Project Spotlight: ORB & Open Deliver: Digital Educational Content for Health Workers and Communities July 25-29

By Joaquin Blaya, PhD Moderator | 21 Jul, 2016

Hi everyone,
We’re continuing with our Project Spotlights and next week (July 25-29) we’re going to have the group that has created Open Deliver for providing educational content to frontline health workers.

Open Deliver is a process for creating, adapting, and delivering digital content. This process can be institutionalized by governments for leveraging the rapid growth of mobile device availability for training frontline health workers (FHWs) at a national scale.

Open Deliver promotes re-use of content and the technology used for content delivery by centralizing operations on a single platform. This approach promotes collaboration among program representatives avoiding duplication of content and technology for each new program. The Open Deliver process also enables Governments to react very quickly to emergency health crisis such as Ebola allowing them to publish relevant materials to mobile devices in days rather than months.

It combines existing, open source technologies into a single production process. These technologies include: ORB, mPowering’s platform for sharing mobile training content; Moodle, a learning management system for course creation; and OppiaMobile, a mobile app for delivery of course content.

We’re lucky to have 4 key members of the team from different countries.

Mike Bailey is the Senior Country Advisor for the mPowering Frontline Health Workers Partnership.   Mike has over 20 years of experience as a systems development and program manager and was awarded the Distinguished Service Award by the American Public Health Association’s International Health Section.

Okey Okuzu is a healthcare visionary and serial entrepreneur who identifying ways of improving healthcare delivery to underserved markets and populations using emerging technologies. He founded InStrat Global Health Solutions in 2010 to focus on Global Health Innovation by identifying and deploying technology based healthcare solutions to underserved markets using SMS and 3G wireless technologies. 

Laila Hussain is a social and behavior change communication (SBCC) specialist who has worked with rural communities across Pakistan. She has in depth experience in the design and implementation of community based programs ranging from maternal and child health to education and disaster risk management. Laila is passionate about engaging with hard to reach and underserved communities, using SBCC to increase knowledge and awareness, and motivating people to find effective and sustainable solutions to the issues they face.

Huguette Diakabana is a Program/Project Manager for eHealth Africa. She also oversees partner relations at eHealth's Guinea office. Huguette is passionate about applying affordable and sustainable technology based solutions to development issues, especially public health and capacity building. She has over 10 years of field experience, in both private and humanitarian organizations.

I’m also including two documents describing Open Deliver and an evaluation of it in Nigeria.

Replies

 

Lisa Susser Replied at 4:00 PM, 21 Jul 2016

This project spotlight was appreciated and the supporting resources informative.
Keep up the good work.
Thank you.

A/Prof. Terry HANNAN Moderator Replied at 5:02 PM, 21 Jul 2016

Thanks Joaquin and panellists. I am looking forward to this discussion and what it can reveal.

Joaquin Blaya, PhD Moderator Replied at 7:12 AM, 25 Jul 2016

Hi everyone,
We wanted to open this project spotlight for questions and comments.

I wanted to start by asking where open deliver had been implemented and what the size of the implementations where?

Dhafer Ben Amor Replied at 7:23 AM, 25 Jul 2016

Thanks Joaquin.

Nighat Khan Replied at 7:55 AM, 25 Jul 2016

For something I so passionately believe in, I am looking forward to the discussion.
Familiar names are very comforting.

Nighat Khan
Global Health Academy
University of Edinburgh

Mike Bailey Replied at 10:49 AM, 25 Jul 2016

Thanks Joaquin! I have tried to summarize each deployment below but I want to stress we will be focusing on the three places where we have representation on this panel:

1. In the Nigerian State of Ondo where all of the elements of Open Deliver (the Learning Management System, ORB the content resource library and OppiaMobile the android based app) have been deployed and are in the process of being institutionalized;
2. In the Sindh Province in Pakistan where a pilot project using OppiaMobile and Moodle are underway and a collaboration initiative among all content providers and other stakeholders has been initiated to share the technology;
3. In Guinea where an existing generic curriculum for health worker training is in the process of being translated and adapted for use in Guinea with discussions underway as to how to support and implement the entire Open Deliver process for all the FHWs there.

Although each is at a different stage of adoption we are working towards the same overall goal of Government institutionalization of the entire Open Deliver process.

Details for each and information about other deployments are below (as well as an attachment explaining the deployment in Ethiopia).

