Next Steps and Future Directions

Having begun this course expecting to hear about technologies being developed “for” development (as opposed to “with”, “in” or “and”), it’s exciting to see so much careful reflection about the most appropriate and sustainable ways to approach the ICTD field. The enthusiasm and creativity being fostered by Tap and colleagues is really inspiring and hopeful. I appreciate the opportunity to have met and talked with some brilliant, dedicated fellow students working on the frontiers of technology applications in underserved communities.

Specifically, I’m interested in strengthening contacts and collaborations between the iSchool and the School of Public Health to promote multidisciplinary approaches to improving the efficiency and effectiveness of public health in the developing world. A co-listed seminar in “eHealth for a global context” or something like that would be a great start – a curriculum that I’d love to part of developing.

For a next go at this seminar, I would suggest forming topic area/field specific interest groups early in the semester (health, education, agriculture, finance for example) and dedicating ½ hour of each seminar session to those groups meeting and discussing relevant current events or a particular article. This may help to bring together people from the various disciplines represented around those interest areas – forming interdisciplinary teams. Another suggestion is to include interest area review or summary papers as orienting references. Again, this could help to orient students to what’s out there in their interest area (health, agriculture, etc.) but also to identify relevant publications, journals, and communities to be tuned into.

10.28 The Challenge and the Hope: User Involvement in ICTs in Rural Gujarat and Mexico

I was really impressed with Neil’s work. He emphasized and articulated the importance of the context, the background research and ground-truthing of the ideas so well. Both Neil and Yael’s research includes increasing accountability, transparency, local ownership and empowerment through use of ICTs in the resepcive context. Looking forward to following these projects as they evolve.

10.21 Commcare and Bodas for Life

Two of the three presentations today highlighted the importance of Community Health Workers (CHWs) in health care delivery in the developing world. For me, this is one of the most interesting areas of ICT or eHealth – when communication tools and information management systems can essentially multiply the efficiency and/or effectiveness of non-clinical health care and public health support services.

Brian’s experience with the different CHW models is a key one to focus on. So much of what he found in terms of how useful the mobile tools were had to do with the structure and functional roles of the CHW network in each of the 3 organizations. Where the organization was committed to CHWs serving their clinets/patients in a support capacity, the data entry tools reduced the time they required to collect/record information and increased the time those CHWs could spend providing more/higher quality interactions with the people they were there to help. Where the organization was more interested in data collection and surveillance, the CHW’s were perhaps more efficient at that task, although that didn’t necessarily translate into more or better services being provided for the patients/clients. This seems much more an issue of the underlying organizational culture and context for the CHW work than an issue with the mobile health ICT project/tool itself. I appreciate that Brian made that clear, albeit very respectfully!

In the Boda’s for Life project I loved that there was really no rocket science involved in leveraging an existing network and service (taxi motos) and pairing that with a communication and alert system. In this case, as in the CommCare project, mHealth implementation offers a whole range of potential opportunities for increasing the skills that CHWs already have and, by design, the services that they can provide. Likewise the fact that this model was designed form the beginning to be a sustainable social enterprise model is really important. This is so often missing form the donor-supported “dependency” models that have been at work for so long. One of the most exciting elements of this project was the focus on regional scalability of the pilot as the next step. Way to go beyond pilots!

Finally, to see these projects’ themselves motivating more interest in capacity building and training among CHWs is great. CHWs and non-physician services are enormously important in increasing access to health care services and the fact that ICT and eHealth tools are largely being targeted at this part of the picture is exciting.

10.7 CommScape

It was great to hear from Kuang about his process for identifying where he might best fit into this landscape of ICTD work. Listening, learning, understanding cultural contexts for various existing information and communication technology “problems” is such a critical part of successful ICTD design and implementation – I only wish it was a more codified “step” in the institutional and academic approach to technology R&D.

The challenges inherent in data management are enormous when it comes to public health information anywhere in the world, especially in extremely limited resource settings. Kuang’s optimism that community based participatory research approaches to solving these problems is possible was refreshing. Glad to see that Tap’s influence (and others in the field) is rubbing off! Really excited to see what the next steps with CommScape are (or whatever that may morph into).

