[ICT4CHW Millennium Villages Project]

[Prabhjot Singh Dhadialla]

Dear Colleagues,

 

Firstly, thank you to the group for suggesting that we contribute to this discussion.  I've read the threads about costs of CHW/ICT programs with keen interest as it directly relates to ongoing work. I'm currently the Community Health Worker and Health System advisor to the MVP.  In this post I'll give some background about the Millennium Villages Project, the Health component/CHW program and then a bit about our approach to technology usage.  It may seem like a long preamble to getting to the ICT, but I'll say something about why I've done this at the end.  In addition, I'll speak about ongoing scale-up work:  

 

The Millennium Villages Project:

 

The MVP [http://www.millenniumpromise.org/site/PageServer?pagename=mv_main ; http://www.nytimes.com/2010/03/09/world/africa/09kenya.html] was designed to consolidate the world's current implementation knowledge about achieving the Millennium Development Goals and put them into action throughout challenging terrains in Sub-Saharan Africa.  Located in 10 countries at 14 sites, the first wave of Millennium Villages are clusters of about 40 to 80 thousand people -- ~450,000 in total.  The clusters were identified through a process that requires a national government to request MV presence in the country [1].  This triggers a process of identifying areas of high need and then working with the districts to find candidate communities where there was enthusiasm for the process. 

 

This is a high profile development project for a number of reasons:

 

- It's a reprise of integrated rural development, however, with some significant additions of a tightly budgeted/costed model ($110/per/year, inclusive of community contribution, government per capita expenditure, local or iNGO contributions in the vicinity; the gap is what the MV financing model provides), emphasis on upgrading ICT infrastructure, evidence-based interventions with experienced practitioners and the development of expert sub-systems.  

 

- Focus on the operations/mechanics -- "how to" of implementation of evidence-based interventions that have been long-documented but rarely integrated due to the inability to align scales of activity from the community to government

 

- sequenced roll out of key interventions determined by local teams across community development, agriculture, infrastructure (including ICT -- will come back to this), water and sanitation, health, education and business development (I'm sure I'm missing a few)

 

- focused upon meeting the Millennium Development goals while providing guidance to a broader community about how to do this from a technical perspective, a costing perspective, a monitoring and evaluation perspective and an implementation mechanics/operational perspective; the project kicked off in 2006 with most MVs beginning at that time with 5 years of financing and another 5 years of substantially decreased financing anticipating the development of sustainable businesses and absorption of services into government budgets.  

 

- Jeffrey Sachs, the director of the Earth Institute at Columbia University and thought leader of the Millennium Villages project is a vocal advocate of practical approaches

 

The gist of the idea is that for most of the communities, subsistence farming is the way of life [2] and increased crop yields through a judicious and soil-sensitive addition of fertilizer and improved irrigation techniques [3] leads to surplus income.  Part of this income goes to community inputs (i.e. grain bank for school feeding programs) while the rest is available for investments in family health, business development and so on.  It's not as simple as this and as one's intuitive sense may convey -- people don't just fall into line and spend disposable income on health, savings and education for building a better tomorrow.  But it is catalytic and the integrated approach creates an environment where there are a multiplicity of reasons to make less resource constrained decisions.  And our mid-term data shows that this approach has been remarkably effective in key areas, along with some glaring stagnancies that reflect, to varying degrees, the state of "best practice."

 

When you go to a MV, you're immersed in rural village life and it may be difficult to see the political supportive apparatus that ensures that the problems and successes are telegraphed to multiple scales of audiences.  This is done through strong Monitoring and Evaluation (M&E) platforms and an increasing investment into real-time monitoring via ICT so information is used as a management/process improvement tool.  Over this year and next there will be a lot of data from the MVs that will be publicly presented and people from many communities will be asked to help us figure out what's going on beyond some clear cut findings -- especially those that are cross-sectoral and difficult to disambiguate using traditional statistical techniques.  This will come up later.

