mHero

This case study was originally published in the mHealth Compendium Special Edition 2016, developed by the African Strategies for Health project, implemented by Management Sciences for Health with support from the U.S. Agency for International Development (USAID). Updates to the original case study, submitted by the implementing organization in March 2021, appear in the final section of this case study.

Introduction

MHero is a two-way, mobile phone-based communication platform that uses basic text messaging, or SMS, to connect ministries of health and health workers. mHero operates on simple talk-and-text mobile devices—no smartphone or tablet required.

MHero is not a new technology. It’s a way to connect data from existing health information systems (HIS) to allow targeted, real-time communication. mHero brings together components of a country’s HIS using open international interoperability standards for health information exchange. Health officials can use mHero to:

• Communicate critical messages to health workers during a crisis;
• Target messages to health workers based on cadre, location, or skill set;
• Collect critical information that supports resilient health systems, including stock levels, routine formal and informal indicators, one-time assessments, and validation of health worker and facility data; and
• Support surveillance systems for real-time reporting on active cases and potential outbreaks and to reinforce health workers’ skills—part of a country’s solution for Integrated Disease Surveillance and Response (IDSR).

Harnessing the principles for digital development—guidelines that can help development practitioners integrate established best practices into technology-enabled programs—IntraHealth International and UNICEF created mHero in August 2014 to support health sector communication during the Ebola outbreak in Liberia.¹  mHero is currently being scaled up in Liberia, piloted in Guinea and Sierra Leone, and deployed in Mali and Senegal as part of the Global Health Security Agenda to support IDSR use cases.

About mHero

MHero combines iHRIS, an open source human resources information system (HRIS) developed by Intra-Health, and RapidPro, UNICEF’s SMS platform that allows users to create SMS messages in a “workflow” through a website. mHero supports one-time messages to health workers or two-way communication between health workers and the ministry of health. Health workers can initiate messages themselves by sending a standardized SMS to the mHero phone number.

The technology behind mHero includes interoperability with other systems, such as DHIS2, through OpenHIE, an architecture that supports mHero as HIS expands and evolves. Using these open source systems, ministries of health are able to efficiently leverage health information technologies, many of which they have already invested in scaling to improve their own HIS.

What makes mHero work at national scale is rigorous adoption of open international standards for health in-formation data exchange. These include the Care Services Discovery (CSD), Mobile Alert Communication Management (mACM), and HL7 Fast Healthcare Interoperability Resources (FHIR) standards for sharing health worker and health facility data and to provide standards-based communication protocols for health workers. The open source and open standards approach means that the mHero platform is not tied to any specific piece of software and allows ministries of health to readily integrate mHero into their HIS.

A variety of tools support the mHero platform.² These include video tutorials on operating the platform; operations and management tools to support implementation; and a wiki to guide developers and program implementers setting up their own instances of the platform.^3,4

Program Design Process

The mHero platform is designed by facilitating interoperability of existing HIS. Linking iHRIS and RapidPro via an interlinked health worker registry, information on health workers (including cadre, facility, location), as well as their mobile numbers, are pulled from iHRIS and attached to the workflow developed in RapidPro. mHero was also created to be interoperable with District Health Information Software 2 (DHIS2) and interlinked facility registries to ensure standardized facility data are part of the mHero platform. Security, access control, and data synchronization services are provided through the OpenHIM software.

mHero’s initial development was supported by UNICEF, the U.S. Agency for International Development (USAID) through the K4Health Project, and Johnson & Johnson. The design process engaged a number of partners, including Jembi Health Systems, Thoughtworks, USAID, and others. An intentional multistakeholder approach was undertaken in the development and implementation of mHero to include as much collaboration as possible to ensure the platform aligned with other digital efforts to reach health workers, especially during the Ebola response. These stakeholders have expanded to include the World Health Organization, MEASURE Evaluation, Jhpiego, Management Sciences for Health, mPowering Frontline Health Workers, eHealth Africa, Johns Hopkins Center for Communication Programs, International Medical Corps, Dimagi, the Clinton Health Access Initiative and many others.

The most important stakeholder, however, is the ministry of health in the country in which mHero is implemented. mHero is fully integrated into and operated directly by the ministry. The ministry decides which use cases to prioritize and which health workers to target with messages, and develops and sends the workflows. IntraHealth works with the ministries and partners in the respective countries to align mHero with national policies and strategies so the platform can be utilized to support the existing (or future) HIS and to respond to priority health needs.

