© Copyright 2015 Danielle Jaffee

To my family and fiancé, thank you for supporting me through the writing of this capstone paper and throughout my graduate school experience. I am lucky to have individuals in my life who provide an ear for listening and support, as well as a distraction when I needed a break from
Google Docs.
To Professor Zaharna, thank you providing me the support I needed through the writing and editing of my capstone paper. Your confidence in my paper, before I even had it written, calmed my nerves and was very much appreciated.
To the maternal health development field, thank you for providing me with endless interesting reports to read about programs that truly have long-term impact in their communities. It does, and will continue, to drive me to pursue a career in a mission-driven organization.
And finally to my Cohort. I really don’t think I could’ve done this without all of you. Seeing your smiling and equally tired faces was much needed every Saturday morning. From countless
Facebook chats throughout the week to phone call check-ins, all 16 of you have been a great source of support in this journey.

Terms ............................................................................................................................................. 1
Abstract .......................................................................................................................................... 2
Chapter 1: Introduction ............................................................................................................... 3
Study Purpose and Significance ................................................................................................ 4
Study Objectives & Limitations .................................................................................................. 5
Chapter 2: Literature Review ...................................................................................................... 6
mHealth tools for Maternal Health ........................................................................................... 7
Expert Analysis of mHealth Success ......................................................................................... 8
Themes, Considerations, Limitations, & Implications ........................................................... 10
Chapter 3: Methodology............................................................................................................. 14
Chapter 4: Case Profile .............................................................................................................. 17
Ananya Program Profile .......................................................................................................... 17
Aponjon Program Profile ......................................................................................................... 20
Chapter 5: Case Analysis ........................................................................................................... 23
Don’t Go it Alone ..................................................................................................................... 23
Mission Engineering is Integral .............................................................................................. 24
There’s Never a Bad Time to Evaluate ................................................................................... 25
Don’t Put All Your Eggs in One Basket .................................................................................. 26
Best Practices Are Best in Numbers ........................................................................................ 27
Chapter 6: Conclusion ................................................................................................................ 28
References .................................................................................................................................... 30

CHW
CMC
LMIC
FtF
MDG
MDG5 mHealth
SMS
Community health worker
Computer mediated communication
Low and middle-income countries
Face-to-face
Millennium Development Goal
Millennium Development Goal 5 to improve maternal health
Mobile tools in health
Short message service (text message)
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This case study examines successful mobile health (mHealth) technology campaigns to address high levels of maternal and newborn mortality in developing countries. The case study provides a profile and analysis of two mHealth programs, Ananya and Aponjon. The programs were selected based on the volume of relevant material available, along with their program length and close proximity geographically. This case study identifies best practices for integrating mobile technology into maternal health campaigns with the ultimate goal of reducing maternal mortality. The analysis found that both programs are successfully implementing shared best practices that fall in line with the literature on effective methods for mHealth programming.
Specifically, the study found that large programs with many partners, pre-planning, diverse portfolios, and interpersonal interactions provided a solid foundation and ultimately resulted in long-term success.
Keywords Maternal health, mobile technology, international development, mhealth, maternal mortality, infant, India, Bangladesh, behavior change communication, best practices.
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Every 96 seconds, a woman dies due to complications related to pregnancy and childbirth, resulting in 800 deaths each day and more than 289,000 maternal deaths every year according to the World Health Organization’s latest numbers (2014). The majority of these deaths occur in low and middle-income countries (LMIC) and many could have been prevented with tools that are already available in other parts of the world. Additionally, according to
UNICEF (2009) millions of women are affected by pregnancy-related illnesses or experience other conditions, including fistula, infertility, and incontinence.
The Millennium Development Goals (MDGs) are eight international development targets that were established following the Millennium Summit in 2000, a meeting organized by the
United Nations (2014), which brought together many world leaders. All member states (189 at the time) and 23 international organizations committed to help achieve the goals by 2015.
Millennium Development Goal 5 (MDG5) is focused on improving maternal health. Under
MDG5, countries are committed to reducing maternal mortality by three quarters between 1990 and 2015. Since 1990, maternal deaths worldwide have only dropped by 45 percent according to the WHO (2014), lagging behind the targets.
New and novel approaches are necessary to address these staggering figures. Two such initiatives funded by the International Telecommunications Union (2010) and the mHealth
Alliance (2012) have recommended the use of mobile phone technology as a way to improve maternal health services and ultimately save lives.
The most recent report by Ericsson (2014), a multinational communications technology and services provider, indicates that the global mobile penetration has reached 94 percent and
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mobile subscriptions now total around 6.8 billion. The actual number of subscribers is closer to
4.6 billion, since many people have several subscriptions such as a personal and work phone.