In Guinea a curriculum developed for Ethiopia as been re-engineered as a generic curriculum and taken up by eHealth Africa and localized for use by the health workforce there. Our vision is to optimize that curriculum for use on mobile devices to provide the community health workers there with a reliable source of validated content. Given the countries present circumstances it is unrealistic to expect face to face trainings to take place on a scale that will meet every worker’s educational requirements. Huguette Diakabana is on the panel to discuss the vision we have for Guinea and the challenges that remain there.

In Ondo State mPowering, is working with the Ondo State Primary Health Management Board, InStrat, and Medical Aid Films to conduct electronic Pre Training Baselines Assessment, Screen video content to 200 FLHW in 20 facilities, and Conduct Electronic Post Training Assessment. 
InStrat will extend content to all 100 facilities in our 6 operating States covering ~ 1,000 FLHWs. Additionally, Ondo State Government already committed to rolling out program to ~550 PHCs in State and introducing format to State Medical School 
Okey Okuzu is available to discuss details about the deployment and there is an attached summary provided as well.


In the Sindh Province in Pakistan a prototype Android-compatible mobile phone application called Roshan Mustaqbil (Bright Future) was developed last year. The prototype incorporates key elements of the IPC toolkit which has been developed for community level health workers and is divided into two sections, mLearning and mCounseling. The ultimate aim of the app is to assist Lady Health Workers in delivering MNCH messages effectively during their counseling sessions using the IPC approach in order to stimulate behavioral activation around these issues.

Within the province it was recognized by many stakeholders that similar efforts were being conducted by other implementing partners potentially contributing to a fragmented mHealth landscape which is so common in so many countries. A collaboration workshop was convened last fall which included IPs, sponsors, private sector representation who all agreed they needed to come together over a single resource represented by the Open Deliver process. Laila Hussain who worked closely on the project is on the panel to discuss some of the challenges and opportunities in the deployment of the technology.

Other Deployments:

Gyan Jyoti in Bihar
The application uses audio-visual content to provide client counseling support and self-learning opportunities to FLW in India. Launched as a prototype in a small community in Bihar, it contains over 30 films ranging from doctor counseling, user testimonials to short entertainment films, Gyan Jyoti is used as a decision support tool to increase uptake of family planning at the community level by increasing awareness, dispelling misconception and addressing client queries during one-on-one counseling sessions. Detailed analytics provide interested parties with an understanding of how the app is being utilized by the health worker in service to the community.

iDEA in Nigiera
In conjunction with The Nigerian Urban Reproductive Health Initiative (NURHI) the Interactive Distance Education Application (iDEA) system for midwives was launched in 4 cities in order to provide a platform from which providers can access relevant educational content and resources from Android based smart phones or tablets. iDEA was developed to supplement existing forms of traditional training while providing a sustainable means for updating content remotely and evaluating usage. (The application is available for free from Google Play from the app section if you search for “NURHI”).

OppiaMobile in Ethiopia
In collaboration with the Tigray Regional Health Bureau and the Dr Tewelede Regional Health Science College, the project aims to use mobile technology to support the training of 160 HEWs currently enrolled at the college. By providing the HEWs with relevant course content loaded on mobile phones, and ensuring targeted support from tutors and project staff, the project expects that these HEWs will have better knowledge and skills upon deployment, resulting in reduced maternal and child mortality in the region.

Maimunat Alex-Adeomi Replied at 12:50 PM, 25 Jul 2016

Great project spotlight on health IT.

I am interested in the ORS platform in Ondo state. Having worked as a health service provider with community health workers in a rural community in Ondo under the State Hospital's Management Board, I am very interested in the evaluation of the current pilot and plans for scale-up.

Mike Bailey Replied at 5:46 PM, 25 Jul 2016

Hi Maimunat

I hope that Okey will be able to offer more information but in the meantime one of the parters on the project - Medical Aid Films - posted a summary on their website:

http://www.medicalaidfilms.org/a-new-partnership-to-transform-health-worker-t...

Mike Bailey Replied at 11:10 PM, 25 Jul 2016

Hi Nighat,

In another discussion forum on this site you pointed out:

"With mobile network penetration increasing at faster pace in LMICs than first world, it is hard to resist the euphoria of its potentials in health sector. Historically many mhealth projects have failed to scale up barring a few. We must carefully think plan and implement our projects. In order to do so we have to study and study hard the reasons for failure. As money is tight and failure shouldn't be an option."

