Leap

by Ruchit Nagar

They say an infant’s footprint can be used for biometric verification. The eyes, face, and fingerprints don’t work as well. It’s still a bit of a pain to uniquely identify between a pair of twins (we certainly don’t yet have an elegant solution if twins swap our necklaces besides use of some type of child-safe permanent toe-nail paint). Recently at the GAVI Infuse conference in Geneva, I learned from a fellow innovator about the advent of DNA-based identification for infants using a swab test and a microfluidics set-up to pick out sets of unique SNPs (Single Nucleotide Polymorphisms). This struck me as cool, but cost-prohibitive for the majority of the developing world.

But anyways, the aforementioned footprint of a child provides a metaphor (useful or not) to examine Khushi Baby’s progress these past months (since our last blog post – sorry about that we were very busy).

We’re young. Hardly 2 years old, we are still an early stage, “startup”, team. Our footprint resembles one of a child: twenty odd core members, core field staff, consultants, interns, and student volunteers who ask for little, sacrifice a whole lot, span three continents, and define our team. 25 more field staff will be joining next month. Our current median team member age is around 22. We’re young, broke, and unapologetically determined.

 

 

We’re also unique. Our footprint can be verified without much difficulty.

We recently had a chance to attend GAVI’s INFUSE workshop, which pooled 18 finalists who were leading the frontier of innovations for uptake, scale, and equity in immunization. Many teams were building data collection apps for nurses, just like us:

Medic Mobile, Akros, mTika, BroadReach, Commcare, Zindagi Mehfooz, Shifo, Fionet, and some others.

None provided a solution for the nurse who was unable to sync her device, who reached the field, and who was presented with a child from a different village – the nurse who had to guess the child’s vaccine record.

The same holds true for ANMOL, the UNICEF India supported app which was rolled out throughout the state of Andra Pradesh to collect maternal and child health, to replace the Reproductive and Child Health register, at the last mile.

That’s why we are unique. We started with the assumption that connectivity is not guaranteed. We built a system that can decentralize and digitize patient data at the point of care so that the interface between health worker and mother/child is held regardless of geography, device, or nurse. It’s a simple idea that the paper card already serves to purpose – that each patient should have a copy of their own medical record.

It’s equally important to note that a wearable copy of the record is more likely to be retained than a paper card. Our wearable in particular has a cultural significance to protect the child from evil eye that cuts across communities around the world, well beyond Northern India.

Our footprint is small, but it’s growing.

The Seva Mandir Randomized Controlled Trial presented us with 214 mothers to follow-up with in our system. We weren’t able to detect a measurable difference in our primary outcome: the timeliness of the mothers sticking to the vaccine schedule. We did however see some promise in the fact that the necklace was 5 times more likely to be retained than the paper equivalent by the third DTP vaccine of the child. Mothers were much more likely to discuss the necklace than the card with their household and community. Mothers accepted the necklace. The median time to sync the records was just under 60 hours (compared to over a month with the log book), and to date we have captured 15,012 vaccination attempts from just about 1,500 children. We can tell you how many of those vaccinations were successfully administered (north of 80%) and the reasons why some vaccines were denied. [Credit is due to John Swensen for the frontend and Praneeth Sadda for the backend for building our 1.0 system].

We started with infant vaccines. Now we are growing to cover the entire Reproductive Child Health Register. That in family planning, antenatal care, birth, postnatal care, and then infant vaccines. ANM nurses throughout India use this standard book prescribed by the National Health Mission. Now they will have an efficient, digital system to capture the same (117+ fields of data). Making things efficient matters. We understand the media exaggerates projects like ours to say that we have saved lives. To clarify, we have no evidence to prove that directly, but yes, saving lives is our ultimate aspiration. Process innovations that help aid the delivery of life saving care are still worthwhile and motivate us to believe in what we are doing. Our footprint is still small.

We’ve been incubated to grow our footprint beyond one of a small-scale research endeavor into one of a scale-ready social enterprise. Yes, the metaphor is still being milked.

UNICEF Innovation recognized us as one of two winners of their Wearables for Good Challenge last November. The months that have followed have been transformative for our growth.

We’ve been incubated by a mentorship community assembled by UNICEF Innovation including: Frog, Arm, FactoryX, Cooley, PCH International, Philips, and Orange. We’ve been building our new scale-ready system with awesome dev team (Daniel, Olaide, Brian) from Andela for the past four months.

