FCV Health Knowledge Notes Using Technology in Fragile, Conflict, and Violence (FCV) Situations Five key questions to be answered Many technologies are now widely used by humanitarian and development partners to collect data, improve planning and project implementation, and strengthen monitoring and evaluation in fragile and conflict-affected contexts—and many other technologies are in the pipeline. Within the World Bank, there is growing interest to incorporate technology more strongly into FCV projects; at the same time, there is also a recognition that technology is not a “one size fits all” solution, and some technologies may be more appropriate for certain contexts than others. This note offers some basic guidance to Task Team Leaders (TTLs) on how to approach this “new frontier” when considering the use of technology in FCV health projects. WHAT challenges can technology help address Q1 in FCV settings? Challenge How technology can help  Many remote technologies such as satellite imagery, social media, and radiofrequency identification (RFID) do not require strong ground presence for data collection  Geospatial information systems (GIS) can help manage and collate field data to identify Planning and data collection needs, detect emerging trends, and help with efficient resource allocation  Social media, SMS text messaging, and mobile apps can identify user needs when traditional surveys are not feasible  SMS or tablet-based surveys can be quicker to deploy and analyze, with field data rapidly uploaded to the cloud Need for flexibility and adaptation  Satellite imagery and social media can provide near real-time updates on changing conditions; social media posts are often geocoded, providing valuable localizing detail as well  SMS, mobile, and web-based platforms can connect patients with emergency services, improve supply chain management, deliver education messages, and monitor adherence to medications  Telemedicine, virtual counseling, and e-learning can provide services to otherwise Implementation and service delivery inaccessible or difficult to reach populations  E-learning tools can provide valuable guidance and advice to clinicians and facility mangers  Drones, mobile medical equipment, and cheap 3D printers can improve the delivery and availability of aid and basic supplies in remote or hard-to-reach areas  Many technologies, such as GPS tracking, RFID, and geospatial mapping, can track the delivery of inputs and ensure that services (and providers) are reaching their intended populations Oversight, monitoring, and  Social media can serve as a powerful grievance redress mechanism, giving recipients transparency (and populations at large) a platform for voicing needs and dissatisfaction  Mobile or digital payments to health workers can help ensure that salaries or bonuses reach the intended recipient and are not being diverted by intermediaries 1 Source: UN News WHAT basic enabling Regulatory and legal frameworks: Some countries have Q2 factors should be policies and regulations restricting the use of certain technologies. During the Ebola crisis, for example, assessed for technologies electronic payments to health workers were allowed in in FCV settings? Sierra Leone, but for legal reasons not as easily replicated in neighboring Ebola-affected countries. Capacity of existing infrastructure: Many technologies require stable electricity, mobile, or wireless networks. Local capacity: Some technologies require greater TTLs should carefully assess the scope, capacity, and maintenance, field testing, trouble-shooting, etc. upon reliability of in-country networks before proposing deployment, and necessary local capacity should be technologies that depend upon such infrastructure. ensured to safeguard against delays. Technology saturation and use: Contrary to some Appropriateness for task: The choice of technology must beliefs, cellphone ownership and social media use are often be tailored to the problem at hand. Although satellite quite high among populations in FCV settings, particularly imagery, for example, is good at identifying airstrike refugees and forcibly displaced persons. This is not damage and new refugee camps, it may fail to detect street- universally true, though, and cellphone/social media use level damage or displaced populations living in buildings in may lag among certain age groups, income quintiles, etc. urban areas, etc. Q3 WHAT risks and limitations should be considered with these technologies? BOX 1.1 Risk Considerations when Selecting Technologies in FCV projects  Bias. Technologies can make data collection faster and easier, but they can also introduce bias. If cellphone ownership is concentrated in certain areas or among certain demographics, SMS-based surveys will disproportionately capture those groups and may not be appropriately representative of populations in need.  Verification. Data collected using remote technologies often needs to be verified through other modalities to ensure accuracy and reliability. This process often involves some degree of “triangulation” with other sources.  Safety. While remote technologies can make data collection safer, some technologies may expose in-country teams to elevated risks. Because tablets can be resold for a profit, for example, using them may make survey teams targets for theft or attack. Armed groups have also been documented as harassing enumerators using tablet-based technology.  Privacy. For technologies relying upon GPS data (cellphones, sensors, etc.) to track locations or population movement, care should be taken to ensure that all data is de-identified and no personal information is collected without consent. Authorities in many Arab spring countries have used social media posts to identify and target outspoken critics.  