MobiHealth: Developing Health Service Networks through Mobile Solutions in Low Resource Settings 1.

Relevance to VERDIKT call

The developing world is engaged in addressing various public health related challenges, including strengthening of their health information systems. The mobile technology has been identified as an important tool to this strengthening process, and has led to the development of the mHealth research domain which seeks to identify appropriate mobile based applications and implementation strategies to address public health challenges. The MobiHealth project is an interdisciplinary project within this domain that aim at developing new knowledge about the development and use of mobile IT in low resource settings. In particular, it focuses on the creation of sustainable health service networks for primary health care workers. Strengthening the social networks of health services, we address the digital divide and propose mobile internet solutions to bridge that gap. By mobile internet solutions in low resource settings, we mean connectivity solutions that range from SMS to (mobile as a modem) to the Internet. MobiHealth addresses the Norwegian Governments initiative on Millennium Development Goal (MGD) 4&5 on supporting improvements in Maternal and Child Health.

2. The MobiHealth Project

2.1 Background and Status of Knowledge
MobiHealth extends the vision of health services information infrastructure to the villages drawing upon the potential of mobile IT solutions. The penetration rate of mobile phones is of a magnitude greater than that of computers with internet access, and also more affordable and accessible1. Limited electricity and technical support renders PC less sustainable than mobile phones which are less vulnerable to such problems. The mobile phone is also largely domesticated into the everyday life of common people, including those living in rural areas, which is not the case with computers. Currently, it is estimated that there are 2.2 billion mobile phones in the developing world, compared to 305 million computers,2 and 65 times more mobile Internet connections than Internet connections3. Developing countries represent the fastest growing mobile markets in the world and hence this project aims at tapping into this commonly available infrastructure to provide health information services. Research into the topic of how sustainable mobile health information can be effectively deployed is limited, and this project thus lies in the frontiers of health information systems research.4 Mobile phones provide rich potential to strengthen social networks, comprising for example the field level nurses, community health workers, the medical doctors and the rural population seeking health care services. Such networks are particularly important in countries lacking public safety nets, and this project would carry out research in understanding how the mobile phone can enable the creation, evolution and sustaining of such social networks.56 Health service networks refer to the multitude of
1

Wade, R.H. 2004. Bridging the Digital Divide: New Route to Development or New Form of Dependency, in the Social Study of Information and Communication Technology Innovation, Actors and Contexts. Avgerou, C., Ciborra, C., & Land, F. (eds.). 185 206, New York: Oxford University Press, 755 - 778. 2 http://www.nytimes.com/external/readwriteweb/2009/02/20/20readwriteweb-mobile_phones_to_serve_as_doctors_in_developing_c.html 3 http://www.nytimes.com/2009/05/08/world/asia/08iht-letter.html?pagewanted=1&_r=1 4 Donner, J. 2008. Research Approaches to Mobile Use in the Developing World: A Review of the Literature. The Information Society 24, 140-159. 5 Horst, H. & Miller, D. 2005. From Kinship to Link-up: Cell Phones and Social Networking in Jamaica. In Current Anthropology, 46, 5, 755 - 778.

vertical and horizontal ties between health workers, possibly also clients, in low-resource environments. Given the existing insufficient support of such networks, it is relevant to investigate to what extent and in which ways health service networks can be enhanced through the use of mobile technology. Building on a long tradition of research in sociology and network analysis, we are aware of the key role of social networks for fostering sustainable innovations in communities of practice7 and in health8. For example, Cross et.al9 note the possibility of transforming informal groups into valueproducing networks through improving the communication flow and knowledge reuse, and the role of technology in achieving this. Particularly related to health, a recent study in Rwanda found that mobile ownership of micro entrepreneurs had an effect on social networks; it amplified primary relations while enabling new professional ties10. The international consortium behind MobiHealth is cross disciplinary (informatics, medicine, public health) comprising researchers, users, as well as providers of health infrastructure and information systems. MobiHealth builds on previous NRC projects such as Global health e-infrastructures: integration and use of information (Verdikt) and Integrated Health Information Systems (HIS) for vaccination in developing countries (GlobVac). In turn, these projects build upon the Health Information Systems Program (HISP), initiated as a NORAD project (1995-98) in South Africa, and now responsible for the development of the pioneering FOSS based District Health Information Software (DHIS), currently considered as a global innovation and adopted by the WHO as a key component of its Public Health Information Toolkit. The MobiHealth project will seek to seamlessly integrate the mobile phone with the DHIS, thus making the health information infrastructure more robust for rural areas in India, Malawi, Nigeria, and Vietnam where HISP is currently actively. MobiHealth will cooperate with four related projects. OpenMRS11 lies in the forefront of open source based medical record systems in developing countries. OpenMRS has emerged as a key building block in a number of HIS due, in part, to the fact that it is flexible and standard based. OpenRosa12 is another open source community that works on mobile data collection and decision support. Third, the Millennium Village Project13 operates in 10 countries helping villages to achieve the MDGs through community based, low-cost, integrated rural development strategies that includes primary health care. The Open Architectures, Software and Information Systems for Africa (OASIS) will collaborate on demonstrating full continuity of health information from community level to facilities, and up through the administrative levels to the Ministry of Health. The field of the MobiHealth project is generally nascent1415, enabling a significant potential for both research and practice.
6

