced. Rather, we have focused on
suggesting frameworks and provocative questions to stimulate
community debate and new forms of collaboration to reach scale.
The opinions contained in this paper are solely those of the
authors and may or may not be shared by those that contributed
to this piece.

EXECUTIVE SUMMARY:

THE JOURNEY TO SCALE

The path to our destination

is not always a straight one.
We go down the wrong road,
we get lost, we turn back.
Maybe it doesnt matter
which road we embark on.
Maybe what matters is that
we embark.
Barbara Hall

The digital health community is on a

journey to deliver health impact.
We have achieved considerable success in the past
decade, demonstrating that information and
communication technology (ICT) can improve health
services delivery in the developing world.
Although our achievements implementing pilots should
be celebrated, we must also acknowledge that digital
health interventions are not yet routinely used as part
of all global health service delivery and have not yet
been proven to demonstrate large scale health impact.
We propose that digital health interventions will impact health outcomes
significantly only when routinely used, or institutionalized, as a common
practice in service delivery. When institutionalized, digital health interventions
will provide frontline health workers with real-time, operational data affecting
every conceivable part of the primary care continuum from ensuring adequate
stock to checking lab reports to workforce training, thus addressing current
capacity issues and improving quality of care. In this way, greater institutionalization will achieve the health impact for which we all strive. This paper is
intended to stimulate debate on what targeting institutionalization implies for
our investment and collaboration strategies.
The path to institutionalization begins when a common challenge and possible
solution emerge and create a case for action. This need and opportunity convince
multiple leaders in the value chain to contribute by providing initial seed
funding; developing effective products; supporting standards; driving clear
value propositions; and ultimately embedding the change through policies,
program management, and champions. When the products or services persist
beyond catalytic funding and are so embedded in the daily practices at each
level of the health system that alternative options no longer seem viable,
successful institutionalization has occurred. Examples from some business
and global health practices illustrate a common pattern of levers that lead to
institutionalization, as shown in Figure 1.

FIGURE 1

WHAT DOES IT TAKE TO

INSTITUTIONALIZE A PRODUCT OR SERVICE?
FIGURE 2
TRIGGER

LEVERS FOR INSTITUTIONALIZATION

CASE FOR ACTION

TYPICAL SEQUENCE

The right leader

The right solution

The right approach

The right capacity

Lacking a shared goal of achieving

institutionalization has fragmented
how the digital health community
funds and applies these levers,
limiting digital healths potential to
become sustainable and dramatically
improve health outcomes in
developing world markets. To achieve
institutionalization, all stakeholders
should adjust current approaches.
Figure 2 illustrates our vision for
digital health investments.
The community can take several steps
to accelerate institutionalization.
First, we should develop a collective
blueprint of existing digital health
investments and meaningful
measurements of institutionalization.
This discussion will help align key
actors on milestones indicating
progress. Second, a few examples of
comprehensive, national digital health

WHAT IF
EVERY DIGITAL HEALTH
INVESTMENT WERE

Leadership

Effective
product

Viable economic
model

Supportive policy,
regulation and
standards

Effective program
management

Human capacity

implementations should be catalyzed

and tested. Third, we recommend
aligning and deepening cross-matrix
investments in the seven levers so that
they can be broadly shared across
countries.
The digital health community
contains creative, persistent, and
passionate innovators. Our current
approaches are not working, however,
and we are seeking a more holistic
approach to digital health as a
component of health systems. If
defining institutionalization as
our goal resonates, we propose that
the community call for ongoing
dialogues in 2015 to refine what
institutionalization means, what
enables it, how we measure it, and
determine what investments we can
make together to scale digital health
interventions.

Triggered and selected

according to the needs of
the health system?
Mandated and driven by
the Ministry of Health?
Enabled by committed,
long-term funding and
robust program
management so solutions
have time and support to
iterate, evolve, and embed
into existing systems and
practices?
Built around realistic,
long-term funding models?
Integrated into existing
national platforms?
Selected and designed
to conform to agreed
standards?
Designed and implemented
with the participation of the
end users and long-term
implementers?

THE JOURNEY TO SCALE

SO FAR:
Why is a new approach required?

If you do not change direction, you may end up where you are heading.
Lao Tzu

Photo: PATH/Richard Anderson

This paper describes a journey toward successful scale in digital

health interventions. Along the journey, use of digital tools for
health will shift from being a disruptive innovation to being
institutionalized as common practice.
Our vision is a world where we no longer refer to mHealth or eHealth services, but
rather take as a given that digital tools are incorporated seamlessly throughout health
systems, enabling greater health impact.
To achieve this vision, we believe the
digital health community should
deliberately and clearly define that we
are working towards a common goal of
institutionalization and develop an
investment strategy to achieve it. This
paper is intended to stimulate debate
on the following questions:

Like most long and arduous journeys,

reaching our destination will require
time, investment, and collaboration.
We recognize that our collective effort
to deliver meaningful health impact
using digital interventions could be
transformational to the communities
we serve.

What does the goal of

institutionalization mean for scale?

WHY NOW?

What levers enable institutionalization?

How can we work together to reach
institutionalization?

Over the past few decades, the number

of digital innovations has exploded,
fundamentally changing the way
people engage with information and
with one another. At 7.2 billion, there
are more mobile connections than

people on the planet. 30 percent of the

worlds population has access to and
uses the Internet. Asia accounts for half
of all mobile-phone subscriptions, and
use of digital technology in Africa is
growing rapidly, with roughly 170
million Internet users. An estimated
one billion users in Africa will access
the Internet through low-cost mobile
phones by 2050.i These consumer
trends, coupled with declining
hardware and communications costs
globally, offer a huge opportunity to use
ICT as a tool to address long-standing
issues in health services delivery.

Sources: International Telecommunication Union, GSM Association.

11

FIGURE 3

DIGITAL HEALTH SERVICE LAUNCHES HAVE PROLIFERATED

728 services are reportedly active today

NUMBER OF MOBILE HEALTH LAUNCHES PER YEAR

130
120
110
100
90

+30.6%

80
70
60
50
40
30
20
10
0
PRE 2005

2005

2006

2007

2008

2009

2010

2011

Yet the majority of interviewees, when asked to identify digitally enabled health services that have successfully
scaled, cannot name more than 1 or 2 examples, if that.
Note: Figures based only on mobile-enabled products and services in developing world tracked by GSMA (including those merged/closed). Excludes services in
pipeline with an impending launch.

Although many small-scale digital

health interventions have been
introduced to tackle global health
challenges, the use of digital devices for
health services has not achieved the
promise suggested by the high levels of
market penetration by ICTs. As Figure 3
shows, there is no shortage of digital
health service product launches in
developing markets.ii Yet these efforts
tend to be fragmented and slow to build
on the achievements and lessons of
others.iii Even those who use their

ii

iii

iv

devices daily to manage everything

from their communications, banking,
and entertainment needs, have not
embraced digital health interventions
to the same degree.
Much work remains before connected
devices are as essential to a health
worker as a stethoscope, or patients
monitor their health status as
frequently as they monitor trending
tweets. The presence of the phone and
point-of-service applications are

powerful catalysts, but they are not

sufficient for adding value to health
service delivery. Scale still eludes us,
and other barrierssuch as the lack of
national eHealth infrastructure, the
structure of development financing,
weak economic models, insufficient
leadership, and the deployment and
program management capacitymust
be tackled if we are to reach it.iv

Data for the graphic is from the Bill & Melinda Gates Foundation, based on GSMA Mobile for Development Intelligence data; GSMA Mobile for Development
deployment tracker. Accessed October 4, 2014.
The mHealth Alliance and Vital Wave Consulting. Sustainable Financing for Mobile Health (mHealth): Options and opportunities for mHealth financial models in
low- and middle-income countries. Washington, DC: The mHealth Alliance and Vital Wave Consulting; February 2013. World Health Organization. Monitoring the
building blocks of health systems: A handbook of indicators and their measurement strategies. Geneva: World Health Organization; 2010.
The mHealth Alliance and Vital Wave Consulting. Sustainable Financing for Mobile Health (mHealth): Options and opportunities for mHealth financial models in
low- and middle-income countries. Washington, DC: The mHealth Alliance and Vital Wave Consulting; February 2013.

12

DECIDING ON THE
DESTINATION:

Defining institutionalization as our goal for successful scale

No one has a problem with the first mile of a journey.
Even an infant could do fine for a while. But it isnt the
start that matters. Its the finish line.
Julien Smith

IN THIS SECTION
WE WILL CONSIDER:
What are the current
definitions of scale
for digital health
interventions?
How will aligning
on the goal of
institutionalization help?

Photo: Drew Arenth

An agreed goal for scale has yet to emerge within the

digital health community.
As Figure 4 shows, digital health thought leaders describe scale quite differently.
Some organizations maintain a more traditional definition of coverage of a target
population of patients or providers within a geography (i.e., scaling up) or across
geographies (i.e., scaling out). Relevant scale also differs dramatically by the type of
digital product or service (e.g., medication adherence or national health management
information systems [HMIS]), making it difficult to align on a meaningful goal for the
entire suite of digital interventions.
v

Another perspective is to shift from

viewing mHealth innovations as a
direct way to achieve a health outcome,
toward viewing them as a strategy to
overcome obstinate barriers to the
delivery of known efficacious interventions. In this framing, success is when,
integrated mHealth strategies
together address multiple gaps in the
pathway to universal health coverage,
improving performance in the quality,
cost, and coverage necessary to provide
care to all in need.vi
A more holistic health systems viewpoint on scale is emerging. The Groupe
Speciale Mobile Association (GSMA),
reflecting mobile operator perspectives,
has shifted its definition of scale from
achieving a certain level of subscriber
volumes and average revenue per user

vi

vii

targets, to a more strategic view of the

potential long-term value of offering
sustainable mHealth services in
partnerships across multiple markets.vii
Donors such as the German Federal
Ministry for Economic Cooperation and
Development (BMZ) and Norwegian
Agency for Development Cooperation
(NORAD) similarly have taken a
longer-term view of their eHealth
investments given that their priorities
are more focused on overall health
systems strengthening. Their investments have focused both on developing
long-term capacity and extensible
software platforms.
Although these various definitions of
scale are not mutually exclusive, the
slight differences in the end goal can
deter community alignment on steps

toward achieving scale. We propose

that regardless of your definition, a
digital product or service, no matter
how robust or how many people use it,
only successfully scales when it is
embedded or institutionalized into the
workflow of health system service
delivery or a recipients daily habits.
WHY INSTITUTIONALIZATION

Institutionalization is all around us.