Perception. Depending upon the context, the use of certain technologies, such as satellite imagery or GPS tracking, can be perceived as “spying” by populations or authorities, and care should be taken to explain these modalities in advance to local partners and ensure local acceptance.  Sustainability. Studies of mobile health pilot interventions have shown that many are often either discontinued or lack feasible plans for scale-up. Particularly for service delivery projects that may incorporate technological solutions, TTLs should consider barriers to scale-up and sustainability.  Cost. Cost of technology deployment can vary widely. The cost of satellite imagery, for example, depends upon the size of land area or resolution to be analyzed. Many mobile platforms are free, but programmers and surveyors are not. 2 Q4 HOW have technologies been used in World Bank FCV health projects? Technology Potential Uses in Example WB Details FCV Settings Project/Country • Early warning alerts • WB partner UNICEF is using • Health promotion and Yemen Emergency mobile platform RapidPro to education messages SMS text Health and Nutrition send SMS text messages to • Population surveys messaging Project (P163741) health workers and facility • Beneficiary feedback managers to collect monitoring • Third-party monitoring data on project implementation data collection • Data • WB-sponsored livelihood collection/surveys surveys are capturing data via • Medication hand-held devices, allowing Pulse of South Mobile apps compliance uploads to real-time Sudan • Diagnostic assistance dashboards, including • Supply chain questions on access to management hospitals • Decentralized e- • Partnership among donors and Democratic Republic health records/HMIS Ministry of Health to roll out a of Congo: Health Web-based • Supply chain decentralized HMIS based on Systems platforms management the DHIS-2 platform, with key Strengthening • E-learning tools and Project (P145965) data on inventory and digital counseling consumption • E-vouchers for health worker payments Sierra Leone: Ebola Electronic • Provided hazard pay to health • E-vouchers for health Emergency payment workers in Sierra Leone through services (refugees) Response Project systems national e-payment system • Cash-based aid for (P152359) displaced populations • In Syria, the Bank used high- • Tracking/quantifying Syria Economic and resolution satellite imagery to population movement Social Impact document infrastructure (IDPs, refugees) Analysis (ESIA) damage in hospitals in 10 cities Satellite • Assessing health (2017) (including Aleppo) imagery and infrastructure • In Somalia, the Bank and remote sensing damages, Somalia Drought partners used satellite imagery functionality, and Impact Needs to estimate IDP populations and accessibility Assessment (DINA) settlements in major urban (2018) areas, as well as access to health facilities • Crowdsourcing data collection on local • Social media analytics health needs, Iraq Damage and performed on more than 2 Social media infrastructure damage Needs Assessment million posts from Mosul, • Outbreak prediction (2018) including 40,000 commenting • Grievance redress on hospitals • Information “hubs” • Tracking mobile teams and health GPS tracking workers Nigeria: Polio • Used GPS tracking to monitor and Geospatial • Data collation, Eradication Support locations of vaccinator teams Information analysis, and Project (P130865) and ensure compliance Systems (GIS) visualization • Transparency of funding flows 3 WHAT “disruptive Q5 technologies” are on the horizon? Several technologies are being touted as potential “game- changers” for healthcare delivery. These include advances Source: Johns Hopkins University School of Medicine in data sharing, utilization, and verification—such as blockchain, big data, ground sensors, and artificial  Drones and ANTs: Automated drones (unmanned intelligence—as well as platforms and tools for healthcare aircraft systems) can map displaced populations, delivery, such as drones, biosensors, and new mobile provide real-time visuals on infrastructure damage, apps. Many remain experimental or aspirational in FCV and deliver medicines and supplies. The World Bank contexts, but some are already being used in the field. has used drones to model flooding risks in Tanzania and post-cyclone damages in Vanatua in 2015. Zipline  Blockchain: Blockchain is a decentralized record- launched the world’s first national-scale drone-based keeping technology that can improve transparency in blood delivery system in Rwanda in 2016. UN agencies financial agreements and help reduce corruption. have tested drones for mapping, planning, and delivery UNICEF’s innovation fund is supporting grants to start- in DRC, CAR, and Malawi. The UN has also deployed up companies exploring blockchain technology for unmanned vehicles called Aid Necessities improving contracts and resource delivery in FCV Transporters (ANTs) to deliver supplies over rough or settings. In 2017, the Bank launched a Blockchain Lab, insecure terrain. and some have suggested that blockchain could help improve supply chain management for vaccines. The  3D printers and portable medical equipment: Some technology remains largely investigational in FCV 3D printers now cost less than $1,000 and have been health applications. used in refugee settings to rapidly produce basic supplies. Examples of FCV-relevant medical  Artificial Intelligence (AI): Efforts to combine artificial technologies are also becoming more common, intelligence and mobile technology in healthcare are including mini-X-ray machines and solar-powered drug growing. In 2017, the UN held its first-ever “AI for refrigerators used by WHO. Global GOOD Summit,” spotlighting AI-based mobile  Geo-enabling: Geo-enabling can provide near real- programs to assist with medical diagnoses and ensure time monitoring and supervision of projects and medication compliance. Such efforts must be interventions through the of collection and analysis of considered within their context, as the former WHO geo-tagged field data. Using handheld ICT tools (i.e. Director-General noted: “What good does it do to get smartphones or tablets), geo-enabled data can an early diagnosis…if a country offers no opportunity automatically be uploaded and integrated into to a for treatment, has no specialists or specialized facilities central server where the information can be connected and equipment, or if the price of medicines is to the monitoring and evaluation framework or used to unaffordable?” effectively plan and develop projects.  