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Andrew Wyborn (CEO), Susan High (Operations Director) & Tim High (Technical Director)

Andrew Wyborn (CEO)

Susan High (Operations Director)

Tim High (Technical Director)

Interview by Kamran Rafiq (ISNTD)

Ahead of Greenmash CEO Andrew Wyborn's presentation at this year's ISNTD Bites conference, follow this in-depth interview with the company Greenmash about the Mango platform for surveillance, mHealth and measurement & evaluation, and its potential impact on vector-borne diseases and neglected tropical disease control! Greenmash's Mango platform offers a complete mhealth data surveillance, monitoring, and reporting solution that can operate in the toughest environments.

The biggest on trend message coming out of the NTD ecosystem right now is 'data data data' - with so many potential data streams from supply chain to diagnostics and so how does Greenmash play out against this backdrop?

Andrew Wyborn (AW): Yes, that’s a great question. By way of background, Greenmash is a UK based software and services organisation supporting international development agencies, private companies, ministries and research institutes. We help get data from the toughest environments using mobile devices and generate meaningful reports, charts and maps in real time to enable sensible decisions to be taken to improve monitoring, management, surveillance and performance management. We develop, deploy and support systems on a robust and scalable cloud-based mobile application platform known as Mango and are operational in many low resource countries including 12 in sub-Saharan Africa. We have deployed solutions for a wide variety of health areas including NTDs, HIV/AIDS, Malaria, Family Planning, Sexual and Reproductive Health and many of these solutions are 'cross-cutting' including commodity tracking, referrals and e-vouchers and disease surveillance.

Getting the data is, in many cases, the easy bit. The value that we add is turning that data into meaningful information that can be used to support informed action. We work closely with our clients and partners to understand their requirements. This includes identifying the data sources, which can include health workers at the community and primary health care levels. We also agree upon the frequency that the data needs to be collected and identify the most appropriate available channels to enable us to collect that data - this often includes SMS and Voice messaging, USSD, Android applications and direct data input in to web forms. We configure Mango to manage the data to support the requirements of our client. This can include presenting the data as information automatically in a rich series of reports, charts and maps that are available at any time to any authorised user. We can automate workflows and processes and push the information to the people that need it, in real-time.We can also capture data from third-party systems and applications and integrate Mango with other management information systems to help create an information 'eco-system'.

Susan High (SH): Greenmash enables all levels of an organization to benefit from the data streaming in. While the robust features of the Mango platform capture, manage and analyse data, the Greenmash team provides a layer of expertise and experience. We partner with you to redefine processes so data is captured in the most cost effective and efficient way, and then we help you parse the data into information that is valuable to your different departments and teams. The power of data is pulling it together in a meaningful way so it can shine a light on the critical indicators within your business and allow you to see if you are performing as you should be. Greenmash has the tools, and knowledge to do this.

Tim High (TH): Data allows teams to make informed decisions about where best to apply their efforts and funding, without it, programs may or may not work and money may be spent in areas that aren't achieving the full potential. With mango data collection teams can choose the best way to obtain the data depending on the infrastructure available at the point of collection. Mango provides its own set of data collection tools from basic SMS and USSD tools through to feature rich mobile applications, as well as providing a strong API built on open standards that allows third party apps to push data into mango. Once the data is in mango we provide workflow and reporting tools that allow you to slice the data anyway you want, or we can push that data into other reporting tools such as DHIS2. The aim of all of this is really turning what was a piece of raw data into information that then leads to decisions. Data on its own is really just facts, decisions come from what you can do with it.

Developments such as the African Center for Disease Control (CDC) going live at the start of this year have further highlighted the data gaps that exist in both the region and at a wider level - how can your Mango system facilitate the filing of these gaps?

AW: The biggest gap is often from 'the last mile’ i.e. the community and primary health care levels where the majority of healthcare services are delivered. This is where we are particularly strong. We have the ability, experience and the technology to connect the last mile to the rest of the health system. Some examples include the work we are involved in with Sightsavers and FIND.

For Sightsavers we have configured Mango to improve the monitoring and management of Mass Drug Administrations for a range of NTDs including schistosomiasis, onchocerciasis, lymphatic filariasis and trachoma. This provides Sightsavers visibility into and control of the pre-distribution census and drug distribution itself. Treatment coverage requirements are automatically calculated and Mango informs the program participants as to appropriate actions e.g. continue treatment, stop treatment and so on, based upon the coverage achieved at each reporting stage. The stock usage is also monitored which has resulted in significant cost savings and reductions in loss and wastage. Following a successful pilot program in Cameroon, Sightsavers are now implementing Mango in 18 countries.