Globally, mobile subscriptions continue to grow at approximately 6 percent per year according to Ericsson (2014). The greatest growth of mobile phones is primarily in LMIC, where maternal mortality is the highest, as noted by Mechael (2009). As of 2010, according to the
GSMA Development Fund (2012), commercial wireless signals cover more than 85 percent of the global population, providing an even greater reach than the electrical grid.
The use of "emerging mobile communications and network technologies for healthcare" is called mHealth, a term coined by professor and academic Robert Istepanian (Istepanian,
Laxminarayan, & Pattichis, 2006). This encompasses the use of both simple phones, capable only of voice and short message service (SMS) communication, as well as smartphones with many other capabilities, including access to application software known as apps and websites
(PATH, 2012). Now more prevalent than ever, mobile phone use in the health sector becomes more attainable.
The continued growth of mobile phones, combined with the urgency to save the lives of women during childbirth, makes the use of mHealth for this purpose an immense and exciting opportunity. Accordingly, the question guiding this research is: How can mobile health technology tools be used to create more engaging, persuasive health communications campaigns that reduce maternal mortality?
Study Purpose and Significance
The purpose of this study is to identify best practices for integrating mobile technology into maternal health programs so that behavior change can result in reduced maternal mortality.
This study is significant because mobile phone technology has become a popular medium
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through which health interventions are delivered to pregnant women in low-resource settings. An analysis of mobile technology techniques in successful campaigns will provide a foundation from which technology specialists can develop more effective tools and campaigns.
Study Objectives & Limitations
The objectives of this study are two-fold: First, this study identifies best practices for using technology to reach pregnant women in areas with low access to health services. Second, this study pinpoints areas of improvement for technology in health settings to avoid failed programs.
Because it is difficult to determine an exact correlation between mobile health communications technology and the life span of newborns after birth, this study will limit its scope to analyzing mobile phone usage during pregnancy, not examining child health benefits.
The main criterion for success is that a large volume of pregnant women used the tool.
Additionally, I’ve chosen to focus my study on two mobile tools only. There are far more tools that exist than can be covered in one research paper.
Study Overview
The following chapter explores existing literature on communication theories that facilitate the adoption of mHealth tools. The literature also presents the mHealth tools currently being used in maternal health programs, expert analysis on the success of mHealth, and finally themes, considerations, limitations, and implications of the research. This study then employs a case study methodology to examine two mHealth programs: Ananya and Aponjon. Findings are then discussed, bringing attention to specific best practices of Ananya and Aponjon that have led to strong, positive results. The study concludes with a summary of critical concepts and makes recommendations for future research.
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To preface this literature review, it is important to note the significant role technology can play in global development. As technology impacts the way information is shared, maternal health programs need to ensure they use technology in the best way possible. This literature review examines theories that help explain mHealth success, maternal mHealth programs that currently exist, expert analysis of mHealth best practices, and finally themes, considerations, limitations, and implications from the literature.
Theories Explaining mHealth Success
As the world has failed to achieve MDG 5, new innovations in health are needed now more than ever. The increased level of mobile penetration globally provides an opportunity for healthcare providers to expand their reach and improve access to marginalized populations.
Joseph Walther’s (1992) Computer Mediated Communication (CMC) theory focuses on communication that occurs through the use of two or more electronic devices. The theory provides some context as to why mHealth programs have seen some success thus far. While originally used to describe communication through a computer, it was more recently applied to other forms of technology including the use of text-based interaction such as SMS.
Boucher, Hancock and Dunham (2008) explain that receivers of CMC messages tend to overanalyze the identity of the senders of SMS interactions, leading to better impressions of the sender’s personal qualities. For example, a study conducted by Dunham and Hancock (2001) found that although CMC partners rated each other on a smaller number of characteristics than face-to-face (FtF) counterparts, their impressions were more positive than those with a FtF interaction. Because CMC reduces the amount of social cues present in FtF interactions, Walther
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(1996) notes that first impressions aren't based on physical, and instead depend on other information. Senders’ impressions are more flexible to molding than in an in-person interaction.
Walther’s (1996) Hyperpersonal Communication Model goes an additional step further and suggests that CMC can become hyperpersonal or beyond interpersonal, because it "exceeds
[FtF] interaction," thus allowing message senders a host of communicative advantages over traditional FtF interaction.
These related theories help explain why mobile tools have value in the health arena.
