Connecting health – Systemic mHealth solutions for better pregnancy and birth
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Transcript: English(auto-generated)
00:18
Good morning. It's my first time here at the Republica and I must say I'm really
00:30
impressed. It seems to be a really – and I hope the team agrees with me it's really a fun and inspiring event to be at and we really hope that our presentation will contribute to the forum and give you a good feel of how
00:43
digital technologies have become a really important issue in delivering health care in low and middle income countries. So on behalf of the Innovation Factory, I'm happy to welcome you all to the session on Connecting Health, Systemic mHealth Solutions for Better Pregnancy and Birth-Giving Care. What we
01:01
will talk about today is how digital technologies can help overcome a challenge that is really close to the heart of everyone that is representative and that is mothers and children. What I want to start this session with is a story that I was told while working in Tanzania. It's a story that really could have happened in any of the countries that is represented here and I hope it gives you
01:23
a glimpse of why we think this is so important and why we want to present the work today. What I'm going to say is going to be followed by two presentations and a panel discussion at the end. So the story is about a young pregnant woman living in southern rural Tanzania. She's 20 years of age and she's
01:44
pregnant and when she felt her first labour pains, she did what was common in her village. She called the traditional midwife and for the next 11 hours she would be lying on the floor of her small house and the pain with hours
02:02
passing getting more and more unbearable and the birth not progressing. So eventually the midwife did decide, together with the family, to bring her to the next dispensary accessible by road. She was carried by wheel cart. You have to imagine these are streets, not streets like we know. Those are little
02:21
footpaths that we're talking about here. And by the time she got to the dispensary, a nurse was present and she immediately called the ambulance. But again, by the time the ambulance had come, another six hours of pain had passed for Dorothea and by the time she eventually managed to get to the hospital, the doctor wasn't there. When the doctor came back, he delivered the
02:44
baby but it was dead. And you know, this persistent high maternal and neonatal deaths and the resulting disabilities that women are facing in low and middle income countries are still one of the greatest challenge that we are dealing with and what we are going to speak about today are really the concerted efforts by
03:03
experts in Tanzania, Kenya and Cameroon and Germany that are all striving for common vision and that is that women like Dorothea can deliver healthy babies and that pregnancy really becomes a matter of joy and not death. The ideas
03:20
that will be presented today have been developed in the framework of the Innovation Factory, which is an initiative commissioned by the German Federal Ministry for Economic Cooperation and Development and has been supported by the German Technical Corporation, GIZ, and it provides a collaborative space for health and IT professionals to make use of the innovation potential that digital
03:43
technologies provide to support health systems in delivering quality healthcare services. What the initiative recognizes is that digital solutions, health solutions are often developed in silos, in single island fashion and that while they are successful, they don't have the power to make change to the health
04:01
system to create synergy. So the collaborative nature of ideation has really been at the forefront of this initiative and in self-steered country units, experts, policy makers, civil society organizations, medical staff, community health workers, private and public sector have really come together
04:23
to forward systemic e-health solutions based on the special needs of the countries and enhanced by local knowledge. So the process of ideation in these countries has been highly participatory and it has been informed by local needs and backed with international support. All countries have done their own needs
04:43
analysis, the composition of teams and the steering of the teams is very different. The methods for developing the ideas has been different. There's been hackathons, there's been use of design thinking methodology and as that was are the ideas that will now be presented by Stephen. Stephen, I welcome Stephen to the
05:03
stage. Stephen Wanyi, he's a member of the Kenyan country unit and he's a biomedical information specialist with really a wealth of experience and hands on experience in the entire continuum of care from conceptualization, design, development, implementation, use, support, maintenance of digital health
05:24
strategies. He has a really strong focus on standard-based interoperability of digital health systems and Stephen will now be presenting the results of the ideation process of the African Innovation Factory team. So Stephen, your
05:40
turn. Thank you very much. Good morning. Good morning. All right. So thank you very much for the kind introduction. So my name is Stephen Wanyi from Kenya and as I've been introduced, I was involved in this process both for Kenya
06:04
and primarily for Tanzania as well. But besides that, I'm really honored and privileged to be presenting on behalf of Kenya, Cameroon and Tanzania. They're very capable presenters and represented from those three countries here. So I'm really grateful that they trust me to represent and speak for them at least for
06:21
this short session before we get the panel session. So I think as soon as you're done, I'll speak for a couple of minutes and then I think we'll have a panel session where we can respond to your questions in greater detail. So generally, the context of this focus for digital health interventions was the