 

Finally, it's worth noting that despite having a standard core of available practices, the national policy/practice environments and local capacity to implement results in a large degree of natural variation.  We're looking for particular signals related to the MDGs and other crucial aspects that have emerged in the process, against a background of considerable noise.  There is a lot of debate about RCTs etc... and the project has identified comparison villages (different from formal "controls").  My background is in information theory/neural systems (and medicine) and would posit that there are a number of dynamic approaches to dealing with sort of setup that doesn't require the clunky apparatus of RCTs, not to mention the practical/financial problems it presents.  But no broad strokes here, we'll continue to look at opportunities to build a multiplicity of analysis approaches to facilitate as many perspectives as possible.

 

MV Health and CHWs:

 

The health budget is ~$40/person per year.  This is put into a pooled fund that is managed locally by a health coordinator who is from the region in coordination with village health committees.  The coordinators are technically skilled and maybe doctors, pharmacists, clinical officers of other rank -- but they share a common characteristic of paying attention to information and political processes simultaneously.  They live very close to the village and spend a lot of time there.  Their salary is costed for in the MV budget and often times they are seconded from government to ensure that their position is sustainable and scalable (after adequate training).  The site management team forms a functional network of experienced individuals who work within countries at multiple levels; their presence is crucial and scale-up plans include the identification of these sort of people. 

 

The MV Primary Health Case System is predicated upon meeting a localized but uniformly available package of primary care services in the community.  The household is the foci of our efforts, even if simply to facilitate demand at clinics.  This makes CHWs the basic building block of health system development, as much as the building/upgrading of clinics if there were none (usually something there but not always) and the installation of an emergency response system (ERS).  The latter consists of ICT investments to provide cellular coverage to these rural areas, an investment that has being matched and overtaken by market driven investments since the beginning of the project in 2006.  Nevertheless, in all locations there is considerable udnerstaffing of clinics from aspirational national standards and there have been an array of efforts to supplement the clinics.  Even though there is national support for the MVs, there is a limited ability to simply get the MV clinics staffed by fiat (in fact, in some places, people are taken away because of the perception that "millennium has money"[4]).  

 

Variation in CHW programs across countries has been a challenge.  Not only does it require really knowing the existing policies etc... but you have to understand the historical view to village health workers and the reasons for various constraints (volunteer vs paid, certified vs informal etc...).  Most of the time you'll find that the rationale for various policy constraints are historical-circumstantial rather than evidence based or principled.  Show a better way (either from other countries or tested ideas from other areas) and ministries are interested.  But people ain't fools and an idea is only worth its weight in implementation fidelity.  Anyway, our approach has really morphed to tightly defining a standard core of practices across the MVs that CHWs can do and must to really demonstrate their competitive advantage.  They go to households use clinical algorithms to assess fever with RDT's and give anti-malarials, use ORS/zinc for diarrhea, MUAC+referral for malnutrition, close monitoring of pregnant women (pushing facility births) and newborns (various).  That's the core.  Depending on country, CHWs do other stuff too -- family planning, sanitation/hygeine etc... We support and strongly advocate for a number of other things, but nailing down a standardly acceptable core for 10 countries has taken some effort.

 

In all sites, CHWs use paper forms to report their information and the MV standard forms protocol includes localization to language, ministry requirements, and site specific health needs.  If you can imagine, this requires a lot of management and support and this is what I want to underscore.  If management and supervision are not considered with as much interest as the technology, including a budget to support it, you'll hurt an effort.  I say this in stark terms because the cost is "system load" on the human resources and people will pay attention to the technology because it's just more specified in terms of actions etc... It becomes sorta like those tamagotchi toys [http://en.wikipedia.org/wiki/Tamagotchi] where people will pay attention to feeding their digital pet to the detriment of their other responsibilities.  Happens.  But the bottom line is that phones and technology are fundamentally changing the spatial and communication landscapes of rural areas.  If the development community doesn't figure out how to do this work, commercial, for-profit, social venture etc... groups will do so.  "No market, people are poor, that's why we're doing this!"  Agreed, and this community is critically important to set the standards of interaction and really hone in on the true priorities.  Not just for the effort we're involved in, but for where it sits in a broader landscape that extends beyond traditional development boundaries.