Sending an email or text message has
become so entrenched in daily life
that the prior practices of sending a fax
or a letter became virtually obsolete.
In business, the journey to standardize
shipping containers and barcodes
(Appendix 1 and 2) followed this
pattern. In global health, standard
practices as diverse as microscopy and
placing vaccine vial monitors (VVMs)

McClure D, Gray I. Scaling: Innovations Missing Middle. Presented at: Humanitarian Innovation Conference, July 19, 2014;
Oxford, England.
Mehl G, Labrique A. Prioritizing integrated mHealth strategies for universal health coverage. Science. 2014;385(6202):12841287.
Interview with GSMA, October 7, 2014.

14

FIGURE 4

WE LACK A SHARED DEFINITION OF SCALE

FOR DIGITAL HEALTH INTERVENTIONS

DIGITAL HEALTH NGO

We consider a service to be at scale if a vast majority of the intended

users are using it. For example, if 80 percent or 85 percent of community
health workers in a country are using a tool, we consider that scale.

DIGITAL HEALTH
CONSULTANT

Weve defined scale as 1 million users for a consumer-focused service, and

1,000 users for a health provider service.

MOBILE
OPERATOR

A product or service is scalable if we can quickly adapt it for use across

markets. Scale also depends on return; if I can earn a large margin on a service
for a small number of customers, thats as valuable as earning a minimal
margin on a large-volume service.

MEDICAL DEVICE
MANUFACTURER

For commercial direct-to-consumer products, successful scale is in the

millions using a product or service each month, rather than cumulatively.
But you also need a denominator, e.g., cost/user or time/user.

TECHNOLOGY PROVIDER

Scale is when theres an ecosystem, or many groups working together

so users have heterogeneity of support without relying on a sole source.
Scale also is when people who benefit from an intervention pay for it.

Source: PATH interviews. Quotes are lightly edited for clarity.

on every dose of World Health

Organization (WHO)-recommended
vaccines (Appendix 3) followed a
similar journey, from promising idea
to everyday practice.
Agreeing on institutionalization as
our end point has two benefits. First,
it helps the digital health community
align objectives while honoring the
differences among stakeholders
perspectives and motivations. Although
focusing on institutionalization may
appear to suggest that the primary

optic is of a national government and

public health system, the concept of it
as the end-point of scale can be realized
by any of the key actors (Figure 5).
A second benefit is it recognizes the
significant differences across various
types of digital health interventions
from simple short message service
(SMS)-based demand-generation tools
to integrated national-level reporting
infrastructure. Different technologies
achieve scale by different means and
according to different time frames.

A direct-to-consumer service such

as delivery of Mobile Alliance for
Maternal Action (MAMA) messages
to expectant and new mothers
(Appendix 4) is designed, deployed, and
adopted differently and on a shorter
timeline than the cross-cutting
infrastructure investment associated
with a national rollout of DHIS 2
(Appendix 5). Although both may be
institutionalized in a country, the
associated approaches, investment
levels, and timescales required to
achieve it are quite different.

15

FIGURE 5

THE CONCEPT OF INSTITUTIONALIZATION HAS POWER

EVEN WHEN VIEWED FROM DIVERSE STAKEHOLDER LENSES
Most public and private health care
providers have adopted a
standards-based suite of digital tools
Digital health services play a strategic
role in long-term value creation

Most of that donors health-related

investments leverage sustainable
digital health tools

HEALTHCARE
PROVIDERS
MOBILE
OPERATORS

GOVERNMENT

DONORS

PATIENTS

PAYORS

Infrastructure built to manage provider

payments is integrated into national
infrastructure

NGOS

TECHNOLOGY
PROVIDERS

Most major programs leverage

nationally-endorsed digital
health tools

Products and services become

economically sustainable

The lens of institutionalization helps

to define successful scale-up for both
of these very different interventions.
Programs using MAMA are at scale
when their routine use as part of an
integrated approach to awareness and
service demand generation is embedded
into national maternal and child health
strategies and practice, and when

16

mothers incorporate the tool into their

personal approach to childbearing.
DHIS 2 is at scale when a government,
from the ministry of health to the
front-line health worker, routinely
accesses its reporting data to manage
health service delivery and health
system performance across multiple
health areas.

Alignment on the end goal of

institutionalizing digital health
services is a necessary step toward
enabling large-scale health impact.
Once an agreed destination on the
journey is in place, the next step is
to consider the pathway to get there.

PLOTTING THE COURSE:

Levers for achieving institutionalization
The best teachers have showed me that things have
to be done bit by bit. Nothing that means anything
happens quicklywe only think it does. The motion
of drawing back a bow and sending an arrow straight
into a target takes only a split second, but it is a skill
many years in the making.
Joseph Bruchac

Photo: University of Washington/Carl Hartung

IN THIS SECTION
WE WILL CONSIDER:
What levers enable scale
across industries?
Which apply to achieving
institutionalization in
digital health?

Having proposed a destinationinstitutionalization of digital

health interventionsthe next step is to identify the pattern and
levers that can accelerate our progress.
Lessons from promising examples in the digital health sector, as well as from successful
scale-up in other sectors, point to factors that enable institutionalization.
viii

A common first step in successful

scale up is the emergence of a
strong case for action. Sometimes,
an urgent need, such as demand
for an Ebola vaccine, triggers
action. In other cases, new
evidence prompts action, as when
The Lancet series on nutrition and
the Copenhagen Consensus made
a call to action for greater global
investment in nutrition.vix

FIGURE 6

WHAT DOES IT TAKE TO

INSTITUTIONALIZE A PRODUCT OR SERVICE?
TRIGGER

CASE FOR ACTION

The right leader

vii

TYPICAL SEQUENCE

THE RIGHT LEADERS

The next lever results from an

individual recognizing the case for
action, understanding how to address
the problem at hand, and mobilizing
others. One example of this pattern
was the standardization of shipping
containers, conceived by a single
innovator who mobilized an industry-wide transformation (see text box
on page 16). Another example has been
Rwandan President Paul Kagames
vision to implement e-Government.

LEVERS FOR INSTITUTIONALIZATION

The right solution

The right approach

The right capacity

Leadership

Effective
product

Viable economic
model

Supportive policy,
regulation and
standards

Effective program
management

Human capacity

Page on Maternal and Child Nutrition. The Lancet website. Available at: http://www.thelancet.com/series/maternal-and-child-nutrition. Accessed November 14, 2014.
Page on the Copenhagen Consensus II, calling for greater investment in malnutrition and hunger http://www.copenhagenconsensus.com/copenhagen-consensus-ii.
Accessed November 14, 2014.

vix

18

This explicit sponsorship has

encouraged every ministry to
automate service delivery from
immigration forms to patient records.x

Photo: Daniel Ramirez

ACHIEVING SCALE
IN SHIPPING:
Today, every cargo ship in the
world uses standard dimensions
for shipping ANY type of cargo
anywhere in the world. This is
scale institutionalized so that
no one considers an alternative.
Prior to 1956, this situation was
not the case.
Malcom McLean (founder of
Sea-Land Corporate), was
frustrated with the time it took
to load products in ports, and
realized it would be much more
efficient if a container of goods
could be lifted directly from a
truck. In 1955, he invested his own
money in a pilot demonstrating
the art of the possible, refitting
two ships to carry his trailers.
The first ship sailed in 1956 and
immediately demonstrated
significant cost savings. The
results were so stunning that in
1961, the ISO set standard sizes
for all shipping containers.
In consequence, in the decade
after the container first came
into international use, the
volume of international trade
in manufactured goods grew
more than twice as fast as the
volume of global manufacturing
production, and two-and-a-half
times as fast as global economic
output.xi

xi

Case studies and interviews also

indicate, that a single, catalytic
innovator is not sufficient for
institutionalization. Leaders from
other disciplines who share the
catalytic leaders vision and values,
need to join forces, contribute key
inputs (e.g., money, technology,
political will), and work together to
reach institutionalized scale. Figure 7
describes six distinct leadership roles
for digital health interventions that
emerged from our research.
Rwandas ongoing development of its
eHealth infrastructure provides a good
leadership model at multiple stages of
institutionalization. Strong political
leadership at the presidential level
encouraged Ministry of Health
leadership to develop the eHealth
architecture, standardize the
approach, and commit to ongoing
national rollout of multiple systems
(e.g., Rapid SMS, DHIS 2, iHRIS).
Technology partners emerged (e.g.,
IntraHealth, Management Sciences for
Health, Partners in Health, Regenstrief
Institute), working under the
Ministrys leadership to implement
the service, and various funders (e.g.,
Global Fund, U.S. Presidents Emergency Plan for AIDS Relief [PEPFAR]) have
supported financially and advocated
the benefits of the program nationally
and internationally. Together, leaders
across diverse stakeholder groups are
supporting existing use cases and
working to resolve daily challenges.
THE RIGHT SOLUTION

Leaders must make important

investment choices early in the
journey to institutionalization.
Two early and key solution levers are

Photo: University of Washington/Carl Hartung

ACHIEVING SCALE IN
MOBILE MESSAGING:
Launched in 2011 with a
three-year, $10 million investment,
the Mobile Alliance for Maternal
Action (MAMA) is a partnership
among USAID, Johnson & Johnson,
the United Nations Foundation,
and BabyCenter.
MAMA offers mobile message
content in a variety of languages,
as well as tools and resources to
enable programs to deliver
maternal health education and
behavior change messages to
new and expectant mothers via
mobile phones.
Through its direct programs,
MAMA and its partners have
reached nearly 1.1 million
subscribers in Bangladesh since
2012 and over half a million
users since launch in South Africa
in 2013.
Others are now building on
MAMAs work to accelerate their
own programming. For example,
in October 2014, Facebook,
BabyCenter, and Praekelt
Foundation announced they
will work with MAMA to offer
maternal, newborn, and child
health content as part of the
Internet.org appa package of
free basic services aimed at
first-time users of the mobile
internet in Tanzania.

Interview with Management Sciences for Health on October 6, 2014.

Tomlinson J. History and impact of intermodal shipping. Brooklyn, NY: Pratt Institute, September 2009.
Available at: http://www.johntomlinson.com/docs/history_and_impact_of_shipping_container.pdf. Accessed September 17, 2014.