Big Data: The World Bank defines big data as “datasets that are so large and complex that they  Uber-style apps: Uber-style apps are being used to cannot be processed by everyday database connect ambulances to patients in need. The Flare app management tools.” Real-world examples includes is one example currently being used in Kenya and GDELT, which catalogues news stories daily from Rwanda. The app allows first responders to see patient around the globe and allows users to track insecurity, locations in order choose the appropriate vehicles and social unrest, and other trends in FCV countries, and staff before responding. The GoodSAM app takes this the UN ‘s Global Pulse project, which mines social concept a step further, not only dispatching first media to track crisis-related stress. responders, but by allowing remote triage through cell phone cameras, as well as dispatching automated  Ground Sensors: Sensors that detect foot traffic and external defibrillators (AEDs) via drone when population movements may allow for more prospective emergencies arise. data collection. One possibility: monitoring real-time utilization in hospital settings. These include thermal, infrared, pressure-based, and other technologies. 4 BOX 1.2 Selected Resources for Further Reading:  World Health Organization. 2011. Mhealth: New Horizons for Health Through Mobile Technologies: Second Global Survey on E-health. Available: www.who.int/goe/publications/goe_mhealth_web.pdf  World Bank. 2011. Mobile Applications for the Health Sector. Available at: http://siteresources.worldbank.org/INFORMATIONANDCOMMUNICATIONANDTECHNOLOGIES/Resources/m Health_report.pdf  World Bank. 2015. Measuring and Monitoring in FCV Environments: Using New Methods and Technologies (Module VI). Available at: http://fcvindicators.worldbank.org/sites/fcv/files/FCV_Toolkit_mod6_UsingNewMethodsTechnology.pdf  World Bank. 2016. World Development Report: Sector Focus 3: E-health. Available at: http://documents.worldbank.org/curated/en/896971468194972881/310436360_20160263021031/additional/10 2725-PUB-Replacement-PUBLIC.pdf  Drones in Humanitarian Action: A Guide to the Use of Airbone Systems in Humanitarian Crises. Available: http://drones.fsd.ch/wp-content/uploads/2016/11/Drones-in-Humanitarian-Action.pdf  Dette, R. and J. Streets. April 2016. Innovating for Access: The Role of Technology in Monitoring Aid in Highly Insecure Environments. Available: https://odihpn.org/magazine/innovating-for-access-the-role-of-technology-in- monitoring-aid-in-highly-insecure-environments/  Otto K., M. Shekar, H. C. Herbst, and R. Mohammed. 2014. Information and Communication Technologies for Health Systems Strengthening Opportunities—Criteria for Success, and Innovation for Africa and Beyond. Washington, DC: International Bank for Reconstruction and Development/World Bank. Available: https://openknowledge.worldbank.org/handle/10986/21710  Technology for Evaluation in Fragile and Conflict-Affected States. April 2016. Working Paper. Available at: http://fletcher.tufts.edu/~/media/Fletcher/Microsites/Human%20Security/Technology%20and%20Evaluation%20 Hitachi%20Paper.pdf  Mesmar, S. et al. “The Impact of Digital Technology on Health of Populations Affected by Humanitarian Crises: Recent Innovations and Current Gaps.” Journal of Public Health Policy (2016), 37, S167–S200. doi:10.1057/s41271-016-0040-1.  Donini, Antonio and Maxwell, Daniel, “From Face-to-Face to Face-to-Screen: Remote Management, Effectiveness and Accountability of Humanitarian Action in Insecure Environments”, International Review of the Red Cross, Vol. 95, No. 890, 2014, pp. 383–413. Available: https://doi.org/10.1017/S1816383114000265  Lyseen, A. et al. A review and Framework for Categorizing Current Research and Development in Health- related Geographical Information Systems (GIS) Studies. Yearbook Med Inform 2014: 110-24. doi: 10.15265/IY-2014-0008.  Shaw N, McGuire S. “Understanding the Use of Geographical Information Systems (GIS) in Health Informatics Research: A Review.” J Innov Health Inform. 2017 Jun 23;24(2):940. doi: 10.14236/jhi.v24i2.940. • Barcock, A. 2015. Solutions That Are Saving Lives in Humanitarian Response. Aid and International Development Forum, Available at: http://www.aidforum.org/disaster-relief/top-solutions-that-are-saving-lives-in- humanitarian-response.  The FCV Health Knowledge Notes Series highlight operational tips to resolve health issues in FCV situations. These Notes are supported by the Middle East and North Africa Multi Donor Trust Fund and The State and Peacebuilding Fund (SPF). The SPF is a global fund to finance critical development operations and analysis in situations of fragility, conflict, and violence. The SPF is kindly supported by: Australia, Denmark, Germany, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, as well as IBRD. Authors: Kent Garber, Health Consultant, Health, Nutrition and Population Global Practice, World Bank Group Sheila Carrette, Health Consultant, Health, Nutrition and Population Global Practice, World Bank Group For more information on other HNP topics, go to www.worldbank.org/health 5