06:43
reproductive maternal child adolescent health within the three countries. And in terms of contextualizing your thinking, think about the continuum of care from the moment a woman determines that she's pregnant until the fifth birthday of her child. So the question then becomes what can digital health or
07:01
e-health do for that entire continuum of care in terms of reducing maternal mortality, child mortality and morbidity? That's really the question that you're grappling with and the Innovation Factory model helped us to think through how can we effectively apply digital health along that entire continuum to reduce maternal and child mortality and morbidity. So just in terms of context. So
07:24
generally, the three concepts were dealing with these challenges. And again, as has been mentioned earlier, there are a couple of similar challenges and also very different challenges in the three countries as expected. But these were the common challenges across the three countries. Definitely limited
07:40
accessibility to quality community and mother-child services. I think that's very common to most of us who work in those types of countries. And then with communication and coordination between and across various levels of the health care system. So basically, the way health care is provided in these three countries, I
08:01
think as you know, is right from the national level to the community level. For example, in countries like Cameroon, the community level is very disengaged from the health facility level. And so there's a very clear disconnect in terms of service delivery between the lowest level, which is community services, and the next level, which is the health facility level. But also in Kenya and Tanzania as well, there is a huge disconnect vertically and horizontally. So
08:23
continuity of care, referral systems, communication between patients and providers, providers and providers are not as effective. Literacy, again, is a big problem. Mothers don't know what to do when they get pregnant. They don't know the immunization schedule. They don't know when to go to the facility. Similarly, health care workers, particularly community health care
08:43
workers, I think as we know, are not formally trained health care workers. So they don't have the requisite skill sets and the competency and capacity to deliver quality health services. So again, there's an issue of literacy, both for the mother, young mother, and also for the health care providers. And lastly, we all know about data. Lots of data, but lots of challenges in
09:02
making good decisions. A lot of decisions, unfortunately, in most African countries are based on authorities. Who are you, not what is the evidence base. So again, that's a big problem that we're trying to deal with, and that's the justification for digital health as an intervention. So again, as was mentioned earlier, this was a rallying call, or clarion
09:20
call, for the three countries that we want to make pregnancy and birth a matter of joy and not death. That really united the three countries, and we'll see later on in the slides, there is an opportunity for collaboration south to south, again, based on this common rallying call. So let's go to Cameroon. So Cameroon, and it will be discussed later on in more detail in the panel, the main challenges around Cameroon were
09:45
delays. Delays by the mother to understand when to best seek care. Delays in terms of reaching the health facility. Again, as I mentioned earlier on, there's a clear gap in terms of services at the community level. So mothers are unable to access health-based facilities, care,
10:03
the health facilities, sorry. And then there's also a delay in terms of once they get to the health facility, how quickly and efficiently they actually receive health care services. So Cameroon dealt with the delays, three delays, and we'll hear later on from Ms. Ani about those delays and how they affected their thinking in terms of
10:21
developing the solution. But in terms of thinking about the solution, then a lot of the emphasis was on communication and collaboration. How do we connect the different parts of the health care service to ensure that the woman who is pregnant actually gets the information she requires to make good decisions, to seek health care in a timely manner? The community
10:42
health worker is well equipped with knowledge, with capacity, with skills to actually deliver health care services. And then, of course, the health facilities are well equipped. They have doctors, adequate trained health care personnel. They have equipment. They're well-manned and things like that. So we're dealing with that continuum of care in terms of connecting the
11:01
health care services based on where those are provided. So the key objectives for Cameroon, basically in terms of using this model for Innovation Factory, while empowering women, again as I mentioned earlier, to make informed decisions in a timely manner, to seek health care services before it's too late. Again, you heard the story of Dorothy. So that was one of
11:21
the objectives for that country. And also to ensure that the women seek antenatal and postnatal care services effectively. We know that WHO recommends at least four antenatal care visits. Now it's going to eight. But we all know that the number of antenatal care visits by women in most countries is way below what's supposed to be. For
11:40
example, like in Kenya, it's less than 60 percent. You know, that's way below. And it's really contributed to why so many women lose children because they deliver at home or they deliver and skills health care workers. So that's a big problem, again, cutting across the three countries. And then, of course, delaying the referral process. We all know about the need for effective continuity of care.