19

FIGURE 7

LEADERSHIP ROLES

Spark design of a technology

Spark design of a service or program using digital tools in a new way and/or new setting

Sufficiently long funding commitment to allow services to breathe

Engaged donor with appetite to advocate and engage beyond funding

Well-informed, data-driven decision-making

Willingness to support publicly

CONVENE

Foster effective partnerships and engagement with all key stakeholders

IMPLEMENT

Committed leaders from implementing organizations that inspire others to deliver

Early adopters willing to test innovations and forge the path for other providers,
patients, etc.

INNOVATE

FUND

DECIDE

ADOPT

identifying an effective, scalable

product and a viable economic model
that addresses key stakeholder needs.
Key principles underlying development
of effective digital health products
have now been codified in the
Principles for Digital Development.xii
Existing productssuch as DHIS 2,
OpenMRS,xiii OpenLMIS,xiv and others
already follow these principles, with
more emerging each day.
Effective products that become
institutionalized (e.g., mobile phones,
ATM machines) generally offer users
easy alternatives to existing processes,
with benefits that encourage the
average user to follow early adopters.xv
The lesson for digital health interventions is that one must invest upfront to
re-imagine the workflows instead of

xii

simply automating the paper processes.

This is a critical step in modifying,
testing, and simplifying products
before deploying nationally,
particularly since many end users,
such as FHWs or pregnant women, may
be relatively new to using technology
and will need to immediately see the
benefits of the new way of working to
adopt it. Further, all tools must be
measured by their ability to deliver
savings (e.g., time, effort) for the end
users to sustain its use.
These lessons are highlighted in
A Quiet Revolution: Strengthening the
Routine Health Information System in
Bangladesh recently published by
Deutsche Gesellschaft fr Internationale Zusammenarbeit (GIZ) which notes
that a simple tool makes a world of
difference. A key factor behind the

selection of DHIS 2 by the Government

of Bangladesh was that the product had
been well-tested, is stable, and has
consistent backing from the University
of Oslo and NORAD.xvi In addition, prior
to rollout of the system, all parties
partnered with the Government of
Bangladesh to re-imagine how the work
could be done and modified the features
accordingly.
This is not to suggest there is no room
for new product innovation; there is
great promise in piloting exciting new
intersections of technology and health.
However, to achieve sustained impact,
it is critical to strike a balance between
excitement over the next new thing
and the need to build on current
investments and institutionalize a few,
simple, much-needed tools. For
example, MAMA offers standardized

Principles for Digital Development website. Available at: http://ict4dprinciples.org/.

OpenMRS is an open-source enterprise electronic medical record system platform.
xiv
OpenLMIS is an open-source electronic logistics management information system.
xv
Rogers E. Diffusion of Innovations, 5th Edition. New York: Simon and Schuster; August 2003.
xvi
GIZ. A Quiet Revolution: Strengthening the Routine Health Information System in Bangladesh. 2014. Interview with Kelvin Hui, October 24, 2014.
xiii

20

FIGURE 8

ANALYSIS OF THE ECONOMIC VALUE

BY STAKEHOLDER TYPE

COMPARATIVE NET UTILITY

STAKEHOLDER

Value proposition: how mHealth helps stakeholders achieve their mission and goals vs.
the next best alternative (including doing nothing)

PUBLIC
Improved health
outcomes (e.g.,
longer life, higher
quality of life)
Efficiency gains
and cost savings
for health delivery
Higher
productivity levels
for the overall
economy

NON-PROFIT

FOR-PROFIT

Improved health
outcomes

Increased sales/
revenues

Improved health
outcomes

Improved health
outcomes

Efficiency gains
and cost savings in
achieving mission

Efficiency gains
and cost savings
in delivering
products and
services

Efficiency gains
and cost savings
for health delivery

Efficiency gains
and cost savings in
seeking health care

Reputational
benefits (i.e.,
standing in
community)

Reputational
benefits (i.e.,
standing in
community)

Increased
donations/sales/
revenues

Improved health
outcomes

HEALTH WORKER

Note: Improved
branding/PR is not a
driver for long-term
participation

INDIVIDUALS & HH

Higher
productivity levels
for household
Content TM of Vital Wave Consulting

content, as well as lessons and tools

for adapting this content for local
communities. Rather than reinventing
this content and tools, partnerships
are building on MAMAs work to create
and deliver locally relevant content.xvii
Determining what makes a viable
economic model for all stakeholders and
why it is such a crucial lever to achieve
institutionalization is complex.
We define a viable economic model

xvii
xviii

as one that provides incentives and

willingness to pay for all participants
along the value chain. For example,
although private health services are
common in many developing countries,
the bulk of the investment to improve
servicesincluding investments in
health information systems and health
worker trainingdepends on initial,
catalytic government or donor funding,
rather than consumer investment.
Governments, particularly ministries of

health, must balance the need to deliver

care with their interest in developing
their digital health infrastructure.
Similarly, donors need a rationale for
their investments and want to invest in
tools that ultimately generate cost
savings or better, faster health
outcomes. Figure 8 shows a helpful way
of framing the value proposition for
digital health interventions for various
stakeholders.xviii

Interview with MAMA representative and MAMA website.

The mHealth Alliance and Vital Wave Consulting. Sustainable Financing for Mobile Health (mHealth): Options and opportunities for mHealth financial models in
low- and middle-income countries. Washington, DC: The mHealth Alliance and Vital Wave Consulting; February 2013.

21

A sustainable economic model requires

that all key stakeholders derive
sufficient value from their investments
and are willing to put their own
resources into the system. For example,
mobile operators and other industry
participants may initially invest in
digital health interventions for
corporate social responsibility reasons,
but they will require more substantial
commercial incentives over time.
The economic model has to consider
demand; even if an end user (e.g.,
government policymaker, FHW) does
not initially pay for the service, he or
she must invest time to learn and
adopt it. Also, the governments must
demonstrate an early commitment
to co-investing in a digital health
intervention for it to reach true
institutionalization. Digital health
interventions are more likely to scale
if value propositions for each of these
stakeholders are clearly articulated as
the services are being defined even if
the benefits for all are only realized
over time.
THE RIGHT APPROACH

Even the best-designed, most

economically viable products will not
realize their potential if they cannot get
to market. The need for supportive
policy, regulation, and standards for
digital health interventions to reach
institutionalization is fairly clear: few
innovations have become standard

xix

practice within a health system

without inclusion in global and/or
national guidelines and in government
budgets and plans. One example is the
case of VVMs (Appendix 3), which
became institutionalized across
markets only after WHO and the
UNICEF began to advocate their use
and then updated global cold chain
guidelines requiring usage on all
packaging. More than five billion
VVMs have now shipped globally.
Similarly, adoption of barcodes
(Appendix 2) and shipping containers
(Appendix 1) ramped up dramatically
once international standards were
agreed upon, becoming a global norm.
Global health informatics standards
are critical to building robust national
health information system platforms,
and a few key actors are emerging. The
OpenHIE xix community, for example,
has led a broad-based effort to
institutionalize product approaches
to patient and facility registries.
The Health Information Systems
Programme (HISP), a member of the
OpenHIE community, is enabling
institutionalization of DHIS 2 in part
by building on global programming
standards such as HTML 5 and
SDMX-HD to make it interoperable
with Android applications, web portals,
and other information systems.
Incorporating global standards and
employing open application

programming interfaces to all digital

health interventions is critical to
enabling countries and consumers to
harmonize multiple information
systems. Resources such as Connecting
Health Information Systems for Better
Health: Leveraging Interoperability
Standards to Link Patient, Provider, Payor,
and Policymaker Data xx and a pending
WHO publication on selecting
standards and interoperability provide
guidance and tools to help national
informatics leadersxxi select and embed
standards into national information
technology (IT) architectures.
In addition to effective products, strong
economic models, and standards-based
approaches, thoughtful, program
management is a key lever for institutionalization. For example, BBC Media
Actions approach (Appendix 6) to
scaling its suite of mobile services for
maternal and child health demandgeneration tools, first in Bihar and
then at the national level in India,
illustrates some of the key principles
characterizing effective program
management. Engaging the right
stakeholders from the beginning is key;
in Bihar, state government agencies
were partners from the very beginning,
increasingly the likelihood they would
incorporate future investments in their
annual budgets. Likewise, a structured,
disciplined approach and ongoing
delivery of project management and

The Open Health Information Exchange (OpenHIE) community works to help underserved environments better leverage their electronic health information through
standardization.
xx
Ritz D, Althauser C, Wilson K. Connecting Health Information Systems for Better Health. Seattle, WA: PATH and Joint Learning Network for Universal Health
Coverage, 2014. Available at: http://jln1.pressbooks.com/.
xxi
PATH supports multiple peer learning forums around the world. In discussion with eHealth leads in both Asia and Africa, a consistent topic has been which standards
matter and how do we convince policymakers that standards matter.

22

communicationsboth in Bihar and

again at the national levelhave been
critical to helping the state and national
governments to move toward institutionalization. Iterative approaches to
technology design, as well as to
program design, have been crucial to
the services success thus far: BBC
Media Action developed its Mobile
Kunji, Mobile Academy, and Kilkari
services via an iterative user-centered
design process. It has subsequently
localized the content for other states to
take into account differences not only
in language, but in communicable
diseases, government incentive
programs, and the availability of health
products in each state. Within Bihar,
the team modified its rollout approach
as it scaled to improve buy-in and
sustainability by leveraging existing
government health worker training
staff to promote education and adoption
of the tools by frontline workers.xxii
The team also had people on the
ground who drove the day-to-day
implementation, promoting delivery
of a robust project plan. As one sector
expert has estimated, digital health
intervention success is 20 percent about
the intervention itself and 80 percent
about making it happen.xxiii
THE RIGHT CAPACITY

In the end, a good strategy and

approach are gated by the ability to
do long-term execution. Delivering

health services using digital health

interventions requires greater levels of
national human capacity to champion,
choose, design, use, and maintain these
tools. Digital health community leaders
have highlighted that human capacity
and national technology prowess are
both our greatest opportunity and
biggest challenge.xxiv Although
capacity-building efforts have improved
since 2010 with the support of efforts
such as Knowledge for Health, training
programs, and the emergence of
peer-learning networks such as the Asia
eHealth Informatics Network and the
Joint Learning Network for Universal
Health Coverage, the low levels of
embedded ICT experience in most
ministries of health and lack of
familiarity with the complexities of
ICT rollouts at each level of the health
system continue to be a challenge.
As one interviewee noted, Because
health officials are not cognizant of
all the factors involved in ICT
development and deployment and
users may not know the full potential
of the solutions, fully informed
decisions on how ICTs could be used,
designed, or optimized to improve data
collection or service delivery may not
always be manifested.
HISP has been a key champion of
capacity-building, and their approach
offers useful lessons. Part of the
University of Oslo, HISP builds capacity

by combining educational degree

programs with practical, on-the-ground
experience. Informatics students
build, manage, and improve the
DHIS with the guidance of HISP staff.
Participation in DHIS development
helps strengthen commitment and
skills among graduate students; many
students from the developing world who
have worked on its development remain
involved after their return to their
home country. HISPs DHIS 2 Academies
similarly foster a global community of
users and experts and build national
and regional capacity to design, implement, and suggest new features to the
core platform.
Elements of these seven levers are often
discussed by stakeholders. But, if so
many levers for institutionalization are
widely known, why has scale-up for
digital health interventions been so
difficult to achieve? Our hypothesis is
that institutionalization cannot occur
because global investments are
fragmented across the levers so they
cannot be systematically combined and
applied in specific geographies. This
raises the question Is there a way to
align our communitys collective efforts
to reach the institutionalization that
VVMs, barcodes, and container ships
enjoy today?

xxii

Interviews with representatives of the Bill & Melinda Gates Foundation, BBC Media Action, and Grameen Foundation.
Interview with Vital Wave Consulting.
xxiv
Wilson K, Lubinski D. Building Stronger Health Information Systems in the Developing World: Recommendations for Donors, Governments, and Nongovernmental
Organizations. Seattle: PATH; 2010.
xxiii

23

REACHING
INSTITUTIONALIZATION:

What are some strategies to accelerate our journey?