Zainudeen, A. 2008. What Do Users at the Bottom of the Pyramid Want? In ICT Infrastructure in Emerging Asia: Policy and Regulatory Roadblocks.Samarajiva, R. & Zainudeen, A. (eds.), 39 59. Ottawa: IDRC. 7 Rizova, P. (2006) Are You Networked for Successful Innovation? MIT Sloan Management Review, Vol. 47, No. 3, pp. 49-55 8 Smith, K.P. and Christakis, N.A.(2008) Social Networks and Health. Annual Review of Sociology, August 2008, Vol. 34, Pages 405429 9 Cross, R., Laseter, T., Parker, A. and Velasquez, G. (2006). Using Social Network Analysis to Improve Communities of Practice. California Management Review; Fall2006, Vol. 49 Issue 1, p32-60 10 Donner, J. (2007). The Use of Mobile Phones by Microentrepreneurs in Kigali, Rwanda: Changes to Social and Business Networks. The MIT Information Technologies and International Development, Volume 3, Number 2, Winter 2006, 319 11 MamlinB, et.al 2006 Cooking Up An Open Source EMR for Developing Countries. AMIA Annu Symp Proc 12 www.openrosa.org/ 13 Kanter AS et. Al. 2009.Millenium Global Village-Net: Bringing together Millenium Villages throughout sub-Saharan Africa. International Journal of Medical Information. 14 Castells, M., Fernandez-Aredevol, M., Qui, J. L., and Sey, A. (2007). Mobile Communication and Society: A Global Perspective. Cambridge, MA: MIT Press 15 Jagun,A., Heeks, R., Whalley, J. (2008) The Impact of Mobile Telephony on Developing Country Micro-Enterprise: A Nigerian Case Study. MIT Press, Volume 4, Number 4, Fall/Winter 2008, 4765

2.2 Approaches, hypotheses and choice of method

Approaches
MobiHealth will develop generic software based on the open source philosophy in order to address the research objectives (see grant application). This section outlines the mobile applications to be developed and social networks to be strengthened. The suite of health applications that will be piloted on the mobile phones in the different countries include: Community Based Health Information System (CBHIS), and reporting of aggregated data e.g. Integrated Disease Surveillance and Reporting for outbreak control. These two types of applications shall result in generic software on a mobile platform that can support different reporting needs from different health programs, with the ability to automatically generate aggregated data to the national health management information system (DHIS). In addition, Training and Advisory applications where the outreach health workers can request and be advised on general medical and health knowledge, in which training purposes can be embedded. These systems will create communication possibilities across hierarchy and among peers, as well as creating feedback channels for the lowest level to be informed. The systems will be based on the concept of flexible standards with an ease for customization, localization including language and most importantly based on the spirit of open-source. The systems shall run on a low resource setting including mobile phones. The diseases surveillance aspect is an important activity that guides public health action to prevent and control diseases and hence an important component of prevention and control strategies. In addition, the system will act as a feeder to aggregate reporting and analyzing systems like DHIS and contribute to the quality of information which is crucial in public health domain. Because the CBHIS is a name-based system, where individuals will be registered and tracked throughout the duration of the health program they are enrolled in, it is in a position to provide a nearly accurate picture of individual or community health status. Also, within the CBHIS we will explore automatic messages to pregnant women about antenatal visits and to families with babies about immunization. For chronically ill patients e.g. AIDS, the system can remind them of taking medication and they can report back on their status. In these ways, MobiHealth will utilize mobile phones for strengthening the client-staff network. Communication of health data between the clinics and their district administration, support from supervisors and consultations with expertise in the hospitals are normally carried out by people travelling by car. Reporting, feedback, supervision and discussions are hampered by this form of contact, so MobiHealth will try to improve collaboration and information flow both ways between health staff communities by means of the applications mentioned above. Village health workers, birth attendants and voluntary health assistants need contact with clinics and hospitals for consultation of difficult cases and for emergency services during deliveries. They also need to be updated on medical and administrative routines and other changes affecting their work. In addition, they report to the clinic administration on their work and on the health in the villages. Due to the shortage of staff and time consuming and expensive travels, keeping close physical contact is difficult.