12:02
People migrate for different reasons. And so there has to be a system that supports continuity of care. All right. And then the next level of idea is that Cameroon hopes to or was hoping to improve the availability of quality information, the referral process and, of course, providing better evidence for making decisions. Kenya had sort of three solutions that were integrated. If you look on
12:23
the left-hand side, one of the solutions was trying to encourage or strengthen the cooperation process between health care workers. So this bottom picture here shows a community health worker who's listening to a mother to determine the state of her pregnancy. And above, sort of more, a little bit more sophisticated by a skilled
12:41
health care worker. So cooperation between these two is important. That's at the health facility. This is at the village level. And then there's also the compliance in terms of following protocol for practice. Again, you find there's a skilled, trained nurse and unskilled community health care worker. And thirdly, the third solution was on patient provider communication. So using and
13:03
taking advantage of mobile phones to communicate with the pregnant woman. So these are the objectives in Kenya. We wanted to improve the client satisfaction, so the mother. We also wanted to improve the performance of the health care worker and also improve the surveillance capacity of the health system. So once a woman gets pregnant, she's followed up until pregnancy and until the
13:21
fifth birthday of her born child. We were hoping that through the innovation factory process that it was very unique in terms of discovering, validating and prioritizing the solutions using the collaborative requirements development methodology would come up with innovative ideas. And I think we did that to a large extent. And also utilizing and taking advantage of digital
13:40
health assets like mobile phones that most people have in Kenya. And then also given the interest in interoperability, contributing to the enterprise architecture thinking of the country. And lastly, was Tanzania. So Tanzania is a bit different. Tanzania has fairly mature digital health systems, actually three systems that
14:00
Moa will talk about later on. And this picture shows the first problem, which is fragmentation. So they have three major systems that are implemented in the whole country, but right now they're not well integrated. So each system communicates with the health care worker who's at the bottom here and also communicates with the pregnant mother. And they all try to send it to the National Health Information System. So lots of fragmentation and lots of
14:22
problems because of that purpose. Now their solution was to integrate this using interoperability. And generally what this second picture shows us is using, for example, interoperability framework like Open Health Information Exchange, you're able to integrate data and also interoperate systems in a way that ensures sharing of
14:41
data and continuity of care. So that's basically what the second picture is trying to do. And that's what they're really working hard on with leadership from Ministry of Health. And that's generally, you know, the hoping is going to lead to happier mothers and generally happier health communities. So they have a very well mature mHealth community of practice. And this was the
15:01
objective of Tanzania. Again, basically integrate systems strongly because that's a big problem there. Reduce Pilothitis, sorry, which is everyone coming with different or similar ideas and trying them on the same patients. And then, of course, working very closely with Ministry of Health. And through this, they hope to, you know, aggregate data, use it better and make
15:22
it more available and, through collaboration, solve bigger problems. So we have a bunch of opportunities that this is actually a welcome slide to all of you that might be interested in working with the different countries. We have fairly mature concepts. We have fairly mature implementation plans that we can engage with different
15:41
people who are interested in working in these three countries. So, you know, feel welcome to speak with any of us about that part. Conducive environments, given that we work with governments, all these innovations are led by government, Ministry of Health very strongly. So we're well entered into that system. So we have a fairly, I would say, conducive environments to implement these systems and even more
16:00
systems. Interoperability is a big problem in three countries. So if you're an expert in interoperability and integration of systems, again, I think there's an opportunity to work in the three countries. People who work well in open communities of practice, again, big opportunities there as well. If you're in capacity building for healthcare workers, that's a big challenge also that's ongoing. And then if you're in
16:23
research, implementation science, research and evaluation, again, lots of opportunities to do research and inform practice. And, yeah, this is just a bunch of ideas, but we're also hoping that you can share more with us. Thank you very much. Those are the contacts. Thank you, Stephen, for this great
16:46
presentation. Now that we've heard from three African countries, I would like to introduce to you Mr. Titus Kuhnem, who is the key person for the German country, unique, who, like the other teams, have undergone a similar ideation process. And
17:02
they've come up with a wonderful idea that he will now present. Mr. Kuhnem is director of the Charité Medical University Institute of Computer Assisted Medicine. He's a physician at the German Heart Institute in Berlin. And he is the CEO of a company called eMedical Communications and involved in
17:22
product development project management for digital health solutions. Welcome, Mr. Kuhnem. Thank you for the introduction. And Steve, thanks for the brilliant talk. And I'm just looking for mine now.
17:43
It should be following yours, but it does not. I think we have to change the PowerPoint presentation then. Okay, great. Thank you very
18:36
much. Nearly. I think this is a small room here
19:16
and everybody who has problems seeing the slides,
19:20
there's some space in the front. So I think we take that one. So maybe just to have a short view back, historical view about what this digital health means in the context of international development and humanitarian aid. So if you look at the colonial period, I think the
19:42
focus of these actions in terms of aid and international development were very much on tropical medicine, which evolved then more step by step to international health in the cold and immediate post Cold War area where the family planning aspects like Steven presented that
20:02
already came a little bit more on the screen and the first health services were established. This was then followed by something which I would like to call the Global Health 3.0, where we have more the focus and that's the current time on more global and system diseases like which pop up
20:24
also in these countries we are talking about like tuberculosis, diabetes, HIV. And so we have to have to take account much more complex diseases also than just the tropical disease elements, which I mentioned before. And when we are
20:42
thinking about Global Health 4.0, which becomes reality hopefully soon, we need to tackle things which are much more depending also on technology and linking different institutes together. So a single university or a single health center will be not able to tackle that when
21:01
we are talking about patient participation like in the mobile health area, linking data together. Steven also mentioned that particularly for the Tanzania project to aggregate data into one platform to make really powerful use of that. And that's what we would like to call Global Health 4.0 actually. But let's step back now.