If you want to go fast,
go alone. If you want to
go far, go together.

IN THIS SECTION
WE WILL CONSIDER:

We must never be afraid

to go too far, for success
lies just beyond.

African proverb

How can our community

develop a roadmap
collaboratively in 2015?

Marcel Proust

What investments should

we make together to
accelerate reaching scale

Photo: PATH/Felix Masi

Consensus is emerging among donors (e.g., Global Fund,

Gavi, and NORAD) that digital investments are key tools for
strengthening health systems.
Many governments (e.g., Philippines, Rwanda, Nigeria, Ghana) are strengthening their
governance mechanisms, driving their eHealth planning and implementation, and
participating in nascent regional and national informatics peer learning and training
efforts (e.g., Asia eHealth Informatics Network, University of Stellenbosch).
Developers and implementers (e.g., Abt
Associates, Dimagi, Grameen Foundation, John Snow Inc., PATH), have
struggled with scaling products beyond
a district, and are increasingly interested in fostering long-term national
ownership of effective products based
on viable business models and integrated into standards-based, back-end
infrastructure.
Reaching institutionalization and thus
achieving significant health impact
requires combining all of these

elements into a more holistic and

deliberate approach. For the levers
explained in the last section to be
effective, the stakeholders in the digital
health ecosystem need to (1) align on
the long-term vision for digital health;
(2) prioritize a few, focused geographic
investments; and (3) invest in and
leverage some common, reusable assets
that span geographies. The coming year
can be a very deliberate time to catalyze
this next phase of our journey, creating
this alignment and setting the stage for

the next decade in which digital health

interventions are institutionalized
across the developing world.
Our detours have taught us all about
what does and does not work, and we
are crystallizing these lessons into
tangible strategies. If we can join forces
discussing, developing, and implementing the proposed steps outlined below,
we can accelerate our journey to scaling
successful digital health interventions
that embody the attributes in Figure 9.

FIGURE 9

WHAT IF EVERY DIGITAL HEALTH INVESTMENT WERE

Triggered and selected according to the
needs of the health system?
Mandated and driven by the Ministry of Health?
Enabled by committed, long-term funding and
robust program management so solutions have
time and support to iterate, evolve, and embed
into existing systems and practices?

Built around realistic, long-term funding models?

Integrated into existing national platforms?
Selected and designed to conform to
agreed standards?
Designed and implemented with the participation
of the end users and long-term implementers?

25

STEP 1:
AGREE ON THE DESTINATION AND
DEVELOP A ROADMAP

Developing agreement on a shared goal

of institutionalization as our end-point
and required investments are crucial
first steps. We propose that the
community call for a series of dialogues
in which a diverse, cross-sector group
of committed leaders convene over the
course of a year to develop a five-year
blueprint of the investments required
to institutionalize digital health
interventions. This new call would
emphasize our commitment to collaborating on implementing the Principles
of Digital Development and developing
a global action plan to: increase alignment on key frameworks and research
questions; expand the dialogue broadly
within the global health community;
and translate the emerging research
findings into practical constructs and
tools that companies, governments, and

others in the diverse digital ecosystem

can access and adopt. Unless we agree
on the goal and combine forces on the
journey, future investments will simply
replicate our current fragmented state.
To embark upon this roadmap, the
community should consider as part of
the global action plan how to develop
two critical and complementary routes
simultaneously: (a) country-led national
institutionalization efforts; and (b)
cross-market investments in core levers
for institutionalization.
STEP 2:
CATALZYE NATIONAL DIGITAL
HEALTH INVESTMENTS

Step 2 would entail adopting a more

collective, coherent approach to
planning and implementing national
digital health strategies, taking into
account the levers that enable
institutionalization. Building on lessons
from other sectors, such as national

HIV/AIDS or malaria control strategies,

these approaches should start with
assessment and gap analyses of
infrastructure design, and lead to
joint roadmaps, pooled funding streams,
investment prioritization conversations,
and eventually coordinated implementation and monitoring planning in a
few identified markets.
A number of national-level institutionalization efforts in digital health are
emerging: Nigerias government-led
digital health coordination mechanism
under the ICT4SOML, Indias approach
to national-scale digital tools for health
care workers, South Africas approach to
harmonizing messaging to mothers,
and multiple countries experiences
embedding DHIS 2 into health systems.
As the community embarks upon this
step, we will benefit from examining
how these countries are designing and
evolving their coordinated strategies,

FIGURE 10

POTENTIAL COUNTRY INVESTMENTS

NEAR-TERM INVESTMENTS

LONGER-TERM INVESTMENTS

CASE FOR ACTION

Develop rigorous total cost of ownership (TCO)

models and collect consistent health impact data
on each implementation

Sponsor national advocacy and education

efforts on the impact seen from digital health
investments

LEADERSHIP

Require government and donor coordination

before allocating investments

Invest in design and implementation of

country-led strategies

EFFECTIVE
PRODUCT

Direct investments toward making products

inter-operable with existing infrastructure

Evaluate more rigorously each project against

agreed performance levels and health outcomes

VIABLE ECONOMIC
MODEL

Identify the gives and gets for each product

before rollout by stakeholder

Require that each rollout identifies a viable

long-term business model after catalytic
financing ends

SUPPORTIVE
POLICY,
REGULATION AND
STANDARDS

Support national development of eHealth

architecture and implementation plans

Provide incentives to adopt agreed standards and

policy frameworks to national governments

EFFECTIVE
PROGRAM
MANAGEMENT

Require new investments to have dedicated

program management staff through national
rollout

Capture and share best program management

practices within a country

HUMAN CAPACITY

Sponsor greater local university and

entrepreneurs participation from the outset

Embed national informatics capacity in projects

versus using overseas staff

26

including how they are addressing the

individual levers for institutionalization.
The community should then make a few
specific, national-level demonstration
investments channeling deliberate
attention and funding by lever. Figure 10
illustrates some of the near- and
long-term investments that may be
required in a given market. With
sufficient, targeted investment in each
lever, participation by key actors in each
market, robust leadership by government, and patience, these efforts could
demonstrate if this holistic investment
approach achieves health impact, and if
these models can serve as enduring
demonstration examples for other
countries.

These collaborative, country-level efforts

will be more successful if undertaken in
parallel with efforts to strengthen levers
for institutionalization across markets.

A number of near- and long-term

cross-market investments and
approaches logically arise from the
levers, as illustrated in Figure 11.

STEP 3:
INVEST IN CROSS-MARKET LEVERS
FOR INSTITUTIONALIZATION

Some of these efforts already are

underway but are generally fragmented,
competing for resources and attention,
and struggling to achieve sustained
activity or impact across or within
geographies. To break this cycle, the
digital health community should focus
on a set of fewer, yet better-resourced
investments with more robust
partnerships and longer time horizons,
and consider how we can leverage
aggregated demand from many
countries to negotiate improved
financing terms with operators and
licensing agreements with standards
providers.

Step 3 will require harmonizing and

deepening existing investments in
specific, cross-market levers for
institutionalizing country-level digital
health strategies (e.g., human
capacity-building, effective products).
While country-level examples are
critical to demonstrating the potential
impact of institutionalized digital health
interventions, cross-market lessons,
tools, and mechanisms provide core
building blocks and offer economic
synergies for country-level efforts.

FIGURE 11

POSSIBLE CROSS-MARKET INVESTMENTS

FOR SCALING DIGITAL HEALTH INTERVENTIONS
NEAR-TERM INVESTMENTS

LONGER-TERM INVESTMENTS

CASE FOR ACTION

Create better advocacy toolkits to educate

national leaders and donors

Develop modelling tools to demonstrate return

on digital health investments

LEADERSHIP

Call for a global action plan for digital health

investments

Convene stakeholders to develop the action plan

and oversee implementation

EFFECTIVE
PRODUCT

Direct investment toward a smaller pipeline of

best-in-class cross-cutting platform

Cultivate private sector technology firms to invest

in digital health platforms

VIABLE
ECONOMIC
MODEL

Develop financial forecasting tools that any

country can use to consider TCO and return on
investment of new digital health tools.

Develop innovative financing mechanisms

(e.g., demand aggregation)

SUPPORTIVE
POLICY,
REGULATION AND
STANDARDS

Continue more inclusive development of

shared standards and best practice frameworks

Negotiate aggregated licenses for standards and

agree on global standards for developing world
(e.g., WHO/ITU for NCDs)

EFFECTIVE
PROGRAM
MANAGEMENT

Capture and sharing of best practices in more

digestible, practical forms

Investment directed toward most effective models

for implementing digital health

HUMAN CAPACITY

Sponsor regional peer networks and specialized

capacity programs targeted towards practitioners

Develop the next cadre of eHealth leaders

through university-level health informatics
programs in emerging markets

27

CONCLUSION

While the journey to scaled digital health interventions

continues, a willingness to share the journey has emerged.
The digital health community consists of creative, persistent, and passionate
innovators who recognize that it is not about us, it is not about technology,
it is not about money, its about impact.
xxv

We see, however, that our current approaches are not working, and we are seeking answers to enable
us to increase this impact. The call for a deliberate, inclusive dialogue and a coordinated investment
strategy is the first step. Now is the time for the digital health community to pause in our individual
journeys, assess the current landscape, and align on a more common path forward. Recognizing that
lasting change will take time, we can focus on both near- and long-term efforts to develop the digital
health products, practices, and polices required to support high-performance health care systems.
While much work lies ahead, we look forward to collaborating in 2015 to define a roadmap and
invest together. Discussing what institutionalization means for successful scale and how to move
the levers required to get there will enable us to capitalize on digital healths potential to drive
innovation to save lives.

xxv

Principles for Digital Development website. Available at: http://ict4dprinciples.org/.