 

Recently we've introduced the ChildCount+/RapidSMS system that Matt Berg introduced on another thread here.  Earlier, Zoravar Dhaliwal of Community Lab may have spoken about their management systems.  We use both.  Togther, they are the technology enabler for the information management and process improvement methodologies that we'd like to see "installed" to really get higher "implementation fidelity" from CHWs.  This has been very important because in every program I've seen (africa, india, latin america), the CHW roles and responsibilities are underspecified while simultaneously being content overloaded.  Even if the content has been whittled down (i.e. a vertical malaria or DOTS programs) enough to minimize the poor technical/operational specification of the CHW program in general, you're simply lowering expectations to match the fuzzy structure rather than sharpening the latter to experience efficiency gains that create space for an enriched activity set.  This isn't just a question of style or where to place program emphasis, if there is any interest in having valued, full-time, paid CHWs that are truly an integral part of the health system (either public or private), addressing content and technical/operational specification is a must.  

 

I'm sanguine about ChildCount+/RapidSMS in the MVs but I've been far more interested in the process we've had to follow in order to create an appropriate interface for the technology and the broader CHW/Health System/MV goals.  The work that has gone into really understanding the constraints on management, data flow, coordination with other health sector activities as well as the critical element of sequencing/phasing deployment has been critical.  It is precisely the constraints of a technology system that allow for a focus on priorities, but this is a double-edged sword because it's easy to forget that not everything should be channeled through this constraint.  Health can't be viewed through the screen of a mobile phone as much as it is a crucial interface to be incorporated.  We have a superb team on the technology front -- Matt Berg, Andy Kanter, Patricia Mechael -- but they work in coordination with regional CHW coordinators -- Jackline Oluoch and Yombo Tankoano -- who in turn work with CHW managers at every MV site.  The CHW managers communicate with senior CHWs who manage 6 CHWs (when this arrangement is possible, often modified).  This entire team is supplemented by a M&E team that looks at quarterly data while aligning real-time monitoring information.  Finally there is the critical eye on the shifting politics and emerging opportunities to scale-up to national levels.

Finally, much of this work has been shaped by interactions I've had with Jonathan Jackson and Neal Lesh as CommCare has developed.  The concept of a protocol driven health worker support that provides real time monitoring via a management dashboard has been formative.  At this point we're holding on the CommCare work but I think we'll really see a reprise of the type of approach this represents as quality of care really becomes a focus above and beyond setting up these basic primary care systems.  But until then, we're really looking out to this community for ideas, direct support and partnerships that add value to health delivery and systems strengthening.  We're serious about the economic costing and financial impact of this work and I can explain what we're doing in this regard even as we speak.  Even though we're working with certain groups, none of our relationships are exclusive.  We work across too many countries closely with enough governments to preclude this, although there is a degree of coherence that we aspire towards.  

 

But I'll stop here because, well, many of you might have stopped reading some time ago.  I imagine there would be more granular, interesting questions that I can use to provide more information.  If this is too long to digest I'll repost something punchy and short.

 

Best Regards,

Prabhjot Singh

 

---

Dr. Prabhjot Singh Dhadialla

Director, Program for Health Systems Development and Research

Health Systems Advisor, Millennium Villages Project

 

Center for Global Health and Economic Development

The Earth Institute at Columbia University

 

405 Low Library | 535 West 116th Street | New York, NY, 10027

+1 646.675.7049 | pdhad...@ei.columbia.edu |

---

 

[1] the original plan called for 1 site and as the blueprint was released, a dozen countries requested MVs immediately

 

[2] notable exceptions are in the nomadic "village" of Dertu, Kenya, on the border of Somalia/Kenya

 

[3] this isn't a fertilizer dump; it's based upon soil analysis, titering the amounts required through working to educate farmers in villages while culling best practices from other parts of africa/world or successful farmers within a community

 