Removing the FtF with doctors can lead to less intimidating care, either through direct mobile use by the beneficiary or through a Community Health Worker (CHW) that the beneficiary knows and is comfortable with. In addition to the convenience, it allows patients to keep their privacy, which is particularly important for individuals with stigmatized diseases such as HIV and AIDS and those that are a part of minority groups that don’t often get care from formal health settings, as noted by scholar Aranda-Jan (2014). The ability for two-way communication through SMS allows for a quick, personalized response with actionable information from a health care provider.
mHealth tools for Maternal Health
Among the many challenges to improving maternal health is the shortage of professional health workers, lack of timely disease surveillance, use of counterfeit drugs, and health system delivery delays. Diviani, Fiordelli, and Schulz (2013) believe that mHealth tools can help overcome these immense challenges by reducing healthcare costs, time spent waiting for care, and corruption, while at the same time improving access to care.
Many women in LMIC live in rural, hard to reach areas. According to Batavia et al.
(2010), providing community health workers (CHWs) and pregnant women with mHealth tools
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increases their access to higher quality healthcare services, expert advice from formal health systems, and improves their ability to request help or access better equipped centers when complications occur.
Binagwaho et al. (2012) explained how the RapidSMS system monitored pregnancies and reduced maternal and child deaths in Rwanda, demonstrating the potential for successful scaleup of mHealth tools used by CHWs when there was strong government ownership of the process.
The system successfully allowed for interactive communication between CHWs and expecting mothers in their community, the medical health center, a national centralized database, and an ambulance driver in case of emergencies.
Dhadialla, Mjungu, Luk, Svoronos, and Zue (2010) observed that a maternal health project in Tanzania resulted in a successful mHealth tool, thanks to multiple meetings with
CHWs throughout the development process. Facilitating local ownership and innovation led to a product that met the customer (CHWs) needs.
A number of small-scale mHealth pilot studies have also led to some successes in delivering care to expectant mothers. For example, an mHealth tool evaluated by Jo et al. (2014), known as the Lives Saved Tool (LiST) provided CHWs with the ability to plan and prioritize health interventions aimed to reduce maternal, newborn, and child mortalities. The tool has thus far been piloted in Bangladesh and Uganda. During that time, it showed promising results as the data provided innovators and governments priority areas for mHealth strategic focus, resource prioritization, and investment.
Expert Analysis of mHealth Success
Experts in the field recommend a number of strategies to use mHealth technologies effectively in a program. Studies commissioned by a number of organizations and individuals
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(GSMA Development Fund, 2012; McNamara, 2007; Mechael, 2009; Mechael & Sloninsky,
2007) all point to similar recommendations. These include the need for strategic message design, developing an appropriate technology for an intended audience, and constantly monitoring and evaluating the campaign. Additionally, a study commissioned by Vital Wave Consulting (2009) argued that it is imperative to develop strong partnerships and think through a long-term funding plan.
One element important to message design is the need to develop a two-way communication channel with tailored content for a targeted user. Atun et al. (2006) and Batavia et al. (2010) argued that two-way communication provides patients with the enhanced communication capabilities; specifically the ability to ask questions and interact, rather than simply receive information from the sender. Additionally, the timing that a communication is sent out (i.e. frequency, time of day) plays an important role in how the user interprets and reacts to the information (Atun et al., 2006). This may vary based on the end user.
Developing an appropriate mHealth tool with an understanding of the target audience is also critical. Batavia et al. (2010) noted that an mHealth tool creator must know the audience’s level of technological competency and health knowledge, as well as general education, in order to develop a tool that is both understandable and effective at accomplishing its objectives. In the mHealth environment, the interface design and ease of use are essential in order for the product to garner acceptance and widespread application.
Batavia et al. (2010) stressed the importance of an evaluation to help in designing a suitable, culturally sensitive mHealth tool for a target audience. This includes understanding the communities’ current health needs, phone usage, and phone penetration (amount of people with
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phones). Evaluation doesn’t end at the design phase. Campaigns need to be monitored throughout and modified as needed.
A report conducted by Hausman & Keisling (2011) highlighted how multidisciplinary partners bring diverse strengths and ideas to a campaign. This can include large donors, government entities, non-profit or private organizations, and local or foreign partners, all who participate with each other to improve the delivery of mHealth services.
A plan for long-term program funding, to ensure the program is sustainable and meets its goals, is important in the initial stage, as indicated by Vital Wave Consulting (2009). Continuing the project beyond initial seed funding needs to be considered when developing a program around an mHealth tool.