IntraHealth and UNICEF are building the capacity of mHero implementers at ministries of health in Liberia, Sierra Leone, and Guinea. This includes collaboration to strategically integrate mHero into existing data collection and reporting structures, training in RapidPro to create workflows and in operation of the platform through iHRIS, establishing interoperability between RapidPro and iHRIS, and developing standard operating procedures and other critical management processes to integrate mHero into the existing HIS framework.⁵

Growth in Scale

The first mHero use cases were developed to help Liberia’s Ministry of Health and Social Welfare determine the location of health workers during the Ebola response and which facilities were open. After a successful pilot in four facilities in four counties, the mHero team at the ministry began raising awareness of the platform among county-level stakeholders.

Interest in the system grew as officials realized the platform’s accessibility and flexibility, allowing for new use cases to be developed. These included collecting information about mental health services, conducting an assessment of anthropometric nutrition tools, alerting new staff to their payroll IDs, and collecting information from health workers on their level of family planning training, commodities supply, and service provision.⁶ To date, 22 distinct use cases have reached over 5,000 health workers throughout the country. The ministry is now engaging external partners in the development and sending of use cases, demonstrating its role in leading health worker communications in Liberia.

The success of mHero in Liberia can be attributed to the ministry mHero team’s ownership of the platform and commitment to ensuring mHero is aligned with Liberia’s HIS and that the platform is successful in responding to the ministry’s information and communication needs. As mHero scaled in Liberia, ministries in Guinea and Sierra Leone began planning implementations. Officials from the three countries met through iHRIS and mHero trainings to share experiences developing and deploying the platform, including integration into ministry and HIS structures and best practices for strategic development of meaningful use cases. As of March 2016, the ministry in Sierra Leone had planned its use cases and was close to piloting the platform. Efforts to build a sustainable base for mHero in Guinea are gaining momentum as the ministry develops its HIS strategic plan. USAID has supported scale-up of mHero in the three countries through the Ebola Grand Challenge Innovation Grant through the Global Health Bureau.

In Mali, IntraHealth is working with the Ministry of Health to develop and deploy mHero in both SMS and interactive voice response (IVR) formats to support the surveillance system, including enhancements in real-time reporting and reinforcement of health workers’ skill sets during the surveillance process. In Senegal, the Ministry of Health is deploying a version of mHero across its health regions.

Evaluation and Results

In November 2015, one year after the initial pilot, a baseline assessment was conducted in Liberia to measure frontline health workers’ awareness of, use of, and attitudes toward mHero. Ten-question phone surveys were administered to 266 randomly selected recipients who fit the definition of a frontline health worker. A randomly selected subsample of 20 health workers responded to an extended survey. This survey featured additional queries that elicited more detailed information about respondents’ phone use, including mobile technologies such game playing, accessing social media, and taking online courses. The extended survey also probed participants’ phone use patterns, such as preferred times for receiving and responding to text messages.

Overall, survey findings at baseline proved very preliminary due to a lack of awareness of mHero among respondents. Out of the 266 respondents, only 7.9% of the health workers had heard of mHero, and even fewer knew that mHero was associated with Liberia’s Ministry of Health and Social Welfare. The largest factor contributing to awareness of mHero was exposure, as 81% of those who knew of the platform had received an SMS sent via mHero. Health workers identified various factors motivating them to respond to these messages, with the most frequent reason being that they had been told about mHero prior to receiving the text. Responses to the extended survey indicate that health workers almost universally bring their phones to work each day, and more use their phones for connecting to social media than they do for playing games or taking courses. Health workers report receiving a wide variety of health-related texts each month of varying origin.

An endline assessment using the same questions will be conducted in Liberia in July 2016 toward the end of the USAID Ebola Grand Challenge Project.