With FIND we have configured Mango to capture and manage data for a HAT elimination program. Mango tracks the test results from RDTs. microscopy and LED facilities, creates and updates patient records and alerts the appropriate health centres and patients with information related to the test results and appointments. Health workers at these primary health centres report using SMS messages with those at the larger LED centres using Android devices. FIND have been using Mango successfully since 2015 in Uganda and are about to introduce the same system in to Chad followed by Guinea and Angola.

The data that these systems capture and manage can be analysed within Mango and can also be shared with other tools and systems either by using the simple data extraction tools that Mango provides or by integrating Mango with other systems to support seamless and automated data sharing. Mango helps to fill the gaps and support a comprehensive information environment.

SH: Mango’s strength is in its flexibility, it can be used at all levels within the community, integrate with any system and use a wide variety of technologies all under the same platform. We can collect information from the last mile using basic phones and SMS, moving on to smart phones at Health facilities with internet connection and direct web access at hospitals and the ministry of health. All of this means mango can plug the gap at which ever level is required.

TH: We see mango as a data collection and analysis tool as well as a data hub. This means mango can play a central role in gathering data from hard to reach places, provide operational support for teams on the ground who have their own data requirements, as well as pass data through to others such as the African Center for Disease Control. For us the whole point of applications like mango is that they play a strong role in gathering and storing data and integrate that data into other systems. Everyone has their strengths and ours is getting data.

We recently ran a global hackathon as part of our ISNTD Festival (vreative arts, science communication and tropical diseases) and from the response we received it is very apparent that apps will have a huge role to play in the fight against these diseases - given how varied the scope and type of apps being developed are, how will Greenmash's Mango platform work with apps?

AW: An app can be a very useful way of delivering a set of tools on to an affordable device to enable tasks to be undertaken online or offline. However an app on its own can quickly become 'orphaned' and unless it can be easily updated, and if the data it is managing cannot be shared then it can have limited value. We have a two-pronged approach with apps. Firstly we have the Mango app, available on the Google Play Store now and shortly to be available on all platforms. This enables anyone with a smart device to download the Mango app, browse from their device to their online Mango application, log on and have the surveys and reports that are relevant to them automatically downloaded to their Mango app. Users can then work from their device online or offline collecting, managing and analyzing data. Whenever users have an internet connection they can easily synchronize their Mango app with the Mango website. This uploads any new data they have collected to automatically update the reports, charts and maps in Mango. At the same time the synchronization downloads any changes or additions that have taken place since the previous synchronization. This is fast, simple and ensures that all program participants are working with the same set of tools and same data.

The second option we provide is the Mango application programming interface (API). This allows other apps to be integrated with Mango to take advantage of the data management and visualization tools that Mango provides.

SH: In the current technology ecosystem, no system stands alone and Mango is no different. At Greenmash we believe that informed decisions come when all the data is considered. That’s why we designed mango to integrate with many different applications, enabling data to be collected, managed, stored and most importantly, analyzed in a central location. A vast array of applications can be plugged in with ease. From finger print scanners to increase data collection capabilities to Zapier integrations to push data out into third party systems, mango has an integral role to play.

TH:You can make many choices when developing software, one of the key ones is whether to provide an API or not. A strong API allows third parties to integrate your product with their own, in mango terms it means more data, so for us the decision was an easy yes. Mango's API allows the creation of new surveys, which are essentially the structure of the data we want to collect, to add data, search the data and retrieve aggregated data in the form of reports built within mango as well as much more. The possibilities are endless as to what you can do when you are integrating with a decent API and your apps can expand far beyond anything we ever imagined.

Cost cutting and saving money is an obvious concern for a lot of the actors involved in mass drug administration but this has to be balanced with effectiveness and transparency - how can you achieve his using Mango?

AW: The best example of how this can be achieved is through our work with Sightsavers. In 2014, we deployed Mango in Cameroon as a pilot for Sightsavers to support their MDA for onchocerciasis and lymphatic filariasis. The evaluation of this pilot showed that for the first time the MDA team were able to complete the census before the treatment started. The treatment coverage increased by more than 10% compared to the previous year, the time spent conducting the MDA was reduced by a third, all program data was available at each weekly meeting and, despite the investment in Mango, the pilot showed a savings of almost $70,000 compared to the areas not using Mango. Sightsavers subsequently invested in some system enhancements and introduced Mango in to their MDA activities in Nigeria and seen similar benefits scaled up. We are now working with Sightsavers to introduce Mango to support MDAs in 18 countries.

As with any system, you get out what you put in. Sightsavers have embraced the use of technology to improve their MDA programs, have engaged with Greenmash in a collaborative partnership and have made a big effort to engage their in-country teams, explaining the benefits of using Mango and providing well thought out and well delivered training. The results speak for themselves.