Themes, Considerations, Limitations, & Implications
Within the literature, a number of overall themes arise. The first is that overall, the perceptions of mHealth projects by health workers, patients, and staff are high according to several authors (GSMA Development Fund, 2012; McNamara 2007; PATH 2012). This makes sense given the growth of mobile phones in the past several years around the world and the clear indicators that point to needed health care improvements. Because mobile technology is accepted overall, mHealth projects may see higher rates of acceptance.
Another theme is that mHealth has proven to be a reliable tool for data collection. While some of the literature questions the merits of mHealth and the long-term benefits, the majority of the analysis including reports by Carlile et al. (2013) and PATH (2012) note that it is a better alternative to paper data collection for both general and maternal mHealth.
Finally, a third theme established in the literature by many authors (GSMA Development
Fund, 2012; McNamara, 2007; Mechael, 2009; Mechael & Sloninsky, 2007; Batavia et al., 2010)
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is the need for evaluation before, during, and after an mHealth program to ensure it is successful from both the healthcare practitioner and beneficiary standpoint. This applies to all mHealth programs, including those targeting pregnant women to help ensure the program is on track.
The effectiveness of programs managed by CHWs continues to be a source of consideration. Blanco et al. (2013) noted that while health interventions led by CHWs have led to improved maternal health and improved care at a more affordable price, others have shown that the quality of health services delivered by CHWs may be compromised without proper investments in trainings, policies, and resources.
A final consideration currently underway is exactly how, when, and in what form a pilot project can be scaled up. Should funding be stabilized first? If so, should it be done by a foreign donor or national government? Should the national government integrate it into their programs?
If not, who should be the owner of the program? For the program to be effective and make a difference, all of these questions need answers.
There are also limitations, however, within the literature. While a growing amount of evidence of mHealth benefits to maternal health were documented, they are mainly exploratory studies done on small scale with limited research implications or conclusions. Jo et al. (2014) argue that a limited number of studies systematically demonstrate the effectiveness of the tool to promote maternal health. While robust studies providing evidence are lacking, there is broad agreement that communications access is an essential part of improving the quality and use of maternal healthcare services as outlined by Kuepper, Milen, Noordam, Steklenburg (2011).
Two external factors that may impact mHealth intervention outcomes include: limited research on mHealth apps and a lack of information on the long-term impacts of mHealth in developing countries.
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mHealth success depends on important links that go beyond the programs themselves.
Mobile phones require affordable and reliable plans with telecommunication providers, whose prices remain stable and don’t get canceled at a moment’s notice. There are also issues with legacy systems and interface control; different mHealth programs may not run on older phones or may only be tailored to certain brands (i.e.: Nokia, Motorola).
For smartphones, PATH (2012) suggested that the issue may arise when developing an
App for Apple, Android, or Microsoft among others. Each type of phone requires a unique type of App. Furthermore, the portability of mobile phones has its own intrinsic benefits and drawbacks. The constant movement of phones increases the chances it came become damaged or lost. Another significant issue is the security of personal data with mHealth. Electronic systems are more vulnerable to hacking than alternative paper-based systems given that the information can be accessed from anywhere by someone with technological knowhow.
Finally, there were limitations pertaining to the actual literature reviewed. Specifically, only English-language literature was reviewed when there may be data and findings in other languages. Given that the paper focuses on LMIC where English is not the primary language, important research may have been overlooked.
Based on the survey of scholarship, a number of implications concerning the use of mHealth tools to address maternal health can be drawn about effective mobile health technology techniques. This body of literature strongly suggests that mHealth can have a significant role in improving maternal health if used correctly.
The literature implies that the reliability of data collection through mobile phones as opposed to paper has strong potential to improve the accuracy of health information systems. In
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arguing the merits of scaling up a program, this can play a critical role in securing funding and resources by a government or donor.
The final and perhaps most important implication of this body of literature is that one of the major advantages to mHealth applications, services, and products, is the empowerment of the patient. This transformation is emblematic of a shift of ownership of healthcare from the practitioner to the patient. While traditional healthcare was a one-way conversation/road, it is now an open highway whereby all those with access to the technologies can take ownership of their healthcare and futures. This new sense of power may drive more women to want to use mHealth services.
Based on this combined literature review, it’s possible to suggest the following best practices. First, developing an appropriate technology for an intended audience is important to meet the needs of the end user. Second, monitoring and evaluating the tool and campaign before, during, and after allows for issues to be recognized and changes to be made. Third, programs need a diverse set of partners that bring different skill sets to the table. Finally, it’s important to think through a long-term funding plan to ensure the continuation of a program far beyond the pilot stage.
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This section of the paper provides context for the chosen method/format and content of the research for the capstone. The research question for this study is: How can mobile health technology tools be used to create more engaging, persuasive health communications campaigns that reduce maternal mortality?