28

ACKNOWLEDGMENTS

This paper was produced with the generous support of the

Bill & Melinda Gates Foundation.
The authors are extremely grateful to the numerous colleagues that contributed effort,
insight, and experience sharing their perspectives with the authors.
PATH would like to point readers to the list of excellent work already conducted in this area that informed this paper.
These papers have developed rigorous methodologies and contributed extensively to the conclusions discussed in this paper
and the field generally.

Particular thanks to the following:

Dominic Atweam

Health Systems Specialist, Ghana

Health Service

Dr. Peter Benjamin

Director, mHealth Capacity

Building and emHELP Program

Jeff Bernson

Monitoring and Evaluation

Director, PATH

Dr. Paul Biondich

Associate Professor of
Pediatrics, Indiana University

Kristin Braa

Professor, University of Oslo

Steve Brooke

Commercialization Advisor, PATH

Karl Brown

Associate Director,
Applied Technology,
Rockefeller Foundation

Sara Chamberlain
Head of ICT in India,
BBC Media Action

Haitham El-Noush

Senior Advisor, Global Health,

Education and Research, NORAD

Alice Lin Fabiano

Director of Worldwide Corporate

Giving, Johnson & Johnson

Kai-Lik Foh

Mobile Health Programme

Manager, GSMA

Dr. Michael Free

Senior Advisor Emeritus, PATH

Craig Friedrichs

Director of Health, GSMA

Laura Frost

Partner, Global Health Insights

Kirsten Gagnaire

Executive Director at Mobile

Alliance for Maternal Action

Dr. Richard Gakuba

eHealth/mHealth Consultant,
Rwanda

Dr. Dai Hozumi

Deputy Director, Public Health

Impact, PATH

Kelvin Hui

Technical Advisor (Health

Systems) at GIZ

Debra Kristensen

Director, Vaccine and

Pharmaceutical Technologies,
PATH

Benjamin Kusi

Director of ICT, National Health

Insurance Authority, Ghana

Dr. Alain Labrique

Associate Professor, Johns

Hopkins University

Lesley-Ann Long

Global Director, mPowering

Frontline Health Workers

David Lubinski

Senior Program Officer, Financial

Services for the Poor, the Bill &
Melinda Gates Foundation

Rowena Luk

Vice President of Strategy, Dimagi

Dr. Ousmane Ly

General Director of National

Agency of TeleHealth and
Medical Informatics
Ministry of Health, Mali

Madhu Singh Sirohi

Country Head, India,
Vodafone Foundation

Dr. Alvin Marcelo

Co-chair, Asia eHealth

Information Network

Garrett Mehl

Scientist, World Health

Organization

Rahul Mullick

Chief Technology Officer India Programs, Bill & Melinda

Gates Foundation

Mwihaki Kimura Muraguri

Associate Director for Health,
Rockefeller Foundation

Dr. Henry Mwanyika

Tanzania Country Director, Better

Immunization Data Initiative,
PATH

Perry Nelson

Director, Information and

Communication Technology,
National Health Insurance
Authority, Ghana

Martha Newsome

Vice President, Sustainable

Health, World Vision
International

Brooke Partridge

President and CEO,

Vital Wave Consulting

Dykki Settle

Director of Health Workforce

Informatics, IntraHealth

Chaitali Sinha

Senior Program Officer, International Development Research

Centre

Brendan Smith

Vice President of Professional

Services, Vital Wave Consulting

Knut Staring

Health Information System

Specialist, HISP

John Tippett

Director of Mobile Health,

Grameen Foundation

Randy Wilson

Chief Information Officer

Management Sciences for Health

29

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APPENDICES

APPENDIX 1:
STANDARDIZING SHIPPING CONTAINERS ANALOGUE
TITLE

Standardizing shipping container dimensions

INDUSTRY

Shipping

CONTEXT

Malcom McLean (a highly influential person in the trucking industry, head of

Sea-Land), frustrated with the time it took to load products in ports, realized it
would be much more efficient if a container of goods could be lifted directly from a
truck to a ship, and vice versa, without having to unload and re-load its contents
(intermodalism).xxvi The first container ship sailed in 1956, and demonstrated the
significant cost and time savings. Time spent in port was reduced from days or
weeks to hours. Container shipping grew rapidly due to increasing demand (domestic
and global, as well as demand from the US government for shipping supplies for the
Vietnam War). In 1961, the International Organization for Standardization xxvii (ISO)
set standard sizes for all shipping containers so that they could be stacked on all
modes of transportation (ships, cranes, trucks, trains) in the safest and most efficient
way.xviii Standardization of shipping container sizes facilitated the expansion of the
shipping industry to ports around the world, opening access to new markets at
significantly reduced costs.xxix

SCALE ACHIEVED

In 1966, in the decade after the container first came into international use, the
volume of international trade in manufactured goods grew more than twice as
fast as the volume of global manufacturing production, and two-and-a-half times
as fast as global economic output. xxx Today, hundreds of millions of containers are
shipped around the world each year. xxxi

CHALLENGES

A significant challenge to switching to containerization was posed by port labor

unions, whose workers stood to lose jobs due to the increased efficiency.

xxvi

According to the World Shipping Council, Intermodalism is a system that is based on the theory that efficiency will be vastly improved when the same container, with the
same cargo, can be transported with minimum interruption via different transport modes from an initial place of receipt to a final delivery point many kilometers or miles
away. That means the containers would move seamlessly between ships, trucks and trains.
xxvii
The ISO was founded in 1946 by delegates from 25 countries which felt there was a need for an international organization to facilitate the development of global industrial
standards. Today, 165 countries make up its membership.
xxviii
Page on Containers. World Shipping Council website. Available at: http://www.worldshipping.org/about-the-industry/containers. Accessed September 17, 2014.
xxix
Levinson M. Container shipping and the economy: stimulating trade and transformations worldwide. TR News 246; SeptemberOctober 2006. Available at: http://www.
worldshipping.org/pdf/container_shipping_and_the_us_economy.pdf. Accessed September 17, 2014.
xxx
Levinson page 12.
xxxi
Tomlinson J. History and impact of intermodal shipping. Brooklyn, NY: Pratt Institute; September 2009. Available at: http://www.johntomlinson.com/docs/history_
and_impact_of_shipping_container.pdf. Accessed September 17, 2014.

35

APPENDIX 2:
BARCODES CASE STUDY
A clear value proposition for both retailers and manufacturers brought executives together to set an industry-wide standard
that rapidly scaled and institutionalized barcodes, now used by millions of companies in over 150 countries.

BACKGROUND

For all actors involved in creating and distributing a product

from manufacturer to distributor to retailer to consumerthe
ability to keep track of how much of your inventory you have,
where it is, and when you will need to buy more is very important.
Before barcodes, managing inventory was difficult, and the mistakes were costly.
Better insight into data around inventory and demand can reduce waste, prevent
stockouts, and improve efficiency and profitability.
Before the 1960s, punch-card
technology existed but was bulky and
expensive. Norman Woodland and
Bernard Silver recognized this need for
technology to automatically read
product information and began to
explore solutions. They filed the first
patent for a barcode, named bulls-eye
code due to its resemblance, in 1949.
In the 1960s, grocery trade associations
in the United States began to seriously
pursue barcode innovation as a
potential solution for automated data
capture and improved inventory
management. They worked with RCA to
develop barcodes for groceries in the
1960s, and developed guidelines and
standards based on key principles:
easily readable from any angle,
affordable, and easy to reproduce.
The result of years of research and
meetings was the Universal Product
xxxii

Code (now commonly referred to as

simply the U.P.C. barcode).xxxii
1974 saw the first live scan of a barcode
in a grocery store, on a pack of Wrigleys
gum that can now be found in the
Smithsonian Institute.xxxiii By 1981,
more than 60 percent of grocery stores
nationwide were equipped with
scanners.xxxiv Though it took over 20
years to reach national adoption,
barcodes are now ubiquitous, and are
arguably one of the most significant
productivity improvement innovations
in the supply chain.xxxv
DEFINING SCALE

Barcodes achieved scale once all

products sold in grocery stores
contained barcodes on their packaging,
and all stores contained barcode
readers. The grocer executives leading
the industry associations recognized

the chicken-and-egg situation facing

them: manufacturers would not
produce and apply barcodes if grocers
did not invest in scanners, and vice
versa. Recognizing their power in
numbers, six grocery associations
established a committee in 1970 to
develop a standard, inter-industry code
(UPC) to identify products using a
machine-readable symbol. They needed
a standard to avoid having different
manufacturers use different codes
readable by multiple, incompatible
machines. As more grocers and
manufacturers invested in barcodes,
the numbers grew exponentially.xxxvi
By 1997, 177,000 manufacturer-specific
UPC codes had been created. About five
billion products barcodes are scanned
per day. xxxvii Today, barcodes and barcode
standards have reached global scale,
used by millions of companies in over
150 countries.xxxviii

Page on GS1 US: A History. GS1 website. Available at: http://www.gs1us.org/about-gs1-us/corporate/history/gs1-us-a-detailed-history. Accessed August 27, 2014.
Page on History of GS1 Standards. GS1 website. Available at: http://www.gs1us.org/about-gs1-us/corporate/history. Accessed August 27, 2014
xxxiv
Page on Barcoding History. Barcoding Incorporated website. Available at: http://www.barcoding.com/information/barcode_history.shtml. Accessed August 27, 2014.
xxxv
Sharma A, Thomas D. Looking Backwards to Look Ahead: Lessons from Barcode Adoption for RFID Adoption and Implementation. Presented at: The Conference for
Information Systems Applied Research, 2013; San Antonio, TX. Available at: http://proc.conisar.org/2013/pdf/2824.pdf. Accessed August 27, 2014.
xxxvi
Page 5. Sharma, et al.
xxxvii
Page on GS1 US: A History. GS1 website. Available at: http://www.gs1us.org/about-gs1-us/corporate/history/gs1-us-a-detailed-history. Accessed August 27, 2014.
xxxviii
Ibid.
xxxiii

36

LEVERS FOR
INSTITUTIONALIZATION

APPROACH

LEADERSHIP

The broad cooperation between trade associations with the leadership of top executives and
the establishment of standards-writing bodies enabled support for uniform barcodes to reach
critical mass.xxxix Leaders recognized the network effectthe value of the new technology for a
potential adopter was dependent on how many others were using it. A grocer had no use for a
scanner if manufacturers were not applying barcodes to their products; and vice versa.

