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In Zambia, roughly 13.5% of the population is estimated to have HIV/AIDS, while the number of children (ages 0-14) with the disease is estimated to be 120,000. Programme Mwana uses SMS technology to send lab results between community health clinics and diagnostic labs to improve the process of early infant diagnosis across the country.

Launched in 2010 through a partnership with UNICEF Innovation, the Zambian Ministry of Health, Boston Univeristy, CHAI, and the local UNICEF office, Programme Mwana was designed to be a scalable system to help with infant health interventions, allowing HIV/AIDS results to be sent securely from labs to district clinics. The project was launched simultaneously in Malawi. Merrick Schaefer, who led the development of the project with UNICEF, says that the group focused on participatory design to develop agile, adaptable software that meets the needs of community health workers.

Creating Buy-In, Cultivating Sustainability, and Protecting Privacy

Schaefer says that Programme Mwana focused on the community since its beginning. He explains, "We were trying to design a system that would scale from the get-go. And we looked around at what everyone else had done and what we had previously done and the mistakes we'd made and the pitfalls. We knew we were looking for a system that would work under the harshest constraints in the hardest-to-reach areas that would not cost a lot to operate and run, but still have a large health impact."

Programme Mwana's SMS systems, called Results160 and RemindMi, are built on RapidSMS, an open-source framework for designing SMS-based projects. While Schaefer said that the organization considered using Android/JAVA solutions, SMS was ultimately their best choice for creating an affordable, scalable system.

When results from a test are ready, clinic workers get an SMS saying that the results are available. Workers respond to the message with a personal passcode, and then receive the results via another text with the patient only identified as an anonymized number. Community health workers use their own phones, so Programme Mwana doesn't have to buy phones for participants (which they may have had to do in order to use higher-end features like data transfers), and the text messages are bought bulk at a reduced rate through partnerships with telecoms, with no charges to the health workers.

Programme Mwana operates under the Zambian Ministry of Health, and was developed with local software developers so that there will be on-going, in-country support. Schaefer says that although working with many partners made the initial development process slower, it has ultimately been a boon as the government support helped create buy-in among participants. Also, they found that building the system within national health regulations made the scaling process simpler than if they had built it independently. He says, "The vision was not so much that UNICEF would come in and do this project, but that UNICEF would work with whoever was already in that area. [...] Ultimately, the government had ownership of it and participated the whole way. When it came time to scale, we didn't have to go to the government and say, 'Here's the solution you should be implementing,' it was rather '[Here's] the solution we've been building with you the whole time.'"

The Zambian pilot sites were chosen by the HIV and Nutrition groups in UNICEF as some of the highest-need clinics in the hardest-to-reach areas, so the system was designed to work under harsh conditions. Results160 stores messages when phones are outside of network coverage so that workers can access it even when not in service. In Zambia, Programme Mwana is now used in 61 clinics, and in Malawi it is used in 44 clinics (the Malawian project launched six months after the Zambian pilot began). The goal is to have 250 clinics using Programme Mwana by the end of the year, and complete coverage of Zambia in three years.

Schaefer says that privacy and accountability were huge concerns while developing Results160. All the data coming in and out of the phones is anonymized via a lab requisition number. Results are not sent directly – health workers get a notification that the results are ready and then enter their passcode to obtain the results. After getting the results, workers receive a reminder to delete the message. Finally, results are sent for all mothers covered by health clinics that use Programme Mwana, not just HIV-positive mothers, so being associated with the system does not incur stigma in the community.

Programme Mwana's costs are divided among partners, but UNICEF covered most of the initial development costs. Now that it's moving to scale, the Ministry asks partners to cover the costs of training in the areas they work in, while the Ministry pays to maintain the tool (the servers are hosted by the Zambian Ministry of Health).

Results from an early evaluation of the Programme Mwana pilot in Zambia found that the turnaround time from when community health workers collected data to when lab facilities received it was 57% faster when using SMS. The study also found that the turnaround time between sample collection and delivery to caregivers was 56% faster than the pre-SMS system. Designing with end users in mind and ensuring that there is buy-in from local developers, the government, and beneficiaries are key to creating a successful mobile tool. Programme Mwana is an example of how designing in-country and building partnerships helps create sustainable, scalable mobile projects.  

(Image via Programme Mwana Posterous Blog)