To address this question, I use a case study approach to analyze two mobile health technology tools and observe how they are used to address maternal health in their respective target countries. According to Baxter and Jack (2008), “Qualitative case study methodology provides tools for researchers to study complex phenomena within their contexts. When the approach is applied correctly, it becomes a valuable method for health science research to develop theory, evaluate programs, and develop interventions” (p 544). The case profile method will allow me to evaluate how mobile health tools can succeed within the context of a specific audience and country, rather than at face value. Baxter and Jack (2008) note that using a case study is a good approach when “you cannot manipulate the behavior of those involved in the study” (p 545), which is the case when evaluating an ongoing health program.
Drawing from the research of Yin (2003), I will classify my analysis as a multiple case study. “A multiple case study enables the researcher to explore differences within and between cases. The goal is to replicate findings across cases” (as cited in Baxter and Jack, 2008, p. 548) similar to that of a benchmarking study. Looking at two mobile health tools, side by side, will highlight what helped each program succeed, identify common best practices, and how programmatic variances, focuses, and scope led to different results. Success of one program may not necessarily indicate a best practice, however repetition of actions between two programs can indicate more of a trend towards behaviors that lead to successful programs.
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There are clear advantages of using a case study approach. According to Dominick and
Wimmer (1997) “the case study technique can suggest why something has occurred” (p. 103). In this circumstance, I am hoping to identify why a program was successful. Dominick and
Wimmer (1997) go on to say that the “... method also affords the researcher the ability to deal with a wide spectrum of evidence" (p.103). This allows me to gather information on the maternal health tools through various outlets, including project websites, annual reports, evaluations, news items, and more. Echoing this, Baxter and Jack (2008) indicate that “...the evidence created from this type of study is considered robust and reliable” (p. 550).
There are some disadvantages to the case study approach. Despite the advantages, “...it can also be extremely time consuming and expensive to conduct,” according to Baxter and Jack
(2008, p. 550). There will always be more reports and information about the mobile health tools to analyze, but determining where to focus my attention throughout the course of the research is essential to meeting the deadlines. Yin (1989) points out that "... too many times, the case study researcher has been sloppy, and has allowed equivocal evidence or biased views to influence the findings and conclusions" (cited in Dominick and Wimmer, 1997, p. 103). This is certainly a risk; researchers need to take extra care to include multiple viewpoints in their analysis of a case in order to avoid a bias.
I chose to focus on the Ananya and Aponjon programs as my case studies for a number of reasons. Ananya is a health partnership in India, aimed at residents of Bihar to support an acceleration of progress towards the state's ambitious health goals. Aponjon is a health information service partnership in Bangladesh, aimed at pregnant women, new mothers, and their families to deliver behavior change communication messages via mobile phone. Both programs benefit from sustained longevity (2+ years) and are ongoing. Additionally, both
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programs are based in South Asia, Bangladesh and India, and therefore have clear synergistic relationships from a comparative analysis standpoint. Lastly, and perhaps most significantly, both programs are large in scale and have substantive research and measurable performancebased metrics, thus allowing for a thorough analysis.
Data for the case studies was collected through a number of sources including publicly available websites, news stories, evaluation reports conducted by the implementer and others, and analysis papers. The majority of this information could be found through the websites for these programs. To analyze the data, I will go through all published reports, focusing particularly on measurable data (i.e. beneficiaries using mobile tool) to identify best practices that align with those highlighted in the literature review. I will also indicate where the mobile tool missed opportunities.
As with many research papers, there is the risk that the data presented by an organization/individual is biased and may only highlight achievements, failing to delve into setbacks and major issues. That being said, this issue was mitigated somewhat by drawing on evaluations conducted by third party organizations and donors, rather than only the implementers themselves.
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This section of the paper provides contextual information on two unrelated, ongoing maternal mHealth programs, the Ananya program in India and the Aponjon program in
Bangladesh. This information will serve as the foundation for analysis provided in the next portion of the paper.
Ananya Program Profile
Ananya (meaning ‘unique’ in Hindi) is a five-year partnership (2010-15) between the Bill
& Melinda Gates Foundation and the Government of Bihar, India to support the acceleration of progress toward the state's health goals
1
. The program brings together the Gates Foundation and the State’s departments of Health and Family Welfare, Social Welfare, Rural Development, and
Public Health Engineering, along with other stakeholders, including BBC Media Action,
Banglanatak, Grameen Foundation, GSMA Mobile for Development, Madison World, OnMobile
Global, and Pathfinder International (A Partnership for Better Health in Bihar, 2015).