[4] This is worth addressing.  Yes, MV has money.  It sounds like a lot because it simply can be accounted for and distributed in a prioritized manner.  But we're still talking about a budget of $40/person/year for health, and $110 total, which includes building infra- structures like roads, ICT, corporate donations like phones (all inputs are accounted) etc... This is up from ~15/per/year in most Sub-Saharan africa countries for health, in comparison to ~$8,500/person/year in the US.  So is it gold-plated?  If you call being able to get ORS/zinc semi-reliably gold-plated up from not at all...  Finally, there are some things money can't simply transact although it can facilitate if you know what you're doing ("if you throw enough money at a problem of course you'll solve it"), including appropriate management, attitudes about the unacceptability of routine deaths, broader vistas of what is possible for your family.  

[neal lesh]

Dear Prabhjot,

 

Thanks very much for this generous post!  It really spoke to me- and not just because I'm short and sometimes punchy, myself. 

 

Supporting focused efforts in so many different countries puts you in a great position to highlight important themes for this group to consider.  I wonder if you might be able to identify some of the highest priority needs you see for strengthening community health programs with respect to ict4chw systems?   We won't hold you to them, but do you have a few favorite information-related gaps you would most like to see filled? 

 

One question I get asked sometimes is how important is it to have near real-time information from community health programs. Do you have some insight into this as you I imagine you have experience with different rates of reporting?   Or, put another way, is getting daily data much better than weekly or is weekly much better than monthly?

 

Have you by chance developed any quick indicators that give you a sense of whether a community health program is functioning well?  When you visit an MV, is there a particular question you tend to ask first or things you look for in the CHWs notebooks and forms?

 

And I remember reading something you wrote a while back about the potential importance of cultivating “information literacy” in CHWs.  I wonder if you've seen that play out and if you think ict4chw systems should be oriented around trying to build certain capacities or affording career paths.

 

Finally, it's a great point you make about the importance of supervision and management, and the potential for an ict4chw to hurt a community health system by being a distraction. (We will cancel any plans to distribute tamagotchi’s as well.) I'd love to hear a bit of elaboration in terms of whether you are advocating for increased supervision and management specific to the introduction of an ict4chw system and or if you were underscoring the need for supervision and management generally, regardless of the ICT component. 

 

As always, no need to respond to any or all of that and feel free to improve any of the questions before answering them. 

 

Take care,

neal

[Jahanzeb Sherwani]

Prabhjot,

Thanks for an incredible post.  As a technologist, I and others like me are constantly focused on technology, and in the better cases, we sometimes think a little about training users, and perhaps about information flows.  It's clear from your post that there is a lot that I/we miss in such analysis, and it would be wonderful to get an even more expanded sense of the issues you deal with, including specific examples.  You've mentioned the word 'management' many times -- and this is a word I rarely see in any ICT work, but it's clear that it matters to you and the work you do -- perhaps more so than anything else.  I feel that we're missing a wider perspective on the problems, which necessarily leads to narrower solutions that might not really make a difference, and I believe that a deeper understanding of the wider context would be beneficial to everyone.  Roni and I have seen this with our own work -- we built a system over the course of two years but due to a variety of reasons, it's not deployed anywhere right now -- and while we have some ideas as to why it hasn't, I feel we don't really understand the NGO's perspective in a crystal clear way to know why this is the case.  Management and supervision are clearly important, but to be honest I don't think I know what these words really mean in the specific context of public health organizations and the work they do.

So my request is perhaps not even just a long reply that spells these things out -- but something more than that, perhaps even a workshop where folks like you who have experience on the ground can speak to the more techie people among us.  Maybe even a series of video lectures (see khanacademy.org for an example of how you can teach amazing stuff with youtube) to start with.  This could educate us to widen our view of the problem space and of the challenges that you face in the work that you do, and could lead to a shift in the focus from context-minimal technological solutions to contextually appropriate solutions that really work, and whose value can be seen by all involved, not just the technologists.  At our brief meeting at the Berkeley workshop in August, I was particularly impressed by the perspectives you and Jonathan Jackson brought, and I for one would welcome the opportunity to get a crash course on the chw side of ict4chw.