Absolutely! One way to help ensure investments are properly made in mHealth is through the application of the Principles of Digital Development during program planning and implementation. On the site: http://digitalprinciples.org/ you can see each principle and what each represents for mHealth implementation:

"The Principles for Digital Development are “living” guidelines that can help development practitioners integrate established best practices into technology-enabled programs. They are written by and for international development donors, multilateral organizations, and implementing partners, and they are freely available for use by all."

We believe that the Open Deliver process represents a physical manifestation of these principles and represents a low cost sustainable digital content distribution for health workers everywhere. The design of the process avoids these failures by creating a collaborative resource in ORB that allows for centralized distribution process to prevent fragmentation and duplication by accepting validated content from any contributor. This process allows distribution to smartphones and tablets - requiring only a one time transfer of content to devices which can access all content while offline avoiding costly connectivity charges.

Details about how Open Deliver represents the Principles of Digital Development are attached - offering a path to successful, sustainable implementations.

Thanks for your contribution Nighat.

Attached resource:

Okey Okuzu Replied at 12:35 AM, 26 Jul 2016

Hello Maimunat

Many thanks for your question. Our project consortium engaged the services of an external consulting firm to conduct the project M&E. The evaluation involved Primary Research with facility based and ministry based clients and users; baseline knowledge assessment involving all 180 staff involved in the training; and an end line assessment to measure the improved Knowledge (or more technically - Recall - given the three month duration of the pilot). Interim assessments conducted at the mid point to impressive resonance with the facility staff and the administrators. Our final project evaluation will be ready at the end of August 2016.

We are in current discussions to scale this training platform across all Primary Health Centers in the State. The scaling will ride on the back of a commitment made by the State Government to scale another project across the State. That program will provide the required hardware - tablet computers - and associated data plans that will allow us to deliver the training. We are also exploring several ideas to develop additional content to allow the State to deploy a robust offering of locally developed training content.

debs thompson Replied at 9:15 AM, 26 Jul 2016

Hi Mike,
I am interested in this discussion from 2 different angles. Firstly, I am part of a charity called Peoples-uni (www.peoples-uni.org) that provide masters level courses on public health. We have a range of different learning models - self-directed OOCs through to asynchronous discussions and communities of practice. It will be interesting to work with government departments to look at using a centralised Open Deliver platform to increase availability of our course content.

My other interest is related to the UK, where I am looking at workforce development - I'm keen to understand more about Open Deliver as a platform for one centralised point. What I am not clear about is - Is Open Deliver a process? Can I check what platform/provider supports this?
Debs

Roshani Kothari Replied at 9:38 AM, 26 Jul 2016

Hello everyone,
Hope you all are doing well! Just wanted to share this mHealth
Success Story [1] we posted about our work in Malawi.  Let us know
if you have any questions or are interested in collaborating with us
around mHealth.

Thank you.

Roshani
--Roshani KothariCommunications & Development Director
US:  +1.202.384.6852skype: roshanikothari

  [2] [3] [4]    



Links:
------
[1]
http://www.d-tree.org/success-story-tella-matias-uses-mobile-app-save-lives-m...
[2]
http://f626-pnbs.accessdomain.com/HTTPS://DTREE.NUBAY.NET/SITES/ALL/MODULES/C...
[3]
http://f626-pnbs.accessdomain.com/HTTPS://DTREE.NUBAY.NET/SITES/ALL/MODULES/C...
[4]
http://f626-pnbs.accessdomain.com/HTTPS://DTREE.NUBAY.NET/SITES/ALL/MODULES/C...

Mike Bailey Replied at 10:43 AM, 26 Jul 2016

Hi Debs,

Yes, you are right this is a process based approach and has the technology built in so organizations can implement right away. One of the keys to sustainability over time is not to be tied to a specific product or vendor - particularly if you are implementing technology at a national or provincial scale. One way to avoid that is to define your requirements in terms of a process. As you can see in the attachments, Open Deliver is based on a staged process involved in distributing digital content to health workers.

At each stage are technologies that make that process possible: Moodle for Learning Management, ORB the content sharing library and OppiaMobile which takes content created in Moodle and stored in ORB and runs that content offline (avoiding connectivity charges) on mobile devices . Taken together this is Open Deliver - an integrated system designed to reflect the Principles of Digital Development that Governments or their representatives can own and operate. Governments can also replace each technology if they find a replacement that improves upon the existing and meets their requirements for distributing content to health workers (of course this process and the accompanying technology could be adapted for distance learning in any domain such as education or agriculture).