Ananya is further split into 11 programs, with different partners taking the lead, focusing on radio, training, street theater, listeners' groups, rural marketing, and most importantly for the purposes of this study, mobile. Ananya’s Shaping Demand and Practices program, led by the
BBC's international development charity BBC Media Action, includes four mobile program components: Mobile Kunji and Mobile Academy, both launched in 2012, as well as Kilkari and
1
Unless otherwise referenced, the information used to construct this case profile is drawn from Shaping
Demand and Practices | Rethink 1000 Days | BBC Media Action
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Gupshup Potli, launched in 2013 and 2014 respectively. Shaping Demand and Practices focuses specifically on increasing awareness, changing attitudes, influencing norms, and motivating beneficial health behaviors from pregnancy through a child’s second birthday.
In Bihar, traditional customs determine many health practices, including those related to childbirth. Women are encouraged to deliver their baby at home and told that immunizations aren’t necessary for their newborns. These traditions have resulted in some of the worst maternal and child mortality rates in India – over 300 mothers die from every 100,000 live births, and 16 percent of infants die on their first day in Bihar. Countrywide, according to the World Bank data,
190 mothers die from every 100,000 live births and 4.1 percent of infants die on their first day
(2015). The Mobile Kunji program introduces a free, mobile deck of cards that can be used by a
Community Health Worker (CHW) as a simple audiovisual aid to relay health information to families as part of pre- and post-natal healthcare. The tool provides some medical authority to the health worker, who would normally be without information, and is easy to transport. As of
March 1, 2015, more than 245,000 unique users have accessed Mobile Kunji, playing approximately 14.5 million minutes of content.
Education and financial status, family commitments, as well as the remote locations of
CHWs in Bihar makes travel to education centers near impossible. Mobile Academy brings the classroom to the 200,000 CHWs in Bihar through mobile phones. The audio training course, available by dialing a number from any mobile phone, is designed to expand CHWs’ knowledge of life saving preventative health behaviors and enhance their communication skills. The course
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consists of nine chapters, 36 lessons, and nine quizzes covering nine distinct lifesaving behaviors before and after childbirth. If participants score 50 percent or higher on all quizzes, they receive a printed certificate from the Government of Bihar on their accomplishment. At less than one cent a minute, the total cost is approximately $1.50, paid for by the CHW themselves. As of
March 1, 2015, 68,243 unique users had accessed the program, spending more than 10 million minutes listening. A total of 38,419 have completed the program.
Kilkari (a baby’s gurgle in Hindi) delivers time-appropriate information to families during the most vulnerable 16-month period in the life of a mother and child, starting from the sixth month of pregnancy up until the baby is a year old. Each week for $.018, subscribers receive information and reminders relevant to the pregnancy or the newborn’s specific stage of development, helping reinforce life-saving health behaviors. Anything from reminders to take pre-natal supplements to how to safely bathe a baby is delivered through these messages. If a subscriber misses a call, the calls will recur until the message is received and acknowledged. As of November 1, 2014, 112,963 subscription requests were received and more than 1.3 million calls were made to subscribers
Gupshup Potli (a bagful of conversation in Hindi) is a mobile health message program accessible by a toll-free number. As mothers and their children wait in line for their immunizations and checkups, as part of the monthly Village Health Sanitation and Nutrition Day
(VHSND), CHWs connect to the line and attach their mobile phone to a speaker. The health messages are projected out to the people waiting in line, which could be anything from advice
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about family planning to recommendations of activities after childbirth. After the message is projected, CHWs use cue cards to start the discussion amongst the audience and address questions. For the purposes of this capstone, I will not focus on the Gupshup Potli program, as it is too new to provide substantive evidence, nor does it have enough research for thorough analysis.
Evaluation was conducted throughout the course of all of the Ananya programs, identifying the number of beneficiaries and milestones accomplished. Additionally, reports specifically related to mobile phones were conducted as well as an external report, conducted by
Mathematica, on baseline findings two years into the program (2013).
Aponjon Program Profile
Aponjon (meaning ‘trusted friend’ in Bengali) is a health information service partnership launched in December 2012 by the Mobile Alliance for Maternal Action (MAMA) initiative. The program delivers behavior change communication messages via mobile phone platforms to pregnant women, new mothers, and their families in Bangladesh. Aponjon, also known as
MAMA Bangladesh, is implemented by Dnet, a Bangladeshi social enterprise, in partnership with the Government of Bangladesh’s Ministry of Health and Family Welfare
2
.
Bangladesh is one of four flagship countries where MAMA operates; others include
India, Nigeria, and South Africa. MAMA is a global public-private initiative that aims to deliver health education messages to pregnant women and new mothers using mobile phone technology.