EFFECTIVE
PRODUCT

The clear, underlying value of the potential benefits of barcodes (faster checkout process,
reducing labor required; ability to collect and process information about stock and demand, and
use it to reduce market risk) made it appealing across industries. The ease of use for the end user
was paramount. Clerks were not familiar with technology and needed to intuitively understand
upon first use to reach scale.

VIABLE
ECONOMIC
MODEL

Inflation and rising food prices reduced profitability of food retail and motivated companies to
push for ways to improve efficiency and reduce costs in the grocery industry. Advancements in
capabilities and decline in the cost of computer hardware and software to process and
communicate information encoded in barcodesxl made barcoding affordable.

SUPPORTIVE
POLICY,
REGULATIONS,
STANDARDS

Policies, regulations, and standards enabled barcodes to scale exponentially across industries.
Trade associations established standards early on so different manufacturers, producers, and
sellers could readily adopt barcodes. With standards in place, retailers avoided having to buy
multiple scanning systems to read different barcodes used by manufacturers. Without such
standards, barcodes would have complicated the retail process and likely would not have scaled.
Additionally, states passed laws mandating price stickers be kept on to quell consumer fears
about barcodes replacing price stickers.

TIMELINE

1949: Norman Woodland and

Bernard Silver filed first patent
for bulls eye code.
1952: Patent issued for bulls eye code.
Philco purchased the patent,
then sold it to RCA.
1959: First commercial use of linear
barcodes to track rail cars, called
KartTrak. The first scanner was
installed by Sylvania/GTE on the
Boston and Maine railroad.
1967: The Association of American
Railroads adopted a barcode
standard for all railcars.

19691970:

Computer Identics developed the
first black-and-white barcode and
computer processing and reporting to expand to other industries.
Six grocery associations established a committee to work with
IBM to develop an inter-industry
UPC to identify products using a
machine-readable symbol.
1971: Control Module developed the
first portable barcode scanner.
Computer Identics installed its
first two systems at General
Motors and General Trading
Company.

1973: National Association of

Food Chains adopted the UPC
standard.
1974: The first scan of barcode on
a pack of Wrigleys gum.
Europe adopted a standard code
compatible with UPC.
1977: Scanners were used in about
200 grocery stores; evidence of
the return on investment was
growing.
1980: Thousands of grocery stores were
adopting barcodes each year.xli

xxxix

Haberman, A. Twenty-five years behind bars. Cambridge, MA: Harvard University Press, 2001.
Page on Barcoding History. Barcoding Incorporated website. Available at: http://www.barcoding.com/information/barcode_history.shtml. Accessed August 27, 2014.
xli
Page on Barcode History Timeline. A2B Tracking Website. Available: http://www.birchwoodenterprises.com/a2bnews/A2B_Barcode_TimelineHiRes_withlinks.pdf.
Accessed October 15, 2014.
xl

37

APPENDIX 3:
VACCINE VIAL MONITOR CASE STUDY
The leadership exhibited by committed product champions throughout the product-development process, the policy decision to
promote vaccine vial monitors (VVMs), as well as a procurement and financing mechanism unique to immunization which served as
a demand aggregator helped to institutionalize VVMs on most vaccines supplied in the public sector in low-income countries.

BACKGROUND

Vaccines require constant refrigeration from the point of

manufacturer to point of use. International protocols require
health workers discard any vaccines exposed to heat.
Too often, vaccine potency is compromised due to weaknesses in the cold chain in
resource-poor settings, and vaccine wastage is a significant cost to immunization
programs.
For decades, health workers had no
way of verifying heat exposure, and
guidelines erred on the side of caution,
instructing frontline workers to throw
out any vaccines they suspected of being
too long outside the cold chain. This
likely resulted in the wastage of
significant quantities of good vaccines.xlii
Staff in the World Health Organization
(WHO)s Expanded Programme on
Immunization (EPI) had an idea: what
if each vial of vaccine could be fitted
with a sensor that monitors exposure
to heat, indicating to health workers
when the vaccines actually need to be
discarded? Such monitors were affixed
to cartons of vaccines, and WHO hoped
a similar product could be developed for

xlii

use at lower levels of the health system.

The search for a suitable product began
in 1979, with VVMs finally achieving
scale on all United Nations Childrens
Fund (UNICEF)-procured vaccines in
2006.xliii
The VVM is a label that indicates
cumulative heat exposure, changing
color as a vial of vaccine has been
exposed to temperatures above normal
refrigerated storage conditions. While
the VVM does not measure the actual
potency of the vaccine, it indicates
when excessive heat exposure has
occurred, and health workers are
instructed to discard the vials
accordingly. VVMs have been effective
in reducing unnecessary vaccine

wastage, and assuring the potency of

vaccines even in hard-to-reach areas.
They also enable health workers to more
effectively manage vaccine stocks by
using vaccines that have some heat
exposure (but have not reached their
discard point) before others. VVMs have
also strengthened the implementation
of WHOs multi-dose vial policy,
allowing health workers to use open
vials for more than one day if the heat
exposure end point has not been
reached, further contributing to
reduction in vaccine wastage. In 1995,
the VVM was introduced on vials of
oral polio vaccine (OPV), and over the
course of the following decade, became
a requirement for all UNICEF-procured
vaccines.

World Health Organization. Getting started with vaccine vial monitors. Geneva: World Health Organization; 2002.
Frost L, Reich M. How to good health technologies get to poor people in poor countries? Available at: http://www.accessbook.org/index.htm.

xliii

38

DEFINING SCALE

The time required to develop and

eventually scale a device like the VVM
was a lengthy process, in this case
requiring 26 years from WHOs initial
call for the development of a heat
exposure indicator in 1979 to inclusion
on most UNICEF-procured vaccines in
2006. Once a suitable product had been
identified, efforts to scale the VVM were
CONDITION OF
SUCCESS

accelerated by a convergence of factors,

notably the actions of UNICEF and
GAVI as demand aggregators and a
changing vaccine market. VVMs did
not take off until the timing and
context were favorable.
The development and eventual scale
up of VVMs benefitted greatly from
being embedded within the global
immunization machine, a sphere in

which an unusual degree of global

coordination exists and where
influential gatekeeper organizations
can make the decision to promote the
scale up of such a technology.xliv This
is not the case for most innovations,
which instead work across health
systems, requiring buy-in and
acceptance from multiple stakeholders
and gatekeepers.

APPROACH

CASE FOR
ACTION

Efforts to scale up VVMs benefitted significantly from evidence demonstrating a contribution

to reduced wastage rates. In Turkey, vaccine wastage rates were found to decline by 77 percent.
A study of health worker knowledge, attitudes, and practices in Bhutan found that health
workers found the VVM easy to interpret.xlv This evidence contributed to an enormous and growing
evidence base, and promoted adoption among the global policy bodies and vaccine manufacturers,
because they couldnt come up with excuses. xlvi

LEADERSHIP

The role of product champions at many stages of the process was critical to the success of VVMs.
From the outset, WHO was instrumental in setting the agenda, calling for the development of a
heat-exposure indicator in 1979, and promoting the concept from that point forward. After a successful
product had been identified, WHO exercised its influence as a decision-maker, revising international
cold chain protocols to include VVM. When stakeholders raised concerns about the VVM technology,
WHO acted as a convener, bringing together product developers, vaccine manufacturers, and
international organizations (including UNICEF) to discuss and address concerns.
PATH also provided essential leadership as an innovator, responding to WHOs call and initiating the
search for prospective technologies. When a promising candidate was identified, PATH worked with
the developer (Temptime) to modify the technology for use on vaccine vials, providing leadership in
the implementation of VVM technology on vaccines.
VVMs illustrates the importance of determined leadership throughout the process, from
international organizations like WHO, UNICEF, and GAVI, and also from organizations like PATH,
steering the development and implementation of innovations. Further, the willingness of the product
developer, Temptime, to continually iterate on the technology in response to stakeholder feedback was
essential to bringing vaccine manufacturers on board.

EFFECTIVE
PRODUCT

The VVM is a simple indicator that changes color if a vaccine has been too long outside of the cold
chain. Because VVMs are affixed directly to vaccine vials at the point of manufacture, they do not
drastically alter the workflow of FHWs. Expanded Programme on Immunization (EPI) staff reported
that the labels were easy to interpret, alleviating the need to make subjective judgments about
whether or not to discard vials of vaccine.xlvii
Advocates were able to actually quantify the cost savings attributable to VVMs by reducing vaccine
wastage, a significant cost to immunization programs. This is an important advantage over products
that claim generally to improve qualitylots of things can improve quality. xlviii

xliv

Interviews on September 29, October 9, and October 17, 2014 with people involved in the development and scaling of VVMs.
Frost and Reich 2008.
xlvi
Interview with PATH representative on September 29, 2014.
xlvii
Frost and Reich 2008.
xlviii
Interview with PATH representative, October 9, 2014.
xlv

39

VIABLE
ECONOMIC
MODEL

The expense of adding VVMs is largely borne by vaccine manufacturers. Though they were initially
skeptical, a couple of factors succeeded in convincing them to include the VVM. First was the role of
UNICEF Supply Division (SD) and GAVI as demand aggregators. UNICEF SD is the procurer of vaccines
for most low-income countries, and GAVI is the financer.xlix When both bodies included VVMs in the
minimum set of requirements for tender, vaccine manufacturers were forced to consider inclusion.
Attempts to scale VVMs further benefitted from a changing vaccine market. Because competition
among manufacturers was on the rise, they were more responsive to UNICEFs request to include
VVMs.l Further, the cost of adding VVMs was probably less for new manufacturers than for those that
had traditionally produced vaccines.

SUPPORTIVE
POLICY,
REGULATIONS,
STANDARDS

For VVMs to achieve global scale, supportive policies were required at the global level. In 1999,
WHO and UNICEF issued a joint statement advocating the inclusion of VVMs on vaccines.li
UNICEF included VVMs as a minimum requirement in its 20022003 bid for global tender for new
vaccines. UNICEFs action was further strengthened by GAVI including VVMs as a minimum
requirement in its first request for proposals to introduce underutilized vaccines.