A week in SF had our team assemble from around the world at the SF headquarters of FROG to ask the tough questions:

  • how are we going to redesign this app from the ground up?
  • what do we know, and what do we not know?
  • how do we navigate our complex stakeholder ecosystem?
  • what’s the scope of our business model?
  • how do we move forward with how we tell our story?
  • how do we set up a framework for testing our prototype, our market strategy

 

 

And we had even more help. Our wonderful team of Masters of Advanced Management students at the Yale School of Management were helping us define our five-year business model, pitch, and financial projections. Many assumptions were made. We put a dollar amount on how much we need to raise by next year, and the year after to break even, and to meet our expansion targets (650,000 USD by the end of 2017). Our summer interns also pitched in with in-field paper prototyping of the app.

 

 

Where do our footprints lead?

We started off as a team of students with a public health background, attempting to build a technological solution to a last mile problem. Naturally, we followed a funding stream that complemented our expertise – to conduct rigorous field research to measure the value we hope to create. With the help of the Gates Foundation and 3ie, we will still be largely involved in measuring the ability of our KB system to affect change in health behavior throughout the spectrum of maternal and child health care. We will have mixed methods approaches to consider feedback from the complex ecosystem of stakeholders that will interact with our system, and look to better quantify the time efficiency and relative cost effectiveness of our system against status quo processes.

Not all district governments are in favor of RCTs like ours and for good reason. The rigidity required to measure experimental conditions undermines the flexibility needed in implementing the rural health delivery system. The result in practice can easily turn into a randomized chaotic trial with camps getting cancelled, ANMs getting turned over, tablets being lost, and the rest of the implementation iceberg.

So as we move forward, we need to be more agile in our methodology of evaluating our impact under a framework that encourages iteration and adaptation of our system with automated generation of metrics. The measurement of our system’s value should not hinder the potential value it can create, nor forget to keep the patient at the center.

 

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The mother’s footprints

 

And while we are still trying to understand the boundaries of the impact we can make, we shouldn’t stop striving to make the system bigger, better, and yes, financially sustainable. We are ready to boldly step forward as an impact-first, social enterprise.

Our goal is to sell our system to our first customers – District Ministries of Health – by the end of the year. In the meanwhile, we’ll be leveraging local strategic partnerships to help finance our development and implementation. Mobisoft in Houston/Pune will be coming on board to help us finish the core app, and Safran Identity and Security will be equipping us with their biometrically-enabled MorphoTablet  (although we will still be device agnostic) and related expertise. Why? Well, we want to build a system that can verify patients’ records as their own (how we are storing biometric templates on our NFC wearables deserves its own post), ensure accountability for the nurses, and provide security and integrity to the essential data we hope our system can collect and act upon. After all, this October we plan to roll out in over 300 government villages to track nearly 33,000 mothers and children by the end of 2017, and we take that responsibility very seriously. To do so, we’ll also need to grow our full-time team: designers, anthropologists, data scientists, government lobbyists, marketeers, managers, and of course, developers – please come walk with us to the last mile. Not enough is said about our dev team. As we move forward they will continue help us drive the frontier of innovation, giving our ideas real-world animation, and there is no time like now to get involved (reach out to us at team@khushibaby.org).

Leapfrogging

And just as we’ve set out for the district-roll out, we have found ourselves at an unexpected inflection point. With GAVI’s recognition as a Pacesetter Innovation, we will have a golden opportunity to leapfrog beyond the incremental groundwork and pilots at the District level. If our idea can capture the imagination of central level officials at the country Ministry of Health level, everything can change.

This future is near. With reports of Uttar Pradesh seeking to link Aadhaar with infant immunization cards, and seeing Mexico already take a national level stab at NFC stickers do just that, the seeds for scale may already be planted. The Khushi Baby necklace may have something to say about India’s next digital health identity and record – to fulfill our bold aspirations of being the decentralized (offline and biometrically authenticated), digital key that can connect millions of underserved to a network of health and social services. And you too can insert yourself into this network of good – support us on Bitgiving this month!

Ultimately we measure our growth not by the size of our footprint or by how many steps we have taken forward. It’s not even about whether we are walking or running. At Khushi Baby what we care about is the mud between our toes – the chance to take steps with communities, not just for them.

So the monsoon season is in full swing, and the journey is still ahead of us. Let our footprint show us digging in, working hard, preparing to leap.

 

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paperprototype

field testing

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necklaces

 

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