Your interest concerning a centralized resource is appropriate as ORB, the content sharing library, is the key part of Open Deliver for it offers a way in which anyone can contribute relevant content but unlike YouTube (for example) Governments can enact a content review process to ensure that whatever is submitted is validated and does not duplicate or conflict with what is already available within the library. Also, unlike YouTube, the content can be converted for immediate offline use as an educational resource on mobile devices.
Best,
MB

Maimunat Alex-Adeomi Replied at 10:49 AM, 26 Jul 2016

Thank you Okey for the feedback.

Really commendable project, and I am eager to see the overall outcomes and impact following the state wide implementation.

Best Regards
Maimunat

Mike Bailey Replied at 11:54 AM, 26 Jul 2016

Also as a follow up to Debs specific question about support, here are some relevant links:

Attached resources:

Laila Hussain Replied at 4:31 PM, 26 Jul 2016

Thanks Mike for shedding light on Open Deliver as it relates to governments and their ability to use the technology for mhealth programming (or even programming in other areas). In the context of Sindh, Pakistan, where there is substantial investment in health through NGO funding, Open Deliver process was initiated in partnership with the Sindh government right from the beginning, with the department of health identifying exactly what its needs were i.e., providing refresher trainings and counselling support to its Lady Health Workers (LHWs) - a critical workforce of 23,500 women working in rural Sindh. The presence of a large number of NGOs in the country who are through various interventions, supporting LHWs has led to duplication of resources, but what's worse, a level of confusion within the government and particularly among LHWs themselves, many of whom have attended small-scale refresher trainings or on-the-job coaching through some intervention or other, without any post training follow-up. The Open Deliver process has shown great potential to streamline the work of NGOs working with LHWs, and avoid this confusion, leading to improved LHW performance and better outcomes. Though still in early stages of collaboration, the process of gathering NGOs, assessing interest in contributing content and resources, and introducing the government to the technology itself is underway. I'd be happy to answer any questions about the Pakistan context and the collaboration process itself.

Mike Bailey Replied at 10:49 AM, 28 Jul 2016

I think it might be hard to approach the challenge of training an entire community health workforce from the perspective of a health ministry in a LMIC who is looking at the potential mobile technology has to offer but confused as to how to exploit that potential. Fragmentation of the technology at present is well documented and with the rapid increase in the acquisition of smartphones this fragmentation is likely to get worse as anyone with even a periodic connection will be able to download literally thousands of apps developed for health - many of them with questionable, unvalidated content. By adopting a distribution process that includes a centralized resource - or library - of validated content to assure the quality, prevent duplication, enforce a standard training curriculum and distribute educational materials to all FHWs in all districts in an equitable, low cost manner an entire workforce can benefit from contributions developed and adopted for the operational context by local and international implementing partners.

This has to take place at the level in which the health system is administered - usually national or provincial - and not as it is progressing now with programs that are administered from a global level. So Governments need to own and operate the delivery system that is drawing content from their library of educational resources.

Note the use of the term "delivery system"

Mobile phones like televisions and flip charts, and any other reliable content delivery system, are already capable of delivering customized content at scale through a standardized engineering process. Also the standards surrounding the conversion of content into digital audio, text or multimedia are well established. The other elements that make up a content delivery system using mobile phones (such as the application software, the server technology, etc.) may not have evolved to the point where they can be characterized as a commodity but are close enough so that informed implementers can make proven choices that can reliably scale at a very low cost.

In order to ensure sustainability, decision makers will need to settle on technology that is engineered for eventual institutionalization by a host Government. As mentioned before, there are guidelines, such as the Principles of Digital Development (http://digitalprinciples.org/), that can provide a starting point for Governments trying to decide on programs that are sustainable. The work in Ondo State Nigeria, Sindh Province Pakistan and Guinea - although in the early stages of development - represents this approach.

Naomi Muinga Moderator Replied at 7:59 AM, 29 Jul 2016

Interesting discussion so far...just wondering what are some of the challenges faced when trying to access content in an effort to minimise duplication. Asking this because if you are trying to implement this where there is a lot of duplication already and organisations might not have some of their content 'freely' available that might pose a challenge. An example of some challenges and how they were overcome would be great.

Joaquin Blaya, PhD Moderator Replied at 10:29 AM, 29 Jul 2016

Following up on Debs question about extending the use of Open Deliver I had a couple of questions.

1. If there is an organization that wanted to use Open Deliver to deliver their content for a project, what are the different options they have for using it? Meaning can they download the systems and learn themselves or ask mPowering or others for help, both?

2. If an organization also wants to use current content in the Open Deliver platform for their project, could they use it? and how?