21:24
We have a lot of problems before us, before we can talk about Global Health 4.0. We have large amounts of data, yes, but they remain unused very often. We have a lack of data which we can collect, of course, in the remote areas
21:40
in the cities that works pretty well, but we have something which we call digital device. The more remote things are, the more difficult it becomes to really get high-quality data also. So the quality data must be taken, there must be taken a question mark anyhow always behind it. Is it really helping me? And then we have the lack of
22:00
interoperability. Steven just presented three projects in Cameroon, in Kenya and in Tanzania. Each of this project consists of many other projects. So we have a hugely fragmented landscapes of different solutions. And this is also very important. This is driving costs tremendously. If we are not able to reach a kind
22:23
of critical mass and to homogenize our solutions, we will end up spending a lot of efforts and money into island solutions which might work fine in this particular island, but we will never get the global scope out of that. One
22:41
attempt is a project which I just would like to talk one minute about, where we try to, that's illustrating here the different e-health solutions as a cluster of different hugely fragmented things to bring a little bit order into that mess and to arrange these different health applications in a way
23:01
like, you know, from your iPhone use, app stores where you really can pick those tools you wish to use and those which you are not finding interesting, you are not downloading them or not using them. So we arrange things in a project
23:20
called SATMED. This is a European project in such a way where we have icons and the icons illustrate different ways how you can use the different tools. And the tools means we start with things like, which is interesting for the national level, for instance, where you're
23:40
collecting basic data in the different health centers so that you really know what the prevalence of a disease, what do I need to do to tackle a specific disease, how often is a medication used, what is the treatment applied in a different hospital. So at the registration of the health centers or hospitals, that's the basic information we need to plan aid and to plan a
24:03
health system. If we have not this information available, we can't move ahead, we can't make things better. So that would be the first layer. The second layer is then maybe to rather to go and see how the physician or the patient can benefit from these different things. There are tons of
24:21
applications for radiologists, for cardiologists, for the topic we are talking today about giving birth, child and mother health, all these kind of things. And then the third layer might be even giving skills by education and training programs,
24:41
which we know can be very well done through digital media. So education must not only be performed on the local site. So we have the MOOCs, we have tools like MOOCs where millions of people participate, and they can be, of course, used for medical training, too.
25:01
We have rolled out these projects in different countries, including very difficult countries like Sierra Leone and Benin, Niger and Bangladesh, Eritrea and Philippines. And the global idea of the German Country Unit is to form out of these kind of experience with the new partners from
25:21
Cameroon, Tanzania and Kenya, a kind of common standard to define a standard where we can really share resources. That's also the subtitle of the innovation back stat, sharing ideas and resources and solutions and have a more transnational approach of these ICT solutions for
25:41
health. So which means we have at least a kind of minimum standard of technology and a minimum standard of data that we want to collect. And from there, we can then spread into the communities and into the more rural areas and do have a
26:02
diversity of the applications. But we must have a shared platform which allows us to also share resources, which are sparse. And that's a little bit the idea how this could work. And then we are talking about tools which have already a huge global footprint, like Open MRS with a
26:21
report of more than four million cases per year, Moodle e-learning tool like five million cases per year, so-called digital health information systems with more than three million reported cases and not more new tools like RapidPro or COBOToolbox to unify them in the hospital
26:42
information system environment, combine them in mHealth and aggregate them in the shared data platform. Data analysis, of course, is also very important. We need to make sure that our data has high quality and also the data science aspects become more and more critical. So also here in
27:01
terms of deep learning, machine learning, we have new tools in our hand to pull information about the collected data. And that's basically it. I just had five minutes. I think I used seven at least. Thank you very much. And what has just
27:30
been presented are cool ideas. But they're not just cool. They're really solutions that are close to the heart of the people working at it. The participants of the Innovation Factory are
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all working in that area and they've put a lot of effort into this in order to save the lives of women and babies. They're all unique ideas towards better health systems. They're making use of global experiences and local knowledge and, of course, digital technology. So which leads me to welcoming and presenting to you the panel of
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experts, which is composed by the representatives from each country. And Dr. Kuehne and Stephen, you've already been introduced. Please, please come to the stage. And now it's ladies' time. Madam Achumi and Mariam Leccano. There's one
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more chair we all need. Thank you. So Madam Achumi, she's a midwife and consultant from Cameroon. She's working on maternal and reproductive health. She's working as a consultant and technical advisor to the GIZ. She has also
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been instrumental in, you know, opening the first school's midwives in Cameroon with 450 now that have a license to take care of antenatal and postnatal care services. She's organizing trainings of health workers, furthering her knowledge about partograms and how to take care of women in delivery. We also have
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Mariam Leccano. She's highly experienced in mobile health projects, development, community development projects, project management and e-health. She's currently working as the executive director of the Invention and Technological Ideas Development Organization,
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short ITIDO in Tanzania. She's, however, also the secretary of the mHealth Community of Practice, which is a group of experts and organizations steered by the Ministry of Health that is a platform for technical exchange, coordination and cooperation in the field of digital health in Tanzania. So welcome again to the entire team.