Lessons Learned

A number of key insights and lessons learned have emerged since mHero’s initial pilot in late 2014. These include:

• Ministry of health leadership and ownership: mHero’s success depends on the ministry stakeholders who utilize and implement the platform. It can take time to build a sense of ownership, to identify the strategic “home” for mHero within the ministry, and to integrate mHero into the HIS architecture.
• Awareness-raising with health workers: To encourage their active engagement, health workers need to know that mHero messages are legitimately from the ministry and that their responses are important for decision-making. Flyers, brochures, and other communication tools can help spread the word.
• Infrastructure: mHero’s functionality depends on a number of infrastructure components, including adequate software and hardware to operate the platform and mobile network service throughout the country. Inadequate infrastructure has delayed mHero implementation, in some cases more so than expected, but IntraHealth is working with other implementing partners to improve infrastructure in Liberia, Guinea, and Sierra Leone. The needed infrastructural investments are not extreme and can support other subsystems of an HIS and basic operations of the ministry. This includes basic Internet connection, procuring laptops for ministry staff, and provision of servers and backup servers for data and ensuring security of mHero and iHRIS data. Working with other partners and donors to ensure a strategic approach to infrastructure improvement is important, especially during an emergency response when coordination of investments is challenging.
• Implementation capacity: Though mHero harnesses existing technology, the processes for implementing mHero are new. Ensuring ongoing capacity-building for mHero team members to not only facilitate the interoperability of the systems but also establish procedures that fit within their local context is important, as is building capacity to manage and use data. Through ongoing training and mentorship, both from a distance and through short-term technical assistance, IntraHealth continues to work with mHero teams in the respective ministries to foster skills-building in systems operations and data use. Staff turnover and non-mHero work demands have posed challenges, thus an organizational development approach must be taken in capacity-building efforts.
• Engaging other external partners: Many other donors and implementing partners have been operating in Liberia, Guinea, and Sierra Leone to support the Ebola response and rebuilding efforts, creating an additional but important layer of collaboration and commitment for mHero implementation to be successful.

Future Plans

The future of mHero focuses on thoughtful steps toward the full integration of the platform into ministry of health HIS plans and procedures, ensuring strategic use of the platform to support the needs of health workers and ministries, and raising awareness to encourage message response. Future trainings on both iHRIS and mHero have been planned, as well as workshops on the strategic use of data to inform programmatic and policy decisions. Discussions about interoperability are underway to ensure mHero can directly support other HIS subsystems. Pilot messages will be initiated in Sierra Leone, Guinea, and Liberia in the coming months, demonstrating full regional scale of the platform. In addition, the Liberia ministry is interested in decentralizing use of mHero so that county human resource officers can use it to communicate with health workers in facilities.

Other future plans to expand the capability of the mHero platform include the following:

• Providing mHero functionality at the level of the Interlinked Health Worker Registry, rather than iHRIS, for countries or programs that do not use iHRIS
• Tighter integration with DHIS2 for routine data collection as well as alerts and reminders to support the routine data-collection process
• Streamlined integration for communication with a health facility’s point of contact
• Integration with other communication platforms as alternatives to RapidPro (e.g., CommCare) for countries that are comfortable with their existing platform
• Expanded analytics capabilities

PROJECT UPDATES

IntraHealth International completed major core software improvements in early 2020, resulting in mHero 2.0. The primary reason for the update was to rebuild mHero to be based on the global Fast Healthcare Interoperability Resources (FHIR) standard, as iHRIS was also being updated to be based on FHIR. The update made mHero more widely interoperable with any FHIR-based health information systems (HIS), including DHIS2, OpenMRS, and others. Additionally, mHero supports the Flow Interoperability standards, which enable sharing of data collected through message flows even when done via other communication platforms beyond RapidPro. This greater interoperability expands the possible use cases for mHero.

In the software updates, changes and additions were made to the features and functionality of mHero based on feedback from past users as well as new users. These additions and improvements are ongoing but have so far included the ability to compose new messages within the mHero interface; a simplified process for installation, configuration, and deployment; flexibility to connect to various communication channels beyond SMS; two-way syncing of contacts and contact groups; improved reports and visualizations; options that support sending messages or flows to large groups and even the entire health workforce; the possibility to schedule the sending of a message or message flow for a future time and on a recurring basis; and more.

User and developer documentation has been improved, with a user guide, new tip sheets, a readiness check tool, training materials, and resources related to installation and configuration.

mHero was credited by USAID as an important contributor to controlling the Ebola outbreak by delivering fast, informative communication to frontline health workers, and transmitting immediate, precise case reporting from them (Fast and Waugaman. 2016). mHero has been continuously used in Liberia for general health sector communication—from notifications about upcoming data review visits to knowledge checks related to COVID-19—as well as for tracking stock levels of important supplies, commodities, drugs, and vaccines. Importantly, mHero is used in Liberia for disease surveillance, which was crucial in the post-Ebola outbreak period, and also made it possible to quickly add COVID-19 as a disease that could be reported. Since the initial case study was submitted, Liberia’s Ministry of Health and Social Welfare has independently managed and operated mHero on a national scale. Millions of messages from hundreds of message flows have been sent and received via mHero.