EFFECTIVE
PROGRAM
MANAGEMENT

Temptimes willingness and ability to iterate, making ongoing adaptations and improvements in
response to stakeholder feedback and the needs of specific vaccine manufacturers, was critical.
Different vaccines and vaccine manufacturers had unique labelling systems, and manufacturers
were unhappy about the requirement to introduce a new labelling system for VVMs into their vaccine
production. In response, Temptime agreed to work with each manufacturer to develop a labelling
system that suited their needs.
PATH played a critical project management role, driving the VVM through the early productdevelopment process. This included identifying and testing product candidates, bringing partners to
the table, and persuading the VVM producer, Temptime, to stay involved, when the company feared
the product was not viable. PATH even provided Temptime a loan in 1993 to purchase special labelling
equipment so that they could print VVMs directly on the manufacturers labels. PATHs work was
made possible due to funding through US Agency for International Developments (USAIDs)
HealthTech program and other sources.

TIMELINE

1979: Staff at WHOs EPI called for a heat-exposure indicator

for use at the lowest levels of the cold chain.

1996: All OPV producers complied with UNICEF request

to include VVMs.

1991: Suitable product identified and ready for introduction

on all UNICEF-supplied OPV vaccines.

1999: WHO/UNICEF policy on the use of VVMs in

immunization services.

1994: UNICEF includes VVMs in tender for OPV.

2000: UNICEF includes VVMs in tender for all vaccines.

2006: 45/71 prequalified vaccines include VVMs.

xlix

Interview with PATH representative, September 29, 2014.

Frost and Reich 2008; Interview with PATH representative, October 9, 2014.
li
World Health Organization, United Nations Childrens Fund. Quality of the cold chain. Geneva; World Health Organization; 1999. Available at: http://whqlibdoc.who.int/
hq/1999/WHO_V&B_99.18.pdf.
l

40

APPENDIX 4:
MOBILE ALLIANCE FOR MATERNAL ACTION ANALOGUE
TITLE

Mobile Alliance for Maternal Action (MAMA)lii

INDUSTRY

mHealth

CONTEXT

The MAMA partnership (USAID, Johnson & Johnson, the mHealth Alliance, the United
Nations Foundation and BabyCenter) delivers health messages to new and expectant
mothers in Bangladesh, India, and South Africa via their mobile phones. MAMA started in
2011 with a three-year, $10 million investment. MAMA also creates tools and resources for
mHealth programs serving mothers in a variety of languages. The goal is that these messages
can increase knowledge and change behaviors to improve maternal and child health.

SCALE ACHIEVED

Bangladesh: Since 2012, 1,095,225 subscribers as of October 2014.

South Africa: Launched in 2013, 552,829 users as of October 2014.
India: Pilot just launched in summer 2014.

CHALLENGES

Managing cross-sector partners and their expectations, requirements, and agendas.

Governance structure of MAMA itself. Launched without a solid structure in place.
Cost of messages themselves.

LESSONS

Funding: Substantial up-front investment allowed MAMA to be strategic and flexible,

and build a brand and partnerships that enabled its success.
Collaboration: Engagement, collaboration with, and buy-in from stakeholders from the start,
especially governments, was essential to MAMAs success.

lii

This information was gathered from the MAMA website and from an interview with a representative on October 2, 2014.

41

APPENDIX 5:
DISTRICT HEALTH INFORMATION SOFTWARE (DHIS 2)
CASE STUDY
By adopting open standards and an inclusive, iterative design approach, DHIS 2 has been institutionalized within 12 countries,
and is a key element of digital health strategies of an additional 34 countries.

BACKGROUND

The District Health Information

Software (DHIS) is widely adopted and
used to strengthen public health
systems by improving the collection
and use of health indicators. The
Health Information Systems
Programme (HISP), a global research
and implementation network with
major bases in South Africa and
Norways University of Oslos
Department of Informatics, developed
and maintains the DHIS with key
funding from the Norwegian Agency
for Development Cooperation (NORAD).
HISPs approach is participatory in
nature, grounded in a belief in
empowering workers who were
affected by or threatened by new
technology, by exploring ways in which
their influence over technological
solutions could be ensured.liii HISP
works with ministries of health and
global health organizations implementing health programs to use DHIS to
collect, visualize, and report on

liii

liv
lv

indicator data on a national or project

scale. HISP sees its role as being
responsible for shaping the culture of
information use through training
local technologists, decision-makers,
and health managers, as well as
contributing to the global body of
knowledge through research and
dissemination.
DHIS has been designed in three
release. The first version of DHIS was
developed for one district in South
Africa in 1996 after the fall of apartheid,
and was based on the Microsoft Access
platform. DHIS 2, the newest version
launched in 2008, is a free, web-based,
open-source information system
developed in Java that can run on any
hardware. DHIS 2 can be used for health
data collection, validation, analysis,
and presentation.liv The HISP network
now has bases around the world, in
South Africa, India, Nigeria, Tanzania,
Uganda, and Vietnam, so that it has a
closer presences to its users, operating
in the same contexts.

DEFINING SCALE

DHIS was designed for institutionalization in a given market and for smooth
customization in order to replicate fairly
easily across markets. According to
HISP, DHIS is at scale when it becomes
the national health management
information system. Bangladesh,
Burkina Faso, the Gambia, Ghana, India,
Kenya, Liberia, Rwanda, Sierra Leone,
Tanzania, Uganda, Zambia, and
Zimbabwe are all using DHIS as their
national health information system.
DHIS is being used for programs and
pilots in many other countries, bringing
its global network of users to include 46
countries in Africa and Asia.lv

Page on the Process of Developing the DHIS. HISP website. Available at: http://www.mn.uio.no/ifi/english/research/networks/hisp/hisp-history.html.
Accessed October 16, 2014.
Page on What is DHIS2. DHIS 2 website. Available at: https://www.dhis2.org/doc/snapshot/en/user/html/ch01.html#mod1_1.
Page on HISP. HISP website. Available at: http://www.mn.uio.no/ifi/english/research/networks/hisp/.

42

LEVERS FOR
INSTITUTIONALIZATION

APPROACH

CASE FOR ACTION

DHIS was designed to meet post-apartheid South Africas needs: an inexpensive

health management information system that could collect data at the facility level
and be integrated into a decentralized health system. With 12 national-scale use
cases, DHIS has demonstrated effectiveness in enabling more transparent, timely,
and accurate data.

LEADERSHIP

HISP has championed DHIS from the early days of its innovation and design,
through coordinating a global network of developers, advocating adoption by
ministries of health and helping to implement throughout national systems.
NORAD took the lead as a funder, enabling sustained resources to build a strong
and flexible platform.

EFFECTIVE PRODUCT

DHIS 2 is designed to empower users with better access to and control over data at
all levels of the health system. The flexible platform has customizable options for
inclusion, developed by a global team working on the ground with its users. Being
open-source, further customizations are always possible. The interface can be
translated into eight languages and users can switch between languages easily.
Data-validation rules help ensure data quality and accountability at the source.

VIABLE ECONOMIC MODEL

Committed, core funding from NORAD and PEPFAR and ties to the University
of Oslos Department of Informatics enables HISP to refine the software platform
over time.

SUPPORTIVE POLICY,
REGULATIONS, STANDARDS

DHIS 2 is a free, web-based, open-source information system developed in Java that

can run on any hardware. By adhering to existing global standards (e.g., HTML 5 and
SDMX-HD), DHIS 2 is easy to learn and adapt, and is highly interoperable with
third-party clients like Android apps, web portals, and other information systems.

EFFECTIVE PROGRAM
MANAGEMENT

HISPs philosophy led it to adopt a highly participatory and iterative development

approach, involving rapid prototyping in the context of use with the participation
of the users themselves.

HUMAN CAPACITY

HISPs DHIS 2 Academies create a global community of users and experts, building
national and regional capacity to design, implement, and maintain DHIS software.
Participation in DHIS development helped foster commitment and skills in a broad
set of graduate students.

TIMELINE

1997:
1999:
2001:
2003:
2004:
2006:
2008:
2011:
2014:

lvi

HISP developed DHIS 1, a free, database application based on Microsoft Access, selected mainly because it was
already common amongst potential users in South Africa.
South Africa rolls out DHIS as national health information systems.lvi
DHIS 1 implemented in all provinces and districts in South Africa.
HISP South Africa established.
DHIS 1.4 developed and implemented with users in Cape Town, Botswana, and Zanzibar.
The first implementation of DHIS 2 in Kerala, India.
After improvements, DHIS 2 was implemented in more than 20 Indian states.
First DHIS 2 Academy held in Dar es Salaam, Tanzania.
DHIS is at national scale in 12 countries, and has implementations in 46 countries, and has held 14 DHIS 2 Academies.

Statistics South Africa. Assessment of the Health Information System in South Africa. Geneva: World Health Organization; 2009.
Available at: http://www.who.int/healthmetrics/library/countries/HMN_ZAF_Assess_Draft_2009_04_en.pdf.

43

APPENDIX 6:
BBC MEDIA ACTION CASE STUDY
The emerging Indian national government approach to using mobile services for FHWs and families to improve maternal and
child health offers helpful lessons in scaling up digital services. A committed set of champions in government and beyond designed
and demonstrated the value of an iterative, structured approach to meeting key FHW and family needs with simple tools that
integrate into existing health systems.