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I would like to start this session with a couple of questions from myself to the teams, but you will also have later on the opportunity to ask your own questions. So my first question goes out to the global level, and that is to Dr Kuehne.
30:00
You've, you know, you've all worked in a really participatory nature on a global challenge through proposing local solutions. The German country unit somewhat goes beyond that level, and I would like to understand a bit more from you what global opportunities you see in strengthening these local solutions that are at stake.
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Thank you. Well, I just tried to convince you in my short talk about how important it is to really have shared solutions. I think if we don't reach a common level, at least a minimum standard, then we are lost simply because the cost will otherwise be too high to really push this
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digitalization through medical application in our target countries. And I think we will miss a huge opportunity to introduce these tools timely. There might be a gap otherwise of 10, maybe 15 years until we come to a second
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opportunity to introduce things like that. And I think digitalization, of course, is not curing patients, but as I said, it's the fundamental on which any health care system must build on. If I do not have any valid data, I can't make health care. If I do not know about what my
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patients are suffering at, I can't plan my health care. If the doctors are not able having access to share expertise, they can't become experts. And all these things can be easily solved by digital tools which already exist. But we need political
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support, that's point one, which might be lacking. And we need also the willingness of the players to really agree on a standard form and kind of format to push things jointly ahead. And that's why I think such a global approach is very
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important to realize the local approaches. Exactly. Great. Yeah. Fully agree with that. Now, going from a global to the local level, what I would like to ask to Madame Achumi, since she's really, you know, hands on in the field, I mean, you heard the story of Dorothea. How would you
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say that, you know, a project like Happy Mothers would change the life of Dorothea and how we've been talking about linking, we've been talking about systems, how does the project integrate within the health system? Thank you. Good morning, everybody. Guten Morgen. And my first language is Bonjour. I think we understand the
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story and we have this story in much country. And we have an integrated solution with smartphone and a platform with three main functions. The first function is better information and home-based care with community health worker. And the second function
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is improve reference process. Reference process is improve communication between community health worker and the staff in the health center. Because here we have the problem of three delay, the time to take a decision to go to the hospital, the time to reach in the hospital and
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the time to the staff of health center to take a decision. And now we have the evidence of data, of base community data are improved to take a good decision. I think that is the different opportunity that we can have with the smartphone,
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the smartphone and the embedded application and also a platform with different civilization of community. Thank you, Madam Achumi. We're talking about the potential benefits that these technologies can bring to the health care
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systems in low middle income countries. And we've heard numerous efforts that are already out there and some might actually even ask, so why do we need, you know, even more projects that are going in that area? Well, you know, integration and scaling up is yet to take place in many parts. So a question that goes out to
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Tanzania would be, you know, how is the innovation factory and the project that you've been developing different from what has been done before? And, you know, how you're over trying to overcome this challenge? Okay. May I greet you in Swahili. Thank you. In Tanzania
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we had a lot of mHealth and eHealth projects already, but the problem we are trying to solve is repetitive of those projects. And the problem is all these projects are just being implemented in the richer places. Those places which are hard to deal with, projects are
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not going there. So our innovation was to help the Ministry of Health to make all these projects be integrated and to have a system which will guide all the project implementers to know what to do and where to do. There is no need of repeating the same kind of project, the
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same kind of solution in the same area. And that's a problem we have. We might find projects that have been done in the same areas many times, three times, four times, and different results. Ministry need data, but data should be from all the country, not just a few areas in Tanzania. So we as implementers, we thought that it could be better if the
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Ministry of Health will help us to coordinate all the projects in Tanzania so that they can be implemented in the areas where we are not being reached to the standard of the Ministry, not to our standards. So because at the end, the Ministry is the one which needs data, the Ministry is the one which needs improvement of
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the people, the Ministry is the one which needs good results, not ours. We are just partners to the health. So our aim was to change all that habit we have in the implementation process. We wanted to reach other areas which were not reached, but with coordination of the Ministry of Health.