SH: Greenmash isn’t just about the software. We believe it is our responsibility to ensure that we provide every client an overall improvement to process and visibility into the performance of the overall system. The expertise of the Greenmash team combined with mangos versatile features, highlights inefficiency in processes or gaps in data collection. Once problems are identified, clients can then use mango to implement new processes and improve performance. This typically results in cost savings which, while not a project goal, is a happy outcome.

TH: The purpose of any software is really to make the manual task you were performing more efficient. If it's not doing that its costing you, even if that software was free. As a technology company, our focus is to make things more efficient. That starts with an analysis of your requirements through to the training of your users. The potential savings mango provides in terms of time and money can be staggering. An example of this is when we produce instant reports for users with complex calculations that otherwise would have taken them weeks of collating data from various paper forms with a high chance of human error and gaps in data. This not only represents a huge savings in both time and money, it frees staff to focus on other more important tasks.

We often hear that half the battle is to get the end user to engage especially when it comes down to technology constraints and also in some cases cultural inertia - how have you encountered this and if so how have you overcome this?

AW: Getting users to engage is the key to success. For many users Mango may be the first time they have had to engage with technology at work. From the technology aspect, we always try and work with what is easily available rather than introduce a new 'black box'. At the community and primary health care level this often means engaging with health workers through their own basic mobile phone, or feature phone. We can integrate Mango with local mobile network operators to enable us to send and receive messages to these simple phones using SMS or voice messages with the choice being determined by factors such as literacy levels and local availability of network services. Where available we can use Interactive voice response (IVR) services to enable health workers to dial a number and simply respond to questions in their local language. USSD is another simple technology that works well in last mile situations and allows us to configure menus of questions in Mango that can be presented to health workers on their feature phones just using the local mobile networks. We can usually negotiate a free-to-use number to allow health workers and patients to engage with the process without incurring costs. Where budget allows we can also automatically distribute incentive or reward payments directly to the health workers basic phones in response to timely and correctly formatted receipt of data.

Mango is language independent and can support multiple languages in the same country. In Cameroon for example where we work with multiple partners across a number of health programs, the health workers registered in Mango can specify if they want to receive messages in English or French. In Tanzania, the choice is Swahili or English. In Madagascar its French, Malagasy or English, and so on.

When using voice messaging, response rates can be improved if the voice messages come from a familiar voice. An example of this is in Somaliland where we worked with PSI. Mango was used to register pregnant women in to a program known as the Umbrella of Safe Motherhood. The registered women where then sent voice messages from Mango that were relevant to the stage of their pregnancy. The message content was designed by PSI and recorded by a well-known local sports person whose voice was instantly recognizable.

As Sightsavers have shown it is also important to engage at all levels, from senior management down. Explain why the technology is being introduce and what the benefits are. Having made the decision to introduce technology its then important to use it - chase up those people that are not reporting to ensure they realise the importance of what they are doing and the cost of not doing it. Also listen to any complaints and ideas and keep a log of them - the best system enhancements come from user feedback. Also build some informational messaging in to the process. Simple regular feedback is proven to help users engage and to feel motivated. It can be a hard and lonely life in the 'last mile' and technologies like Mango can be used very effectively to encourage health workers to feel that they are valued and part of a team.

SH: There are two parts to user engagement. First users need to see the benefits the new technology and processes bring. The technology needs to either make their current work load easier or add additional knowledge they will find helpful. If users can’t see a reason for using the technology, or if it adds additional work, then it’s difficult to maintain high response levels in already over worked communities. Secondly, users need to be engaged and their efforts need to be validated. It’s important to keep users engaged with the system by letting them know that the information they send in is valuable to the larger effort, that it’s being used, and that someone is counting on them to provide it and is monitoring it. If users feel the data they provide is disappearing into a black hole, they will either stop sending it or not send the correct information.

TH: Change is always a difficult thing. And, when introducing software systems, the resistance can sometimes be strong. The only way to overcome this is to listen and understand the cause of the resistance. Arbitrarily enforcing change only leads to further resistance. As with most projects the software is only part of the story, it’s the process change that causes the most concern to users. When something that previously took days to complete is done with a click of a mouse it can be disconcerting. The key thing to remember, particularly in the environments we work in, is that there is far more important work to be done than collating documents. Mango allows you to focus on the import work, leading to greater knowledge and advancement. Often when we implement new systems the users can immediately see the benefit, whether it is treating more people more effectively, or having visibility into the scale of the issue they are tackling. By eliminating the mundane and manual tasks, users can step back, see and focus on the crucial program elements, enabling them to direct funding more efficiently, which is what makes this job so satisfying.

As Greenmash will be presenting at our 19th July 5th annual vector control and disease surveillance meeting ISNTD Bites - how could these 2 communities benefit from using Mango and what would be your message to them before the meeting?