Hypotheses
Addressing the objectives (see grant application) we plan an action research project with field sites in four developing countries designed to test the following hypotheses.

H1: Mobile applications and usage can bridge the digital divide in areas with no computers and Internet. H2: Understanding and reinforcing the social networks at the village and district levels will be the key to establish a sustainable health service network. H3: Knowledge and software can be shared across countries and practices with an ease for customization and localization. H4: Generic software based on open source can be developed on a mobile platform to cater for the various needs of health programs such as Immunization, Mother & Child care, HIV, Malaria etc These hypotheses will be empirically operationalized through a set of action and result oriented sub goals and deliveries (see grant application) which will be explored across the global range of existing infrastructures through pilot sites. While the activities mentioned in 2.2.1 address the health sector in particular, the core idea of using mobiles to replace other computer technology in areas with poor infrastructure except GSM coverage is a general one. Hypothesis 1 will therefore also require comparisons with other sectors.

Research Methods
Our research group has a long tradition of conducting action-oriented and interpretative research1617. In a similar vein, the MobiHealth project will be conducted as collaborative action research18. In particular, we will use the canonical action research method192021 for each of the four field studies. The canonical action research method is characterized by its cyclical process model, rigorous structure, collaborative researcher involvement, and primary goals of organizational development and scientific knowledge22. The canonical action research method has proven to be productive in applied research that seeks topnotch knowledge contributions. Although there are a variety of action research approaches available to information systems researchers (ibid), Susman and Evereds23 canonical action research method is one of the most widely adopted24. As a canon of action research, the method formalizes the standards of this iterative, rigorous, and collaborative research process by describing it in terms of the following five phases: Diagnosing refers to the joint (researcher and practitioner) identification of situated problems and their underlying causes. During this phase, researchers and practitioners jointly formulate a working hypothesis of the research phenomenon to be used in the subsequent phases of the action research cycle.

16

Braa, J., O. Hanseth, et al. (2007). "Developing Health Information Systems in Developing Countries: The Flexible Standards Strategy." MIS Quarterly 31(2): 381-402 17 Braa, J., E. Monteiro, et al. (2004). "Networks of Action: Sustainable Health Information Systems Across Developing Countries." MIS Quarterly 28(3): 337-362 18 Mathiassen, L. (2002). "Collaborative Practice Research." IT & People 15(4): 321-345
19 20

Davison, R. M., M. G. Martinsons, et al. (2004). "Principles of Canonical Action Research." Information Systems Journal 14: 65-86

Lindgren, R., O. Henfridsson, et al. (2004). "Design Principles for Competence Management Systems: A Synthesis of an Action Research Study." MIS Quarterly 28(3): 435-472. 21 Susman, G. and R. Evered (1978). "An Assessment of the Scientific Merits of Action Research." Administrative Science Quarterly 23: 582-603. 22 Baskerville, R. L. and A. T. Wood-Harper (1998). "Diversity in Information Systems Action Research Methods." European Journal of Information Systems 7(2): 90-107. 23 Susman, G. and R. Evered (1978). "An Assessment of the Scientific Merits of Action Research." Administrative Science Quarterly 23: 582-603. 24 Davison, R. M., M. G. Martinsons, et al. (2004). "Principles of Canonical Action Research." Information Systems Journal 14: 65-86

Action planning is the process of specifying the actions that can improve the problem situation. Typically, this process includes specifications of IT-prototypes based on problems discovered in the diagnosing phase. Action taking refers to the implementation of the intervention specified in the action planning phase. Evaluating entails the joint assessment of the intervention by practitioners and researchers. This is typically done in the practical problem situation in which the initial diagnosis was conducted. Specifying learning denotes the ongoing process of documenting and summing up the learning outcomes of the action research cycle. These learning outcomes should constitute knowledge contributions to both theory and practice, but they are also recognized as temporary understandings that serve as the starting point for a new cycle of inquiry.