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Thank you, Maui. I think we've really seen, you know, a lot of people are approaching this, but also where the commonalities are. So this is the question that now goes out to Stephen. You know, we've talked about the individual context, but there are also a lot of commonalities and, you know, there's both in the challenges that we
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are encountering, but also in the solutions that are being developed. So which commonalities do you see and what do you see an advantage of, you know, working together on these challenges? Thank you. I think for me, I see this, I would say, in four words, which are all starting to see. So I think the first one is
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communication, collaboration, coordination and continuity of care, in the sense that I think if you look at the fundamental challenges that we're all facing across the four countries, well, I guess the three countries, majorly, the underlying factor really is just really lack of
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systems that promote continuity of care and which are powered by interoperability that is based on standards. I don't think we're going to stop the proliferation of systems, which are very different from each other. I think the fundamental thing we need to focus on is how do we support continuity of care using standards-based interoperability and that's really what you're focused on a lot
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and I'd say that's really the opportunity for us here. Great. Cool. Okay, so, you know, a question that really also goes out to the panel. Where have you seen the advantage of not working as an individual organization on the ideation process but actually working as a
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team, working within your country but also across the countries and it's a question that goes out to all of you. I think the first one for me is learning from each other and that also uses the resources very wisely. Then I think
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I would say there's also a very growing, rapidly growing, I would say, trend where there's a growing need for digital global goods, common goods as they're called, so that, you know, reuse and improve rather than reinvent and recreate. Thank you. I think that this project
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is welcome in the health system in my country because health care's work responds better to community need. That is the first problem and the second is that community health worker is well integrated in the system and the policymaker can take a good decision because the data is okay. And the serious problem that we have in
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the country is that community health worker is not a formal level. When it's not a formal level, it's not very well integrated and we want that the project support the government that we take community health worker like a formal level in the system. Thank you. To my side, this
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Working Together group, we learned that in some issues, we have advanced, others have not. So there is a lesson learned from one country to another, which can improve our health systems but can help to solve the problem we have. There is no need of falling in the same pit while others have already fallen and they know
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the way out. So if Cameroon has not yet reached that level, they can learn from maybe Tanzania and we can learn from Germany and other countries. There is no need of repeating the same mistakes while others has already saved it. Do you also want to add on that? I just can say I
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totally agree and I think the problems are not the same but they are similar enough that we can form a joint voice to awaken a little bit the policymakers to support these kind of projects in the future a little bit better than they did in the past. Okay, great. Thank you for your ideas on this. So, you know, we've talked about
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that we need political support. We've talked about that we need minimum standards for, you know, building strong local solutions. We need to look at the systemic solutions that look at all the levels of the health system and also especially at community health that has been affected in certain areas. We need to look at the integration
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of system rather than repeating solutions. We need to look at, I think you've summarized it very well with your four Cs, communication, coordination, collaboration and continuity of care and in that also in creating a learning environment and, you know, really sharing ideas. We too often, I
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think, sit in our own little, you know, nutshell and think without sharing ideas and I think that really that sharing ideas can lead to a lot of, you know, enhanced effort like we've seen here. So now I think I really would like to, you know, give you the opportunity to also ask questions to
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our experts who has a question. And so, yes, please. Thank you very much for the brilliant presentation. I'm Dr. Denis Amer from Cameroon. Of course, I'm
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happy to see Madame Ani. So my concern is about this integration with the community. I think Ani rightly said it, that, you know, our community participation in health is not formal, has not been formalized. I've been doing benevolent work. And
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you know, when somebody is doing benevolent work, you always call the community, community participation. Come and do this for health. Come and sensitize the women to come to the hospital. But they have to move to the health facility. They have to spend their time. And that one, the government has just been talking about community participation, but not thinking about the
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motivation. I'm so happy that now we're having this PBF, which is performance-based financing, which started by saying that, OK, now we have more than 60 percent of deliveries done in our health facilities, meaning that more than 40 percent are still carried out in the community. And so all
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these traditional birth attendants, now what are they doing to motivate them to know that they can identify the risk factors and bring these patients to the hospital or these women? Delivery is a natural process, but complication starts, comes, and that is when we have the mortality. And I think with
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this idea of integrating, I mean, the community with the health facilities, that will be great enough to see that we can really minimize this mortality or these challenges. Thank you. Thank you. I think what you just brought up is a really important issue, and that is the involvement of national
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stakeholders in the development of such ideas. And I think that's something that has been key in each of the countries. I mean, we've worked in teams where, you know, the Ministry of Health was also in the steering. So eventually all the ideas that have been developed and are being developed there, they're already in that sense integrated and addressed at
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this level. And like in the case of Cameroon, I think the way the idea has been structured is actually through, you know, this project, you will also be able to very much inform policymakers of the needs that you were talking about, the needs to, you know, really formalize the system, really give community health workers, you know,
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not only a role but, you know, a formalized role in the system. I don't know if any of you would like to add to that. Thank you. I agree. Welcome. I'm happy to see you. But the problem that we have, again, is the problem of traditional heirloom. You know that traditional heirloom and birth attendants, they give
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more service, and it's not expensive that hospital. But the second problem is that some services in hospitals are more expensive. And we have a serious problem in our country is the problem of midwife. Know that there is no midwife. It's not a long time that the school of midwife is open. And it's open since
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and close. And we begin the new open in 2012, I think. And we have the first coma, and the two other coma are not integrating the system. And that is the serious problem that if we want to work with the community, it's good to have provider. It's good to have a midwife
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to work with them. And I think that before I come here, I supervise the prototypes in first in one region, in one region with a happy mother. And we have a delegate. You know what we say? Delegate is a chief in the one region of health who thought that she wanted the level of community be formal in the
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minister. If it's formal, it is good. I want to support it. Yeah. So let's hope that, you know, the way projects are structured, that can all also happen. More questions from the floor. Where's the microphone? Yeah. Okay, sure. Thank you.