9.23 Telemedicine and Franchising

This was another example of an approach to increasing access to diagnostic and clinical services in underserved areas in the developing world. The model of using a commercial relationship to leverage both demand and supply of a health service sits fine with me, but to then extend the individual benefits to the service provider and service user to a greater social benefit on any appreciable scale seems a far stretch to me when related to family planning services in this example. I appreciate the fact that the idea here is to increase individual access to family planning services in a setting where individualized care delivery is being promoted, especially in India where there is a complex history of controversies over various kinds of family planning interventions at the population level. I’m not convinced however, that this particular model is realistic in it’s market niche in this case.  The costs of the initial investment for the franchise owners and primary clients (young women in both cases here) seem very high. Likewise, there are tons of externalities beyond just the logistics and costs of setting up an ICT intervention of this scale.

The article that accompanied Terri’s presentation highlights 3 key areas in the conceptual framework of telemedicine that this kind of ICT enterprise model should address: assuring the availability of services, assuring the quality of services, and assuring use. This pilot project’s results have not convinced me (so far) that these are being met. Although an interesting approach to a really important problem – access to quality care at affordable prices in rural areas – I’d be interested in seeing how/if this is scalable and what the actual family planning/population health level indicators show about impact on targeted outcomes so far.

9.9 Establishing Relationships

I was really excited and inspired to hear about Tap’s approach to field work and involvement with ICTD issues. There are centuries of oppression and absurdity involved with technology solutions to “development” problems. The fields of health and agriculture and finance have been particularly bad of applying paternalistic approaches to solving the problems OF under-served communities FOR under-served communities in the past. Tap’s approach to technology development and application in his own work and those of his students and colleagues is refreshing to hear about, and in my opinion really important to internalize.

Building trust and rapport is so critical to successful research, but of course, caring about the longer-term effects of those relationships is equally important. Being a good listener, thinking through sustainability from the beginning, addressing real (not imagined) problems, taking the time and making an effort to understand the cultural/political/social/economic context in which you’re working – this is what is hopefully going to help make the next generation of “practitioners” of development more effective than those that have come before us.

One point that Tap raised that is unique to some of the ICTD world is how to measure and evaluate the effectiveness of technology solutions across many axes when resources may be so limited to invest in “high value” interventions (in Public Health parlance) – usability, efficiency, cost-effectiveness, and the longer-term issues with potential changes in infrastructure changes. This is the skill-set that I’m most interested in developing further: impact evaluation strategies to help inform ICT and eHealth solutions to priority global health problems. How do we dynamically evaluate how well something is working and how to make it better (or decide to go with another kind of ICT solution, or none at all) when there are so many externalities to ICT solutions being successful?

9.2 ICT for Global Health

Neal Lesh presented a much-appreciated perspective on ICT for health in limited resource settings. I met Neal in June and have had several chances to hear his grounded, well informed voice-of-reason about the potential (and potential pitfalls) of focusing on ICT solutions to global health problems. “Computer and ICT innovation CAN help address efficiency, cost-effectiveness and quality of care, but let’s make sure we’re improving health as we develop tools to help do this” is a paraphrasing of one major point he shared. I think this is a really critical point to focus on. ICTs and “eHealth” have been shown to have some really interesting potential when implemented in appropriate and sustainable ways — but we’re still very early in the process of understanding how pilot projects (the majority of what’s out there) can be scaled effectively to have public health-level impacts. It’s hard to balance fostering ingenuity, innovation and creativity in ICT tool/system design with keeping the focus on targeted population health outcomes.

Neal also did a great job of pointing out that different kinds of ICT and eHealth solutions may need different kinds of business/funding models. For me, in the Public Health field, it becomes really important to then identify which support structures are appropriate for which phases of ICT development and implementation — design, piloting, implementation, monitoring and evaluation, and long term system/tool maitenance and adaptation as needed. Local capacity building for all of these phases is key to long term sustainability on the developer end of things, but ALSO on the implementer end. Health care service providers (doctors, nurses, health care facilty managers, community health workers), health advocates, policy makers, the public and private sectors, researchers and academicians, and of course patients should also be brought into the conversation about appropriate ICT for health solutions.

I’m looking forward to hearing more about how to address some of the most critical issues of knowledge sharing and transfer, sustainable support models for in-country management of ICT and eHealth systems, etc.