In sum, our previous research demonstrates that the action research methodology is an excellent basis for guiding applied research as to ensure the fulfillment of the dual goal of contributing to practical relevance and scientific excellence2526. MobiHealth builds on previous and ongoing research and implementation activities within the HISP network. In particular, we have identified the sites in India, Nigeria, Malawi, and Vietnam as particularly suitable for studies of mobile solutions for health service networks. The canonical action research method will be applied to each of the sites as outlined above. This will not only facilitate the coordination of the project but also enable comparative studies. Criteria for choosing the countries is where DHIS is implemented, where there is a strong HISP team and where the physical and technical infrastructure is in a state where mobile will be beneficiary. The technical infrastructure in these countries varies significantly, with Vietnam being the only well developed Internet infrastructure. On the opposite side Nigeria and Malawi are the countries with least developed Internet and computer infrastructure. India having very low Internet penetration, however expanding their mobile infrastructure through enabling new standards such as 3G, which facilitates faster data transfer rates and hence enables the usage of content rich mobile internet applications.

2.3 Project plan, project management organization and cooperation

The MobiHealth project covers 4 years (2010 2013) (see milestones and deliverables in grant form) and will be organized as work packages supported by effective project management for coordinating and sharing of best practice. A central challenge of the project is to deal with the complexity of health service network innovation, resulting from the multiplicity of actors and technologies involved. In addition, research will be conducted in low-resource settings where the infrastructure requires smart ways of organizing the research endeavor. A key research strategy is to involve local health personnel, not only for obtaining information, but also to participate in the design and evaluation of the technical solution in an action research framework. The project group will consist of both academic staff and field site representatives (see grant application).

25

Braa, J., O. Hanseth, et al. (2007). "Developing Health Information Systems in Developing Countries: The Flexible Standards Strategy." MIS Quarterly 31(2): 381-402 26 Braa, J., E. Monteiro, et al. (2004). "Networks of Action: Sustainable Health Information Systems Across Developing Countries." MIS Quarterly 28(3): 337-362

The research will be organized as collaborative practice research, 27 as depicted n Figure 1 below.

Figure 1: Project overview Key competences needed for the project are: Strengthening country competence in Mhealth: The project will be conducted in countries with quite diverse cultures and levels of technology, and local knowledge and contacts are seminal to achieving the aims and objectives. Jrn Braa, Jens Kaasbll, Eric Monteiro, Sundeep Sahay have been part of HISP from the beginning and Sundeep has headed the HISP activities in India since inception in 1999. Public health competence: The domain of DHIS require in depth competence within public health, epidemiology and health management. Paul Biondich, the founder of OpenMRS and Vincent Shaw are both physicians. Chris Moyo has years of experience of health management. In addition all the local teams will include doctors at different levels. Social network theory: The core research aim is to understand how m-health solutions may empower health personnel through social networks. Both theoretically and methodologically this requires insight in the formation and the dynamics of social networks. Bendik Bygstad and Kristin Braa have worked in this field for several years. Mobile practice theory: The project aims at developing new concepts in order to contribute to a theory of mobile practice. Strong competence is thus needed within mobile technology, behavior science and theory building. Ola Hendfridson, Kristin Braa and Jo Herstad have 10 years of experience in mobile technology design and behavior research. Method: The project is methodologically quite challenging, requiring strong skills in conducting action research at village level. All seniors have taken part in several action research projects (e.g. Braa et al 2004), and are inventors of the networks of action research approach.

The commitment and involvement of the seemingly large number of researchers and field sites is facilitated by the design of the projects environment. Our dual goal to improve practice and build knowledge is what drives this environment forward. In fact, since mobile health service networks present us with challenges that lie in the forefront of both research and practice, academics and practitioners need to work together in pursuing the projects goals. WP 1: Project management: The project will be coordinated and managed from the University of Oslo. Kristin Braa, as project manager, will work 40 % on the project. In each country a project team will be established with one person responsible. The Norwegian management team together with the
27

Mathiassen, L. (2002). "Collaborative Practice Research." IT & People 15(4): 321-345.