2
Unless otherwise referenced, the information used to construct this case profile is drawn from MAMA
Bangladesh
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MAMA was launched in May 2011 by the United States Agency for International Development
(USAID) and Johnson & Johnson, in collaboration with the United Nations Foundation, the mHealth Alliance, and BabyCenter LLC.
In Bangladesh, access to timely and reliable health information, including those for pregnant women and new mothers, is challenging. Although some progress has been made in the past ten years, maternal and infant mortality rates in Bangladesh remain high. These deaths can oftentimes be avoided with access to health information and basic care. Aponjon was created to fill this need through the power of mobile phones. The program provides health information and basic care to pregnant women and new moms at various stages through their phone. Information is also provided to families, including spouses, mothers, and mothers-in-law. By December
2015, three years after launch, Aponjon aims to reach two million women and one million family members. As of February 2015, the program has reached 1,236,919 subscribers.
Similarly to Ananya’s Kilkari program, which delivers time-appropriate information to families during the most vulnerable 16-month period in the life of a mother and child, Aponjon’s weekly messages are timed to the stage of pregnancy or age of the newborn with information on self-care during and after pregnancy as well as information on caring for a newborn. According to the Center for Health Market Innovations, messages cost 2 taka (about 2.5 US cents) per week and at least 20 percent of women who register will receive it free of charge (2015).
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Aponjon has conducted evaluations throughout the course of the program including developing a monitoring and evaluation framework prior, looking at lessons learned after
500,000 subscribers, and developing an agenda for 2015.
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How can mobile health technology tools be used to create more engaging, persuasive health campaigns that reduce maternal mortality is the fundamental research question underpinning this research product. The analysis provided in this section will evaluate the programs highlighted in the previous sections, along with information gleaned from the literature and related theories, to identify the essential qualities that have led to the program success.
With a growing number of health programs integrating technology to support their efforts, why do some fail? Why did Ananya and Aponjon programs succeed in meeting their objectives? Based on the case profiles of these two programs, a number of observations resonate with best practices identified in the literature.
Don’t Go it Alone
The first observation tied to the success of both case studies is the importance of partnerships. Despite the temptation to hit the ground running, mobile health programming appears to be done best through a consortium of vetted and invested partners that bring different strengths to the table; this is the case in global development programming in general. The need for programs to have a diverse set of partners that bring different skill sets was also one of the best practices identified in the literature review.
The Ananya program has several partners of differing strengths and expertise. The Bill and Melinda Gates Foundation fund the project. Partners include social enterprises, non-profits, a communication group, and a telecommunication company, which are all listed in the case profile.
This diverse partnership allows for a comprehensive program that addresses Bihar, India’s ambitious health goals from multiple angles and a range of expertise.
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Aponjon’s program in Bangladesh includes partner organizations with access to clinical services and health work, experience in monitoring and evaluation, and technical expertise.
Partnerships exist with six outreach organizations, five telecommunications companies, and the public and private sectors. Each of these partners contributes to the overall program success in various ways.
Mission Engineering is Integral
A second major observation was the importance of mission engineering. While not explicitly stated in the research, both case studies employed rigorous and robust mission engineering principles and practices. Specifically, these programs identified what problem they wanted to solve (often with concrete problem statements) along with clear-cut and measurable needs, goals, and objectives linked to indicators of success. Intuitively, if a program does not have a vision of what success looks like or what problem it is trying to solve, the program may be doomed for failure.
Aponjon’s mission engineering had a strong foundation. It developed a monitoring and evaluation framework report prior to implementation, which involved identifying ways to reach the audience, overall goals, timelines, and more (2012). This report helped set the stage for the program’s success.
While Ananya may have conducted an initial report, it is not available to the public online. They did, however, produce a Memorandum of Cooperation between the Government of
Bihar and the Bill & Melinda Gates Foundation that identified priorities and tasks that would be taken on by each partner (A Partnership for Better Health in Bihar, 2015).
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There’s Never a Bad Time to Evaluate
A third observation tied to the success of both case studies was the importance of evaluation. Best practices suggest that an mHealth program that is associated with long-term objectives (greater than one year of in-country operations) should conduct evaluations during and after programming. This is generally required by large donors like USAID or the Gates
Foundation, but tend to be conducted irrespective of any formal contractual requirement.
Program evaluation from project inception to closeout is critical to ensure continuous improvement of the program and identify pre-planned product improvements. During the program implementation, evaluations need to be conducted to gauge progress thus far, setbacks, and look for areas of improvement. Waiting until the end of the program is too late in the game to make changes, issues that arise mid-program can be modified in order to get back on track. A final evaluation is integral to identify lessons learned for future programming, to avoid pitfalls and repeat successful practices.