Jahanzeb Sherwani

Adjunct Faculty

Language Technologies Institute

Carnegie Mellon University

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[pedrom]

Hi,

Hi,
This is an interesting series of exchanges and as a new comer to the
forum I would like to make a few general comments which apply equally
to other ICT /NGO forums.
It would be useful if the dialogue was split into the “problem”, the
“solution” “implementation” and “lessons” learnt . To me it gets
confused as to what the goal of the project has been [problem to be
“solved”] and the technical solution and how it was implemented
[pilot , over what time, number of on site visits , mix of local
versus external staff etc ]. It would be more of a framework rather a
proscribed method. Where a comment is made for given project it would
be good for us new comers if it said for background see ….

For the millennium village project ; my questions would be [in
addition to those already posed]
What was the project set up to do ; timescales and stages of project
implementation [were pilots set up in a spread of countries] ;
external versus in country man power effort required ; ongoing
monitoring and what value added does the project bring.

Another general point, slightly provocative what role do NGOs really
need to play in facilitating this type of project :rather than say
giving US$100k for a project and letting the country get on with it?
Intuitively it seems to be project management, facilitation and
focused money?

best Peter

> khanacademy.orgfor an example of how you can teach amazing stuff with

> youtube) to start
> with.  This could educate us to widen our view of the problem space and of
> the challenges that you face in the work that you do, and could lead to a
> shift in the focus from context-minimal technological solutions to
> contextually appropriate solutions that really work, and whose value can be
> seen by all involved, not just the technologists.  At our brief meeting at
> the Berkeley workshop in August, I was particularly impressed by the
> perspectives you and Jonathan Jackson brought, and I for one would welcome
> the opportunity to get a crash course on the chw side of ict4chw.
>
> Jahanzeb Sherwani
> Adjunct Faculty
> Language Technologies Institute
> Carnegie Mellon University
>

> > *From:* Prabhjot Singh Dhadialla [mailto:pdhadia...@ei.columbia.edu]
> > *Sent:* Thursday, March 11, 2010 10:48 AM
> > *To:* ict...@googlegroups.com
> > *Cc:* neal lesh; Jonathan Jackson
> > *Subject:* [ICT4CHW Millennium Villages Project]

>
> > Dear Colleagues,
>
> > Firstly, thank you to the group for suggesting that we contribute to this
> > discussion.  I've read the threads about costs of CHW/ICT programs with keen
> > interest as it directly relates to ongoing work. I'm currently the Community
> > Health Worker and Health System advisor to the MVP.  In this post I'll give
> > some background about the Millennium Villages Project, the Health
> > component/CHW program and then a bit about our approach to technology usage.
> >  It may seem like a long preamble to getting to the ICT, but I'll say
> > something about why I've done this at the end.  In addition, I'll speak
> > about ongoing scale-up work:
>

> > *The Millennium Villages Project:*
>
> > The MVP [http://www.millenniumpromise.org/site/PageServer?pagename=mv_main
> > ;http://www.nytimes.com/2010/03/09/world/africa/09kenya.html<http://www.millenniumpromise.org/site/PageServer?pagename=mv_main%20;...>]

> ...
>
> read more »

[Prabhjot Singh Dhadialla]

Thanks Neal.  So many good questions in here and so I'll respond in a short and punchy manner, namely bullet points embedded below.  

On Mar 13, 2010, at 11:34 AM, neal lesh wrote:

Dear Prabhjot,

 

Thanks very much for this generous post!  It really spoke to me- and not just because I'm short and sometimes punchy, myself.  

 

Supporting focused efforts in so many different countries puts you in a great position to highlight important themes for this group to consider.  I wonder if you might be able to identify some of the highest priority needs you see for strengthening community health programs with respect to ict4chw systems?  

>> There is a critical need to view CH programs as sub-systems of an integrated and scalable primary health care system.  We have trouble comprehending the constraints that exist at other scales (district, regional, NGO-sphere, popular uptake, private sector, national etc..) because we don't really know what are the parameters of the systems where we work.  I used the word sub-system because it does imply some higher order structures that are required for seeing exponential increases in impact just like roads and electricity are infrastructural 'game-changers' that span multiple village/district units to be implemented.  We have some idea of these integrating/accelerating/scale-enabling structures but not nearly enough.