country coordinators will constitute the project board which will meet annually. A web tool will be established and used for reporting and internal project communication. A detailed project plan including the 3 work packages will be developed by the project team discussed at the first workshop. Each country project develops a country plan which will also be discussed and decided at the workshop. The project plan will be revised and updated every year. Deliverables WP1: D1.1 Detailed project plan developed to be revised annually. D1.2 Establishing website and wiki for internal, external communication, and software repository D1.3 Establish country team in collaboration with the local partners D1.4 Establish network of developers WP 2: Research on developing, piloting and evaluating MobiHealth: The five action research phases will be conducted and repeated throughout the project in all the four countries. The parts of the action planning which includes software development will be coordinated, such that the general properties of the solutions can be separated form the country specific ones. There will be one common software development team with one key responsible developer in each country that will work with the global. Collaboration will be supported by workshops as well as the establishment of an electronic forum for the developers. The local MobiHealth team will consist of a PhD student and a technical/field work assistant. The PhD student and her/his supervisor from Oslo will jointly manage the local project, and be part of the local HISP team. During the last year of the project, the PhD students will work on completing their theses in Oslo. The evaluation of sustainability will therefore be carried out by the researchers from Oslo with assistance from the local technician. In order to ensure the systematic documentation of actions, events and results during the project, each local project manager will have a field work assistant appointed, with the specific responsibility of collecting the primary data of the process. In addition to interview summaries and minutes, the documentation will also include source code and mobile interfaces, digital video and audio, and photos. A central project documents base will be established, in order to ensure a relatively uniform documentation, allowing for comprehensive case analysis and cross-case analyses28. Deliverables WP2: D2.1 Develop of generic MobiHealth software, including integration with DHIS D2.2 Establish pilots in India, Nigeria, Malawi and Vietnam D2.3 Evaluation on impacts of information on health service networks and delivery WP 3: Networking and Knowledge Dissemination: In this work package we address knowledge sharing and knowledge dissemination within and across country by involving all the different actors in the MobiHealth project. MobiHealth forum: The MobiHealth forum is the platform for knowledge sharing between the health service networks and their action research projects. Input from the various evaluations of pilots in the
28

Miles, M.B., and Huberman, A.M. (1994). Qualitative Data Analysis, (2nd ed.). Thousand Oaks: Sage Publications.

different countries will be shared in the MobiHealth forum. Participants (both researchers and practitioners) from each network will disseminate the experiences gained throughout the process. University of Oslo will be the coordinator of the MobiHealth forum. The MobiHealth forum will be held once a year. The last meeting will be open to the general public, where representatives of other industry networks, living labs, and innovation consortia will be especially invited. Researchers forum: The researchers forum seeks to support the academic side of the project by providing a platform for knowledge exchange between researchers at the different sites. At these meetings, people from the international network will be invited to provide their international experiences to our MobiHealth project. The project will have a core of senior researchers that will contribute to theory building and research methodology. They will have the key responsibility for the knowledge dissemination. The workshops will be important in that respect where the PhD students and senior researcher work together on analysis of the different field material. International network: The international network consists of researchers in the information systems and health area. Apart from continuous collaboration through virtual forums, we plan to organize two meetings when the international network meets project participants in the Researchers forum. Key seniors from OpenMRS, Open Rosa, OASIS and the Millennium Village Project will take part in the international network. Deliverables WP3: D3.1: Organization of bi-annual MobiHealth forum. D3.2: Organization of Researchers forum. D3.3: Evaluation of pilots in a comparative perspective

Collaboration
The consortium partners and their expected contributions to this project are summarized in the following. HISP India has more than 10 years experience of working with health information systems in India. DHIS is currently being deployed in almost all states in India to support sub district data registration and analysis activities, and is integrated with the national database through the Ministry of Health web portal. HISP India is in collaboration with Ministry of Health and with support from Norad piloting a mobile based sub-center reporting in 5 states. Health workers in facilities at the lowest level are provided with a mobile to report routine data to the district and state level through the DHIS. Malawi has been running a basic health information system by use of DHIS since 2003. Recently, researchers at the University of Malawi have become engaged in the further development and research in close cooperation with the Ministry of Health. GSM is the only viable network. Nigeria has been using the DHIS at the national and state levels. However, computer equipment is usually either in short supply or poorly maintained where it exists. Power supply is very poor; and transportation through long distances and from hard-to-reach areas is difficult. We are currently piloting sub-center reporting through mobiles in one cluster in 2 states to overcome these problems. HISP started out in Vietnam in 2005 as a collaboration project with a local university in Ho Chi Minh City. Today HISP Vietnam acts as an individual team of 9 members based in HCMC with competence in the software development as well as the medical domain. The team takes the responsibility in developing both the global DHIS software as well as supporting local requirements by developing

customized modules. The team also works to implement and develop the Vietnamese HIS both at the national and province level.