Mike Bailey Replied at 11:14 AM, 29 Jul 2016

Hi Naomi,

Good question. Increasingly donors and governments recognize the implications of uncoordinated development of content and individual, isolated training to support small programs. There is an excellent report sponsored by the MoH in Uganda that outlines the implications of the existing (i.e. even before the implementation of distance education) uncoordinated approach towards training health workers. In the report the following implications surfaced in relation to the impact on Uganda's Village Health Teams:

* Although the Government of Uganda owns the VHT programme, VHTs pay more allegiance to the IPs [Implementing Partners] who provided them with more facilitation than government.
* Poor IP coordination creates a problem for supervision of the programme and eventually in sustainability when the partners’ projects end.
* In areas with few or no implementing partners, it implies that the communities may not be benefitting from the VHT activities supported by such partners [leading to an inequitable distribution of training]
* Implementing partners were not coordinated in offering their support to the VHTs. For example, they motivated VHTs differently, they had different reporting formats, and their programme training followed different methodologies and durations.
Source: Uganda Ministry of Health. National Village Health Teams Assessment in Uganda March 2015. The assessment was conducted in all 112 districts in Uganda from November 2014 to January 2015.

Along with Government recognition of this problem donor organizations such as the UK's Department for International Development (DfID) are also acting where Frances Sibbet the DFID Digital Service Lead plans to require providers of digital services to abide by the Principles of Digital Development which will make duplication of technology used for content delivery and the development of digital content hard to justify.

Although there is not a lot that can be done about existing duplication, going forward one could envision LMIC health systems moving towards a mobile optimized, digitally based curriculum stored within a centralized, curated library at the national level making duplication nearly impossible unless the program is conducted without Government involvement. Not only would this approach pay for itself in the redistribution of funding from the reprinting of hard copy manuals to the maintenance of a single delivery system, it would also provide a means to establish what content is working and what is not in terms of health worker training and promotion of community adoption of healthy behaviors. It would also begin to address the mHealth evaluation problem where researchers could focus on the impact of content within a comparable context (i.e. a single country's health system) and bypass the need to re-test a proven content delivery system.

Finally, a platform like Open Deliver can incentivize contributions of content by providing implementing partners with a means to deliver their content directly to FHWs. Without having to pay for the development of their own delivery system they can use the left over funding for the development of multimedia resources that meet the needs of a health workforce where literacy and the effectiveness of traditional textbooks in training is in question.

Attached resource:

Mike Bailey Replied at 11:41 AM, 29 Jul 2016

Hi Joaquin,

Thanks for the question. There is an important distinction that must be made between the Open Deliver platform and the technologies that make up that platform. Open Deliver combines existing, open source technologies into a single digital content distribution process. These technologies include: ORB, mPowering’s platform for sharing mobile optimized training content; Moodle, a learning management system for course creation; and OppiaMobile, an Android based mobile app for delivery of course content. Although individual organizations could theoretically adopt all 3 tools for their own use (as they are all open source) Open Deliver, as an integrated platform, is not designed to be used in that way. The intent behind the integration is to enable Government health systems to institutionalize the content used for training their health workforce and the system used for delivering that content. mPowering is doing its best to work with Governments, donors and private and public sector partners to help them envision the adaptation of this approach as a means to address problems surrounding sustainability, the duplication of resources and the inability to properly evaluate impact.

That being said individual organizations are likely to be in situations where they don't need to work closely with Governments or need a large scale implementation. In those cases they can go to the Digital Campus website (https://digital-campus.org/ ) and follow directions provided there to create their own courses in Moodle and then transfer those courses to OppiaMobile so they can be accessed from a mobile device. The amount of support required will depend on the degree of competency surrounding the use of this technology.

With regard to your second question about using current content in the Open Deliver platform for their project, I would point out that the the technological component responsible for storing content is ORB. This can be accessed at anytime by anybody to both contribute and access content for their own use. A user does not require access to the remaining parts of the Open Deliver platform to use the content on ORB. The process for contributing to, or downloading from ORB is provided on the website ( http://health-orb.org/ ). Contributions can be made here: http://health-orb.org/resource/create/1/ and will usually go through a review/curation process before appearing on the site. There are no constraints to downloading the existing content on ORB. You don't even have to register (although we encourage users to do so).

Joaquin Blaya, PhD Moderator Replied at 5:52 PM, 29 Jul 2016

We wanted to thank the members who showed us Open Deliver and all of the
participants for their time.

This is both a process and tools that hopefully will continue to expand.

Have a wonderful weekend,

Joaquin