AW: Greenmash has worked with many programs that include vector control and disease surveillance, particularly malaria. Common uses of Mango within these interventions include commodity management, disease surveillance reporting and the use of electronic vouchers and mobile payments to support distribution programs such as nets.

Commodity management addresses the issue of stock-outs and over-stocking that in turn can lead to wastage as drugs pass their expiry dates. Mango can be configured to request and capture commodity data such as stock-on-hand, directly from primary health facilities and even community health workers. Mango can automatically and continuously run calculations to show consumption rates and can automatically prompt health workers via SMS to place orders for new stocks when the reported stock-on-hand reaches a level that indicates a potential stock out. Mango displays clear reports, charts and maps to indicate stock and consumption levels, can identify and report on the nearest available resupply or reallocation points, and can be configured to push alerts and email reports to the most appropriate program staff to make it easy to take informed action - and hard to avoid taking that action. Using Mango has proven to lead to significant improvements in commodity management including reducing stock-outs and improving procurement and supply chains. Examples include a reported 24% reduction of RDT stock outs in Kenya (SMS for Life program), reduction in ACT stocks outs from 57% to almost zero in Ghana and a national scale deployment of Mango by the national malaria control program in Cameroon.

Disease surveillance can be improved, and informed action supported, by capturing data on a regular basis from sources including primary health facilities and community health workers. How we do that with Mango depends on the locally available infrastructure. In many instances, we simply assign codes to the key surveillance indicators and train the health workers to report these using SMS on a regular scheduled basis. So for example the weekly number of outpatients could be assigned the code A, the number tested for malaria could be B, the number positive could be C and so on. Requests for data from Mango can then be replied to with a simple message containing the indicator codes and the appropriate numbers from the register. This data automatically updates reports, charts and maps in Mango in real-time and sends automatically generated reports and messages to the program team. Surveillance and commodity data can be overlaid on maps in Mango to show, for example, the disease prevalence compared to the availability of commodities. And Mango can share this data by integrating with other systems such as DHIS2 and logistics management information systems.

Some vector control interventions, such as net distributions, can be improved using electronic vouchers that can be generated, distributed, validated and managed by Mango. Each voucher can contain a unique number that can be easily validated to facilitate the provision of an appropriate number of nets per person. This can also link to the commodity management component within Mango to reduce the stock levels by the number of nets provided. This approach reduces the dependence on paper, reduces opportunities for fraud, avoids expensive, error-prone and time-consuming manual data entry, and gives program managers the ability to monitor and manager distribution programs in real time.

Mango can play an important part in other vector control activities such as mapping communities prior to indoor residual spraying activities and recording the progress of these activities in real time. Mango can provide the opportunity to better monitor and manage vector control and disease surveillance activities and the rich data sets that are captured directly at source can be analysed to support improved policy making.

Multisectorial collaboration is very much an open-ended equation - what type of partnerships have you been involved in and importantly which ones are you looking for in the future?

SH: We are excited to be launching a new partner program alongside our web version of mango in Q3 of this year. There are many great organisations throughout the developing world who have shown an interest in working with local clients to help them implement mango, and we are excited to support these organizations and provide more assistance on the ground. At a strategic level, we have a number of partnerships already where we have developed platforms to solve a specific need and these have then been rolled out to numerous countries to provide economies of scale. We see this as a win-win for everyone and would like to work on more strategic partnerships as well. Finally, we will be launching MyMango, a new version of mango designed for those that prefer a subscription solution and need more flexible pricing plans.

TH: To make any project work you generally need multiple parties involved. From Governments and NGO's through to mobile networks, aggregators and individuals in remote health facilities, mango crosses the board in the multi sectorial approach. Building relationships with these groups is a key part of a successful project as mango sits in between all of them providing each with the information they need. Greenmash has a history of successfully fostering multi sectorial relationships to successfully accomplish a variety of initiatives. We work with the Prime Ministers Office in the DRC to deliver an application the enables the detailed evaluation of the current status and capabilities of key facilities across the DRC to include health, education and agriculture. We suppor t Sightsavers in multiple countries as they provide a mass drug administration to inhabitants living in high risk areas and surgery for onchocerciasis and lymphatic filariasis and Schistosomiasis resulting in a more accurate MDA with high cost savings. We enable the NMCP in Cameroon to provide stock visibility for over 4000 health facilities.

As for future partnerships, Greenmash is open to hearing from anyone. We are dedicated to providing organizations access to the information they need and will soon launch a new version of mango, MyMango, that offers a variety of plans. Ranging from a free trail to a full enterprise version, MyMango has something for every budget, enabling you to get setup and running in minutes.

For further information, please contact:

Andrew Wyborn

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