BACKGROUND

In 2010, the government of the Indian

state of Bihar entered into a partnership
called Ananya with the Bill & Melinda
Gates Foundation to improve reproductive, maternal, newborn, and child
health (RMNCH) services across the
state, which has a population of nearly
104 million people, including 27 million
women of child-bearing age.
One of several elements of the
integrated Ananya program is a suite
of mobile-enabled services designed
and developed by BBC Media Action
in order to communicate lifesaving
information and help to shape healthy
behaviors that tackle the main causes
of RMNCH-related deaths. These
services include:
Mobile Academy, launched in May
2012, features a fee-based, interactive
voice response (IVR)-based training
course to refresh FHW knowledge of
nine maternal and child health behaviors
and to enhance their interpersonal
communication skills with families in
their communities.lvii
Mobile Kunji, launched in May 2012,
is an FHW job aid featuring a toll-free,
IVR-based service and printed deck
of illustrated cards for use during
counseling sessions with families.

lvii

Kilkari, launched in September 2013,

is a fee-based IVR subscription service
for families, providing audio information
on maternal and child health issues at
appropriate times in the pregnancy and
childhood lifecycle.
BBC Media Action developed these
services using the Grameen
Foundations modular, open source
software, Mobile Technology for
Community Health (MOTECH) as the
back-end rules engine, database and
reporting system. Thoughtworks was
contracted to implement the system
in India. OnMobile Global Ltd, one of
Indias largest mobile technology
solution providers, also played a critical
role by providing the front-end,
commercial-grade IVR software
platform, which integrates the services
with multiple mobile operator networks
and billing systems.
Thus far, the results in Bihar are
promising. As of June 2014, 38,512
FHWs, or 96 percent of the FHWs in
the eight program districts in Bihar,
were exposed to Mobile Academy and
Mobile Kunji.lviii Monthly, 48,000 people
use Mobile Kunji, playing nearly 11
million minutes of content, and 28,000
FHWs have graduated from the Mobile
Academy course, playing more than 7.6

million minutes of content.lix Since

September 2013, when Kilkari was
launched in the eight priority districts
in Bihar, more than 82,000 subscription
requests have been received.
Encouragingly, nearly 70 percent of
families are listening to all the content
they receive, and loyalty to the service
is high.lx The Government of Bihar
has agreed to scale up the services
state-wide, and, with the support of BBC
Media Action and the Gates Foundation,
has now added 12 districts to the
original eight.
In terms of impact on health-related
behaviors, as-yet unpublished Ananya
mid-line evaluation in Bihar suggests a
strong positive correlation between the
rollout of Mobile Kunji and changes in
specific health behaviors, suggesting it
is an effective complement to other job
aids and tools used by FHWs. The study,
which will be supplemented by a
forthcoming evaluation specific to the
BBC Media suite of services in Bihar,
finds that 40 percent of the women who
received a home visit from an FHW in
the previous six months had been
exposed to Mobile Kunji, and that while
a causal relationship may not exist,
households exposed to Mobile Kunji
typically received longer home visits
from FHWs. Among pregnant women

BBC Media Action. Health on the Move: Can Mobile Phones Save Lives? Policy Brief #7. February 2013.
BBC Media Action. Take up and usage of Mobile Academy and Mobile Kunji in Bihar. Working paper. September 2014.
lix
BBC Media Action data.
lx
BBC Media Action data.
lviii

44

exposed to Mobile Kunji, there was a

28 percentage point increase in the
number who took recommended steps
to prepare for birth (e.g., arranged
transport, identified a hospital in case
of emergency, saved critical phone
numbers, saved money) than those who
had not been exposed. Mothers exposed
to Mobile Kunji had a 13.5 percentage
point increase in the practice of
complementary feeding for children
aged 6-11 months. Early analysis
concludes that exposure to Mobile
Kunji adds substantial value in
predicting behavior; is strongly
correlated with delivery preparation
and complimentary feeding; and serves
as a good complement to other job aids
and tools used by frontline workers.lxi
Sustained take up and usage of the
services in Bihar, historically one of
the more challenging states in terms of
health outcomes and ease of operations,
led others to replicate the model. In
2013, the state governments of Odisha
and Uttar Pradesh elected to adopt
versions of this suite of RMNCH
mobile tools. BBC Media Action
launched Mobile Kunji and Academy
in Odisha with support from the United
Kingdoms Department for

lxi

International Development and from

the state government in February 2014,
and has just launched the services in
Uttar Pradesh with support from the
state government and the Gates
Foundation.
Meanwhile, with the election of a new
national government in April 2014, the
national Ministry of Health received
renewed support and impetus to
encourage rollout of Mobile Academy,
Mobile Kunji and Kilkari across all 35
Indian states and territories. In August
2014, the Indian governments Ministry
of Health and Family Welfare (MoHFW)
approved the pan-India rollout of the
three services. The Gates Foundation
and BBC Media Action, in partnership
with the Grameen Foundation and
Dimagi, will develop a national toll-free
platform for the services. BBC Media
Action and the Gates Foundation also
are working very closely with the
ministries to develop and support the
rollout strategy.
DEFINING SCALE

Indias sheer size often has others

trying to define the concept of scale.
BBC Media Actions mobile program in
Bihar arguably was a pilot, as it tested a

suite of interventions in eight of Bihars

districts before scaling up to the
remaining 30 districts or replicating in
other states. However, with nearly
40,000 FHWs in these eight districts,
this program covered an objectively
large population.
But perhaps more importantly, the
Indian example demonstrates the value
of defining scale as institutionalization.
In Bihar, the overarching Ananya
program, which featured BBC Media
Actions services, was only possible due
to the committed partnership of the
state government, including the Chief
Minister of Bihar and the Secretary of
Health and Executive Director of the
State Health Society. Decisions by the
states of Odisha and Uttar Pradesh, and
subsequently by the national Ministry
of Health, to fund and implement the
services demonstrates significant
commitment and investment in the
services.
The table below offers some of the key
lessons learned from the Bihar and
pan-India projects, across each of the
levers for institutionalization.

Chamberlain, S. A Mobile Guide Toward Better Health How Mobile Kunji is Improving Birth Outcomes in Bihar, India. Chapter in MIT Innovations Digital
Inclusion: The Role of Local Content. November 2014; citing data from the Ananya midline evaluation survey, carried out by the Mathematica Policy Research in
2014. BBC Media Action. Take up and usage of Mobile Academy and Mobile Kunji in Bihar. Working paper. September 2014. Pre-publication evaluation data
provided by BBC Media Action.

45

LEVERS FOR
INSTITUTIONALIZATION

APPROACH

CASE FOR
ACTION

The evidence that a large-scale mobile program for FHWs and mothers could succeed in a
challenging operating environment such as that of Bihar was a critical factor convincing Odisha
and Uttar Pradesh decision makers to include the program in their annual budget and program
implementation plans. It is very unlikely the national government would have adopted the suite
of services without the evidence of sustained uptake and usage by FHWs at scale in Bihar, as well
as requests for funding by five additional states, to support its decisions.

LEADERSHIP

Senior-level government commitment and leadership, including the serving Chief Minister of
Bihar and the Secretary of Health and Executive Director of the State Health Society, have been
crucial to institutionalization in Bihar. Government leadership enabled replication in Odisha
and Uttar Pradesh, and the leadership of the MoHFW led to the decision to introduce the services
across India.
BBC Media Actions Head of ICT in India and National Creative Director India and their teams have
played a recognized role as dogged champions with government, industry, and other stakeholders,
providing structure for the effort and delivering the painstaking lobbying and negotiations required
to seal the commitment of government, mobile operator, and other stakeholders.
The Gates Foundation has played a recognized role in offering a sustained funding commitment,
as well as in convening government and other stakeholders to ensure ongoing commitment across
the partners.
Senior, local champions from both BBC Media Action and the Gates Foundation played a key role
in advocating and provide strategic support to the Ministry on a sustained basis for months.

EFFECTIVE
PRODUCT

BBC Media Action undertook six rounds of user testing research across diverse districts to ensure
the services and training approaches were appropriate for the local populations. For example,
research indicated the importance of local languages and dialects, so the IVR scripts and voices
were adapted to be appealing to the diverse populations in the program footprint.
A key design feature in Bihar is simplicity; in particular, the IVR approach was adopted in
recognition of the generally low level of literacy amongst the target population. The suite of
products is likely to become ever simpler from the user perspective, featuring a single long code
for use with any mobile operator network.

VIABLE
ECONOMIC
MODEL

In Bihar, BBC Media Action worked with partners to develop a rigorous business case, which was
a critical success factor for encouraging mobile operator participation. All major operators in
Bihar participated, and while they agreed to a significant reduction in the cost of a standard
commercial IVR call, they participated because they recognized the value the services added to
their commercial offerings.
The economics of the national rollout have been tailored to reflect more of a public health financing
approach to offering the service. The national government plans to pay the airtime costs for the
services, reflecting a public sector financingrather than consumer-basedapproach to funding
the services. But again, its been critical to demonstrate to the central government that the services
can be cost-effectively managed at scale, with relatively manageable operational challenges.

SUPPORTIVE
POLICY,
REGULATIONS,
STANDARDS

46

A national ministry of health mandate to adopt the services provides a green light to incorporate
the services.

EFFECTIVE
PROGRAM
MANAGEMENT

HUMAN
CAPACITY

The India experience demonstrates the power of a strong approach to implementation,

which those involved cite as a key success factor. Highlights include:

Designing for scale from the outset, using tried and tested IVR technology that was
already ubiquitous pan-India and leverages the handsets that health workers and families
already own.

Employing strong commercial skills, a robust business case was developed for each mobile
operator to support negotiations to reduce tariffs. Detailed capital and operating expenses at
scale were calculated and shared with the central government to support its decision-making.

An iterative approach, both for the services themselves, as well as the program-delivery
approach, such as learning over time to work more closely with early adopters in the
communities and to leverage existing government FHW trainers to promote adoption.

Supporting the national government with strong project management tools, practices,
and capacity in order to define roles and responsibilities during the crucial start-up phase.

Adopting a sequenced approach to rollout nationally, to enable lessons learned to inform

subsequent deployments.

Adopting an integrated approach in terms of building on existing, large-scale management

information systems.

Designing a centralized technology platform for delivering services across states, but
tailoring content to meet the local needs in each state.

In Bihar, BBC Media Action initially introduced Mobile Academy to 40,000 FHWs via a 15-minute
teaser. Subsequently, they added a 15-minute training program at the health sub-center level.
This latter approach, which involved working with existing government health supervisors,
helped build both their capacity and buy-in for the long-run. They also learned that showcasing
and rewarding success (rather than highlighting gaps) helped to encourage FHW adoption of tools.
The rollout approach features sustained monitoring and supervisory support to health workers on
the ground, to encourage long-term and effective usage of the services.

TIMELINE:

2010:

Project Ananya, including the BBC Media Action suite of mobile services for demand generation,
begins in Bihar.

2011:

Primary market research carried out, prototypes developed, user-testing conducted.

May 2012:

Mobile Kunji is launched in eight districts in Bihar.

May 2012:

Mobile Academy launched in eight districts in Bihar.

Sep 2013:

Kilkari launched is launched in Bihar.

2013:

State governments of Odisha and Uttar Pradesh agree to replicate Mobile Kunji and Academy.

2014:

Mobile Kunji and Academy launch in Odisha and Uttar Pradesh.

April 2014:

National Ministry of Health begins discussion of national-level services.

October 2014: National Ministry of Health announces plan to support national rollout of the RMNCH mobile suite.

47

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