45:43
Good morning. How about the subway? Yeah, I have one comment and then the question in the last. I'm just giving you an early, early evidence of what has been talked about, the learning from each other, the lead sage. We used to have a, no, we used,
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we are still going on the cooperation between, we have the Hamburg and the charity, together with Bela Tanga, regional hostel, along as we see Kamerlone, Bamenda, in northern part of Kamerlone. So this is the point that we, we need
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now, because in Hamburg when they believe in the RCR, high advanced, but Kamerlone and Tanzania, they look like similar, they share challenges. So what they, we made it is a south collaboration. And now what we came in, we, in Kamerlone we found
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that they are doing better. So, and in support of the ESTA project, we are supported to Tanga hostel to go to Bamenda. We then, so they have a good off functioning unit, so-called customer care. So we wanted to learn. When we went and learned, now we are doing fantastic at Tanga, even more
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than Kamerlone, I can say, so sorry for saying so. So we're doing even better. So this, this learning from each other is better and a very strong tool that we can make up. So when we are coming up with a dicta word, so learning of the situation, our colleagues from Kenya can come look now, as
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Stephen said, we are doing better in some extent than a mother and child, they have a communication. This is a good tool. But now coming up, of course we have, we are now having more opportunity than before. My friend from the charity, we had a tool was supported, technically supported by the charity
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called Hoster Performance Self-Assessment Tool. Now the problem is sustainability. The sustainability is the challenge now. Well, now this year, the joint venture was almost over. Another project came in and supporter, they're having implementers in the
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country, like Everplan, now they are there, and now they are out. They came, now we have an option, option UK. So the Everplan, they haven't, they came with another, also another tool, focusing on the mother and child. In short time, now Everplan came, went out, option came in with another
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approach. This is now the challenge. Now the question is, are you loving out loud, wonderful, really wonderful motto of the year. So are you looking at, in this digital world, is it coming out in your mind, did it come in your mind, the
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issue of sustainability? Just very briefly, I think really great thanks for this input. I think this is a key challenge that we are all facing, and that is that continuous fluctuation within development, cooperation of different partners, different approaches, you know, and not talking to
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each other, not trying to really ensure that sustainability. So I think this is a call that really goes out to, you know, all the ministries that goes out to all the organizations that are supporting. But I think it's also a question, an issue that is trying to be addressed, at least in Tanzania, through the community of practice and
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others. So maybe Maui can also a bit add to that. Yeah, what he's saying is true. I'm part of implementing organization, and in our community, we are more than seven community organizations implementing AMP Health. We saw the same problem, that today I have found from GIZ, I'm
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implementing AMP Health. Another one came in the same area with a search kind of project, slightly different, with another approach at the same place. Mine has not yet been adopted by the government. The other one comes not yet adopted. No sustainability, no scalability, it scales. So
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we as community decided to have this kind of project that we need to push the government to set standards for all the projects we want to do in Tanzania, so that it can be easy for the government to adopt them when the funds goes out. If we want to collect data for DHIS, my project
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should be at the same standard with the others project. So when I came, I do A, B, C. When somebody else came, should do E, F, G, and the other one should continue there, so that things can be scalable and can be adopted by the government, not the way we are now in Tanzania. Everyone
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comes at the same place with the same kind of project, but slightly changed. Which is probably why you know that the importance of what Dr. Quine was presenting is, you know, here. The problem remains, you and Tanzania are doing it different than your colleagues in Cameroon, and then we still have the fragmentation on a larger scale. So I rather, I
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mean, that's a first great step, and I'm really happy to see that the Tanzanian government is taking a little bit of responsibility, at least. But I think we should even push harder and further to a kind of Agenda 2030, where we really force all the players to accept the common standard, and if this is not, and to have also a long-term plan, how to homogenize it.
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And otherwise, we will end up with the same what we have. It's a little bit, yeah, some things work, some other will not work, and this is a pity because our resources are obviously endless, not endless.