We won't hold you to them, but do you have a few favorite information-related gaps you would most like to see filled? 

>> We have a considerable costing related information gap.  This isn't a matter of sheer accounting practices for commodities, but an evaluation and specification of roles/responsibilities/tasks that do or don't consume the time of the people involved in a health worker program.  Furthermore, we don't have a sense of how sticky the information that travels via ICT projects is upon target people in the community who were not exposed to the original dissemination points.  Info that travels via ICT should be looked at using epi-techniques using exposure models to more rigorously determine the impacts on end-user community health.  A thought.

 

One question I get asked sometimes is how important is it to have near real-time information from community health programs. Do you have some insight into this as you I imagine you have experience with different rates of reporting?   Or, put another way, is getting daily data much better than weekly or is weekly much better than monthly?

 

>> I'm going to deflect for a second and say that whatever information is available should be plowed back into activities across as many scales as possible.  Sometimes monitoring and evaluation is done of large projects after 5 years (for various legitimate reasons) but not everyone who participated knows the reported results!  In fact, its very rare for implementers to hear about this information at all.  So my emphasis would be upon creating a working environment where feedback and information is the 'interstitial fluid'/currency of exchange.  Whether this happens monthly, weekly, daily or before you know it -- that's up to a lot of technical, financial and management factors that should be inline with weakest-link capabilities.

Have you by chance developed any quick indicators that give you a sense of whether a community health program is functioning well?  When you visit an MV, is there a particular question you tend to ask first or things you look for in the CHWs notebooks and forms?

>> We sure have!  Lots of times, actually.  But as you know, coming up with quick indicators isn't even half the battle.  The ones that struck me as obvious years ago like "referral completion rate by household/individual per CHW" take an immense amount of work to get reliably.  They feel as hazy as aspirational policy statements even when the implementation pathway is very clear, standard operating procedures delineated and roles and responsibilities adumbrated.  But let me not overstate the case: we have a limited dashboard of obtainable indicators that reflect the some of the following, "do you have CHWs who regularly visits households?" "do they use consumable supplies in the course of these interactions that we can use as crude proxies of activities?" "are they paid and full-time?" etc... These come through our quarterly Millennium Village Information System (MVIS) online dashboards that our active and effective M&E team (led by Dr. Paul Pronyk) has developed.  The only reason I point this out is that we'll eventually get to the 'referral completion rate by individual' type of question, thanks largely to OpenMRS and RapidSMS integration with our management systems.  Our bi-weekly performance management indicators that will come online across all sites via the ChildCount+ system should really be a leap forward.

I really look out for some basic things when I go to MV sites -- are they recording information systematically.  are they paid.  are they under strain even if reporting effectively.  do they spend time in households.  can they prioritize their workloads (preg mothers, sick children etc...).  does the clinic facilitate their work.  do they collect and follow up vital event information (birth/deaths).  bascially lots of close-ended qualitative and open-ended quantitative.  10 countries means immense variation, but there really are some principles/signal that rises from the noise.  I suppose that's one of the amazing things about working in low-resource systems -- the dynamic ranges are wide enough to backup into large existing fields of support (i.e. decision making, performance management, risk assessment, delivery and distribution systems) that can be contextualized and digested by targeted communities.

 

And I remember reading something you wrote a while back about the potential importance of cultivating “information literacy” in CHWs.  I wonder if you've seen that play out and if you think ict4chw systems should be oriented around trying to build certain capacities or affording career paths.