Through a variety of different activities and sources of funding, mHero has also been installed and deployed in Uganda, Kenya, and DRC, in addition to testing or use on a small scale in Sierra Leone, Guinea, Senegal, and Mali.

• In Uganda, UNICEF is using mHero to sync contact information between their community health worker registry and FamilyConnect, a RapidPro system that is used to send out stage- and age-based messages to pregnant women and new mothers.
• In Kenya, the HRH Mechanism is using mHero to send training refresher content and reminders of key messages related to COVID-19 (such as contact tracing, home-based isolation care, infection prevention and control, stigma and psychosocial support, and more). 
• In DRC, mHero is being used initially to check in on the health and safety of health workers, asking if they are experiencing any COVID-19 symptoms and whether they are using PPE.

Project Evaluation

As part of USAID’s Fighting Ebola Grand Challenge, IntraHealth International conducted an end line assessment of frontline health workers in Liberia in July–August 2016 to measure changes in awareness of, use of, and attitudes toward mHero, as compared to baseline data captured in October–November 2015. The same short survey, consisting of a maximum of nine questions, administered by phone during the baseline assessment was used for the end line assessment. A random sample of 426 health workers, stratified by county, was selected for the survey, of which the research team was able to reach 246.

Overall, survey findings showed an increase in health worker awareness of mHero from November 2015 to August 2016. At end line, the percentage of respondents who had heard of mHero prior to participating in the survey increased 138% from the baseline. The number of health workers who correctly responded that the Liberia Ministry of Health (MOH) sends mHero SMS increased 333% from the baseline. As with the baseline, the largest factor contributing to awareness of mHero was exposure, with 85% of those who knew of the platform reporting that they had received an SMS sent via mHero. These findings indicate that the MOH’s use of mHero had expanded greatly over the course of implementation. The majority of health workers indicated that they were motivated to reply to mHero messages because the texts related to their job, while others indicated that it was part of their role as health workers to respond to SMS from the ministry. Framing their motivations to respond as a responsibility, or part of their job duties, was a valuable finding, as it demonstrated that mHero was gaining acceptance among health workers in Liberia as an on-the-job tool. 

The recommendation was for the MOH to capitalize on the high level of awareness and motivation to use mHero for new communication and data collection use cases. Additionally, successful implementation of the platform within the MOH demonstrated that mHero could be considered a communication platform for other ministries within the government of Liberia.

The continuous use of mHero in Liberia since it was initially deployed in 2014 is a testament to the sustainability of the platform by local health officials beyond the scope and support of a donor-funded project.

References/Resources

Original Case Study

1. “The Principles.” Principles for Digital Development, accessed March 15, 2016. http://digitalprinciples.org/

2. “Toolbox & Resources.” mHero.org, last modified April 19, 2016, http://www.mhero.org/toolbox-resources

3. Leitner, Carl. “mHero Videos by Carl.” YouTube.com, last modified September 1, 2015, https://www.youtube.com/playlist?list=PLVSgzqqaj15C4JEF-_GD5n8553ZgO_Nc

4. “MHero Installation and Configuration.” ihris.org, last modified March 1, 2016. https://wiki.ihris.org/wiki/MHero_Installation_and_Configuration

5. “RapidPro Table of Contents.” RapidPro.io, accessed March 21, 2016. http://docs.rapidpro.io/

6. Puckett BenDor, Amanda; Nicholson, Emily. “Spotlight: mHero Connects Frontline Health Workers with Mental Health Services in Liberia.” IntraHealth.org. December, 2015. http://www.intrahealth.org/page/mheromentalhealth

Project Updates

Fast, Larissa and Adele Waugaman, Fighting Ebola with Information: Learning from the Use of Data, Information, and Digital Technologies in the West Africa Ebola Response (Washington, DC: USAID, 2016). https://www.usaid.gov/sites/default/files/documents/15396/FightingEbolaWithInformation.pdf.