Country and institutional partner

Department of Informatics, University of Oslo Ministry of Health Malawi University of Malawi HISP India: Society for Health Information Systems Programmes Birla Institute of Technology and Science (BITS, Pilani), India HISP Nigeria HISP Vietnam OASIS OpenMRS OpenRosa Millennium Village Project

Role and input to the MobiHealth project

Coordination overall project and network of partners. Providing the direction on the technical systems development. Supervise PhD and Master students. Run the PhD program. Provide overall direction in bringing in the public health and medical knowledge into the design Take part in the country team and teaching mobile technology to Master students. Coordinate pilot site in India and take part in development team. Technical systems development and the implementation of solutions. Implementing organization for HISP activities in India since 2000. Has implementation experience of running mobile HMIS pilots in 5 states. BITS is one of the leading university of India. BITS will provide overall direction in bringing in the public health and medical knowledge into the implementation and training. Coordinate pilot site in Nigeria and take part in development team. Implementing organization for HISP activities in Nigeria since 2003. Running mobile HMIS pilots in 2 states. Coordinate pilot site in Vietnam and will take a lead part in the development team. Participating in the researchers forum on the competence of open architecture. Participating in the researchers forum with the experience of open source based medical record implementations in developing countries. OpenRosa fosters open source, standards-based tools for mobile devices. Participating in the researchers forum with the experience of e.g.JavaRosa Participating in the researchers forum with the experience of implementation strategies

3 Perspectives and compliances

3.1 Compliance with strategic documents.
On a global level, MobiHealth addresses key challenges identified by the WHO and Health Metrics Network for strengthening the systematic management of health information through the use of integrated information systems. The Norwegian Government is also firmly committed to supporting the WHO and United Nations Millennium Development Goals, and has launched their MDG 4 & 5 initiative in 4 countries, including India and Nigeria. National policy documents from the Norwegian Ministry of Health has repeatedly underscored the importance of making Norwegian health infrastructure across regions, disciplines and professions more seamless i.e. integrated . MobiHealth is in line with the Department of Informatics, UiO strategy. In India, Nigeria, Malawi and Vietnam MobiHealth are in line with national health policy documents.

3.2 Relevance to society

The sub-objective 1 on extending the Internet, computers and the electricity grid with mobiles is a general principle which can be exploited in other sectors as well, e.g., education, agriculture and transport. Reports on use of GSM and Internet in these settings point to needs for communication, and MobiHealths focus on supporting and extending social networks will extend the knowledge of mobile solutions for such purposes in developing as well as developed countries.

Further, this principle points to a possible policy for developing countries on how to bridge parts of the digital gap by exploiting the mobile technology.

3.3 Environmental aspects. N/A. 3.4 Ethical aspects.

The project is working closely with WHO and involved Ministries of Health in the implementation countries and will follow closely their instructions on ethical issues. Specifically, MobiHealth will seek permission from the respective national committees for ethical approval, with a detailed plan for how patient information is collected, stored, managed, and removed from areas outside of the health sector itself.

3.5 Gender equity and gender perspectives

The focus on the Norwegian Governments MDG 4 & 5 initiative (reducing maternal and child mortality) is directly linked to gender equity. Also in Norway and other developed countries, the improvement of public health objectives of MobiHealth are linked to gender equity as women and children are key beneficiaries of public health services. Gender equality is the key issue in this target, and collecting gender specific information is one of the challenges to be addressed by the project. While computers have been a male dominated world, mobile phones have a relatively larger proportion of female users, e.g., the well known female owned village phone business in Bangladesh. Mobile phones have also opened for improved communication between the housewives in villages who have migrant worker husbands in cities. A policy of extending the Internet through the GSM network is therefore also a policy of improved gender equity. From the project management point of view, we will ensure that at least 40% of researchers and PhD students engaged by the project are women.

4 Communication with users and utilization of results

4.1 Communication with users
Results will also be communicated through the Indian, Vietnamese, Malawian and Nigerian Ministries of Health through practical improvements. Ultimately it is the common citizen who will benefit from the improved health services. The project will follow a participatory action approach and cooperation and communication with users is an integral part of the research approach. The last MobiHealth forum will be dedicated to a wider audience where industry networks, living labs, and innovation consortia will be especially invited.

4.2 Dissemination plan

In addition to the research outputs (see grant application form), the project will aim at wide dissemination to the research community, including journals and conferences. Further, the production of products and services which will strengthen the capacity of health services, and also provide firms with more innovative business opportunities, will be developed and made available. Software and other products of the project are all free and open source. Among the channels to be used for dissemination is HISP web portal (www.hisp.info), which contains downloadable open source software as well as auxiliary documents (see grant application for further details).