 

>>Wow, blast from the past.  Yes, I do think about this a bit now and again but only because I know we're not really addressing it well.  One of the most important things we can provide a community member who goes through a CHW program that probably overworks and underpays (if at all) them is a transferable skills base.  The distance between a CHW becoming a doctor or even nurse at many of the MV sites is currently pretty unsurmountable.  But we shouldn't let all that good form-filling, supply chain accounting and direction-following go to waste.  That's critical training for any generic business/organization and should be treated as such.  This is a serious intersection of economic development and health -- the CHW as a labor force that learns health-content to do their work.  As a group teetering on the precipice of informal and formal labor, it's incumbent on us to not only demonstrate their value through cost-effectiveness studies but to actually recognize and augment these currently ancillary skill sets.  ICT is great for this and while m-learning for content has people's attention, we should really be focusing on m/e-learning for the transferrable skill set that makes these programs successful at many scales.  If the CHW program is recognized as a place to be for transforming your life through valuable education, you can even plan for regular, stable turnover while promoting institutional continuity.  

Finally, it's a great point you make about the importance of supervision and management, and the potential for an ict4chw to hurt a community health system by being a distraction. (We will cancel any plans to distribute tamagotchi’s as well.) I'd love to hear a bit of elaboration in terms of whether you are advocating for increased supervision and management specific to the introduction of an ict4chw system and or if you were underscoring the need for supervision and management generally, regardless of the ICT component. 

 

>> Yes.  :-)

[Prabhjot Singh Dhadialla]

Thanks for that kind feedback Jahanzeb.  Let me say that I use the words management and supervision like it's a talisman these days only because I've found that the actions/operations required for successful implementation seem to map back to some things in those fields that once just seemed like empty mantras.  The point is that I'm not an expert in conveying the underlying principles beyond providing examples that have led me to think those skills are important.  This is precisely why a few of us founded Community Lab last year, the organization that Zoravar Dhaliwal leads (posted elsewhere on this forum).  While I'm repeating phrases that become vacuous with overuse, let me say that ICT needs to embrace 'contextual development'* that views the ICT4D/CHW field as a potent catalyst/actuator to meet the needs of communities and organizations.  What does this mean functionally?  Instead of trying to hit a home run that 'proves the point' that ICT is important for CHWs/Development, it's through the gradual and soft-touch augmentation of existing processes that you can gently train an entire community of practitioners the value of this work.  While finding what constitutes a home run that everyone can cheer about.  Because it is valuable!  But it's a bit illiquid right now and treated as a closed-commodity exchange by people who have the technical knowledge and those who don't.  

This is something that I think Community Lab is doing pretty well and even though it's pretty young and evolving, the welcome that CL has had in organizations/companies/governments is really interesting.  Because there is a business model behind the approach that I advocated above that recognizes that grants for novel technologies are hard to follow-up with grants for real iteration and development.  That's also why I think Jonathan Jackson and co founded Dimagi.  In the case of CL, Zoravar's background is in management consulting, system performance analytics, real estate and investment banking.  Another Executive Director is Shashwat Nanda, with deep experience in operational management, partnership development and business processes.  Many others with backgrounds ranging from history (i.e. Krishna Swami) to medicine (i.e. Dr. Catarina Dolsten).  In a non-profit open-source environment that truly values internal staff development and long-term partnership development, there is a core of enthusiasm for an approach that is decidedly pro-technology while being pro-pragmatic and fundamentally about building a community of information exchange.  Anyway, when the CL website is revamped you can find out more and even better, see for yourself through common work.  I'm not writing all of this for show-and-tell, but because we all need a common raft to navigate the rapidly changing motivations of what drives decisions about technology deployment.

*I think I took this from a friend who does urban planning for mixed-use environments.  It just sounds vaguely right, not meant to point to an existing tradition if there is one.

[Prabhjot Singh Dhadialla]

Hi Peter!

Great feedback -- I could have definitely organized my posts better.  In the future I'll try the approach you suggested and see where it takes us.  Let me give it a brief shot:

[Problem]

Does a well structured CHW program with systematic dissemination of performance feedback improve community health, specifically MDG's 4/5 (child and maternal health)?

[Solution]

The solution is a multi year process of "adaptive implementation" of an existing best practice suite of CHW organizational design, information management and supervision techniques towards finding a "core" that could serve the 14 Millennium Village sites across 10 countries.