Whenever possible, it is good practice to catalog any lessons-learned, so they can be shared within the organization for similar or future projects and also externally to peer and industry groups for benchmarking purposes. The most effective organizations understand that it is critical to not only learn from their mistakes but from those of others within and outside of their industry. Pertaining to mHealth projects, organization like the Society for International
Development (SID) or the mHealthKnowledge website, along with academia outlets are good avenues to share findings.
Analysis conducted throughout the course of all of the Ananya programs, identifies the number of beneficiaries reached and milestones accomplished. Additionally, reports specifically related to mobile phones have been conducted as well as an external report, conducted by
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Mathematica, on baseline findings two years into the program (2013). These are widely available online.
Aponjon has conducted evaluations throughout the course of the program, including lessons learned after 500,000 subscribers, and developing an agenda for 2015 moving forward.
Such evaluations reveal the importance of learning from mistakes and planning for the future.
Neither program has conducted final evaluations, as they are ongoing. Given the high volume of reports thus far and that large donors are involved, they will likely occur when the program ends.
Don’t Put All Your Eggs in One Basket
A fourth observation tied to the success of both case studies was the diversity of programming. While some maternal mHealth campaigns succeed as a standalone program in one country and with one tool, it is often the case that these programs do not make it past their initial pilot phase. Operating more than one program, either in various geographic areas or with different target audiences (i.e. mother, community health worker, family members), allows for wider reach and a larger pool to gain lessons learned .
Ananya operates 11 different health programs, all with the same large donors but with different implementing partners taking the lead. The programs focus on health interventions using radio, training, street theater, listeners' groups, rural marketing, and mobile. All programs together create a comprehensive strategy to address health issues that face Bihar, India.
Aponjon is MAMA’s program based in Bangladesh, one of four flagship countries where
MAMA operates. Others include India, Nigeria, and South Africa. Implementing mHealth programs in different environments allows you to try various approaches to meet each unique
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audience’s needs, as well as implement some successful practices identified in one program in another.
Best Practices Are Best in Numbers
A program does not necessarily succeed when it meets just one of these best practices. A program may choose to conduct extensive mission engineering prior to the launch, but if partners aren’t identified and funding isn’t secured, the program will not see long-term success. Nor do many partners and funding, with no prior planning result in a program that succeeds. While not all best practices listed have to exist within a single program, best practices work best when they are grouped together. Ananya and Aponjon are examples of how combined best practices result in successful programs.
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Every 96 seconds, a woman dies due to complications related to pregnancy and childbirth, with the majority of these deaths occurring in low and middle-income countries.
Many of these deaths could have been prevented with tools that are already available in other parts of the world. The continued growth of mobile phones, combined with the urgency to save the lives of women during childbirth, makes the use of mHealth for this purpose an immense and exciting opportunity. The purpose of this study was to identify best practices in using mHealth technology tools that can help reduce maternal mortality.
Mobile health tools that succeeded shared a number of best practices: They had a diverse set of partners, they had clear-cut goals and objectives early on, they had interpersonal contact prior to program development, they integrated evaluations into the program lifecycle, they had a diverse program with multiple components, and finally, they had more than one of these best practices.
These findings are significant and particularly relevant, as they identify some of the major tactics that can be used when an mHealth program is developed. The information gleaned from this analysis can be tied directly to the research question: How can mobile health technology tools be used to create more engaging, persuasive health campaigns that reduce maternal mortality. Overall these findings fall in line very closed with what was identified in the literature review and further confirm organizational needs to develop a thought out, welldesigned mHealth program that have these identified best practices.
While the combined literature review and case profile/analysis reviewed a large amount of research and mHealth programs, it is not possible to give every program the same level of
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attention received by Ananya and Aponjon. Additionally, there are examples that go against the norm and succeed despite not meeting any of the identified best practices.
There is ample room for future research in this field. Once the two programs analyzed in this paper have concluded, it would be of interest to further explore best practices implemented through the course of the program. Another entire research report can focus solely on mistakes made by mHealth program. The list of mishaps is long and can provide equally useful information. Finally, it would be interesting to do another case profile on two programs in another health field, for example malaria prevention, to see how the best programs are similar and different from those used for maternal health.
Despite progress in the reduction of maternal and infant mortality in developing countries, the rates have not declined as rapidly as hoped. Based on the concepts explored in this paper, well-developed mHealth programs present an immense opportunity to reach patients that may have never received care and break through barriers that once existed.
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