Project Mwana consists of a mobile service that delivers HIV results to rural clinics and a messaging platform to ensure the results are communicated directly to mothers. It has reduced the time to deliver critical information from four weeks to minutes and increased post-natal visits.

Project Mwana is being rolled out on a national scale in Zambia and serves as a demonstration project within UNICEF. The leaders of the project conducted workshops with officials from nine different African countries to develop a model for incorporating human-centered design and real-time data into initiatives from education to sanitation to child safety.

Despite major advances in vaccines and treatments, millions of children die unnecessarily each year, as much due to lack of access to information as to lack of access to medical supplies. The Health Minister of Zambia asked UNICEF to improve infant diagnosis and treatment in rural areas that sit far outside the reach of the traditional infrastructure. This was the first opportunity to deliver a program on a national scale that, if successful, could be replicated around the world. UNICEF wanted to ensure that the solution was tailored to the real needs and expectations of the communities involved.

The UNICEF innovation team facilitated an initial series of worksessions with stakeholders from the ministry of health and rural clinics to identify crucial gaps in service that could be effectively addressed with mobile technology. With only three labs nationwide, the physical delivery of HIV test results to clinics could take several months putting the health of the child in jeopardy. The UNICEF team began working on a system to connect labs and clinics directly through mobile technologies so the results could be delivered in real time. But getting the results to the clinic was a small part of the solution as mother’s rarely showed up at clinics for their regularly scheduled post-natal checkups. Our primary challenge was to figure out how to make this information useful and meaningful to community health workers; and how to design a system for follow-up and feedback that would support the needs of mothers.

UNICEF generally takes a top-down approach to designing their programs, which can place undue burden on the participants involved. The UNICEF programming teams are often disconnected from the practical realities in the field. This is particularly painful when mobile technologies are involved. Their programming division generally starts with a fixed idea of what they want to measure and looks to mobile services to automate the data collection process, often adding considerable complexity and redundancy to the day to day loves of front line workers. The challenge here was to convince senior stakeholders that they should view this platform as a service in which value is returned to the participants, and not as a reporting mechanism.

Our hypothesis was that data was fundamentally linked to usage– the more the system engaged and supported community health workers the more likely UNICEF would be to gather relevant data about behavior and health outcomes. This meant that the entire user experience needed to be looked at in terms of the underlying social dynamics. How could it improve the day-to-day work of community health workers and instill a sense of pride in their role (which is under-appreciated by clinic staff)? What forms of incentives, rewards and recognition should be built into the system to encourage usage and support positive outcomes? How could the system continue to learn and adapt to their needs? How could we use design techniques to build sufficient trust so that we could get at these deeper and richer human insights?

The team face challenges in rural Zambia: few families own mobile devices; network coverage is intermittent; there are long distances between villages and clinics; and clinics have only the most antiquated record-keeping systems. This forced us to work with materials and people at hand, focusing on volunteer Community Health Workers (CHWs) who are the only consistent link in the chain. The solution had to be designed for and with them without adding more rules and requirements to further complicate their lives.

The quality of the solution is based entirely on working rapidly and iteratively to design and deploy concepts in small increments. The first piece tested was the system for getting HIV results from a central lab back to the clinic via SMS, replacing a postal system that took up to four weeks to deliver the same information. The success of this solution created trust within the community that was essential to solving the much more difficult problem of helping Community Health Workers understand the information, communicate it effectively to mothers, get infants into treatment, and report back to the health ministry.

The design of this next layer required active participation from the Community Health Workers throughout the process. The team got immersed in their lives and routines both in the clinic and in the community and gave them phones to test out early prototypes. Because CHWs receive very little feedback, they wanted a feature that let all the CHWs within a given community see how many results each worker was delivering per week. The CHWs also requested an open channel to ask questions via SMS. This allows the system to learn from them, not just deliver results to them. Finally each CHW get thanked via SMS whenever they report results, a perfect illustration of the power of mobile technology to provide direct personal feedback and a great example of the type of feature would not been created without a user-centered design process.

This project delivers value by helping UNICEF better achieve its humanitarian and development goals in communities around the world, particularly those with the least access to resources. The current programming process is top-down, driven by central decision-making with outdated reporting mechanisms that take years to deliver meaningful data. The UNICEF innovation team has been working to change that approach on a small scale, partnering with local offices primarily in the health arena to pilot participatory and inclusive solutions. The goal of our partnership is to drive adoption of this approach across the organization, delivering value on a number of different levels:

- Demand for participant and community-led design approaches from UNICEF country offices.
- Increased access and improved outcomes among users of these services.
- Increased ability to measure the impact of these services and iterate on their design.
- Increased willingness by governments to adopt and roll out these services on a national scale.
- Increased capacity to support and enhance these services with local software development talent.

The clearest example of our ability to achieve these goals has been in Zambia where we collaborated on a program to increase access to lifesaving HIV information for mothers and children. This program has reduced the amount of time it takes mothers to receive this information by 57% while dramatically increasing the number of post-natal visits. The program is currently in the process of a national rollout in Zambia and is being replicated by UNICEF teams in Malawi and Sierre Leone.

This is always a tricky topic when you are designing for communities that are completely removed from your own day-to-day existence. In this case we relied on the early work by the UNICEF innovation team which brought together many different stakeholders to identify a specific gap in health services that came out of their own experience. For this reason, we felt confident that the work was welcomed by the community, but also that the scope was something achievable with the teams and resources available.

Our own direct experience through ethnography and participatory design supported this impression. Community health workers responded very positively to having the time and attention of our design team. They were not used to that level of recognition and had strong opinions about how the service should work to support their needs. They were persistent in pushing for a design that was simple, flexible and inclusive. For example, they didn’t want the system to be viewed merely as a way for them to retrieve and post data about mothers. They wanted to be able to ask each other questions directly through an open peer-to-peer channel. It was only through close observation, constant iteration and personal trust that we were able to surface the subtle elements of the user experience that would make it really fit the needs of these individuals. And we were fortunate that the UNICEF team had committed a significant time for the iteration, design and piloting of the program before considering a broader rollout.

This project is fully supported and funded by the government of Zambia based on its ability to deliver key health outcomes related to infant mortality. Both the governments of Malawi and Sierre Leone have show interest in replicating the solution within their national health programs. This should give the program a sufficient base to sustain development for quite some time. In addition, the program was built around local software development talent, who have taken over the maintenance and enhancement of the service in partnership with the UNICEF Tech4Dev team. This has created an opportunity for valuable skill development for the participants in key areas of software development.

The biggest open question is the ability for UNICEF to sustain a major shift in the way they think about program design and incorporate end users into their work. There have been some promising signals from senior leadership as both Tony Lake and Nichoals Alipui (Director of UNICEF Programmes) have held up Project Mwana as a model for the organization. But it will take time to see if the lessons of this project take hold within the organization. We are working with the Tech4Dev team to explore ways to translate the learnings from this and other projects into a cookbook for country offices so that they can more effectively plan and execute similar programs in the future.