[Implementation]

This is fused to the [solution] but largely consists of the strengthening of CHW labor practices (local), local management operational training (local), regional coordination (nairobi and bamako MDG center based) with national governments and expert community input (technology, organizational management, economic development and community-based health) through an iterative process that exposes and addresses weak links in the [solution] process to enable a long-term interaction.  

[Lessons/Outputs]

- Package of regionally adaptable forms that contains core information that stakeholders at multiple scales/fields are invested in deploying

- ChildCount+ as the integrated package of RapidSMS/OpenMRS with further development of feedback loops and management dashboards to improve information exchange

- Re-emphasizing the role of nationally/regionally-integrated HR, accounting, supply-chain management, procurement and other sub-systems as integral to long-term program success.
- The beginning of a real-time monitoring/feedback process that will yield more interesting information as co-deployment of ChildCount+ and management systems improve the specification and responsiveness of the CHW system to the people who comprise it and interface with it.

--

Ok, about the Millennium Villages.  In brief, it as meant to achieve all of the MDGs [http://en.wikipedia.org/wiki/Millennium_Development_Goals] using a scalable costing framework that aimed to elaborate the implementation strategies for existing evidence-based strategies.  We've learned that there is much development to do on the implementation side, even if the "solutions" are known, hence the section above.  83 villages in 12 clusters across 10 countries; each cluster is comprised of a core "MV1" where there is much greater monitoring and evaluation with the participation of the communities as well as ring of "MV2" that have the same interventions/costing framework but are not as intensively measured.  One of the major "interventions" is a technically-skilled local management team (health, education, community, agriculture, ICT etc...) that is crucial to project success and part of the scalability strategy.  All site teams are either local to the region or country but there is a lot of exchange and traffic with members of the broader MV network.  

About the NGO:  first, let me point out that the MVs is not an NGO.  It's a costing framework, a facilitating structure of partnerships (UN, academic, local NGO, businesses, government at multiple-scales, community) and a way to consolidate best-practices in order to put them to the test.  The accounting is rigorous to provide socioeconomic status insights as the MVs develop.  It isn't an academic project either, paving the way for RCT-everything.  There are an extraordinary number of stakeholders. The UN institutions increasingly view it as the primary place to find out how well their recommended best practices are parsed in MV hands.  This comes with community feedback and the best monitoring and evaluation extraordinarily low overhead can buy/deploy. Whatever donor money has been inputted into the project (a pre-defined fraction of the costing framework that includes community, government and local NGO participation) is actively being replaced through local business development, largely targeted in agriculture.  I mention that it's not an NGO because the degree of freedom and degree of ownership is much greater and lower, respectively, than a traditional legal-financial entity.  

As to the 100k: if there is a 100k coming in the direction of impoverished people in countries that are by definition low-income, I won't be the person to deflect it.  And it's not always easy for your average donor to figure out where to send that bundle of cash and without feeling a little concerned about it impacting any one person.  That's the challenge of something that sounds as nebulous as system strengthening; we've certainly learned a lot about how to make relatively small sums of money count not once, but many fold through an integrated approach.  Think about it: a clean-water well isn't just water access, it reduces the risk of potentially deadly diarrhea, provides irrigation for farms that in tandem with appropriate fertilizer can triple yields, and provide a regular source of cooking and hand washing water.  But to really make that connect together rather than being painted as a pipe dream requires more than project management, facilitation and focused money -- technical skill, community engagement (who is going to provide tech support on a broken pipe?) and an honest progress report to the nice people who donated 100k.  Neal Lesh and Teddy Svoronos have a different idea -- why don't we administer microgrants to community members for their solutions?  Once they get the machinery to do this up and running, I'd place my bet on them and if I had a 100k to spend, I'd invest it into a system that facilitated precisely that process.

Prabhjot Singh

[pedrom]

Dear Prabhjot,
Many thanks for a fullsome reply which I will slowly digest and get
back with some more specifics [if needed]
best Peter

On Mar 15, 6:26 pm, Prabhjot Singh Dhadialla