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I was going to add that I think if some of you have not seen this, there is nine principles for digital development, if you have time to look them up, and they've really been formed out of these sorts of experiences, and I think they're really good collective principles that bind us, that I think should actually lead us to forming a code of conduct, both as
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development partners and also as implementers, to also support government to implement these, these are really governance issues. Great. And I think since you're saying that for the Tanzanian team, you know, I'm sure you're welcome both to the community of practice and also, of course, to the Innovation Factor team to contribute with your ideas and the lessons that you've learned in your project, and
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also to welcome you to, I think there's a, there will be a presentation by, is it the Development Innovation Fund in Tanzania on exactly those principles of development, those upcoming, so do get in touch with the team, and I'm sure that, yeah, that's a good start. Yes, please, over there.
52:40
Micro, please, thank you. Yeah, okay. So, just a quick comment to what was just said about the need to push governments or like an
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anecdote, because it's not only governments that help with this fragmentation, you all mentioned it before, but when I was in South Africa, there was this incident of, actually GIZ and KFW accidentally basically proposing a very similar project, and the South African government then asking back, like, guys, are you talking?
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And they lived, they had their offices on the same complex, so it's happening everywhere. Bread for the world is also not that good in that, so it's a problem that also the development agencies and NGOs have to take to their heart, because the short end of the stick is with the executing partners and the
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beneficiaries. But what I actually wanted to ask is, first of all, Mr. Kooner mentioned the political support that is needed, and I was wondering if, because two countries presented here, Kenya and Tanzania, you are in the East African Union, and I was wondering if something is happening
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there in that sense, if there's any energy there between, I think that also includes Rwanda, I'm not so sure, if there's any energy there, and the second question basically to all the panel, because we're talking about mHealth here, not eHealth, as I saw, so I was wondering,
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is there an experience with, well, on the technical level, the most robust and best accepted technical features you're using? Are you relying more on SMS for feature phones, or is it more advanced tools you use?
54:42
Okay, two questions, Stephen. Okay, so I can start with the one about the regional sort of governance. There's the East African community, I think, as most of you might be aware, but I think I would say practically, in terms of just real functionality, nothing much is going on across the countries. There is, within the East African community, there is a sort of section, I think right
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now it's under Rwanda, for eHealth coordination across the six countries in the East Africa community, but I would say country to country, cross-border, isn't as strong, but I think it's evolving towards that point, yeah. Thank you, I think in my country, EF is new. We have gifted month. Gifted month is a project we make like EF that
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begins around one year. We have to try to work together to see how to implement EF in the country, but we have much barrier like electricity shortage, access to electricity, the problem of road is not easy, but we think that it can support provider to make the sensitization and
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education in the community. Thank you. I think I would like to, that last question that you talked about, about mHealth, eHealth, what are the technical solutions that are out there that are already working and successful? I think I would like to pass that question to Lucy because I think that's what their project is also about, looking at what
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projects are successful and how to integrate them. Yeah, in Tanzania, we have two sections. We have eHealth and mHealth. eHealth is much bigger and mHealth is a small branch. mHealth is not only about SMS. We have some more advanced. We have protocol for checking kids, their
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health activities. We call it, the name has just got out of my hand. Steve can help me if he remembers. So we have more than SMSs. We have other protocols which are helping women and under five. We advance that a lot.
56:41
Concerning the first question she asked about collaboration, it's much of political, I can say that, and big guys in the government. But in the real sense, not yet things have been done that way they are spoken. We don't have a collaboration in health issues between Kenya, Tanzania, Rwanda,
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wherever it is in East Africa. Each country has its own stand, its own standard and its own policies. So we are not here to collaborate. Thank you. We only have a few minutes left here. I think what has really, you know, there's a lot of things that have come out and there's a wealth of experiences out there.
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So I think the first lesson is really, you know, getting together, really sharing the experience that there is out there. I know, for example, Tanzania, they've done a mapping of all the projects that are there. Is it 120 or something that is there? So there is a wealth of experience. Get out there, ask for it. Get connected. The names of the participants were on the
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last slide. Please just come forward. I think the other thing that we've really learned is the issue of it's a call for long term thinking, for sustainability, for global standardization and for, you know, using that for localized context, for looking at those principles of digital development that are out there and, you know, really having a code of
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conduct yourself. I would like to pass on the microphone for a very quick, before wrapping up, to Anna. Just say, you know, last word. Yeah. Thank you. I'm Anna Teich, advisor in the Innovation Factory. No? Yeah, it's on? Oh, okay. And I'd just like to say thank you on behalf of
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BMZ, of the Ministry of Economic Cooperation and Development and of GAZ for all the efforts that the health experts and IT experts sitting here as representatives of all the other people
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in your countries, in your institutions and networks and, yeah, that you really pushed forward the connectivity between the initiatives that are there already and to help to combine
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and link between the different levels really from the bottom up, from the mothers and the children up to the government, to the policymakers and all people in between the medical staff and everyone who is important. And, yeah, I'd just like to express my
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appreciation and I hope that the concepts and the innovations will thrive and I hope also that there are some contacts to have afterwards and, yeah. I'm glad to see you.